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Knowledge - Headache
1. Background you need to know about the headache. More details...
2. Do you receive an appropriate diagnosis? More details...
3. Primary headache disorder.
Migraine More details...
Tension-Type Headache (TTH) More details...
Cluster Headache and other Trigeminal Cephalalgias (TAC) More details...
Other primary headaches More details...
4. Secondary headache disorders
Headache attributed to head and/or neck trauma More details...
Headache attributed to cranial or cervical vascular disorder More details...
Headache attributed to non-vascular intracranial disorder More details...
Headache attributed to a substances or its withdrawal More details...
Headache attributed to infection More details...
Headache attributed to disorder of homoeostasis More details...
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other facial or cranial structures More details...
Headache attributed to psychiatric disorder More details...
Cranial neuralgias and central causes of facial pain More details...
Other headache, cranial neuralgias, central or primary facial pain More details...
5. Key steps towards successful headache management More details...
Headache - Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
Description: Disorders of the cervical spine and of other structures of the neck and head have frequently been regarded as the commonest causes of headache, since many headache originate from the cervical, nuchal or occipital regions or are localized there. Moreover, degenerative changes in the cervical spine can be found in virtually all people over 40 years of age. The localization of pain and the X-ray detection of degenerative changes have been plausible reasons for regarding the cervical spine as the most frequent studies have shown that such changes are just as widespread among individuals who do not suffer fro headaches. Spondylosis or osteochondrosis cannot therefore be seen as the explanation of headaches. A similar situation applies to other widespread disorders: chronic sinusitis, temporomandibular joint disorders and refractive errors of the eyes. Therefore, a specific causal relationship should be established between headache and eyes, ears, nose, sinuses, teeth, mouth and other facial or cranial structures where these exist. The diagnosis becomes definite only when the headache resolves or greatly improves after effective treatment or spontaneous remission of the craniocervical disorder. IHS summarizes this group of headaches as the following:
Headache attributed to disorder of cranial bone
Headache attributed to disorder of neck
Headache attributed to retropharyngeal tendonitis
Headache attributed to craniocervical dystonia
Headache attributed to disorder of eyes (e.g. acute glaucoma, refractive errors, heterophoria or heterotropia-latent or manifest squint, ocular inflammatory disorder)
Headache attributed to disorder of ears
Headache attributed to rhinosinusitis
Headache attributed to disorder of teeth, jaws or related structures
Headache or facial pain attributed to temporomandibular joint (TMJ) disorder
Headache attributed to other disorder of cranium, neck, eyes, ears, nose, snuses, teeth, mouth or other facial or cervical structures
Comment: As the other secondary headaches, elimination of the causes is generally the final resolution. However, it may not be easy or practical to do that in this group of disorders. Thorough physical, neurological and other specialized exams are often needed to find out the accurate diagnosis and warrant the treatment success. Comprehensive management is highly recommended due to the complexity of the causes. Team approaches include physical therapy, muscle relaxants, NSAIDS / Cox-2 inhibitors, anticonvulsants, antidepressants, trigger point injection, nerve block, acupuncture, pain psychotherapy and even invasive anesthetic invasive procedures. Patients are encouraged to contact this center for more useful diagnostic and therapeutic information.
Headache - Key steps towards successful headache management
The author recommends the key points towards the successful management of headache.
1. Allow enough times to communicate with the patients. The placebo effect in headache studies typically accounts for 30-40 % of the treatment outcome.
2. Obtain a detail headache history. This gives over 80-90% of information needed for the accurate diagnosis
3. Complete the thorough physical and neurological exams. Some special tests applied in orofacial pain, orthopedics can be very useful to rule out the secondary causes.
4. Establish broad differential diagnosis. The headache may be due to the structural from the face and neck, or a mixture of different types of headache.
5. Always rule out the secondary before conclude the patients have primary headache disorder. Up to 7-10 % of the chronic headache can be caused by cerebral venous sinuses thrombosis reported by some studies.
6. Propose a comprehensive treatment plan for the patients. The most powerful management should include behavioral modification, oral and intravenous polypharmacotherapy, pain procedures, physical therapy, acupuncture and pain psychology.
