Neurology >
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
- Lifestyle changes
- Cluster Headache
- Acute attack
- Give 100% oxygen in non-rebreathable mask
- Sumariptan
- Prevention
- Avoid triggers (alcohol)
- Medication: CS/verapamil
- Acute attack
- 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
- Increased risk of ischaemic stroke (especially with aura).
- 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)