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Headache

From Wikipedia, the free encyclopedia


For other uses, see Headache (disambiguation).

Headache

Synonyms cephalalgia

Woman with a headache

Classification and external resources

Specialty Neurology

ICD-10 G43-G44, R51

ICD-9-CM 339, 784.0

DiseasesDB 19825

MedlinePlus 003024

eMedicine neuro/517 neuro/70

Patient UK Headache

MeSH D006261
[edit on Wikidata]

Headache is the symptom of pain anywhere in the region of the head or neck. It occurs
in migraines, tension-type headaches, and cluster headaches.[1] Frequent headaches can affect
relationships and employment.[1] There is also an increased risk of depression in those with
severe headaches.[1]
Headaches can occur as a result of many conditions whether serious or not. There are a number
of different classification systems for headaches. The most well-recognized is that of
the International Headache Society. Causes of headaches may include fatigue, sleep
deprivation, stress, the effects of medications, the effects of recreational drugs, viral infections,
loud noises, common colds, head injury, rapid ingestion of a very cold food or beverage, and
dental or sinus issues.
Treatment of a headache depends on the underlying cause, but commonly involves pain
medication. Some form of headache is one of the most commonly experienced of all physical
discomforts.
About half of adults have a headache in a given year.[1] Tension headaches are the most common
affecting about 1.6 billion people (21.8% of the population) followed by migraine headaches
which affect about 848 million (11.7%).[2]

Contents
[hide]

1Cause

o 1.1Primary vs. secondary headaches

o 1.2Primary headaches

o 1.3Secondary headaches

2Pathophysiology

3Diagnosis

o 3.1Red flags

o 3.2Old headaches

o 3.3New headaches

o 3.4Neuroimaging

o 3.5Classification

4Management

o 4.1Migraines

o 4.2Tension-type headaches

o 4.3Cluster headaches
o 4.4Secondary headaches

o 4.5Neuromodulation

5Epidemiology

6History

7Children

8References

9External links

Cause[edit]
There are more than two hundred types of headaches. Some are harmless and some are life-
threatening. The description of the headache and findings on neurological examination,
determine whether additional tests are needed and what treatment is best. [3]
Primary vs. secondary headaches[edit]
Headaches are broadly classified as "primary" or "secondary". [4] Primary headaches are benign,
recurrent headaches not caused by underlying disease or structural problems. For
example, migraine is a type of primary headache. While primary headaches may cause
significant daily pain and disability, they are not dangerous. Secondary headaches are caused by
an underlying disease, like an infection, head injury, vascular disorders, brain bleed or tumors.
Secondary headaches can be harmless or dangerous. Certain "red flags" or warning signs
indicate a secondary headache may be dangerous.[5]
Primary headaches[edit]
90% of all headaches are primary headaches. Primary headaches usually first start when people
are between 20 and 40 years old .[6] The most common types of primary headaches are
migraines and tension-type headaches.[6] They have different characteristics. Migraines typically
present with pulsing head pain, nausea, photophobia (sensitivity to light) and phonophobia
(sensitivity to sound). Tension-type headaches usually present with non-pulsing "bandlike"
pressure on both sides of the head, not accompanied by other symptoms. [7] Other very rare types
of primary headaches include:[5]

cluster headaches: short episodes (15180 minutes) of severe pain, usually around one
eye, with autonomic symptoms (tearing, red eye, nasal congestion) which occur at the same
time every day. Cluster headaches can be treated with triptans and prevented with
prednisone, ergotamine or lithium.

trigeminal neuralgia: shooting face pain

hemicrania continua: continuous unilateral pain with episodes of severe pain. Hemicrania
continua can be relieved by the medication indomethacin.

primary stabbing headache: recurrent episodes of stabbing "ice pick pain" or "jabs and
jolts" for 1 second to several minutes without autonomic symptoms (tearing, red eye, nasal
congestion). These headaches can be treated with indomethacin.

primary cough headache: starts suddenly and lasts for several minutes after coughing,
sneezing or straining (anything that may increase pressure in the head). Serious
etiologies(see secondary headaches red flag section) must be ruled out before a diagnosis
of "benign" primary cough headache can be made.