Comment: Acupuncture becomes more and more popular in USA. Most of the controlled studies favor or in the trend of favor the use of acupuncture in migraine management. The recent publication from Dr. Zhao and colleagues comprehensively reviews the mechanism and clinical profile on the use of acupuncture in headache (Zhao C et al. Medlink Neurology, 2003).
Headache - Other headache, cranial neuralgia, central or primary facial pain
Description: This category is intended for those head and facial pain which do not fulfill the above diagnostic criteria.
Headache not elsewhere classified
Comment: There are little evidences for the treatment of this group of headache. The recommendation includes ruling out the primary and secondary causes, and then symptomatic management.
Headache - Cranial neuralgias and central causes of facial pain
Description: Pain in the head and neck is mediated by afferent fibres in the trigeminal nerve, nervus intermedius, glossopharyngeal and vagus nerves and the upper cervical roots via the occipital nerves. Stimulation of these nerves by compression, distortion, exposure to cold or other forms of irritation or by a lesion in central pathways may give rise to stabbing or constant pain felt in the area innervated. IHS summarizes this group of disorders as the following:
Classical trigeminal neuralgia
Symptomatic trigeminal neuralgia
Classical glossopharyngeal neuralgia
Symptomatic glossopharyngeal neuralgia
Nervus intermedius neuralgia
Superior laryngeal neuralgia
Other terminal branch neuralgias
External compression headache
Cold-stimulus headache (e.g. external application of a cold stimulus, ingestion or
inhalation of a cold stimulus)
Constant pain caused by compression, irritation or distortion of cranial nerves or
upper cervical roots by structural lesions
Ocular diabetic neuropathy
Head or facial pain attributed to herpes zoster
Attributed to acute herpes zoster
Central causes of facial pain
Central post-stroke pain
Facial pain attributed to multiple sclerosis
Persistent idiopathic facial pain
Burning mouth syndrome
Other cranial neuralgia or other centrally mediated facial pain
Comment: Understanding of neuroanatomy is fundamental toward the diagnosis. Because few diagnostic tests can be helpful in assisting the diagnosis of neuropathic pain, therefore, a detail headache or pain history and comprehensive physical/neurological exam are required to make the accurate diagnosis. Anticonvulsant, antidepressant and office procedures are extremely useful in management.
Headache - Headache attributed to psychiatric disorder
Description: The studies on association between headache and psychiatric disorders are very limited. Headache can be one of the complaints associated with some psychiatric disorders such as major depressive disorder, panic disorder, generalized anxiety disorder, somatoform disorder, and psychotic disorder (delusion).
Comment: Organic etiologies must be ruled out before diagnosis of psychiatric disorder is made. Polypsychopharmacotherapy and psychotherapy play a very important role in the treatment. The cooperation of psychiatrists and headache specialists is needed to maximize the treatment outcome.
Heache - Headache attributed to disorder of homoeostasis
Description: This group of headache is caused or associated with significant disturbances in arterial pressure, myocardial ischemia, altered arterial blood gases, volume disturbances as in dialysis and disorders of endocrine function, fasting.
Headache attributed to hypoxia and / or hypercapnia
Sleep apnea headache
Headache attributed to arterial hypertension (e.g. pheochromocytoma,
Hypertensive crisis with or without hypertensive encephalopathy, pre-eclampsia or eclampsia, acute pressor response to an exogenous agent
Headache attributed to hypothyroidism
Headache attributed to fasting
Comment: Elimination of the causes is the final treatment option. Cooperation from specialists in relevant to the etiology is necessary to prepare a comprehensive treatment plan.
