Headache Classification

• Headache is a common presenting complaint in medical and dental practices.
• Evaluation involves differentiating organic (secondary) from functional (primary) disorders.
• Headache can be a symptom of diseases affecting the intracranial and extracranial structures of the head.
• Subarachnoid hemorrhage is an example of organic craniofacial pain.
• In primary or functional craniofacial pain, the pain itself is the disease.

Classification of Headaches

• Primary headaches include migraine, tension-type, cluster, and other trigeminal autonomic cephalalgias.
• Secondary headaches are attributed to head/neck trauma, cranial/cervical vascular disorders, and nonvascular intracranial disorders.
• Still other secondary headaches may results or be attributed to substance use/withdrawal, infection, and psychiatric disorders.
• Further causes are cranial neuralgias, central causes of facial pain, or disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial/cranial structures.

Sinister Headache Features

• Late onset (after 50 years)
• New or different headache
• The worst headache experienced
• Rapidly peaking intensity (except cluster, trigeminal neuralgia)
• Worsening subacute headache
• Nocturnal occurrence
• Association with exertion, sexual activity, Valsalva's maneuver, or sneezing
• Focal neurological signs or dysfunction, excluding aura
• Systemic illnesses or abnormal physical examination (e.g., fever, stiff neck, hypertension)

Clinical History of Headaches

• Essential for evaluation as most patients have no physical signs.
• Important details include pain characteristics, premonitory/associated symptoms, family history, effects of pregnancy/menstruation, medical/surgical history, and treatment responses.
• PQRST (provocation, quality, region, strength, time course) aids history taking.
• Time course refers to age of onset, chronicity, pattern, duration, and frequency

Clinical History: Additional Considerations

• Childhood headaches are often primary.
• Migraine onset ranges from childhood to young adulthood.
• Exclude organic diseases like temporal arteritis or space-occupying lesions in late-onset headaches (over 50 years).
• Long-standing headaches (over 20 years) are usually not linked to severe neurological diseases.
• Sudden onset or change in headache character require investigation.
• Pattern of pain differentiates cluster headaches; organic headaches tend to be continuous versus episodic trigeminal neuralgia.

Migraine

• it is a common, under-diagnosed episodic headache disorder,
• A hereditary influence exists
• Family history is present in 50% of patients

Migraine (Clinical Features)

• Onset between ages 20 to 40.
• 25% present before age 10, 10% start with pregnancy.
• Attacks occur at any time, day or night, varying in frequency and lasting hours.
• Five phases of an attack include prodrome, aura, headache, resolution, and postdrome.
• Not all phases presented in every attack

Migraine Phases

• Five phases: Prodrome, aura, headache, resolution, postdrome
• Prodrome experienced in 60% of patients, preceding aura by hours or days.
• Prodrome signs: changes in mood/behavior, gastrointestinal symptoms, drowsiness, excessive yawning, thirst, fluid retention, aversions (odors, light, sound)

Migraine Types and Aura

• Two types are migraine with aura and migraine without aura (more common).
• Aura is the hallmark; 10-20% of sufferers experience this.
• Visual symptoms include teichopsia, photopsia, scintillating scotoma, hemianopia, and visual hallucinations.
• Aura includes auditory or olfactory hallucinations, sensory and motor symptoms like hemiparesis.
• Development occurs over 5-20 minutes, lasting less than an hour.

Presentations of Migraine Aura

• Visual symptoms are the most common.

• Negative Disorders:

  • Hemianopsia
  • Quadrantopsia
  • Scintillating scotoma

• Positive Disorders:

  • Teichopsia (fortification spectrum)
  • Photopsia (flickering of light)
  • Macro/microsomatognosia
  • Other visual hallucinations

Sensory Symptoms

• Numbness starting from the hand and spreading to the face and tongue
• Perioral tingling
• Paraesthesia

Auditory Symptoms

• Vertigo and tinnitus
• Auditory hallucinations

Olfactory Symptoms

• Olfactory hallucinations

Motor Symptoms

• Hemiparesis
• Dysarthria
• Dysphasia

Migraine (Headache Phase)

• Typically unilateral and throbbing, moderate to severe, aggravated by exertion
• About half the patients experience dull and non-throbbing headache.
• Pain can be bilateral at onset (40%) or unilateral, generalizing later.
• Location is often retro-orbital or fronto-temporal.
• Can radiate to the occipital and neck, mimicking cervical spine disorders.
• Migraine headache lasts less than a day, can persist for a few days

Migraine - Resolution and Postdrome

• Resolution:

  • Headache phase followed by resolution over hours
  • Patients may prefer to sleep it off.

