Headaches

Welcome to the module on headaches!

The purpose of this module is to increase the awareness and understanding of migraine headaches. Headache disorders, which are characterized by recurrent headache, are associated with personal burdens of pain, disability, and financial cost.

Did you know?

  1. Headaches are one of the most commonly encountered chronic pain conditions.
  2. Approximately 1/2 of the adult population have had a headache at least once within the last year.
  3. 12% percent of the general population have migraines
  4. Migraines are 3 x more common in women than men

In this module, you will learn:

  • About migraine headaches
    • How they are diagnosed
    • How they are treated
    • Strategies to prevent migraine headaches
  • What are medication overuse headaches

Symptoms

Migraines are recurring attacks of moderate to severe pain.  Migraines are considered to be chronic if the headaches occur on more than 15 days per month over a period of at least three months. Migraine are characterized by one-sided throbbing headaches lasting 2-72 hours that happen repeatedly.

Specific diagnostic criteria

The International Classification of Headache Disorders has published specific criteria for the diagnosis of these headaches:

  • Diagnostic Criteria

    1. At least five attacks.
    2. Headache lasting 4-72hrs
    3. Headache has at least two of the following four characteristics:
    • Unilateral location
    • Pulsating quality
    • Moderate or Severe pain intensity
    • Aggravation by or causing avoidance of routine physical activity
    1. During headache at least one of the following:
    • Nausea and/or vomiting
    • Photophobia and phonophobia

The two major subtypes of migraines:

  • Migraines without aura

    • Migraine without aura is the most common type, accounting for approximately 75 percent of cases.
  • Migraines with aura

    Some people can tell when they are about to have a migraine because they see flashing lights or zigzag lines or they temporarily lose their vision. These disturbances are known as “aura". The most frequent auras consists of visual symptoms such as bright spots, dark spots, tunnel vision, or zigzag lines. Attacks of migraine with aura may be less responsive to certain medications than those without aura.

Key concepts:

  • There are specific symptom criteria that determine whether it is a migraine or another type of headache
  • Some people have what are called "aura" before their migraines, while people do not. 
  • Migraines with an without aura can respond differently to medications.

Diagnosing a Migraine

The diagnosis of migraine is usually made by a thorough history and a physical examination. Occasionally, further investigations such as imaging may be warranted to rule out secondary causes especially in the following scenarios:

  • Abnormal neurological examination.
  • New headache in older patients.
  • Headache increasing in frequency and severity.
  • Worst headache ever.
  • Sudden onset of headache.

Ruling out other possibilities

 

Your clinician will check to see if it could your headaches could be explained by other things.

Other possible diagnoses could include:

  • Other types of primary headaches, such as tension-type headache and trigeminal autonomic cephalalgias such as cluster headache
  • Secondary headaches
    • Secondary headaches are headaches caused by another disorder such head trauma or a brain tumor.

Key concepts:

  • Not every headache has the same underlying cause
  • Your doctor will ask you questions about your health history and examine you to try to figure out what is causing your headaches.

Acute treatments

Migraines can be treated immediately (after they start- acute treatments) or in ways to prevent them from happening (with daily medication aimed at reducing the frequency or intensity of the headaches).

Having a good plan on how to manage headaches acutely is extremely important as poor treatment has been associated with transition from headaches that happen once in a while to a chronic pattern of migraines.

Evidence-based treatments that help after a migraine has started include medications known as triptans as well as Tylenol and certain nonsteroidal anti-inflammatory drugs (NSAIDs).

Learn more about these kinds of treatments below

  • Triptan Medications

    These medications have been used for a long time and have proven to be effective in aborting migraine headaches. 42% to 76% of patients experience pain relief at 2 hours. Triptans are usually given orally, but can also be taken as a nasal spray especially in patients who experience nausea or vomiting during migraine attacks. It is advised to take them as early as possible during an attack and not take more than 7-10 a month. Triptans are contraindicated in individuals with a history of stroke, heart attack, coronary artery disease, uncontrolled hypertension, and peripheral vascular disease. It is important to inform your health care provider of other medications you are currently taking as some medications may interact with triptans.

  • Non Specific Analgesics

    Several nonspecific analgesics have been shown to be efficacious in the acute treatment of migraine. These include Aspirin, Tylenol, ibuprofen, naproxen, and diclofenac. These medications can sometimes be used in combination with triptans. Although these medications are effective but if used too often they may result in rebound headaches, also known as medication over use headaches.

  • Nerve Blocks

    Although they do not have the same level of evidence as some of the medications used to treat headaches, nerve blocks have been reported to provide long-term improvement lasting weeks. Peripheral nerve blocks are easily performed in the outpatient setting, are generally accepted as safe and well tolerated. Examples of such blocks include: greater occipital, supratrochlear, and supraorbital nerve blocks. The medications used in a block include local anesthetic and steroids.

Nausea and vomiting frequently complicate migraine treatment and can often be the underlying cause of why medications do not work. In these situations, anti-nausea medications can be added.