primary exertional headache: throbbing, pulsatile pain which starts during or after
exercising, lasting for 5 minutes to 24 hours. The mechanism behind these headaches is
unclear, possibly due to straining causing veins in the head to dilate, causing pain. These
headaches can be prevented by not exercising too strenuously and can be treated with
medications such as indomethacin.

primary sex headache: dull, bilateral headache that starts during sexual activity and
becomes much worse during orgasm. These headaches are thought to be due to lower
pressure in the head during sex. It is important to realize that headaches that begin during
orgasm may be due to a subarachnoid hemorrhage, so serious causes must be ruled out
first. These headaches are treated by advising the person to stop sex if they develop a
headache. Medications such as propranolol and diltiazem can also be helpful.

hypnic headache: moderate-severe headache that starts a few hours after falling asleep
and lasts 1530 minutes. The headache may recur several times during night. Hypnic
headaches are usually in older women. They may be treated with lithium.
Secondary headaches[edit]
Headaches may be caused by problems elsewhere in the head or neck. Some of these are not
harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication
overuse headache may occur in those using excessive painkillers for headaches, paradoxically
causing worsening headaches.[3]
More serious causes of secondary headaches include:[5]

meningitis: inflammation of the meninges which presents with fever and meningismus, or
stiff neck

bleeding inside the brain (intracranial hemorrhage)

subarachnoid hemorrhage (acute, severe headache, stiff neck WITHOUT fever)

ruptured aneurysm, arteriovenous malformation, intraparenchymal


hemorrhage (headache only)

brain tumor: dull headache, worse with exertion and change in position, accompanied by
nausea and vomiting. Often, the person will have nausea and vomiting for weeks before the
headache starts.

temporal arteritis: inflammatory disease of arteries common in the elderly (average age
70) with fever, headache, weight loss, jaw claudication, tender vessels by the temples,
polymyalgia rheumatica

acute closed angle glaucoma (increased pressure in the eyeball): headache that starts
with eye pain, blurry vision, associated with nausea and vomiting. On physical exam, the
person will have a red eye and a fixed, mid dilated pupil.

Post-ictal headaches: Headaches that happen after a convulsion or other type of seizure,
as part of the period after the seizure (the post-ictal state)

Pathophysiology[edit]
The brain itself is not sensitive to pain, because it lacks pain receptors. However, several areas
of the head and neck do have pain receptors and can thus sense pain. These include the
extracranial arteries, middle meningeal artery, large veins, venous sinuses, cranial and spinal
nerves, head and neck muscles, the meninges, falx cerebri, parts of the brainstem, eyes, ears,
teeth and lining of the mouth.[8][9] Pial arteries, rather than pial veins are responsible for pain
production.[5]
Headaches often result from traction to or irritation of the meninges and blood vessels. The
nociceptors may be stimulated by head trauma or tumors and cause headaches. Blood vessel
spasms, dilated blood vessels, inflammation or infection of meninges and muscular tension can
also stimulate nociceptors and cause pain.[9] Once stimulated, a nociceptor sends a message up
the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts.
Primary headaches are more difficult to understand than secondary headaches. The exact
mechanisms which cause migraines, tension headaches and cluster headaches are not known.
There have been different theories over time which attempt to explain what happens in the brain
to cause these headaches.
Migraines are currently thought to be caused by dysfunction of the nerves in the brain.
[10]
Previously, migraines were thought to be caused by a primary problem with the blood vessels
in the brain.[11] This vascular theory, which was developed in the 20th century by Wolff, suggested
that the aura in migraines is caused by constriction of intracranial vessels (vessels inside the
brain), and the headache itself is caused by rebound dilation of extracranial vessels (vessels just
outside the brain). Dilation of these extracranial blood vessels activates the pain receptors in the
surrounding nerves, causing a headache. The vascular theory is no longer accepted. [10][12] Studies
have shown migraine head pain is not accompanied by extracranial vasodilation, but rather only
has some mild intracranial vasodilation.[13]
Currently, most specialists think migraines are due to a primary problem with the nerves in the
brain.[10] Auras are thought to be caused by a wave of increased activity of neurons in the cerebral
cortex (a part of the brain) known as cortical spreading depression [14] followed by a period of
depressed activity.[15] Some people think headaches are caused by the activation of sensory
nerves which release peptides, such as serotonin, causing inflammation in arteries, dura and
meninges and also cause some vasodilation. Triptans, medications which treat migraines, block
serotonin receptors and constrict blood vessels.[16]
People who are more susceptible to experience migraines without headache are those who have
a family history of migraines, women, and women who are experiencing hormonal changes or
are taking birth control pills or are prescribed hormone replacement therapy.[17]
Tension headaches are thought to be caused by activation of peripheral nerves in the head and
neck muscles [18]
Cluster headaches involve overactivation of the trigeminal nerve and hypothalamus in the brain,
but the exact cause is unknown.[19]