• Postdrome:

  • Follows resolution, lasting hours to days
  • Presents tiredness, impaired concentration, irritability, anorexia, limited food tolerance

Migraine Triggers

Stress

• Migraines can occur during relaxation after intense stress. Menstruation
• Menstruation can precipitate the condition, while sleep and pregnancy may help ameliorate it. Triggering Factors for Migraine Attack
• Certain types of food
• Alcohol
• Certain vasodilators
• Strong odours
• Changes in weather

Migraine - Management

• Correct diagnosis is essential.
• Diagnostic criteria are valuable.
• Recognize that not all patients have classic signs/symptoms.
• Avoid triggering factors when possible.
• Often, headaches are not caused by a single, identifiable, or avoidable trigger

Treatment of Pain: Broadly Divided Into

• Psychological
• Pharmacological
• Physical

Therapeutic Guidelines for Migraine During Headache-Free Periods

• During headache-free periods, teach patients to avoid trigger factors.
• Food, prolonged exertion, alcohol, and drugs trigger migraines. Lifestyle Changes
• Regular exercise, balanced meals, and adequate sleep should be encouraged.

Pharmacological Therapy of Migraine Is divided into:

• Symptomatic: Aims at aborting attacks, reducing severity and duration
• Prophylactic: Aims at preventing/reducing number of attacks

Anti-Migraine Drug Treatment Considerations

• Some birth control measures must be in place for female patients of childbearing age.
• The teratogenic potential of most anti-migraine drugs not been cleared.
• Valproate poses neural tube defects

Role of Regional Blocks

• It is limited
• Try the procedure when all other methods have failed
• Trigger point injections may be considered
• Nerve blocks may also be considered

Cluster Headache

• Less common than migraine
• Affects males more than females with onset in the late 20s
• Can affect any age group
• Diagnosis is exclusively clinical
• "Cluster" refers to the periodicity of attacks occurring daily or several times a day

IHS Diagnostic Criteria for Cluster Headache

• At least five attacks fulfilling criteria B-D
• Severe/very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15–180 minutes if untreated.
• Ipsilateral presentation of:
  • Conjunctival injection and/or lacrimation
  • Nasal congestion and/or rhinorrhoea
  • Eyelid edema
  • Forehead and facial sweating
  • Miosis and/or ptosis
• Sense of restlessness or agitation
• Attacks occur from one every other day to eight per day
• Not attributed to another disorder

PATHOGENESIS OF CLUSTER HEADACHE

• Neurogenic element
• The trigeminal nerve and trigeminal vascular structure are involved with this
• pain's location relates to the ophthalmic and maxillary branches

Management of Cluster Headache

Abortive

- Oxygen inhalation (6-7 litres/minute) for 15 minutes at onset
- 5HT1 agonists: ergotamine,dihydroergtamine and sumatriptan
- Dexamethasone

Prophylactic

- Calcium channel blockers: this is the 1st-line prophylactic treatment(Verapamil)

• Lithium
  • lithium combined with verapamil is the most effective treatment for chronic cluster headache

Advanced Management Cluster Headache

• Neuroablation
  • Neuroablation of the trigeminal nerve using radiofrequency or glycerol
• To achieve optimum outcome
  • Achieve best results, use both the ophthalmic and maxillary branches

Tension-Type Headache

• Highly prevalent and thus it is the most common headache type
• It is divided ;the episodic type and the chronic tension headache

Tension-Type Headache: Prevalence

• Episodic tension headache is common

  • Females are more commonly affected, in all age groups, races, or education levels.
  • Prevalence peaks in the 30-39 year age group, with a direct impact on education levels in both sexes.
  • About half of those who have received graduate school education have been afflicted with the disorder.

• Chronic tension headache is not as common

  • Although females are more susceptible, the prevalence decreases with increasing education.
  • Has greater social and significant individual impact than the episodic type.
  • There is more reporting of lost working days.

Tension-Type Headache: Characteristics

• The headache is symmetrical with non-disabling severity
• Vascular features like throbbing, nausea, & photophobia are absent
• Not related to any aura symptoms
• Intensity pain ranges from mild to moderate
• Describes the pain feeling is described as tightness and pressure
• Distribution of this headache is commonly bifrontal & bioccipital
• Depression may be a common featured in chronic tension headache

Tension-Type Headache : Pathogenesis

• Stress leading to contraction of head muscles thus leading to tissue ischemia and pain
• In the past it has been named muscle contraction headache

Tension-Type Headache : Management

Treatment can be divided ;

• Psychological Relaxation techniques with training
• Physical TENS or topical treatment
• Pharmacological -simple analgesic with muscles relaxants to disrupt the attack

Procedures

• Trigger point injections
• Tricyclic AD to the reduce the the number and severity of attacks

Cervicogenic Headache

• Cervical abnormalities can produce anterior or posterior headache
• Unilateral headache without shifting if triggered by head and neck movement
• Pain can originate in the neck with a radiation to your head
• There is significant neck involvement with the reduction of movement
• Can be with mechanical stimulation moving diffusely to the shoulder and arm

Cervicogenic Headache: Mangement

• Treatment for headache related to the related of the cervical issue
  • Use symptoms to help identify correct cervical spine
• The treatment plans are with the spine specialist
• Physiotherapy has high support
• Injections on trigger points helps