18A. Migraine and other primary headaches

Migraine

Definition and epidemiology

Migraine is an episodic primary headache disorder with disabling attacks lasting 4-72 hours with moderate or severe headache, usually accompanied by nausea, vomiting and/or photophobia and phonophobia, and sometimes preceded by a short-lasting aura of unilateral fully-reversible visual, sensory or other central nervous system symptoms.

It affects 12% of the population and affects women more often than men.

Pathomechanism

Cortical spreading depression, a wave of electrophysiological hyperactivity across the brain followed by inhibition is implicated in migraine.

Trigeminovascular system, a system of trigeminal sensory neurons that innervate large cerebral vessels, vessels of the meninges, large venous sinuses, and the dura mater, is also involved. Cortical spreading depression may activate meningeal nociceptors in the trigeminovascular system, leading to pain and sensitisation of these neurons.

Clinical features

Migraine can occur with or without aura. Some people have chronic migraine with daily mild-moderate headaches with exacerbations with migranious features.

Aura refers to sudden onset reversible neurological symptoms. In migraine, the auras are usually visual and cause vision loss or bright spots. The aura can occur with or before the headache.

The headache itself is usually unilateral, throbbing or pulsatile, and accompanied by nausea, photophobia, and phonophobia. It can last for hours.

Patients sometimes have prodromal symptoms in the days before the attack, symptoms like depression and irritability.

Migraine attacks can be triggered by factors like stress, menstruation, nitrates, fasting, wine, sleep disturbances, smoking, certain foods, etc.

Treatment

Acute episodes of migraine are treated with triptans and other analgesics.

Many drugs can be used for migraine prophylaxis, including tricyclic antidepressants, antiepileptics, antihypertensives, and anti-CGRP antibodies.

Cluster headache

Definition and epidemiology

Cluster headache is a type of trigeminal-autonomic cephalgia. It’s sometimes called “the worst pain a human can experience”. 80% of patients are smokers.

Clinical features

The patients have very severe headache usually lasting from 15 minutes – 3 hours. They can occur multiple times a day. Patients often have ipsilateral autonomic symptoms like rhinorrhoea, ptosis, or miosis.

Patients may sometimes go months or years without attacks.

Treatment

Acute episodes of cluster headache are treated with triptans and other analgesics, as well as 100% oxygen inhalation.

Many drugs can be used for cluster headache prophylaxis, including verapamil, lithium, and steroids.

Tension headache

Definition and epidemiology

Tension headache is the most common type of primary headache. It may be due to tenderness of the neck muscles.

Clinical features

Tension headache is dull, non-pulsating, and bilateral. There is no aura or autonomic symptoms.

Treatment

Acute episodes of tension headache are treated with NSAIDs. Tricyclic antidepressants and antiepileptics can be used for prophylaxis.


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