Headaches: migraines, tension headaches, cluster headaches

Definition

According to the International Headache Society (IHS), headaches can be divided into primary headaches (independent illnesses), secondary headaches (as a result of other illnesses) and cranial neuralgia (facial pain due to nerve stimulations).

The primary form includes migraines, tension headaches, cluster headaches and other types of headache, e.g. from colds, coughs or major stress.

 

Causes

Migraines

The causes and mechanisms of migraines are still only partly understood.

One potential explanation is that migraines result from congenital, disturbed responsiveness of the brain to external and internal stimuli. This increased sensitivity means the brain produces and releases much more of the neurotransmitters noradrenaline and, particularly, serotonin. As a result, the vessels expand and inflammatory substances are released, which triggers the pain.

A genetic predisposition, combined with various factors, leads to such headaches. The following triggers can cause or worsen migraines:

·         Strong emotions, stress, anxiety, depression, fatigue, lack of sleep

·         Hormonal changes: periods, ovulation, the contraceptive pill

·         Food: alcohol (red wine), cheese, tropical fruits, chocolate

·         Medication: nitroglycerin, calcium antagonists

·         Environment: flashing (disco) lights, noise, elevation, cold, smoke, sudden weather changes, wind

·         Behaviour: nervousness, release after stressful periods (weekends)

·         Internal cycles: sleep cycles, seasons, jetlag

Migraines present in two main forms: with and without aura. Aura means neurological phenomena and symptoms that precede or accompany the pain. Disturbed vision and motor problems, even symptoms of paralysis in the extremities (fingers and toes), are common.

Women are more frequently affected than men.

Tension headaches (episodic, chronic)

Tension headaches are the most common type of headaches. They mainly present as occasional episodes and affect between 50% and 75% of people. Typically, they start in your thirties or forties.

In around 3 per cent of cases, the headaches become chronic. By chronic tension headaches, we mean more than 15 attacks per month over a 3-month period or 180 attacks per year.

The exact cause of tension headaches is not known. Various factors have been reported as triggers:

·         Chronic (long-term) or acute (sudden) mental or physical exertion

·         Muscular tension in the neck, shoulders, eyes or face

·         Changes in the weather

·         Sleep deprivation

With chronic tension headaches, organic causes or other illnesses (secondary headaches) should be ruled out.

Cluster headaches

Cluster headaches are powerful and probably the worst headaches there are. They always only affect one side of the head. There may be several attacks in succession per day (so-called clusters), each lasting up to three hours. They particularly occur at night. The attacks are often accompanied by facial symptoms, such as sweat, tears, red eyes or a runny nose.

The causes are mainly unknown, although local disturbances in specific areas of the brain, such as the hypothalamus, probably play a role. Men (particularly young men) are more often affected than women. Alcohol, particular flavourings such as glutamate, but also chocolate, cheese and medication containing nitroglycerin (used for angina) or histamine (for allergies) can exacerbate or even trigger the headaches.

Symptoms

Migraines

A typical migraine has several phases:

Pre-phase (prodrome): Migraines often manifest some hours or even one or two days in advance with warning symptoms, the so-called prodrome.

·         Nervousness, irritability, concentration difficulties, withdrawal

·         Euphoria, hyperactivity, indifference

·         Sensitivity to light and noise, disturbed vision (shimmering, blind spots), frequent yawning

·         Ravenous appetite or loss of appetite, thirst, diarrhoea, constipation

·         Feeling cold

Aura: A so-called aura is seen in around 15% of migraine sufferers. This involves dysfunction of the brain or brain stem, which can last from a few minutes to an hour. There may be disturbed vision, paraesthesia (tingling or burning) in the extremities or face and, more rarely, temporary paralysis.

Headache phase: Typically, the medium-to-strong, generally one-sided, throbbing headaches are worsened by activity and often last hours or days.

There may also be:                                                                 

·         Nausea, vomiting, sensitivity to light

·         Sleep disturbances

Recovery phase: While the headache is subsiding, there is often tiredness, weakness or low mood.

Tension headaches

·         Headaches are oppressive, dragging, not throbbing.

·         Light to moderate pain, with physical activities usually still possible.

·         The pain is on both sides of the head, often around the temples.

·         Rarely: sleep disturbances, dizziness, nausea and disturbed vision.

Cluster headaches

·         Extremely heavy stabbing or piercing headaches that appear in clusters during the day, but more commonly at night

·         Repeated, usually daily clusters (serial headache attacks, up to 8 times a day), that can last from minutes to hours, or can even occur over days or weeks.

·         Then there are often no symptoms for months or years

 

Diagnosis (tests)

To diagnose the various types of headache, a particularly clear, detailed medical and family history is needed, including the symptoms. Keeping a headache diary can provide important evidence for diagnosis and treatment.

Migraine history should include:

·         Start, localisation and duration of headaches

·         Frequency of attacks and intensity of pain (0–10 scale, 0=no pain, 10=greatest conceivable pain)

·         Type of pain (sharp, dull, stabbing)

·         Other symptoms (dizziness, visual disorders, paraesthesia)

·         Trigger factors

·         Factors that increase or reduce pain

·         Context of migraines (work, school, family, anxiety)

·         Individual resilience

·         Work, leisure and social habits

·         Family history

·         Time frame (if possible over years)

·         Previous treatment and its outcome

·         Medication taken (overconsumption -–headache tablets can also lead to headaches!)

·         Expectations and motivation

Further possible tests

·         Neurological, physical tests

·         Possible lab tests, if other diseases are potential causes

·         Computed tomography (CT) or magnetic resonance imaging (MRI), only if tumours, damage or brain haemorrhage, for example, are potential causes

Treatment

Migraines

Triptans, a modern drug group, both cause vasoconstriction (narrowing of blood vessels) and limit the release of inflammatory substances. They counteract other symptoms, such as nausea, vomiting and sensitivity to noise and light. It is important to keep a migraine diary on which doctors can base treatment.

Alternative supplementary treatment

·         Regular exercise, stress management

·         Acupuncture, massage

·         Relaxation techniques

·         Recognising and removing trigger factors (migraine diary)

·         Bed rest, darkness, sleep, cold or warm compresses

Tension headaches

Occasional tension headaches can be treated with painkillers (aspirin or paracetamol): these should only be used in a controlled way over the short term; relaxation exercises and/or massage can also help. It is vital to avoid risk factors and triggers as far as possible.

Alternative therapies

·         Acupuncture, acupressure

·         Heat or cold therapies

·         Contrast bathing (foot or full-body to stimulate circulation: no warmer than 38°, followed by a cold shower)

·         Muscle relaxation, autogenic training, yoga

Cluster headaches

Triptans are used for cluster headaches, as for migraines. These can be administered by the person affected themselves, as an injection under the skin or as a nasal spray. Normal painkillers do not generally work. Inhaling 100% oxygen through a mask is also effective. Calcium antagonists such as verapamil and steroids are used for prevention.

Otherwise, patients should use the same measures as for migraines, including keeping a headache diary.