Heache - Headache due to infection
Description: Headache is a common accompaniment of systemic viral infections such as influenza, sepsis. In intracranial infections, headache is usually the first and the most frequently encountered symptom. Occurrence of a new type of headache which is diffuse, pulsating and associated with a general feeling of illness and / or fever should direct attention towards an intracranial infection even in the absence of a stiff neck. This group of disorders includes:
Headache attributed to intracranial infection (bacterial meningitis, lymphocytic
meningitis, encephalitis, brain abscess, subdural empyema)
Headache attributed to systemic infection (bacterial, viral, etc)
Headache attributed to HIV/AIDS
Chronic post-infection headache (e.g. post-bacterial meningitis)
Comment: The key is to find out the etiology. Necessary tests include infectious workup, brain MRI / CT with contrast, PCR, etc. Antibiotic probably is the most important treatment. Cooperation with infectious specialist is greatly encouraged.
Heache - Headache attributed to non-vascular intracranial disorder
Description: Headaches in this category are mainly secondary to the changes in intracranial pressure, non-infectious inflammatory diseases, intracranial
neoplasia, seizures, and rare conditions such as intrathecal injections and Chiari malformation type I, and other non-vascular intracranial disorders.
Compared to those on primary headaches, there are few epidemiological studies on these headache types. Controlled trials of therapy are almost non-
existent. These headaches include:
Headache attributed to high cerebrospinal fluid (CSF) pressure
Headache attributed to idiopathic intracranial hypertension (IIH)
Headache attributed to intracranial hypertension secondary to metabolic, toxic or hormonal causes
Headache attributed to intracranial hypertension secondary to hydrocephalus
Headache attributed to low CSF pressure
Post-dural puncture headache
CSF fistula headache
Headache attributed to spontaneous (or idiopathic) low CSF pressure
Headache attributed to non-infectious inflammatory disease (e.g. neurosarcoidosis, aseptic meningitis, other non-infectious
inflammatory disease, lymphocytic hypophysitis)
Headache attributed to intracranial neoplasm
Headache attributed to increased intracranial pressure or hydrocephalus
Caused by neoplasm
Headache attributed directly to neoplasm
Headache attributed to carcinomatous meningitis
Headache attributed to hypothalamic or pituitary hyper- or hyposecretion
Headache attributed to intrathecal injection
Headache attributed to epileptic seizure
Headache attributed to Chiari malformation type 1 (CM1)
Syndrome of transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL)
Headache attributed to other non-vascular intracranial disorder
Comment: The key for treatment is to find out the underlying etiologies and eliminate them if possible. Valuable diagnostic tests include diagnostic and
therapeutic lumbar puncture, EEG, MRI, MRA, MRV, CTangiogram, ESR, CRP, etc. The possible treatment options include muscle relaxants,
acetaminophen, antidepressants, diuretics, lumbar puncture, trigger point injection and nerve block, acupuncture and pain psychotherapy.
Heache - Headache attributed to a substances or it's withdrawal
Description: Headache can be induced by certain substances, which may be due to unwanted effect of a toxic substance, unwanted effect of a substance in normal therapeutic use, unknown effect of experimental drugs. A diagnosis of "Headache attributed to a substance" usually becomes definite only when the headache resolves or greatly improves after termination of exposure to the substance. In addition, chronic headache can commonly be caused by the overuse of medications. By far, the most common cause of migraine-like headache occurring on > or = 15 days per month and of a mixed picture of migraine-like and tension-type-like headache on > or = 15 days per month is overuse of symptomatic migraine drugs and/or analgesics. In general, use of certain medications for > or = 10 days per month on a regular basis for 3 months will likely cause medication-overuse headache. This group of headache disorders includes:
Headache induced by acute substances use or exposure
Headache induced by nitric oxide donor, phosphodiesterase inhibitior, carbon monoxide, alcohol, monosodium glutamate, cocaine, cannabis,
histamine, calcitonin gene-related peptide
Headache as an acute adverse event attributed to medication used for other indications
Headache induced by other acute substance use or exposure
Medication-overuse headache (MOH)
Combination medication-overuse headache
Headache attributed to other medication overuse
Probable medication-overuse headache
Headache as an adverse event attributed to chronic medication, like hormone supplement
Headache attributed to substance withdrawl (caffeine, opioid, estrogen, other chronically used substances)
Comment: Frequent headaches occur > 15 days per month and affect 5% of women and 2.8% of men. The two most common frequent headaches are chronic tension-type headache and transformed/chronic migraine. Chronic headache is very commonly caused by medication overuse or withdrawal, and often requires comprehensive management. Such treatment will at least include detoxification or elimination of the overused medications, and symptomatic/comforting/soothing therapies. Most of the treatment can be completed in the headache and only occasionally hospitalization is needed. Patients and primary care doctors are encouraged to consult the headache specialists or experienced neurologists for accurate diagnosis and comprehensive treatment plan.