Diagnosis[edit]
Differential diagnosis of headaches

Tension headache New daily persistent headache Cluster headache Migraine

mild to moderate dull moderate to


severe pain
or aching pain severe pain
duration of 30 minutes duration of at least four hours duration of 30 minutes duration of 4
to several hours daily to 3 hours hours to 3 days

periodic
may happen multiple occurrence;
Occur in periods of 15 days a
times in a day for several per month
month for three months
months to several per
year

located one side of located on one or


located as tightness or located on one or both sides of
head focused at eye both sides of
pressure across head head
or temple head

pain describable as pulsating or


consistent pain
sharp or stabbing throbbing pain

nausea, perhaps
no nausea or vomiting
with vomiting

no aura no aura auras

may be accompanied
uncommonly, light sensitivity to
by running nose, tears,
sensitivity or noise movement, light,
and drooping eyelid,
sensitivity and noise
often only on one side

may exist with


exacerbated by regular use
tension
of acetaminophen or NSAIDS
headache[20]

Most headaches can be diagnosed by the clinical history alone. [5] If the symptoms described by
the person sound dangerous, further testing with neuroimaging and/or lumbar puncture may be
necessary. Electroencephalography (EEG) is not useful for headache diagnosis. [21]
The first step to diagnosing a headache is to determine if the headache is old or new.[22] A "new
headache" can be a headache that has started recently, or a chronic headache that has changed
character.[22] For example, if a person has chronic weekly headaches with pressure on both sides
of his head, and then develops a sudden severe throbbing headache on one side of his head, he
has a new headache.
Red flags[edit]
It can be challenging to differentiate between low-risk, benign headaches and high-risk,
dangerous headaches since symptoms are often similar.[23] Headaches that are possibly
dangerous require further lab tests and imaging to diagnose.
The American College for Emergency Physicians published criteria for low-risk headaches. They
are as follows:[24]

age younger than 30 years

features typical of primary headache

history of similar headache

no abnormal findings on neurologic exam

no concerning change in normal headache pattern

no high-risk comorbid conditions (for example, HIV)

no new concerning history or physical examination findings


A number of characteristics make it more likely that the headache is due to potentially dangerous
secondary causes which may be life-threatening or cause long-term damage. These "red flag"
symptoms means that a headache warrants further investigation with neuroimaging and lab
tests.[6]
In general, people complaining of their "first" or "worst" headache warrant imaging and further
workup.[6] People with progressively worsening headache also warrant imaging, as they may
have a mass or a bleed that is gradually growing, pressing on surrounding structures and
causing worsening pain.[23] People with neurological findings on exam, such as weakness, also
need further workup.[23]
The American Headache Society recommends using "SSNOOP", a mnemonic to remember the
red flags for identifying a secondary headache:[22]

Systemic symptoms (fever or weight loss)

Systemic disease (HIV infection, malignancy)

Neurologic symptoms or signs

Onset sudden (thunderclap headache)

Onset after age 40 years

Previous headache history (first, worst, or different headache)


Other red flag symptoms include:[6][22][23][25]

Reason why red


Red Flag Possible causes flag indicates Diagnostic tests
possible causes

New Temporal arteritis, mass in brain Temporal arteritis Erythrocyte


headache is an inflammation sedimentation rate
after age 50 of vessels close to (diagnostic test for
the temples in temporal arteritis),
older people,
which decreases
blood flow to the
brain and causes
pain. May also
have tenderness in
neuroimaging
temples and/or
jaw claudication.
Some brain
cancers are more
common in older
people.

