Primary headache

Mohamad dawoud
6th course
Kharkiv national medical university.
• Primary headaches are group of headache
that are not caused by any other cause as
infection, trauma, subarachnoid hemorrhage.
• The most common forms of primary
headaches:
 Migraine
 Cluster headache
 Tension-type headache.
 migraine
• Migraine is a primary headache characterized
by recurrent episodes of unilateral,
localized pain that are frequently
accompanied by nausea, vomiting, and
sensitivity to light and sound.
• In 25% a patient experience an Aura
preceding the episode ( focal neurologic
deficits..)
• The exact etiology of migraine is not well
known , genetics may predipose the patient
for having migraine, as well some factors can
trigger migraine attack ( alcohol, citrus,
nicotine, poor sleep..).
• migraine attack mostly occurs through 4
stages:
• PRODROMAL ( 24_ 48h before the headache,
yawning , sleep disorder…)
• AURA ( paroxysmal, focal neurologic deficits
preceding the headache can be typical as
visual scotomas, parasthesia, aphasia. Or
atypical as paresis and diziness…)
• HEADACHE ( unilateral usually, throbbing ,
pulsating headache especially in the frontal,
frontotemporal, duration usually 4-24 h,
accompanying symptoms as photophobia and
phonophobia).
• POSTDROME( feeling of exhaustion or
euphoria, muscle weakness..).
• Migraine is a clinical diagnosis based on
patient’s history and physical examination.
• Imaging are not routinely indicated, unless red
flags are present .MRI is the prefered image.
• Treatment of migraine:
 Limit stimuli ( light , noise..)
 Treat nausea, vomit ( anti-emetics as
metaclopromide..),
 IN MILD TO MODERATE HEADACHE treat with
NSAIDs .
 IN MODERATE TO SEVERE HEADACHE start with a
migraine specific agent as triptans and ergotamines.
 General prophylaxis with patient having frequent
attacks >3 months , or hemiplegic migraine regardless
of frequency( anti-convulsants,beta-
blockers,NSAIDs…)
 Tension-type headache
• tension-type headache (TTH) is a primary
headache disorder and the most common
type of headache overall. Tension-
type headaches are characterized by a dull,
nonpulsating, band-like pain that is often
bilateral.
• Not accompanied by photophobia and
phonophobia and classified to either acute or
chronic.
• Etiology is not well known but some factors
may trigger TTH as poor sleep,
alcohol,fatigue,mood disturbances..
• TTH is episodic in nature lasting from 30min
to couple of days, band like headache,
bifrontal usually , dull , pressing, non-pulsatile
, photophobia and phonophobia are not
usually present and palpation of muscles of
head may reveal pericranial tenderness.
• Tension-type headache is primarily a clinical diagnosis
 based on a history of typical features and
normal neurological examination. Severe underlying
conditions should be ruled out.
• Can be divided into:
 inFrequent episodic type headache( >10 episodes, <1
day/month, duration 30 min to 7 days).
 Frequent episodic type headache(>10 episodes on
14days/m)
 Chronic TTH (>15d/m,may last hours to days and may be
continous).
• Both pharmacologic and nonpharmacologic strategies can be used for
the treatment of tension-type headache. In addition, any underlying
conditions (e.g., depression) should be identified and treated.
• Pharmacological therapy
– Episodic tension-type headache: NSAIDs
(e.g., ibuprofen, aspirin) or acetaminophen
– Chronic tension-type headache and frequent episodic type: consider
prophylactic therapy (e.g., with amitriptyline).
• Non-pharmacological therapy: Consider if there is a significant decrease
in patient's quality of life.
– Lifestyle and behavioral modification (e.g., exercise, weight reduction)
– Psychobehavioral treatments (e.g., cognitive-behavioral therapy, relaxation
training)
 Cluster headache
• Cluster headach is a type of primary headache,
patient with cluster headache suffer from pain in
the periorbital area and area supplied by the
trigeminal nerve, conjunctival injection.
• Tends to occur in episodic patterns followed by
months of remission.
• Etiology of cluster headache is not clearly
understood, risk factor is tobacco use and triggered
by alcohol, histamine and seasonal fluctuation.
• Headache characteristics
– Agonizing pain
– Strictly unilateral, periorbital, and/or temporal
– Short, recurring attacks 
–  that usually occur in a cyclical pattern (“clusters”) 
• May become chronic (less common), with interruptions of less than one month
between cluster bouts
• Attacks often wake patients up during sleep.
• Ipsilateral autonomic symptoms
– Conjunctival injections and/or lacrimation
– Rhinorrhea and nasal congestion
– Partial Horner syndrome: ptosis and miosis, but no anhidrosis
• Restlessness and agitation
• Diagnosis is based on patient history and
physical examination; after ruling out any
serious diseases that may present with same
features as cluster headache.
• Acute
– Oxygen therapy with FiO2 100%
– First-line: triptans (e.g., sumatriptan) or zolmitriptan 
– Pain relievers (i.e. NSAIDs) are generally not recommended because their onset
of action is too slow.
• Prevention 
– First-line treatment: verapamil
• Steroids (e.g., prednisone) are very effective at ending a cluster cycle and may be used to
bridge the time until verapamil becomes effective.
– Second-line treatment: lithium, topiramate, ergot derivatives
• Interventional therapy
• Interventional procedures (e.g., ablative injections, deep brain
stimulation) may be considered in patients with cluster headache who
do not respond to medical therapy.