Heache - Headache attributed to cranial or cervical vascular disorder
Description: The diagnosis of headache attributed to vascular disorder usually becomes definite only when the headache resolves or greatly improves within a specified time after its onset or after the acute phase of the disorder. When this is not the case, or before the specified time has elapsed, a diagnosis of headache probably attributed to vascular disorder is usually applied. Alternatively, when headache does not resolve or greatly improve after 3 months, a diagnosis of chronic post-vascular-disorder headache is appropriate. The diagnosis of headache and its causal link is easy in most of the vascular conditions because the headache presents both acutely and with neurological signs and because it often remits rapidly. The close temporal relationship between the headache and these neurological signs is therefore crucial to establishing causation. This group of headache includes:
Headache attributed to ischemic stroke or transient ischemic attack
Headache attributed to non-traumatic intracranial hemorrhage
Headache attributed to unruptured vascular malformation (saccular aneurysm, arteriovenous malformation, dural arteriovenous fistula,
cavernous angioma, encephalotrigeminal or Leptomeningeal angiomatosis-Sturge Weber syndrome)
Headache attributed to arteritis (giant cell arteritis, primary central nervous system angiitis, secondary central nervous system angiitis)
Carotid or vertebral artery pain
Headache or facial or neck pain attributed to arterial dissection
Headache attributed to intracranial endovascular procedures
Headache attributed to other intracranial vascular disorder Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and
Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-like episodes (MELAS)
Headache attributed to benign angiopathy of the central nervous system
Headache attributed to pituitary apoplexy
Comment:. The key for treatment is to find out the underlying etiologies and eliminate them if possible. Neuroimaging studies such MRI, MRA, MRV, CTangiogram and special lab tests like ESR, CRP will be extremely helpful in assisting in diagnosis. The possible treatment options include muscle relaxants, acetaminophen, antidepressants, trigger point injection and nerve block, acupuncture and pain psychotherapy. An experienced Stroke specialist may be needed to work with the headache specialist for a complete treatment plan.
Heache - Headache attributed to head and/or neck trauma
Description: Headache is a symptom that may occur after injury to the head, neck or brain. Frequently, a headache result from head trauma is accompanied by other symptoms such as dizziness, difficulty in concentration, nervousness, personality changes and insomnia. It is easy to establish the relationship between a headache and head or neck trauma when the headache develops immediately or in the first days after trauma has occurred. On the other hand it is very difficult when a headache develops weeks or even months after trauma, especially when the majority of these headaches have the pattern of tension-type headache and the prevalence of this type of headache I the populations is very high. Headache disorders in this category include:
Acute post-traumatic headache
Attributed to moderate or severe head injury
Attributed to mild head injury
Chronic post-traumatic headache
Attributed to moderate or severe head injury
Attributed to mild head injury
Acute headache attributed to whiplash injury
Chronic headache attributed to whiplash injury
Headache attributed to traumatic intracranial hematomas
Headache attributed to epidural hematoma
Headache attributed to subdural hematomas
Headache attributed to other head and/or neck trauma
Acute headache attributed to other head and/or neck trauma
Chronic headache attributed to other head and/or neck trauma
Acute post-craniotomy headache
Chronic post-craniotomy headache
Comment: The key for treatment is to find out the underlying etiologies and eliminate them if possible. Neuroimaging studies such head and neck CT, MRI, MRA, CTangiogram and special lab tests like PT/PTT/Platelet count will be extremely helpful in assisting in diagnosis. The possible treatment options include anticonvulsants, muscle relaxants, NSAIDS, acetaminophen, antidepressants, trigger point injection, nerve block, facet block, acupuncture, physical therapy and pain psychotherapy. Patients or physicians can call this center for more information.