A bleed in the
brain irritates the
meninges which
causes pain.
Pituitary apoplexy
(bleeding or
impaired blood
supply to the
Very sudden Neuroimaging, lumba
Brain bleed (subarachnoid hemorrhage, pituitary gland at
onset r puncture if
hemorrhage into mass lesion, vascular the base of the
headache computed
malformation), pituitary apoplexy, mass brain) is often
(thunderclap tomography is
(especially in posterior fossa) accompanied by
headache) negative
double vision or
visual field
defects, since the
pituitary gland is
right next to
the optic
chiasm (eye
nerves).

As a brain mass
gets larger, or
a subdural
hematoma (blood
outside the vessels
underneath
Headaches
the dura) it pushes
increasing in Mass, subdural hematoma, medication Neuroimaging, drug
more on
frequency and overuse screen
surrounding
severity
structures causing
pain. Medication
overuse headaches
worsen with more
medication taken
over time.

New onset Meningitis (chronic or People with HIV Neuroimaging,


or cancer are
immunosuppresse
d so are likely to
get infections of
the meninges or
headache in a
carcinomatous), brain infections in the lumbar puncture if
person with
abscess including toxoplasmosis, metastas brain causing neuroimaging is
possible HIV
is abscesses. Cancer negative
or cancer
can metastasize,
or travel through
the blood or
lymph to other
sites in the body.

A stiff neck, or
inability to flex
Headache the neck due to
Neuroimaging,
with signs of pain, indicates
Meningitis, encephalitis (inflammation of lumbar puncture,
total body inflammation of
the brain tissue), Lyme disease, collagen serology (diagnostic
illness (fever, the meninges.
vascular disease blood tests for
stiff neck, Other signs of
infections)
rash) systemic illness
indicates
infection.

Increased
intracranial
brain mass, benign intracranial pressure pushes
Neuroimaging,
Papilledema hypertension (pseudotumor on the eyes (from
lumbar puncture
cerebri), meningitis inside the brain)
and causes
papilledema.

Trauma can cause


Severe bleeding in the Neuroimaging of
Brain bleeds (intracranial
headache brain or shake the brain, skull, and
hemorrhage, subdural hematoma, epidural
following nerves, causing a possibly cervical
hematoma), post-traumatic headache
head trauma post-traumatic spine
headache

Focal neurological
signs indicate
something is
Neuroimaging, blood
Inability to Arteriovenous malformation, collagen pushing against
tests for collagen
move a limb vascular disease, intracranial mass lesion nerves in the brain
vascular diseases
responsible for
one part of the
body
Change in mental
status indicates a
global infection or
Change in
inflammation of
personality, Blood tests, lumbar
Central nervous system the brain, or a
consciousness puncture,
infection, intracranial bleed, mass large bleed
, or mental neuroimaging
compressing the
status
brainstem where
the consciousness
centers lie

Coughing and
exertion increases
the intra cranial
pressure, which
may cause a
vessel to burst,
Headache
causing a
triggered by
subarachnoid
cough,
hemorrhage. A
exertion or Neuroimaging,
Mass lesion, subarachnoid hemorrhage mass lesion
while lumbar puncture
already increases
engaged in
intracranial
sexual
pressure, so an
intercourse
additional
increase in
intracranial
pressure from
coughing etc. will
cause pain.

