The New England Center of Headache
NECH is conveniently located in Stamford, CT and is easily reached via the Merritt Parkway, Route 684, and I-95, as well as by train, airplane, and bus. For further information or to make an appointment
Migraine - Cluster - Tension-Type - Causes
Headache is ubiquitous in the United States with over 90% of adults having had at least some degree of headache within the last year. Migraine occurs in approximately 17.6% of females and 5.7% of males for a total of 13% of the population. This translates to 8.7 million females and 2.6 million males who are occasionally moderately to severely disabled by their migraine headaches.
Migraine frequently goes undiagnosed by a physician. Only 29% of males and 41% of females are properly diagnosed. Migraineurs most likely to go undiagnosed are:
- People living in low income households.
- People who do not experience aura, vomiting, or disability.
Headache has a big impact on society being the primary complaint in over 10 million consulting patients. The annual cost of lost labor is approximately 17 billion dollars. Forty percent of Americans experience significant headaches.
A new headache classification was introduced by the International Headache Society in 1988 and published in the international journal Cephalalgia that year. It breaks headache disorders into 13 categories headed up by migraine, tension-type headache, and cluster headache. It differentiates these headaches from secondary or organic headaches. To diagnose migraine without aura one must have had at least five attacks lasting between 4 and 72 hours. At least two of the following four characteristics must be present:
- Unilateral location (one side of the head)
- Pulsating quality of the pain (to the beat of your heart)
- Moderate or severe intensity
- Aggravated by mild activity (such as bending over or walking up stairs)
At least one of the following must be present:
- Nausea or vomiting or both
- Photophobia and phonophobia (both sensitivity to light and sound)
Migraine with aura (classical) begins with visual changes such as colored, zig-zag lines, blinking and moving across the visual field for 20-30 minutes, followed by a unilateral headache.
There are five phases of migraine including the prodrome, the aura, the headache, the headache termination, and the postdrome.
Migraine occurs slightly more in boys under the age of 10 than girls and occurs three times more frequently in adult woman than men. It is inherited with 90% of migraineurs having a strongly positive family history. The frequency of migraine is usually 1 to 4 times per month. The duration is 4 to 72 hours. The onset is gradual, building over 30-60 minutes. The pain quality may start as a deep, dull, steady pain but often becomes throbbing, moderately severe, or severe and pulsatile. It is unilateral 60% of the time and in the frontotemporal or orbital area, sometimes involving the neck. It is associated with many symptoms such as nausea, vomiting, diarrhea, anorexia, photophobia, sonophobia, and cold extremities. Migraine has many triggering factors such as stress and worry, menses, oral contraceptives, lack of sleep, change in the sleep/wake cycle, weather, altitude, certain drugs, sun and flickering lights. Allergies are not usually a triggering factor.
Migraine in woman occurs 60% of the time during menses and 5 to 10% of the time exclusively during menses. Migraine seems to be precipitated by falling levels of beta estradiol and can be treated by replacement of estrogen using the estrogen patch, or by combating prostaglandin by giving NSAIDs prior to menses.
The pathogenesis of headache has been narrowed down to the central theory, the vascular theory, and the neurogenic inflammation theory. The central theory suggests that it may be due to an unstable serotonergic neurotransmission related to cells in the midbrain dorsal raphe. Migraine is thought to begin as an electrical phenomenon in the cerebrum which then affects blood vessels, biochemistry, and causes neurogenic inflammation. Low levels of extracellular magnesium have been found. The old vascular theory of Wolff may still be operative. However, no definite relationship has ever been shown between cerebral blood flow, and migraine pain. Migraine headache seems to be associated with dilated meningeal arteries and is effectively treated by constricting those arteries. Dr. Michael Moskowitz believes that preventing neurogenic inflammation in the meninges at the periphery of the trigeminovascular system which, by decreasing the release of neuropeptides and reducing stimulation of afferent nerve fibers, can prevent headache pain.
Serotonin (5-HT) is thought to play a critical role in migraine physiology. Serotonin is distributed throughout the brain. It is found mostly in the brain stem. Serotonin receptors of the 5-HT1 family are important in acute migraine treatment.
It is important to understand that migraine and tension-type headache may be on opposite ends of a spectrum and may coexist as a mixed headache syndrome. Many patients have occasional severe migraine type headaches in their teens and 20's and develop more frequent milder headaches in addition to migraine in their 30's and 40's, which is the mixed headache syndrome. This is also known as transformed migraine.
The concept of analgesic rebound headache must be recognized to treat patients effectively. It is defined as the worsening of head pain in chronic headache sufferers due to the frequent and excessive use of off-the-shelf analgesics, barbiturates, or opiates. Treatment always begins by withdrawing patients from excessive use of analgesics or ergotamine.
It is important to understand the pharmacology of anti-migraine drugs. To stop an acute migraine one must stimulate activity at the 5-HT1D and 1B receptors. The 1F receptors may also be important. To prevent migraine from occurring one must take daily medication which antagonizes activity or down regulates 5-HT2 receptors.