Heache - Other primary headaches
These headaches are relatively uncommon. These disorders include:
Primary stabbing headache
Primary cough headache
Primary exertional headache
Primary headache associated with sexual activity
Primary thunderclap headache
New daily-persistent headache (NDPH)
Heache - Cluster Headache and Other Trigeminal Cephalalgias (TAC)
Description: Compared to TTH and migraine, this group of headache disorder occurs much less in frequency. All the TAC headache disorders share the clinical features of headache and prominent cranial parasympathetic autonomic features. Experimental and Human functional imaging suggests that a normal human trigeminal-parasympathetic reflex is activated in TAC, with clinical signs of cranial sympathetic dysfunction being secondary. Cluster headache is relatively common in TAC disorder. Cluster headache is attack of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15-180 minutes and occurring from once every other day to 8 times a day. The attacks are associated with one or more of the following: conjunctival injection, watery eyes, nasal congestion, running nose, forehead and facial sweating, small pupil, eyelid drooping, eyelid edema. Because of the complex of TAC, patients are recommended to consult the headache specialist for the detail regarding diagnosis and management of TAC. The IHS summarizes the TAC category as the following:
Episodic cluster headache
Chronic cluster headache
Episodic paroxysmal hemicrania
Chronic paroxysmal hemicrania (CPH)
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
Probable trigeminal autonomic Cephalalgia
Probable cluster headache
Probable paroxysmal hemicrania
Comment: The treatment of Cluster headache includes acute abortive, transitional prevention, and longterm prevention therapies. Because the short duration and severity of painful attack, acute abortive treatment should be given right at the time of the attack onset. Transitional preventive therapy buys time for the longterm therapy to become effective. The longterm preventive therapy usually last weeks to month, depending on the length of the cluster cycle. The following list the common drugs used in the cluster headache management.
Transitional preventive therapy
Longterm preventive therapy
Heache - Tension -Type Headache (TTH)
Description: Infrequent episodic tension-type headache lasts minutes to days. The pain is typically bilateral, pressing or tightening in quality and of mild to
moderate intensity, with or without photophobia or phonophobia, not worsen with routine physical activity, no nausea. The IHS classifies the spectrum of
tension-type headache as the followings:
Infrequent episodic tension-type headache
Associated with pericranial tenderness
Not associated with pericranial tenderness
Frequent episodic tension-type headache
Associated with pericranial tenderness
Not associated with pericranial tenderness
Chronic tension-type headache
Associated with pericranial tenderness
Not associated with pericranial tenderness
Probable tension-type headache
Probable infrequent episodic tension-type headache
Probable frequent episodic tension-type headache
Probable chronic tension-type headache
Comment: As mentioned above, TTH is the least studied primary headache disorder. The current treatment options include acute abortive and chronic
preventive therapy. Recent publication from Drs. Zhao and Stillman thoroughly reviewed the treatment options of TTH [Zhao C & Stillman MJ. Expert Opin
Abortive or acute therapy
Nonsteroidal anti-inflammatory agents (NSAID)
Prophylactic or preventative therapy
Botulinum type A toxin
Heache - Migraine
Description: Migraine can be divided into two major sub-types. Migraine without aura is a clinical syndrome characterized by headache with specific features and associated symptoms. Migraine with aura is primarily characterized by the focal neurological symptoms that usually precede or sometimes accompany the headache. Some patients also experience a premonitory phase, occurring hours or days before the headache, and a headache resolution phase. Premonitory and resolution symptoms include hyperactivity, hypoactivity, depression, craving for particular foods, repetitive yawning and other less typical symptoms reported by some patients. 80% of the migraine do not have aura. The migraine attack lasts 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, physical activity and association with nausea and/or photophobia and phonophobia. IHS classifies the migraine disorders as the following:
Migraine without aura
Migraine with aura
Typical aura with migraine headache
Typical aura with non-migraine headache
Typical aura without headache
Familial hemiplegic migraine (FHM)
Sporadic hemiplegic migraine
Childhood periodic syndromes that are commonly precursors of migraine
Benign paroxysmal vertigo of childhood
Complications of migraine
Persistent aura without infarction
Probable migraine without aura
Probable migraine with aura
Probable chronic migraine
Comment: The treatment of migraine includes acute abortive therapy and chronic preventive therapy. Current abortive treatment options include triptans, non-steroidal anti-inflammatory drugs (NSAIDS), Intravenous therapy of dihydroergotamine (DHE 45) and antiemetics. Triptans provide 55-75% of 2 hour response rate (pain is reduced from moderate-severe to free-mild degree at 2 hour after administration). A patient with attack frequency more than 3-5 times per month or fewer attacks but very disabling should consider the preventive therapy. Typical preventive treatment options include anticonvulsants, tricyclic antidepressants, herbal or supplemental agents. The efficacy of them ranges from 40-60% in different controlled studies. The following lists the most common and effective treatment agents/options for migraine; they are supported by clinical experience and/or research evidence.