Old headaches[edit]
Old headaches are usually primary headaches and are not dangerous. They are most often
caused by migraines or tension headaches. Migraines are often unilateral, pulsing headaches
accompanied by nausea and/or vomiting. There may be an aura (visual symptoms, numbness or
tingling) 3060 minutes before the headache, warning the person of a headache. Migraines may
also not have auras.[25] Tension type headaches usually have bilateral "bandlike" pressure on both
sides of the head usually without nausea or vomiting. However, some symptoms from both
headache groups may overlap. It is important to distinguish between the two because the
treatments are different.[25]
The mnemonic 'POUND' helps distinguish between migraines and tension type
headaches. POUND stands for Pulsatile quality, 472 hOurs in length, Unilateral
location, Nausea or vomiting, Disabling intensity.[7] One review article found that if 45 of the
POUND characteristics are present, migraine is 24 times as likely a diagnosis than tension type
headache (likelihood ratio 24). If 3 characteristics of POUND are present, migraine is 3 times
more likely a diagnosis than tension type headache (likelihood ratio 3).[7] If only 2 POUND
characteristics are present, tension type headaches are 60% more likely (likelihood ratio 0.41).
Another study found the following factors independently each increase the chance of migraine
over tension type headache: nausea, photophobia, phonophobia, exacerbation by physical
activity, unilateral, throbbing quality, chocolate as headache trigger, cheese as headache trigger.
[26]
Cluster headaches are relatively rare (13 in 10,000 people) and are more common in men than
women. They present with sudden onset explosive pain around one eye and are accompanied
by autonomic symptoms (tearing, runny nose and red eye). [5]
Temporomandibular jaw pain (chronic pain in the jaw joint), and cervicogenic
headache (headache caused by pain in muscles of the neck) are also possible diagnoses. [22]
For chronic, unexplained headaches, keeping a headache diary can be useful for tracking
symptoms and identifying triggers, such as association with menstrual cycle, exercise and food.
The National Migraine Center has free headache diaries to download at their website. [27] While
mobile electronic diaries for smartphones are becoming increasingly common, a recent review
found most are developed with a lack of evidence base and scientific expertise. [28]
New headaches[edit]
New headaches are more likely to be dangerous secondary headaches. They can, however,
simply be the first presentation of a chronic headache syndrome, like migraine or tension-type
headaches.
One recommended diagnostic approach is as follows.[29] If any urgent red flags are present such
as visual loss, new seizures, new weakness, new confusion, further workup with imaging and
possibly a lumbar puncture should be done (see red flags section for more details). If the
headache is sudden onset (thunderclap headache), a computed tomography test to look for a
brain bleed (subarachnoid hemorrhage) should be done. If the CT scan does not show a bleed, a
lumbar puncture should be done to look for blood in the CSF, as the CT scan can be falsely
negative and subarachnoid hemorrhages can be fatal. If there are signs of infection such as
fever, rash, or stiff neck, a lumbar puncture to look for meningitis should be considered. If there is
jaw claudication and scalp tenderness in an older person, a temporal artery biopsy to look for
temporal arteritis should be performed and immediate treatment should be started.
Neuroimaging[edit]
Old headaches[edit]
The US Headache Consortium has guidelines for neuroimaging of non-acute headaches. [30] Most
old, chronic headaches do not require neuroimaging. If a person has the characteristic symptoms
of a migraine, neuroimaging is not needed as it is very unlikely the person has an intracranial
abnormality.[31] If the person has neurological findings, such as weakness, on exam,
neuroimaging may be considered.
New headaches[edit]
All people who present with red flags indicating a dangerous secondary headache should receive
neuroimaging.[25] The best form of neuroimaging for these headaches is controversial.[6] Non-
contrast computerized tomography (CT) scan is usually the first step in head imaging as it is
readily available in Emergency Departments and hospitals and is cheaper than MRI. Non-
contrast CT is best for identifying an acute head bleed. Magnetic Resonance Imaging (MRI) is
best for brain tumors and problems in the posterior fossa, or back of the brain.[6] MRI is more
sensitive for identifying intracranial problems, however it can pick up brain abnormalities that are
not relevant to the person's headaches.[6]
The American College of Radiology recommends the following imaging tests for different specific
situations:[32]

Clinical Features Recommended neuroimaging test

Headache in immunocompromised
MRI of head with or without contrast
people (cancer, HIV)
Headache in people older than 60
MRI of head with or without contrast
with suspected temporal arteritis

Headache with suspected


CT or MRI without contrast
meningitis

Severe headache in pregnancy CT or MRI without contrast

Severe unilateral headache caused MRI of head with or without contrast, Magnetic Resonance
by possible dissection of carotid Angiography or Computed Tomography Angiography of head and
and/or arterial arteries neck.

