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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.

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What Type of Headache do I have ?

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  1. 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

  2. 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.

  3. 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

  4. Tension Headache or Migraine?

  5. 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.

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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)

  11. 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.

  12. 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.

  13. 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.

  14. Sinus Headache or Migraine?

  15. 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.

  16. 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.

  17. 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.

  18. “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

  19. One Nerve Pathway:Multiple Symptoms of Migraine

  20. 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

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