Dihydroergotamine (D.H.E. 45)
Valproic Acid (Depakote, Depacon)
Calcium channel blockers
Coenzyme Q 10
Botulinum toxin type A (Botox)
Trigger point injection
Occipital nerve block
Cervical plexus block
Team / multidiscipline approaches
Headache - Do you receive an appropriated diagnosis?
Failure of the headache treatment is commonly due to the inaccurate diagnosis. As a patient, you have the right to know what the exact problem is. The following is the classification of head and facial pain proposed by the IHS in 2004. Dr. Zhao comments briefly on the management of each group of them. Interested patients or physicians are encouraged to contact this center for more detail information.
Headache - Background you need to know about the headache
Headache is one of the most common disorders seen in the primary care and neurology clinics. By far, the most common primary headache disorder in the general population is episodic tension-type headache (TTH), which affects 40% of the population each year. The lifetime prevalence in the general population ranges in different studies form 30 to 78%. It is the least studied of the primary headache disorders, despite the fact that it has the highest socio-economic impact. TTH is a bilateral headache in mild to moderate pain degree, and majority of the patients thus will not visit the doctors. They usually self administer over-the-count medications like Tylenol, Ibuprofen. Recent publication from Drs. Zhao and Stillman has thoroughly reviewed the TTH (Zhao C & Stillman MJ. Expert Opin Pharmacother. 2003;4(12):2229-37). Migraine is the second commonest primary headache disorder affecting 18% of women and 6% of men every year. There exist 28 million migraine sufferers in US in 1999. One out of four households had at least one member with migraine. The prevalence is highest in the 25-55 age groups. The direct cost of migraine is 2.5 billion dollars and indirect cost 13.5 billion dollars each year. Fifty-one percent of women miss the equivalent of 6 or more days of work per year due to migraine, which accounts for 93% of all work lost due to migraine. Thirty-eight percent of men lose that same amount of time (6 days), accounting for 85% of work loss because of migraine. Frequent headaches occur > 15 days per month and affect 5% of women and 2.8% of men. The two most common frequent headaches are chronic tension-type headache (CTTH) and transformed/chronic migraine. This group of headache is most difficult to treat. Medication overuse is probably the most common reason leading to the chronic headache. Migraine is the most common headache disorder seen by doctors. Close to 70% of the migraine are treated by primary care physicians and 20% by neurologists including headache specialists. However, by 1999, only 48% of the migraine sufferers have received correct diagnosis and more than half of the patients are not diagnosed. Therefore, there is urgent need to educate the headache practitioners to improve their skill to recognize the migraine before delivering the best care to the patients. The Headache Classification Subcommittee of the International Headache Society (IHS) has proposed the first edition of diagnostic criteria for head and facial pain in 1988 and the 2nd revised edition will be published in January 2004. This gives a comprehensive guideline for the practitioners to make the diagnosis, even though some practitioners argue this guideline may not be very practical at least in USA. Unfortunately, few practitioners have known this guideline. This may be one of the reasons that headaches including migraine and chronic headache are still one of the most difficult neurological disorders being treated successfully.
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Tel.: (626) 457-1688
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