CT of head without contrast, Computed Tomography


Sudden onset headache or worst Angiography of head and neck with contrast, Magnetic
headache of life Resonance Angiography of head and neck with and without
contrast, MRI of head without contrast

Lumbar puncture[edit]
A lumbar puncture is a procedure in which cerebral spinal fluid is removed from the spine with a
needle. A lumbar puncture is necessary to look for infection or blood in the spinal fluid. A lumbar
puncture can also evaluate the pressure in the spinal column, which can be useful for people
with idiopathic intracranial hypertension (usually young, obese women who have increased
intracranial pressure), or other causes of increased intracranial pressure. In most cases, a CT
scan should be done first.[5]
Classification[edit]
Headaches are most thoroughly classified by the International Headache Society's International
Classification of Headache Disorders (ICHD), which published the second edition in 2004. [33] The
third edition of the International Headache Classification was published in 2013 in a beta version
ahead of the final version.[34] This classification is accepted by the WHO.[35]
Other classification systems exist. One of the first published attempts was in 1951. [36] The
US National Institutes of Health developed a classification system in 1962.[37]
ICHD-2[edit]
Main article: International Classification of Headache Disorders
The International Classification of Headache Disorders (ICHD) is an in-
depth hierarchical classification of headaches published by the International Headache Society. It
contains explicit (operational) diagnostic criteria for headache disorders. The first version of the
classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in
2004.[38]
The classification uses numeric codes. The top, one-digit diagnostic level includes 14 headache
groups. The first four of these are classified as primary headaches, groups 5-12 as secondary
headaches, cranial neuralgia, central and primary facial pain and other headaches for the last
two groups.[39]
The ICHD-2 classification defines migraines, tension-types headaches, cluster headache and
other trigeminal autonomic headache as the main types of primary headaches.[33]Also, according
to the same classification, stabbing headaches and headaches due to cough, exertion and
sexual activity (sexual headache) are classified as primary headaches. The daily-persistent
headaches along with the hypnic headache and thunderclap headaches are considered primary
headaches as well.
Secondary headaches are classified based on their etiology and not on their symptoms.
[33]
According to the ICHD-2 classification, the main types of secondary headaches include those
that are due to head or neck trauma such as whiplash injury, intracranial hematoma,
post craniotomy or other head or neck injury. Headaches caused by cranial or cervical vascular
disorders such as ischemic stroke and transient ischemic attack, non-traumatic intracranial
hemorrhage, vascular malformations or arteritis are also defined as secondary headaches. This
type of headaches may also be caused by cerebral venous thrombosis or different intracranial
vascular disorders. Other secondary headaches are those due to intracranial disorders that are
not vascular such as low or high pressure of the cerebrospinal fluid pressure, non-infectious
inflammatory disease, intracranial neoplasm, epileptic seizure or other types of disorders or
diseases that are intracranial but that are not associated with the vasculature of the central
nervous system. ICHD-2 classifies headaches that are caused by the ingestion of a certain
substance or by its withdrawal as secondary headaches as well. This type of headache may
result from the overuse of some medications or by exposure to some substances. HIV/AIDS,
intracranial infections and systemic infections may also cause secondary headaches. The ICHD-
2 system of classification includes the headaches associated with homeostasis disorders in the
category of secondary headaches. This means that headaches caused by dialysis, high blood
pressure, hypothyroidism, and cephalalgia and even fasting are considered secondary
headaches. Secondary headaches, according to the same classification system, can also be due
to the injury of any of the facial structures including teeth, jaws, or temporomandibular joint.
Headaches caused by psychiatric disorders such as somatization or psychotic disorders are also
classified as secondary headaches.
The ICHD-2 classification puts cranial neuralgias and other types of neuralgia in a different
category. According to this system, there are 19 types of neuralgias and headaches due to
different central causes of facial pain. Moreover, the ICHD-2 includes a category that contains all
the headaches that cannot be classified.
Although the ICHD-2 is the most complete headache classification there is and it includes
frequency in the diagnostic criteria of some types of headaches (primarily primary headaches), it
does not specifically code frequency or severity which are left at the discretion of the examiner.[33]
NIH[edit]
Main article: NIH classification of headaches
The NIH classification consists of brief definitions of a limited number of headaches. [40]
The NIH system of classification is more succinct and only describes five categories of
headaches. In this case, primary headaches are those that do not show organic or
structural etiology. According to this classification, headaches can only be vascular, myogenic,
cervicogenic, traction and inflammatory.

