Headache

Migraine Headache
Tension-Type Headache    
Rebound Headache

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Migraine Headache
Common Features of a Migraine
What Causes Migraine and Who Gets Migraine Headaches?

Treatments for Migraine
Drug Therapy
Nondrug Therapy

Migraine headache is a very common condition that varies remarkably from person to person. It can be very mild in some (for example, rare headaches that respond to acetaminophen or ibuprofen) but can be totally disabling in others.

Common Features of Migraine:

	episodic headache
	one-sided headache (typically temple or forehead)
	nausea and/or vomiting
	phonophobia (sensitivity to sound)
	family history
	pulsating (throbbing) pain
	photophobia (sensitivity to light)
	sensitivity to odors

How is the Diagnosis of Migraine Made?
The diagnosis of migraine headache is based only on the patient's description. The neurological examination is usually normal. The following diagnostic criteria have been developed by the International Headache Society (IHS):

1.	At least five attacks that fulfill the criteria below (Items 2 - 4)
2.	Headache attacks last 4 to 72 hours (untreated or unsuccessfully treated)
3.	Headache has at least two of the following characteristics:
		unilateral (one-sided)
		pulsating quality
		moderate or severe intensity (inhibits or prohibits daily activities)
		made worse by walking stairs or similar routine physical activity
4.	During headache, at least one of the following occurs:
		nausea and/or vomiting
		photophobia (sensitivity to light) and phonophobia (sensitivity to sound)
5.	History, physical and neurologic examination do not suggest a brain tumor, infection, or blood vessel abnormality (all very rare)

IMPORTANT: A patient experiencing symptoms of an aura for the first time should be evaluated by a physician.

Should a Brain MRI or CT Scan Be Performed?
In migraine headache, a brain MRI and CAT scan are normal. This type of test is often not needed if the headache description fits the diagnosis of migraine, the neurological examination is normal, and the person's age and other factors do not suggest another diagnosis. Patients often need the evaluation of a physician, who is best able to judge whether a test would be helpful, when headaches first start or when mild headaches suddenly become more severe or more frequent.

What Causes Migraine and Who Gets Migraine Headaches?

Migraine headache is thought to be a genetically inherited disorder strongly influenced by environmental factors. A person may inherent a predisposition for developing migraine headaches, but other factors such as stress, hormonal changes, or sleep disturbances are necessary to experience a migraine.

Pathophysiology or abnormalities in the body that cause migraines are still not known. Several theories exist, but none has been proven to be the sole cause of migraine. The theories include:

	The vascular theory -- brain blood vessels first constrict and then dilate (causing throbbing pain)
	The spreading depression theory -- a slow spreading of abnormal nerve impulses that move over the brain and trigger migraine
	The serotonergic theory -- abnormal changes in the neurotransmitter serotonin cause migraine
	The neurovascular theory -- an abnormal inflammatory response in the trigeminovascular system (nerves and blood vessels outside of the brain) results in a series of events ultimately causing migraine
	The vascular-supraspinal-myogenic theory -- several abnormal reactions interact to cause migraine, including changes in blood vessels, changes in the central nervous system (brain, serotonin, and stress), and myofascial triggers (spasm of deep muscles in the neck and shoulders)

Who Gets Migraine Headaches?

Many studies have reported that approximately 15-20% of women and 5-6% of men around the world suffer from migraine. Most patients develop their first migraine headache in adolescence or early adulthood. Many women report that headaches worsen before or during the menstrual period. Headache tends to gradually improve after menopause. Pregnancy may improve, worsen, or have no effect on migraine. In any individual woman, each pregnancy may affect migraine differently.

For information about migraine headaches in children, follow this link.

Treatments for Migraine

Drug Therapy

Drug therapy is the most often recommended treatment for migraine (with and without aura). Drugs for headache are divided into two types:

abortive/symptomatic medications
prophylactic medications

Abortive/symptomatic medications are those drugs that are taken at the onset or during a headache attack in the hopes of stopping the headache from occurring or decreasing the symptoms associated with the headache. When prescribing abortive/symptomatic medications, it is very important to remember the following points:

Each migraine patient is different; it is not possible to predict whether a particular person will respond favorably to a drug.

If abortive/symptomatic medication is used excessively, the development of Rebound Headache Syndrome can result. (Rebound headache means headache that is actually worsened by the overuse of short-acting abortive medication). Some authorities recommend that a patient take no more than 10 doses of abortive/symptomatic headache medication per month. Others allow more but become very concerned when abortive/symptomatic drugs are needed more than a few times each week.

Abortive/symptomatic headache medications include:

	over-the-counter analgesics (such as aspirin, acetaminophen, ibuprofen, naproxen, etc.)
	prescription nonsteroidal anti-inflammatory drugs (such as diclofenac, ketorolac, etc.)
	barbiturates (such as butalbital)
	ergots (such as ergotamine or dihydroergotamine)
	antiemetics (such as prochlorperazine)
	opioids (such as meperidine, morphine, etc.)
	triptans (such as sumitriptan, naratriptan, etc.)

Prophylactic headache medications are those drugs that are taken every day, regardless of whether a headache is being experienced, in the hopes of preventing headache attacks. These daily medications should only be prescribed when patients have frequent headaches (e.g., three or more times per month) that are significantly interfering with quality of life.

When prescribing prophylactic headache medication, it is very important to remember the following points:

	every migraine patient is different; response to a drug cannot be predicted
	only one drug should be prescribed at a time
	most drugs should have careful dose adjustment. The first dose is relatively low, and the dose is gradually increased if a headache occurs and if no intolerable side effects are experienced by the patient.

Prophylactic headache medications include:

	beta-blockers (such as propranolol, nadolol, atenolol, etc.)
	calcium channel blockers (such as verapamil, etc.)
	antidepressants (such as amitriptyline, nortriptyline, desipramine, doxepin, venlafaxine, etc.)
	anticonvulsants (such as valproic acid and gabapentin)
	nonsteroidal anti-inflammatory drugs (regular doses of indomethacin, naproxen, or other drugs)
	ergots (such as regular doses of ergotamine or methysergide)
	alpha-2 adrenergic agonists (such as clonidine or tizanidine)
	Feverfew (nutraceutical with some confirmatory scientific evidence)

Nondrug Therapy

Biofeedback
Many studies have shown that biofeedback can be effective as both abortive and prophylactic treatment for migraine.

Stress Management
Many studies have found that stress is a common trigger for migraine (in over 60% of patients). Techniques that help relieve stress, such as relaxation, imagery, and even yoga, have been shown in studies to be very effective.

Acupuncture
Some migraine patients may obtain benefit from acupuncture.

Physical Therapy
Studies have shown that aerobic conditioning (getting in shape) can reduce the amount and intensity of migraine. Also, some patients find that techniques that may reduce the degree of muscle tension in the neck and shoulder musculature can reduce the frequency of headache; methods include trained stretching exercises, osteopathic manipulation, and craniosacral manipulation.

Dietary Alterations
In some individuals with migraine, certain foods may trigger an attack. These foods include alcohol, chocolate, coffee, foods that contain MSG (monosodium glutamate) and tyramine-containing foods. Patients vary in their response to foods, and it is not necessary to recommend that all migraine patients stop eating potential triggering foods. Patients should become aware of the foods that trigger their headaches and avoid these.

Headache/Pain Clinic Treatment
Most often, migraine headache patients can be successfully managed by one physician without the need for a comprehensive pain clinic treatment. However, some migraine patients with severe headaches that fail to respond to routine measures may need a multidisciplinary approach involving several headache specialists, which may be provided in headache and pain clinics.