The following discussion is for general informational purposes only and is not meant to provide the reader with specific medical advice. Please consult with your personal physician, or with a neurologist, for specific advice, guidance and information regarding your particular circumstances.
Headache is one of the most frequent reasons for medical consultation. The most prevalent headache type is tension headache, which is usually mild, unassociated with significant disability, managed without physician input, and responsive to over-the-counter analgesics (if treatment is required at all). On the other hand, when patients need to consult a primary care physician because of headaches, the most common diagnosis is migraine.
Migraine affects approximately 12% of the United States population. Epidemiological studies suggest that migraine is incorrectly diagnosed in roughly 50% of cases. Doctors and patients contribute to this misdiagnosis problem. Of the roughly 50% of misdiagnosed patients who actually have migraine, 40% of those are misdiagnosed with sinus headaches and 30% are misdiagnosed with tension headaches. Correct diagnosis is essential so that appropriate, successful treatment can be offered and also to avoid inappropriate and unnecessary treatments.
Some migraine sufferers experience a prodrome which can precede a headache by hours or days and can include such symptoms as yawning, fatigue, mood swings, food cravings and a heightened sensitivity to sensory stimuli such as light, sound and odors.10 to 20% of migraine sufferers have focal neurological symptoms preceding the actual headache. This warning is referred to as an aura, which is believed to be due to a temporary disruption of normal brain function occurring 20 to 30 minutes before the pain. Common symptoms during the aura are vision disturbances such as flashing lights with zigzagging lines, blurred or lost vision or lateralized tingling, weakness or speech or cognitive difficulties. As the aura clears, the headache often begins (rarely, patients experience aura symptoms without headache). Migraine is commonly associated with a throbbing-type headache that may start or remain lateralized to one side of the head. Almost all recurring episodic disabling headaches are migraines. Associated features that strengthen certainty of diagnosis include a positive family history, associated symptoms such as nausea, vomiting, and light, sound or movement sensitivity. Common triggers include hormonal fluctuations (women between the ages of 20 and 50 are three times as often affected as men in the same age range) and migraines often are associated with menses. Other migraine triggers that can lead to confusion with tension and sinus headaches respectively include stress and barometric pressure changes.
Migraine is diagnosed based largely on a consistent clinical history and the absence of atypical features but may require additional testing to exclude conditions that can mimic migraine. It is up to the physician to make a clinical diagnosis of migraine. Features that should cast some doubt on that diagnosis include headaches associated with fever, weight loss, HIV or systemic cancer. If there is a change in level of consciousness or lateralized weakness, a sudden, split second onset, or new onset headaches in an older person, the diagnosis of migraine should be one of exclusion. Lastly, a headache which is distinctly different from or worse than any previously experienced warrants immediate medical attention.
There are many acute treatments available for migraine and ideally treatment should be individualized to a specific patient's needs. In patients where specific avoidable triggers can be identified such as alcohol exposure, marked variation in sleep-wake schedule and skipping meals, behavior modification can make some difference, but most patients with migraine ultimately require pharmacotherapy. Mild migraine with minimal disability often responds to nonspecific over-the-counter simple analgesics including aspirin, acetaminophen and nonsteroidal antiinflammatories or combination analgesics with caffeine. Those migraine sufferers who tend to experience more disability usually require specific prescription migraine medications, such as the triptans, that work on the early unfolding migraine process. When headaches do not respond to the initial treatment, it is usually good to have a rescue medication available that might be a stronger narcotic pain medication or antiemetic. In patients where nausea and vomiting are early prominent symptoms, oral medications do not make sense and there are medications available for self-injection or nasal administration that do not require gastrointestinal absorption.
The acute treatments optimally should not be used more than two days per week. With more frequent use, there is the risk of transforming episodic migraine into a pattern of chronic migraine or chronic daily headache. Sometimes if a patient has entered that cycle, abstinence from analgesics is required. In patients who require excessively frequent dosing with acute symptomatic medication, where those treatments are contraindicated, or in patients who still become disabled frequently despite optimal acute treatment, there are a number of medications available for prophylaxis to reduce the frequency of headaches. Hormonal manipulations in women who have menstrual associated migraine can be helpful as well. With optimal outpatient therapy, it is a reasonable goal to avoid, or at least markedly reduce, the need for emergency room visits or hospitalizations.