Management[edit]
An old advertisement for a headache medicine.

See also: Management of chronic headaches


Primary headache syndromes have many different possible treatments. In those with chronic
headaches the long term use of opioids appears to result in greater harm than benefit. [41]
Migraines[edit]
Migraine can be somewhat improved by lifestyle changes, but most people require medicines to
control their symptoms.[5] Medications are either to prevent getting migraines, or to reduce
symptoms once a migraine starts.
Preventive medications are generally recommended when people have more than four attacks of
migraine per month, headaches last longer than 12 hours or the headaches are very disabling. [5]
[42]
Possible therapies include beta blockers, antidepressants, anticonvulsants and NSAIDs. [42] The
type of preventive medicine is usually chosen based on the other symptoms the person has. For
example, if the person also has depression, an antidepressant is a good choice.
Abortive therapies for migraines may be oral, if the migraine is mild to moderate, or may require
stronger medicine given intravenously or intramuscularly. Mild to moderate headaches should
first be treated with NSAIDs, like ibuprofen, and/or acetaminophen. If accompanied by nausea or
vomiting, an antiemitic such as metoclopramide (Reglan) can be given orally or rectally.
Moderate to severe attacks should be treated first with an oral triptan, a medication which mimics
serotonin (an agonist) and causes mild vasoconstriction. If accompanied by nausea and
vomiting, parenteral (through a needle in the skin) triptans and antiemetics can be given.
Several complementary and alternative strategies can help with migraines. The American
Academy of Neurology guidelines for migraine treatment in 2000 stated relaxation training,
electromyographic feedback and cognitive behavioral therapy may be considered for migraine
treatment, along with medications.[43]
Tension-type headaches[edit]
Tension-type headaches can usually be managed with NSAIDs (ibuprofen,
naproxen), acetaminophen or aspirin.[5] Triptans are not helpful in tension-type headaches unless
the person also has migraines. For chronic tension type headaches, amitriptyline is the only
medication proven to help.[5][44][45] Amitriptyline is a medication which treats depression and also
independently treats pain. It works by blocking the reuptake of serotonin and norepinephrine, and
also reduces muscle tenderness by a separate mechanism. [44] Studies evaluating acupuncture for
tension-type headaches have been mixed.[46][47][48][49][50] Overall, they show that acupuncture is
probably not helpful for tension-type headaches.
Cluster headaches[edit]
Abortive therapy for cluster headaches includes subcutaneous sumatriptan (injected under the
skin) and triptan nasal sprays. High flow oxygen therapy also helps with relief. [5]
For people with extended periods of cluster headaches, preventive therapy can be necessary.
Verapamil is recommended as first line treatment. Lithium can also be useful. For people with
shorter bouts, a short course of prednisone (10 days) can be helpful. Ergotamine is useful if
given 12 hours before an attack.[5] See cluster headaches for more detailed information.
Secondary headaches[edit]
Treatment of secondary headaches involves treating the underlying cause. For example, a
person with meningitis will require antibiotics. A person with a brain tumor may require
surgery, chemotherapy and/or brain radiation.
Neuromodulation[edit]
Peripheral neuromodulation has tentative benefits in primary headaches including cluster
headaches and chronic migraine.[51] How it may work is still being looked into.[51]

