Common Headache

Related Terms

 Classical Migraine Headache

 Common Migraine Headache
 Migraine Headache with Aura
 Migraine Headache without Aura

Differential Diagnoses
 Brain aneurysm
 Brain tumor
 Cluster headache
 Meningitis
 Opiate dependence
 Sinusitis
 Stroke
 Subarachnoid hemorrhage
 Temporal arteritis
 Tension headache
 Vascular pathology (e.g., cerebral aneurysm)

Specialists
 Family Physician
 Internal Medicine Physician
 Neurologist

Comorbid Conditions
 Cardiovascular disease
 Endocrine disorders
 Neurological conditions (e.g., epilepsy)
 Psychiatric disorders

Factors Influencing Duration

Length of disability depends on the severity, frequency, and duration of migraine
headaches, along with the individual's response to treatment.

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Definition
Migraine is a type of headache characterized by narrowing (constriction) of vessels in the
brain, followed by painful dilation and inflammation of the same blood vessels. It is
described as a "sick headache," not only because there may be nausea and vomiting, but
also because the individual typically feels completely disabled throughout the duration of
the headache.

The pain is moderate to severe, throbbing or pulsating, and usually localized to one side
of the head. Migraines can last from hours to days, and may also be associated with
sensitivity to light and sound. The headaches can be preceded by an aura or warning
symptoms related to the blood vessel narrowing and may include visual disturbances,
limb numbness, tingling, or hyperactivity. Migraine with aura is a classification that
represents 20% of migraine headaches. A designation of migraine without aura,
representing about 80% of all migraines, has replaced the former classification of
common migraine (Blanda).

In the mid-twentieth century, migraine was believed to be only vascular in origin, but the
pathophysiology is explained today as a complex interaction of neural and vascular
events (neurovascular theory) (Sahai-Srivastava). A state of hyperexcitability of neurons
in the cerebral cortex of the brain has been demonstrated through MRI studies of the
aura that precedes migraine. In migraine with aura, the trigger is a wave of neuron
excitation in the gray matter of the cortex (cortical gray matter), followed by a wave of
neuron suppression. Blood vessels in the cortex constrict and dilate corresponding to
these waves. This pre-migraine process is referred to clinically as cortical spreading
depression. The reason this process occurs in some individuals is not fully understood.

Coexisting medical conditions such as seizures, sleep disorders, high blood pressure
(hypertension), and depression may be associated with migraine. Migraines may also be
triggered or made worse by certain foods (chocolate, aged cheeses, peanuts, red wine,
food additives [monosodium glutamate (MSG), nitrates]), alcohol, insufficient sleep,
stress, and hormonal changes associated with the menstrual cycle.

Risk: About 70% of patients have a first-degree family member with a history of
migraine. Among adults, women are at greater risk than men, with a female-to-male
ratio of 3:1 (Blanda). Before puberty, migraines occur more often in males (Blanda). The
age of onset varies but most commonly occurs by age 30; migraines are rare in
individuals older than 50 (Blanda).

Incidence and Prevalence: In the United States, headache affects 60% to 80% of all
individuals; an estimated 10% to 20% of the population suffers from migraine
headaches. Frequency of headaches varies greatly by individual. About 6% of men and
15% to 17% of women in the United States have migraine, making it the second most

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common type of headache syndrome in the United States; the most common are tension
headaches (Blanda).

In the United States, white women have the highest incidence of migraine, and Asian
women have the lowest incidence (Sahai-Srivastava).

Diagnosis
History: Individuals may report symptoms associated with the headache, such as
nausea, vomiting, pale skin, dizziness, or sensitivity to light (photophobia) and sound
(sonophobia). The individual should be questioned about duration, location, pulsating
quality, intensity, presence of aura, and frequency of headaches. Visual disturbances
account for most symptoms that may be associated with the aura, including bright spots
resembling stars, sparks, geometric patterns, or lightning bolts (fortification spectra).
When the bright spots disappear, blind spots (scotoma) or decreased vision may follow.
Other symptoms associated with the aura may include numbness, especially of the hand
and lower face. Weakness, clumsiness, or speech disturbances are less common. The
aura usually lasts about 30 minutes, followed by a brief period of normalcy before the
headache begins.

Some individuals may report behavioral changes before or after attacks, that include
depression, anxiety, irritability, excitability, or a change in sexual appetite. Identifying
possible triggers may help distinguish migraine from headache caused by other disorders
such as a brain tumor. Investigating family history and obtaining details of previous
headaches may be essential to the diagnosis.

Physical exam: The exam may reveal no specific findings, or may reveal abnormalities
such as recent head or neck trauma and muscle spasms that can help establish diagnosis
and aid in selecting treatment. The presence of systemic symptoms such as myalgia,
fever, weight loss, scalp tenderness, or jaw pain while eating may indicate a more
serious cause of headache. Neurological examination includes evaluation of brain and
nerve function, sensory discrimination, reflexes, strength, coordination, and cognitive
abilities. Eye examination may reveal neurologic disease, diabetes, high blood pressure
(hypertension), and other coexisting medical conditions. Confusion, seizures, impaired
consciousness, balance problems, weakness, or paralysis that may occur temporarily
during the headache suggest a migraine variant (e.g., vertebrobasilar migraine, status
migrainosus, ophthalmoplegic migraine) (Sahai-Srivastava).

