Primary Headache

Primary Headache :

On the basis of underlying cause, haeadches are divided into two categories- Primary and Secondary.Primary Headaches are characterized by absence of any demonstrable pathology on laboratory investigations. Fortunately, these are the most common type of headaches. These are further divided into multiple sub-types depending upon the patient’s symptoms. Migraine, Tension Type Headache, Cluster headache and other Cranial Autonomic Cephalalgias, Medication overuse headaches etc. are included in this category.

Secondary headaches are less common, but the pain here is a protective mechanism and is the sign of underlying pathological process of the body. Pain due to sinusitis, dental abscess, vasculitis, trauma, strokes, brain tumors, ear-infection, refraction errors, glaucoma, conjunctivitis etc are common examples of secondary headaches.

What kind of tests are required for the diagnosis of primary headaches?
In general, a detailed history and appropriate clinical examination is enough for the headache diagnosis. However, since headache s may develop due to multiple pathologies, sometimes you may undergo the laboratory tests to determine the cause of headache. These tests are required for the diagnosis of secondary headaches only. Neuro-radiological examination (CT Scan or MRI of head) is not always required, nor does it always rules out the presence of secondary headaches. Since there are multiple tests available, these are best chosen by the specialist after listening and analyzing your complaints in detail.

MIGRAINE
This is the most common type of headache amongst all. Generally the disease starts in the adolescence and continues till middle ages, but newer reports suggest that this is seen at all ages. This is more common in females as compared to males.

Do I suffer from migraine?
Migraine classically presents with:

severe, pulsating or throbbing pain
most of the times on one side of the head
typically lasts for few hours to days
pain increases with the movement of head or body
associated with nausea, vomiting
sounds are perceived louder
light or smells are intolerable

sometimes, patients develop aura, i.e., he may witness flashes of lights, scotomas, abnormal sensation in the body accompanying the headache, difficulty speaking, swallowing, weakness in the limb etc.

Why does it occur ?

Migraine is essentially a heterogenous disorder and no single cause can be ascribed to it. Most of the persons are biologically predisposed to it (in other words, they are born with some genes, not a single gene that lowers their migraine threshold- amount of hit required to induce pain) or functional abnormality in the brain becomes apparent when the (second or environmental) second hit is there. This hit can be in the form of precipitating or trigger factors such as stress, certain foods including alcohol, lack of sleep, change in sleep schedule, missing a meal, exposure to hot or cold environment, flickering lights, change in weather, or can be continuous illness e.g., depression, anxiety disorders, personality factors e.g., perfectionist or anxious, menstruation, hormonal contraceptives or HRT in females etc. Final outcome is activation of trigemino-vascular system and release of inflammatory mediators that induce and maintain headache.

What are different types of migraine ?
According to the recent classification proposed by International Headache Society, Migraine can be grossly divided into two major types- Migraine with aura and migraine without aura. Migraine without aura is more common than migraine with aura. Some people suffer from a single type of headache while other may have episodes of both subtypes. Ascertainment of the subtypes may be helpful in management of the illness.

What does medical science offer to me?

we now have drugs that can relieve the pain. We have two kind of drugs- Drugs for termination of acute attacks and secondly the prophylactic medicines. Simple analgesics e.g., aspirin, paracetamol, mefanemic acid, naproxen sodium, opoid analgesics, ergots and triptans are used for terminating the acute attack. These drugs have specific indications and side-effects. Unless they are given with proper instructions (when, how and how much of a given drug should be taken), they can be harmful. The massege is- take the medicins early but not too frequently.
Prophylactic drugs are those drugs that help in reducing the frequency, severity or duration of attacks. Now we have number of drugs that are relatively safe even after long term use. They are given under specific circumstances and choice of the drug is very individualistic. Hence, you must contact a specialist to make sure that you are given the best drug. Besides this other factors that induce or maintain the illness are also given due attention.

How long should I take the prophylactic drugs?
This decision is very individualistic and depends upon the patient’s illness.

What if I am not improving despite taking prophylactic drugs?
There can be many reasons for it. As we have told you that choice of drug is individualistic and your doctor may require time to choose a drug that offers you best relief.; Dosing and its schedule may require a change, you may require a change in the drug or addition of another drug; You are having co-existent problems that require proper attention. Unless they are addressed, you may not improve. In such cases it is best to approach a specialist.

TENSION TYPE HEADACHE :

Who gets this kind of headache?
Almost everybody experiences this kind of headache at least once in his life. It is more common in females and virtually nobody is spared. It is common among children also!

How to recognize this kind of headache?

This is a mild-moderate intensity headache which is present all over the head and lasts for few hours to days. It gives a feeling as if somebody had tied a band around the head or as if the head is heavy. Unlike migraine, people do not experience nausea/vomiting, aura, or any other symptom during this headache.
This simulates the pain of eye-straining, common cold, mild trauma to head etc. This is most common type of headache and significantly limits the working capacity.

What causes this kind of headache?
Previous theories suggested that it occurs due to muscle straining around the neck and scalp. However, recent research shows that trigeminovascular system plays an important role in this kind of headache.
In general, stress- both emotional as well as physical may act as inducing factors.

What can I do to help myself?
First of all, you must get yourself examined so as to confirm the diagnosis. Secondly, you must follow the therapist advise and take the proper treatment. Remember, it frequently accompanies the depression and often becomes chronic. That’s why timely recognition and adequate management of the illness is required.

Should I take the pain-killers for this headache?
Yes, you may, but not very often as this increases the illness and you may develop medication overuse headache.