For the symptomatic treatment of migraine, one can start with simple analgesics such as aspirin, acetaminophen, and ibuprofen or combinations such as Excedrin. Next, one may move up the ladder by using a medication which contains butalbital (Fiorinal) or isometheptene mucate (Midrin). Nonsteroidal anti-inflammatory medications can be tried. Ergotamine tartrate by mouth or rectal suppository may be very effective. This medication should be preceded by antinausea medication such as promethazine (Phenergan) or metoclopramide (Reglan).
Dihydroergotamine (D.H.E. 45) can be used intramuscularly, subcutaneously, or intravenously to abort a headache. It is soon to be available as Migranal which is a nasal spray. The intravenous form is frequently used in the hospital situation. Steroids can sometimes be used as can the only injectable NSAID ketorolac (Toradol) intramuscularly. Opiates should be used cautiously and sparingly. Butorphanol nasal spray (Stadol NS) can be very helpful in recurrent headache, when migraine specific medication are either contraindicated or have not been helpful. Stadol is used therefore as a rescue medication and not as a primary migraine medication. Its advantage is that it works quickly to relieve pain and usually helps patients to sleep. As a kappa receptor agonist (as opposed to a mu receptor agonist) it is somewhat less likely to cause dependency, however as a class IV opioid, it can cause dependency and should be used cautiously.
Sumatriptan (Imitrex) injection was released in this country in April, 1993 and has been effective in over 75% of patients within one hour and in over 80% of patients within two hours. Headaches may recur in 30 to 40% of patients. A great majority of patients rate the drug as the best abortive drug they have ever used in migraine. Side effects such as tingling, flushing, heaviness, pressure, and burning may occur, but last only 30 minutes. This drug should not be given to patients with coronary artery disease or any significant risk factors for coronary artery disease or uncontrolled hypertension.
In 1995 the 25 and 50 mg tablets were released in the United States. Most patients do better starting with the 50 mg tablet. A maximum of 300 mg orally can be used per day. It works in 50-60% of patients by 2 hours but can take 1-2 hours to work.
In the fall of 1997 the 5 and 20 mg nasal sprays were released in the United States. The usual dose is a 20 mg spray in one nostril stat which may be repeated one time in 24 hours waiting at least 2 hours after the first dose. The nasal spray works quicker than the tablet, beginning to work in 15 minutes in some patients. It is effective in approximately 63% of patients and there are very few side effects other than a bad taste.
Zomig (zolmitriptan) is recently available as a 2.5 and 5 mg tablet. It has the same precautions and side effects as Imitrex but in some patients it may work slightly faster, more completely and with fewer side effects. Some patients who have not responded to Imitrex do very well on Zomig.
Amerge (naratriptan) is available at a 2.5 mg dose and has a longer time to onset of relief but fewer side effects.
Maxalt (rizatriptan) should be available by mid 1998 as a 5 and 10 mg tablet and a rapid dissolving disc. It may have a more rapid onset of activity and a higher efficacy rate.
Other triptans expected in the future are eletriptan, frovatriptan and IS-159.
Preventive treatment of migraine include aspirin, beta blockers, calcium channel blockers, tricyclic antidepressants, and the newer serotonin reuptake inhibitors, MAO inhibitors, serotonin type2 antagonists such as methysergide (Sansert) and cyproheptadine (Periactin). Clonidine (Catapres) and anticonvulsants may be tried. Divalproex sodium (Depakote) is helpful in migraine and has been approved by the FDA. Gabapentin (Neurontin) may be helpful.
The nonpharmacologic treatment of migraine is important and should always be tried first. Patients and their family must be educated regarding treatment approaches and goals and taught how to eliminate certain triggering factors. Stress management and relaxation exercises such as biofeedback are often helpful. Chronobiological therapy which attempts to promote regular sleep and eating habits can be useful.
When outpatient therapy fails, inpatient therapy with intravenous D.H.E. 45 and a multidisciplinary approach can be effective in over 70% of complex headache patients. Emergency room therapy usually includes either the use of subcutaneous dihydroergotamine or sumatriptan, IM ketorolac or IV prochlorperazine.
Future therapies for acute episodes of migraine include other triptans and agents which do not constrict blood vessels but work via other mechanisms such as inhibiting neurogenic inflammation or preventing vasodilation. These include 5-HT1F agonists, neurosteroids and nitric oxide synthase (NOS) inhibitors.
We know a lot more about the causes of headache today then we did just 10 years ago and our treatment modalities are considerably more effective than they used to be.
Cluster headache occurs in middle-aged men and is a daily severe, unilateral, orbital, supraorbital, or periorbital steady pain lasting 15 to 180 minutes. The pain is so intense it is often described as though a hot poker is being thrust into the eye and twirled. The pain is associated with at least one of the following autonomic signs on the ipsilateral side:
- Conjunctival injection
- Facial sweating
- Nasal congestion
- Eye lid edema
Cluster periods occur for 4 to 6 weeks out of the year and usually disappear for 6 to 12 months. Patients have 1-3 attacks per day, often awakening them at night.
Tension-type headache is a dull, pressing, pain that can occur in any part of the head but is usually bilateral. It waxes and wanes throughout the day and may occur on a daily basis (chronic tension-type headache). It is usually not associated with aura, throbbing, nausea or vomiting.
Causes of Headache:
- chronic fatigue
- emotional stress
- hormonal fluctuations
- weather/seasonal changes
- travel through time zones
- skipping/delaying meals
- sensory stimuli
- certain foods