Epidemiology[edit]
Approximately 6477% of people have a headache at some point in their lives. During each year,
on average, 4653% of people have headaches.[52][53] Most of these headaches are not
dangerous. Only approximately 15% of people who seek emergency treatment for headaches
have a serious underlying cause.[54]
More than 90% of headaches are primary headaches.[55] Most of these primary headaches are
tension headaches.[53] Most people with tension headaches have "episodic" tension headaches
that come and go. Only 3.3% of adults have chronic tension headaches, with headaches for
more than 15 days in a month.[53]
Approximately 1218% of people in the world have migraines. [53] More women than men
experience migraines. In Europe and North America, 59% of men experience migraines, while
1225% of women experience migraines.[52]
Cluster headaches are very rare. They affect only 13 per thousand people in the world. Cluster
headaches affect approximately three times as many men as women. [53]

History[edit]

An 1819 caricature by George Cruikshank depicting a headache.

The first recorded classification system was published by Aretaeus of Cappadocia, a medical
scholar of Greco-Roman antiquity. He made a distinction between three different types of
headache: i) cephalalgia, by which he indicates a shortlasting, mild headache; ii) cephalea,
referring to a chronic type of headache; and iii) heterocrania, a paroxysmal headache on one
side of the head. Another classification system that resembles the modern ones was published
by Thomas Willis, in De Cephalalgia in 1672. In 1787 Christian Baur generally divided
headaches into idiopathic (primary headaches) and symptomatic (secondary ones), and defined
84 categories.[40]

Children[edit]
In general, children suffer from the same types of headaches as adults do, but their symptoms
may be slightly different. The diagnostic approach to headache in children is similar to that of
adults. However, young children may not be able to verbalize pain well. [56] If a young child is
fussy, they may have a headache.[57]
Approximately 1% of Emergency Department visits for children are for headache. [58][59] Most of
these headaches are not dangerous. The most common type of headache seen in pediatric
Emergency Rooms is headache caused by a cold (28.5%). Other headaches diagnosed in the
Emergency Department include post-traumatic headache (20%), headache related to a problem
with a ventriculoperitoneal shunt (a device put into the brain to remove excess CSF and reduce
pressure in the brain) (11.5%) and migraine (8.5%).[59][60] The most common serious headaches
found in children include brain bleeds (subdural hematoma, epidural hematoma), brain
abscesses, meningitis and ventriculoperitoneal shunt malfunction. Only 46.9% of kids with a
headache have a serious cause.[57]
Just as in adults, most headaches are benign, but when head pain is accompanied with other
symptoms such as speech problems, muscle weakness, and loss of vision, a more serious
underlying cause may
exist: hydrocephalus, meningitis, encephalitis, abscess, hemorrhage, tumor, blood clots, or head
trauma. In these cases, the headache evaluation may include CT scan or MRI in order to look for
possible structural disorders of the central nervous system.[61] If a child with a recurrent headache
has a normal physical exam, neuroimaging is not recommended. Guidelines state children with
abnormal neurologic exams, confusion, seizures and recent onset of worst headache of life,
change in headache type or anything suggesting neurologic problems should receive
neuroimaging.[57]
When children complain of headaches, many parents are concerned about a brain tumor.
Generally, headaches caused by brain masses are incapacitating and accompanied by vomiting.
[57]
One study found characteristics associated with brain tumor in children are: headache for
greater than 6 months, headache related to sleep, vomiting, confusion, no visual symptoms, no
family history of migraine and abnormal neurologic exam.[62]
Some measures can help prevent headaches in children. Drinking plenty of water throughout the
day, avoiding caffeine, getting enough and regular sleep, eating balanced meals at the proper
times, and reducing stress and excess of activities may prevent headaches. [63] Treatments for
children are similar to those for adults, however certain medications such as narcotics should not
be given to children.[57]
Children who have headaches will not necessarily have headaches as adults. In one study of
100 children with headache, eight years later 44% of those with tension headache and 28% of
those with migraines were headache free.[64] In another study of people with chronic daily
headache, 75% did not have chronic daily headaches two years later, and 88% did not have
chronic daily headaches eight years later.[65]

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