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What Type of Headache do I have ?. David M. Biondi, DO Director, Headache Management Programs Spaulding Rehabilitation Hospital Consultant, Massachusetts General Hospital Instructor in Neurology, Harvard Medical School Boston, MA. Headache in the Population.

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what type of headache do i have

What Type of Headache do I have?

David M. Biondi, DO

Director, Headache Management Programs

Spaulding Rehabilitation Hospital

Consultant, Massachusetts General Hospital

Instructor in Neurology, Harvard Medical School

Boston, MA

headache in the population
Headache in the Population
  • 99% of women and 93% of men have had headache during their lifetime
  • 25% of women and 8% of men in the United States have had migraine headache
  • 18% of women and 6% of men have had migraine over the previous year
  • Prevalence is highest between age 25 – 55 years
  • An estimated 30 million have migraine and up to 10 million have chronic daily headache (> 15 headache days per month) in the U.S.
headache history
Headache History
  • Headache attacks
    • How it begins
      • Precipitating event, illness, injury
  • Headache attack descriptions
    • Frequency and patterns
      • Any significant changes
    • Location
    • Time to peak intensity
    • Duration
    • Quality and intensity
    • Warning symptoms and aura
    • Associated symptoms and level of disability
    • Triggers and aggravating or relieving factors
tension type headache or migraine
Tension-type Headache or Migraine?

Migraine is 6.3x more common than TTH

TTH is 1.5x more common than migraine

TTH is 3.3x more common than migraine

Percent(%)

* People who want to talk to the doctor about their headaches or who

have headaches that interfere with daily activities.

Lipton RB et al. Neurology. 2003;61:375-385.

episodic tension type headache
Episodic Tension-type Headache
  • A. Number of days with such headache < 180/year (<15/month)
  • B. Headache lasting from 30 minutes to 7 days
  • C. At least 2 of the following:
          • Pressing/tightening (non-pulsating) quality
          •  Mild or moderate intensity (may
          • inhibit, but does not prohibit activities)
          • Bilateral location
          • No aggravation by walking stairs
          • or similar routine physical activity
  •         D. Both of the following:
          • No nausea or vomiting (anorexia may occur)
          • Photophobia and phonophobia are absent, or one but not
          • the other is present
  •         E. At least 10 previous headache episodes fulfilling these criteria
  • F. No evidence of organic disease
migraine without aura
Migraine Without Aura
  • Headache lasting from 4 to 72 hours
  • At least 2 of the following
      • Unilateral location
      • Pulsating quality
      • Moderate or severe intensity
      • Aggravation by routine physical activity
  • At least 1 of the following:
      • Nausea and/or vomiting
      • Photophobia and phonophobia
  • At least five attacks fulfilling these criteria
  • No evidence of organic disease
tension type headache or migraine9
Tension-type Headache or Migraine

Mild

Moderate

Severe

Aura

Unilateral

Vomiting

Bilateral

Aggravated

by Activity

Photophobia

Nausea

Throbbing

Pressure

Tension-Type

Migraine

© 2002 Primary Care Network

migraine aura
Migraine Aura
  • Positive Neurological Symptoms
    • Reversible brain/neurological symptoms
      • Visual flashes, spots, or zig-zag lines
      • Traveling tingling sensations
    • Gradual development over >4 minutes
    • Resolves within 1 hour
  • Negative Neurological Symptoms
    • Reversible brain/neurological symptoms
      • Visual blind spots
      • Numbness
      • Speech or word finding problems
      • Trouble thinking
    • Resolves within 1 hour
even my hair hurts allodynia
Cutaneous allodynia

“Hair hurts”

Painful when:

Shaving

Combing hair

Touching scalp

Resting head on pillow

Pulling hair back (wearing a ponytail)

Wearing eyeglasses or contact lenses

Wearing hat or head band

Other painful events

Water hitting head or face while showering

Breathing through nose especially cold air

Cooking over a hot stove

Rubbing the neck or shoulders

Hanging head down or bending over

“Even My Hair Hurts”(allodynia)
neck pain during migraine
Neck Pain During Migraine
  • Prevalence
    • 75% of subjects
  • Descriptions
    • 69% - tightness
    • 17% - stiffness
    • 5% - throbbing
    • 5% - other

82% had previously been given a diagnosis of tension-type headache

Kaniecki R. Neurology. 2002;58(Suppl 6):S15-S20.

migraine pain intensity and disability
Migraine Pain Intensity and Disability

9% Function Normally

>75% Report Severe to Extremely Severe Pain

53%

Severe Impairment or Bed Rest Required

39%

Some Impairment

Patients (%)

Lipton RB et al. Headache. 2001;41:638-645.

slide14

Dilemmas in Diagnosing Migraine

  • Visual aura
    • only 15-20% of migraineurs
  • Head pain can be non-throbbing
    • in ~40% of patients
  • Head pain can be bilateral
    • in ~ 43% of patients1
  • Sinus pain and pressure, stuffiness, rhinorrhea & weather association is often present
    • in up to 97% of migraine attacks2
  • Neck pain is often present
    • in up to 75% of migraine attacks3

1. Data on File. GlaxoSmithKline.

2. Cady RK, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.

3. Kaniecki RG, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.

slide16

Myth

Headaches that are triggered by weather or are associated with sinus symptoms are not migraines.

Fact

  • Up to 50% of migraine patients report their headaches are influenced by weather1
  • 45% of migraine patients report sinus symptoms including2

– Lacrimation

– Nasal congestion

– Rhinorrhea

1. Raskin NH. Headache. 2nd ed. New York: Churchill Livingstone; 1998.

2. Barbanti P et al. Cephalalgia. 2001;21:295.

headache a minor criteria in aao hns sinusitis
Major factors

Purulence in nasal cavity on exam

Facial pain/pressure/congestion*

Nasal obstruction/blockage/ discharge

Fever (in acute only)

Hyposmia/anosmia

Minor factors

Fever (chronic)

Halitosis

Headache

Fatigue

Dental pain

Cough

Ear pain/pressure/fullness

Headache: A Minor Criteria in AAO-HNS Sinusitis

Headache is a minor factor in the diagnosis of rhinosinusitis, according to AAO-HNS*

* Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign.

* American Academy of Otolaryngology-Head and Neck Surgery Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7.

are common in the presentation of migraine

97%

Moderate/Severe Pain

89%

Pulsatile

85%

Worsened by Activity

84%

Sinus Pressure

82%

Sinus Pain

79%

Photophobia

67%

Phonophobia

63%

Nasal Congestion

40%

Runny Nose

IHS Migraine Symptoms

38%

Watery Eyes

29%

Aura

27%

Itchy Nose

25%

Vomiting

“Sinus Symptoms”

Are Common in the Presentation of Migraine

“Sinus” Symptoms

N = 2424

0%

20%

40%

60%

80%

100%

Schreiber C. Poster presented at: American Headache Society Meeting; June 21-23, 2002;Seattle, WA.

sinus headache in primary care
“Sinus” Headache in Primary Care

Migraine w/o or with Aura

IHS 1.1, 1.2

Migrainous

IHS 1.7

n=2520

Other

Source: SUMMIT Study

summary
Summary
  • Tension-type headaches are very common in the general population
  • Migraine headaches are also common but are more common than tension-type headaches in medical clinics because of greater severity and disability
  • True “sinus headaches” are uncommon
  • Sinus symptoms and neck pain are very common symptoms of migraine
  • Most cases of recurrent “sinus headaches” are migraine especially if there is a family history of recurrent or chronic headaches