Headache or head pain is a very common symptom. It is often without cause, although some brain and blood vessel abnormalities can be causative and may need to be excluded.
It is very important to monitor the frequency of headaches and treatment responsiveness. A headache diary is the most useful tool in this regard. Download one here for 2018 or here for the 2017 diary.
Different types of headache include:
Phases of a Migraine:
Phase I Prodrome:
Though to be related to dysfunction in the hypothalamus, which may be characterized by fatigue, sleepiness, elation, food cravings, depression, irritability, and a variety of other symptoms. During the prodrome, patients are often vaguely aware that an attack is underway.
Phase II Aura (in 15% only):
Aura symptoms include the perception of flashing lights that begin in the center of vision and expand in jagged patterns out into the periphery. Symptoms may be somatosensory, such as creeping or progressive numbness and tingling in the lips or fingers. They may also involve a profound alteration of the perception of space and time (the “Alice in Wonderland” syndrome).
This is associated with an electrical process known as cortical spreading depression, in which a depression in neuronal activity is followed by a reduction in blood flow, usually beginning in the occipital region, which moves across the cerebral cortex at a rate of 2-3 mm per minute.
Phase III, IV Headache:
The generator of the headache is thought to be in a part of the brain called the brainstem. The locus coeruleus or dorsal raphe have been seen to activate in migraine on PET studies.
This causes inflammation of the covering of the brain, the meninges, which is perceived as pain.
Cells perceiving this pain have been found to have dual input, another being from other sensory modalities such as light, though to underly the sensitivity to light, sound and smell known to be associated with migraine. The headache phase may last from four to 72 hours; headache duration may be related to continued brain-stem activation.
Phase V Postdrome:
Once the pain has run its course, there is a postdrome, where the pain is resolved but other symptoms may linger. Patients often describe a feeling of being “hung over.”
Sensory perception and cognition (thinking) may remain impaired and abdominal symptoms (nausea, queasiness, and anorexia) and sore muscles may persist for a day or two. Postdrome symptoms may require treatment in some patients.
Treatment of Migraine
Acute therapy is the treatment used to abort a migraine when it has just started.
Prophylaxis is preventative therapy to reduce the frequency and severity of migraine attacks. This may include Botox as a preventative, given 12 weekly.
A tension-type headache is described as vice-like and is frequently around the head on both sides. It does not have the accompanying features of the above migraine headache on the whole, though there may be sensitivity of the scalp to touch.
The pain is usually mild-moderate but may be disabling.
Analgesics (pain killers) are effective acutely, but preventatives are needed if the frequency is significant.
These are one-sided severe stabbing headaches lasting less than an hour. These often recur at set times during the day and night (clockwork headache). The headache is accompanied by at least one of the following autonomic symptoms: ptosis (drooping eyelid), miosis (pupil constriction) conjunctival injection (redness of the conjunctiva), lacrimation (tearing), rhinorrhea (runny nose), and, less commonly, facial blushing, swelling, or sweating, all appearing on the same side of the head as the pain. The attack is also associated with restlessness, the sufferer often pacing the room or rocking back and forth.
These typically occur in clusters, episodes of 7-365 days with remission of at least a month in between.
Treatments include acute therapy taken in anticipation of an episode of headache, as well as prophylaxis, taken to ideally abort the cluster altogether.
There are numerous types of primary (no underlying cause) and secondary headaches and facial pains.
Some include trigeminal neuralgia, an electric-shock or shooting pain typically affecting the cheek on one side and triggered by touch. Effective preventative therapy as well as surgical options are available.
Some headache types are secondary – due to an underlying cause – and require testing to rule these out.