Look after your brain: Headache

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Characteristics of migraine, tension-type, and cluster headache syndromes

Symptom	Migraine	Tension-type	Cluster
Location	Unilateral in 60 to 70 percent; bifrontal or global in 30 percent	Bilateral	Always unilateral, usually begins around the eye or temple
Characteristics	Gradual in onset, crescendo pattern; pulsating; moderate or severe intensity; aggravated by routine physical activity	Pressure or tightness which waxes and wanes	Pain begins quickly, reaches a crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality
Patient appearance	Patient prefers to rest in a dark, quiet room	Patient may remain active or may need to rest	Patient remains active
Duration	4 to 72 hours	Variable	30 minutes to 3 hours
Associated symptoms	Nausea, vomiting, photophobia, phonophobia; may have aura (usually visual, but can involve other senses or cause speech or motor deficits)	None	Ipsilateral lacrimation and redness of the eye; stuffy nose; rhinorrhea; pallor; sweating; Horner’s syndrome; focal neurologic symptoms rare; sensitivity to alcohol

The child with headache

Approximately 20 percent of children aged 4 to 18 years report having had frequent or severe headaches in the past 12 months.

●Headache in children and adolescents may be due to a primary headache syndrome (ie, migraine headache, tension-type headache, cluster headache or secondary to an underlying medical condition. Secondary headaches usually are related to fever or infection (eg, upper respiratory infection, influenza), but may be due to central nervous system infection or space-occupying lesion.

●The evaluation of headache in children includes a thorough history and physical examination, with particular emphasis on clinical features suggestive of intracranial pathology. The headache pattern helps to determine the etiology.

●Neuroimaging (head computed tomography without contrast or magnetic resonance imaging without contrast) should be performed in children with headache and neurologic signs or symptoms suggestive of intracranial pathology.

●Routine laboratory evaluation usually is not necessary for children with recurrent or chronic headaches. The laboratory evaluation for secondary headache should be tailored to evaluate conditions suggested by information from the history and examination.

●The diagnosis of primary headache disorders is made clinically, based upon the criteria of the International Headache Society. The diagnosis of chronic daily headache also is made clinically (headache on >15 days per month for >3 months in the absence of detectable organic pathology). The diagnosis of secondary headaches depends upon identification of the underlying condition.

●The treatment of chronic headaches requires a systematic approach over several months through which the child returns to normal activities of daily living. It is critical to address excessive school absence and overuse of over-the-counter analgesic medications.

Chronic daily headache

Chronic daily headache (CDH) is not a specific headache type, but a syndrome that encompasses other primary headaches. The term “chronic” refers either to the frequency of headaches or to the duration of the disease, depending upon the specific headache type.

●With headache subtypes of long duration (ie, four hours or more), “chronic” indicates a headache frequency of 15 or more days a month for longer than three months in the absence of organic pathology. These headache subtypes are:

•Chronic migraine headache

•Chronic tension-type headache

•Medication overuse headache

•Hemicrania continua

•New daily persistent headache

●With headache subtypes of shorter duration (ie, less than four hours), “chronic” refers to a prolonged duration of the condition itself without remission. The headache subtypes in this category are the following:

•Chronic cluster headache

•Chronic paroxysmal hemicrania

•Hypnic headache

•Short-lasting unilateral neuralgiform headache attacks

•Primary stabbing headache

●The worldwide prevalence of CDH among adults is approximately 4 percent. Most patients with CDH have either chronic tension-type headache or chronic migraine.

●The diagnosis of CDH is suspected on the basis of a compatible headache history. Other disorders causing secondary headache must be excluded.

●The management of CDH depends on the specific headache type and the presence or absence of medication overuse.