Tests: Tests are performed to rule out other possible causes of headache, such as a
brain tumor or cerebral aneurysm. Imaging studies (CT or MRI) may reveal brain
abnormalities that can mimic migraine. Neuro-imaging is only warranted if the neurologic
examination reveals abnormalities. If the individual's history suggests seizures, a test of
the brain's electrical activity (electroencephalogram, or EEG) may help diagnose epilepsy
that may coexist with migraine. These cases are rare, and therefore the tests are not
routinely done unless warranted by history and physical examination findings. Spinal fluid
may be sampled (lumbar puncture, or LP) to test for infection or hemorrhage. Laboratory

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tests may also be done if an underlying organic condition is suspected.

Treatment
Treatment is aimed at reducing the severity, frequency, and duration of attacks. During a
sudden (acute) episode, it may help the individual to rest in a quiet, darkened room. The
main classes of drugs available to treat acute migraine are agents that narrow blood
vessels (triptans, ergotamines), and non-steroidal anti-inflammatory drugs (NSAIDs)
such as naproxen sodium, ibuprofen, ketoprofen, or ketorolac. Pain killers (analgesics)
such as acetaminophen or aspirin can relieve mild to moderate migraine. Combination
painkillers that contain codeine or caffeine may be helpful.

Once the headache is underway, treatment usually requires a drug that narrows the
opening of blood vessels (vasoconstrictor) to stop the attack. These medications (e.g.,
ergot alkaloid) are most helpful if given during the aura. With the availability of new
types of vasoconstrictor taken by mouth or injection (triptans), pain relief may begin
within a few minutes. If nausea and vomiting occur, medication may have to be
administered under the tongue, by injection, or rectally. Migraine attacks that are severe,
prolonged, or unresponsive to self-administered medications may have to be treated in
the doctor's office or emergency room.

Prevention of migraine is an important part of treatment. Avoiding precipitating factors

may decrease the frequency of acute episodes. If episodes occur more than 2 or 3 times
a month, a variety of drugs can be taken for prevention, including agents that lower
blood pressure (beta-blockers, calcium antagonists), anticonvulsants, tricyclic
antidepressants, an agent that narrows openings of blood vessels and prevents
inflammatory responses (methysergide), and agents that inhibit release of certain
chemicals in the brain (selective serotonin reuptake inhibitors, or SSRIs). The individual
may have to try several different drugs, one at a time, before the headaches are brought
under control. Naproxen sodium has also been used for short-term prevention of
migraine, especially menstrual migraine. Drug combinations may be used for individuals
who do not respond to a single therapy. Beta-blockers and antidepressants may be used
together. Once an effective drug or combination is found, it should be continued for at
least 6 months and then tapered off after the disappearance of headaches. Medication
for acute episodes may be occasionally used with preventive medication if breakthrough
headaches occur (e.g., menstrual migraine).

Prognosis
Occasionally, migraine headaches may spontaneously disappear, especially as individuals

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reach middle age. Self-care is very important, and the migraine sufferer can increase the
chance of successful outcome by taking medications as directed by the doctor and
modifying lifestyle factors such as diet, exercise, avoidance of migraine triggers, stress
management, and proper rest. Any changes in headache frequency or severity should be
communicated to the doctor, and treatment should be adjusted to improve the outcome.

Complications
Migraine sufferers are more prone to develop tension-type headaches that result in
mixed headache syndrome. Excessive use of painkillers may cause rebound headaches
when the drug's effects wear off, and episodic headaches may be transformed into
chronic daily headaches. Acetaminophen alone or with codeine can increase toxicity in
individuals who also take antidepressants; regular alcohol consumption combined with
acetaminophen usage may result in liver toxicity (hepatotoxicity) (Blanda). Coexisting
medical conditions may complicate the disorder by limiting treatment options. Many
medications used to treat headaches affect the cardiovascular system. The relative risk
of thrombotic stroke may be higher in women with migraine. Stroke risk in migraine
sufferers is further increased by smoking or by the use of birth control pills. Migraine
may also be associated with epilepsy or depression. Many individuals (up to 50%)
discontinue their treatment regimen because they have not been satisfied with the
results; this can exacerbate the headaches and increase frequency (Blanda).

Return to Work (Restrictions / Accommodations)

Often the migraine sufferer may be unable to work or perform job responsibilities during
a migraine headache episode. Heavy physical activity may also be limited. Providing a
dark, quiet room where the individual can rest until the attack passes may be helpful.

Failure to Recover
If an individual fails to recover within the expected maximum duration period, the
reader may wish to consider the following questions to better understand the specifics
of an individual's medical case.

Regarding diagnosis:

 Has diagnosis of migraine been confirmed? Is it classified as with or without

aura?
 Have other conditions with similar symptoms been ruled out?
 Has individual experienced complications related to migraine headaches, such as
mixed headache syndrome, rebound headaches from excessive use of
painkillers, chronic daily headaches, or thrombotic stroke?

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  Does individual have a coexisting condition that may limit treatment options or
affect recovery?

Regarding treatment:

 Does individual require medical intervention for most episodes of migraine

headaches?
 Is a change in medication or combination therapy warranted?
 Would individual benefit from self-administered medication?
 Have headache triggers (certain foods, alcohol, insufficient sleep, stress,
hormonal changes associated with the menstrual cycle) been identified and
eliminated, if possible?
 Is individual on prevention therapy?
 Would a combination-drug prevention therapy be more effective?

Regarding prognosis:

 Is individual compliant with prescribed treatment plan?

 Does individual self-administer medication during the aura phase whenever
possible?
 Has individual modified lifestyle factors that may trigger migraine episodes?
 Does individual communicate changes in headache frequency or severity to the
doctor so that treatment adjustments can be made?

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