Preventative Treatments

The goal of preventive therapy is to reduce the frequency of migraine attacks, severity of symptoms, and migraine-related disability. Migraine prevention requires a comprehensive approach that should include trigger identification and lifestyle modifications that reduce the risk of migraine attacks.

  • Lifestyle changes

    Changes in a person’s usual daily routine can trigger migraine attacks. Thus, individuals with migraine are likely to do better if they maintain a stable daily schedule. The following are steps can be taken to help prevent headaches:

    • Drink 1.5 – 2 liters of plain water daily.
    • Eliminate or limit to 1-2 cups of coffee daily.
    • Do not skip meals; Avoid artificial sweeteners, colors, preservatives.
    • Eat 12-15 grams of protein at breakfast within 30mins-1hr of waking up.
    • Have a good sleep hygiene. Have a consistent sleep routine.
    • Practice relaxation and /or mindfulness 5 minutes daily.
    • Exercise for at least 30 minutes per day.

    Maintenance of a daily headache diary is recommended to obtain a record of migraine frequency, treatment patterns, and potential migraine attack triggers. Commonly known migraine triggers include: high stress, weather changes, sex hormone fluctuations in women, not eating, alcohol, sleep disturbance, odors, light, smoke, heat, and certain foods. Foods that are commonly cited as triggers include, processed meats, aged cheeses, and artificial sweeteners. Caffeine overuse and caffeine withdrawal are both associated with headaches and migraine.

  • Preventative medications

    In certain situations acute medications and lifestyle modifications are not enough to prevent headaches or decrease the severity of an attack. In these situations, a preventive medication, vitamin or herbal may be started. Most of these medications are taking daily to prevent headaches. A new line of preventive medications that can be taken once monthly and have been specifically designed to treat headaches are currently being used in Canada. It may take up to 3 months to see an effect after starting any new preventive medication.

    Examples of medications and vitamins currently being used include:

    • Beta blockers such as metoprolol and propranolol.
    • Anticonvulsants such as amitriptyline and venlafaxine.
    • Antidepressants such as valproate and topiramate.
    • A new class of medication known as CGRP antagonists such as Erenumab. Erenumab can be taken once a month in an injectable format to prevent headaches.
    • Vitamins such as magnesium and coenzyme Q10.

    It is important to discuss with your care provider the available options and which of these options is best tailored to you.

Medication overuse headaches

Inappropriate use of acute medication for headaches may actually lead to medication-overuse headaches.

  1. 1-2% of the population have headaches from the medication they take for headaches!
  2. These headaches usually occur daily and upon awakening.
  3. The headache may get relieved by a simple analgesic but reoccurs as the effect of the medication wears off.
  4. All acute medications used to treat headaches have the potential to cause medication-overuse headaches including simple analgesics such as Tylenol and NSAIDS, triptans, opioids, and caffeine use. Opioids carries the greatest risk of inducing medication-overuse headaches.

Treatment of Medication-Overuse Headaches

  • The most important step is to discontinue the overused medication.
  • Depending on the overused medication, your doctor may need to either stop it abruptly or taper it slowly.
  • When the overused medication is being discontinued you may experience a small period of withdrawal symptoms such as worsened headache and nausea. The headache will eventually get better.
  • A preventive medication may need to be added during this phase.
  • Other non-pharmacological therapies can greatly help with the management. These include behavioral therapies, psychological counseling, and targeted physical therapy.

References

 

  • CONTINUUM (MINNEAP MINN) 2018;24(4, HEADACHE):1052–1065.
  • CONTINUUM (MINNEAP MINN) 2018;24(4, HEADACHE):1032–1051.
  • Bigal ME, Borucho S, Serrano D, Lipton RB. The acute treatment of episodic and chronic migraine in the USA. Cephalalgia 2009;29(8): 891–897. doi:10.1111/j.1468-2982.2008.01819.x.
  • Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. Headache 2015;55(1):3–20. doi:10.1111/ head.12499.
  • Zaeem Z, Zhou L, Dilli E. Headaches: a review of the role of dietary factors. Curr Neurol Neurosci Rep 2016;16(11):101. doi:10.1007/s11910-016-0702-1.
  • Pringsheim T, Davenport W, Mackie G, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci 2012; 39(2 suppl 2):S1–S59.
  • Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018; 38:1.
  • Orr SL, Aubé M, Becker WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia 2015; 35:271.
  • Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache 2015; 55:3.
  • Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol 2004; 3:475.
  • Dodick D, Freitag F. Evidence-based understanding of medication-overuse headache: clinical implications. Headache 2006; 46 Suppl 4:S202.

76 Grenville St. Toronto, ON M5S 1B2 Canada

TAPMI Hub Clinic

Phone: 416-323-6269 Office Fax: 416-323-2666 Hours: 8:00 a.m. – 4:00 p.m. Monday – Friday

Administration

Dr. Tania Di Renna, Medical Director William Cachia, Administrative Director