Primary Headaches

“Headaches not caused by an underlying condition”

• Tension Headache
  • The most common type of headache, diffuse, feels like a tight band
• Cluster Headache
  • Recurrent severe headaches on one side of the head (around the eye)
  • Attacks come in “clusters”
• Migraine
  • Pulsating headaches on one side of the head and can be accompanied by an aura
• Trigeminal Neuralgia
  • Chromic pain condition that affects the trigeminal nerve which carries sensation from face to brain

Risk Factors

• Tension Headache
  • Teenagers & Adults
  • Women
• Cluster Headache
  • Male
  • Smoking
  • Alcohol
  • Family History
• Migraine
  • Obesity
  • Family History
• Trigeminal Neuralgia
  • Women
  • Age (>55)

Aetiology

• Tension Headache
  • Triggers include Stress, squinting and posture
• Cluster Headache
  • Unclear
• Migraine
  • Triggers include hormonal, emotional, physical, dietary, environmental, medicinal.
  • Very individual
• Trigeminal Neuralgia
  • Triggers include talking, smiling, chewing, washing, brushing, shaving and wind.

Pathophysiology

• Tension Headache – Muscular origin
• Cluster Headache – unclear
• Migraine – unclear
• Trigeminal Neuralgia
  • Compression of the trigeminal nerve
  • Can be secondary to another condition, such as a tumour, cyst, arteriovenous malformation, and MS

Clinical Presentation

• Tension Headache
  • Bilateral tight band sensation
  • Recurrent
  • Occurs late in the day
• Cluster Headache
  • Short painful attacks around 1 eye
  • 30-180 mins
  • Once/twice a day for 1-3 months
  • + lacrimation or flushing
• Migraine
  • Unilateral
  • Pulsating
  • Trigeminal nerve distribution
  • For a few hours – days
  • May have aura before
  • Worse on movement
  • Photo/phonophobia
• Trigeminal Neuralgia
  • Unilateral
  • Paroxysms of intense stabbing pain lasting seconds
  • Trigeminal nerve distribution (jaw/teeth/cheeks…)
  • Face screws up with pain

Investigations

• Tension Headache – Diagnose based on history
• Cluster Headache – Diagnose based on history
• Migraine – Diagnose based on history
• Trigeminal Neuralgia
  • Diagnose based on history
  • MRI to exclude secondary cause

Management

• Tension Headache
  • Lifestyle changes
    • exercise, yoga, improve posture, break from screens, avoid identified triggers
  • Painkillers
    • Paracetamol or ibuprofen
• Cluster Headache
  • Acute attack
    • Give 100% oxygen in non-rebreathable mask
    • Sumariptan
  • Prevention
    • Avoid triggers (alcohol)
    • Medication: CS/verapamil
• Migraine
  • Avoid identified triggers
  • Prophylactic treatment
    • Propranolol/topiramate
    • Botulinum toxin type A injections (every 12w, last resort
  • During attack
    • Oral/nasal triptan with NSAID/paracetamol
    • Antiemetics
  • Non-pharmacological
    • Warm/cold packs to head
    • Rebreathing into a paper bag
    • Acupuncture
• Trigeminal Neuralgia
  • Avoid identified triggers
  • Medicine
    • Carbamezapine
    • Other anticonvulsant e.g. phenytoin, gabapentin
  • Surgery (if drugs fail)
    • Percutaneous procedures (glycerol, radiofrequency injections, balloon compression) – x-ray directed, damages TN at Gasserian ganglion
    • Stereotactic radiosurgery
    • Microvascular decompression

Complications

• Tension Headache
  • Painkiller headache
• Cluster Headache
  • Prone to injuring themselves during an attack
  • Substance abuse
  • Depression
• Migraine
  • Increased risk of ischaemic stroke (especially with aura).
    • Risk increased by using the combined contraceptive pill
• Trigeminal Neuralgia
  • The emotional strain of repeated episodes – depression
• Avoidance of necessary and social activities

Quick Revision Sheet

Access an overview table of the Primary and Secondary headaches here (pdf)