What should I do if I have frequent headaches of this kind?
You must seek the opinion of a specialist as he can be best person to help you. He may prescribe you with some prophylactic drugs that help you improve the underlying illness.
Non-drug approaches include transcutaneous electrical nerve stimulation (TENS) (which is a treatment for pain), relaxation therapy including biofeedback or yoga, and acupuncture. These are not suitable for everybody, do not work for everyone, and are not available everywhere.

Will these treatments work? If the cause is identified and treated, episodic tension-type headache rarely continues to be a problem. Very often, it improves on its own, or the cause goes away, and no further treatment is needed. For some people, especially with chronic tension-type headache, these treatments do not help or only partially help.
CLUSTER HEADACHE :

How to recognize it?

behind the eye and described as searing, knife-like or boring. It becomes worse very quickly,
reaching full force within five to 10 minutes, and when untreated lasts between 15 minutes
and three hours (most commonly between 30 and 60 minutes). Person is often unable to bear it and frequently tosses. It is common in young males and may occur only during night. Watering and reddening of the eye ipsilateral (same side) to pain is common as well as the watery nasal discharge from the same side. Eyelid may swell during the headache phase to come to normal after that.

What are the triggers?

So-called triggers set off a headache attack. Alcohol, even a small amount, may trigger an
attack of cluster headache during a cluster episode but not at other times. We do not
understand how this happens. There do not appear to be other common trigger factors.

What causes cluster headache?

Despite a great deal of medical research into the cause of cluster headache, it is still not
known. Much interest centres on the timing of attacks, which appears to link to circadian
rhythms (the biological clock). Recent research has highlighted changes in a part of the brain
known as the hypothalamus, the area that controls the body clock.
Many people with cluster headache are or have been heavy smokers. How this may contribute
to causing cluster headache, if it does, is not known. Stopping smoking is always a good thing
for health reasons, but it rarely has any effect on the condition

How do we treat it?

A number of drugs are available for the management of cluster headache. These can be divided into two categories- those that abort acute attacks and those that prevent further occurrence. Preventative medications are the best treatments for most people with cluster headache. Youtake these every day for the length of the cluster episode to stop the headaches returning. They are effective, but you do need rather close medical supervision, often with blood tests,because of the possible side-effects. You may be referred to a specialist for this. The referralshould be urgent because, if you have this condition, we know you are suffering greatly.

What if these don’t work?
There are a range of preventative medications. If one does not work very well, another may.
Sometimes, two or more are used together.

CHRONIC DAILY HEADACHE

What is chronic daily headache?
It refers to a headache that occurs for not less fifteen days a month. It is not a diagnostic entity in itself, rather it represents different types of headaches based upon their etiology. Two common type of headaches are chronic tension type headache and medication overuse headache.

Who suffers from this headache?
Nobody is protected from this kind of headache. It affects people in all ages and both genders; however, it is more common among females for a variety of reasons.
more common among females for a variety of reasons.
What leads to the chronicity of headache?
The factors are not exactly known yet and research is being carried out to understand them. However, to our present knowledge, gender, environmental factors, drug habits, type of headache may affect the development of chronic daily headache. Present knowledge imparts that impression that it is more common among females. Tension type headache and migraine frequently convert into the chronic daily headache and more commonly when adverse environmental factors that help recurrence of these headaches are present. It is more common in headache sufferers with psychiatric morbidity e.g., with anxiety, depression etc and persistent drug use other than prophylactic drugs.

What kind of drugs may precipitate the medication overuse headache?
All the drugs that are used for the termination of acute attack of a headache e.g., non-narcotic analgesics viz. aspirin, paracetamol, naproxen, ibuprofen etc.; triptans e.g., sumatriptan, naratriptan, rizatriptan etc.; ergots when used excessively (>10 days a month or more than thrice a week) may lead to medication overuse headache.
Here, it must be noticed that it is not the quantity of drug in a single day but the frequency of days of use are important in its development. In other words, consuming ten tablets in just two days of a month may lead to toxicity, but not the medication overuse headache. However, when these ten tablets are spread over ten days (one per day), it leads to medication overuse headache.

How do I know if I suffer from the medication overuse headache?
This is not difficult to recognize as it occurs very frequently. Most of the people when do not use the offending agent (pills) develop the headache. It is often a dull aching pain with sleeping difficulties, irritability and feeling lethargic.

Can it be cured?
The treatment depends upon the kind of primary headache and associated health problems. If you have any symptom, you must take the professional help. Removal of offending agent is of paramount importance in the management. During the initiation of therapy, you may experience transient worsening of headache that you have to bear. However, with adequate therapy most of the patients improve.

What will happen if I continue to use the painkillers? These drugs are not free from side effects and they vary with each drug. In general, overuse of non-narcotic analgesics may lead to stomach-upset, acidity, compromise in the kidney functioning and internal or external bleedings. Similarly, use of triptans and ergots may cause hypertension, cardiac illness, infarcts owing to their vaso-constrictor property.
Does this mean that we should not use the painkillers?
Definitely not! For most of the persons with occasional headaches painkillers are safe drugs to terminate the pain. However, considering their side effects, the choice of pill should better be left upon the specialist whom you are consulting. In any case, do not indulge in frequent use of painkillers.
Do I need to undergo any test for the diagnosis?
Generally, tests are not required for the diagnosis and it can be easily made upon the information provided by you and your family. However, in certain cases laboratory investigations may be ordered depending upon your symptoms and clinical examination.

What can I do to help myself? Best is to avoid frequent use of painkillers in cases of headache, by yourself as well as when they are prescribed by a physician. If you are already using the analgesics frequently, better is to abstain yourself at the earliest. This may transiently increase your problem but most of the people get relief within three months. This is slightly difficult to practice than to read, but for a healthy life, it is a small cost. If you are still having frequent pains after three months, consult the headache specialist.