What Type of Headache do I have?

David M. Biondi, DO

Director, Headache Management ProgramsSpaulding Rehabilitation Hospital

Consultant, Massachusetts General Hospital

Instructor in Neurology, Harvard Medical School

Boston, MA

SinusSinus

TreatmentTreatment

TensionTension

MigraineMigraine

The Headache Dilemma…The Headache Dilemma…

Headache in the Population

• 99% of women and 93% of men have had headache during their lifetime

• 25% of women and 8% of men in the United States have had migraine headache

• 18% of women and 6% of men have had migraine over the previous year

• Prevalence is highest between age 25 – 55 years

• An estimated 30 million have migraine and up to 10 million have chronic daily headache (> 15 headache days per month) in the U.S.

Headache History• Headache attacks

– How it begins• Precipitating event, illness, injury

• Headache attack descriptions– Frequency and patterns

• Any significant changes

– Location– Time to peak intensity– Duration– Quality and intensity– Warning symptoms and aura– Associated symptoms and level of disability– Triggers and aggravating or relieving factors

Tension Headache or Migraine?

Tension-type Headache or Migraine?

12

40

29

44

75

120

10

20

30

40

50

60

70

80

Tension-Type Headache Migraine

Population

Waiting Room

SignificantHeadaches*

Migraine is 6.3x more common than TTH

* People who want to talk to the doctor about their headaches or who have headaches that interfere with daily activities.

Lipton RB et al. Neurology. 2003;61:375-385.

Percent(%)

TTH is 3.3x more common than migraine

TTH is 1.5x more common than migraine

Episodic Tension-type Headache

A. Number of days with such headache < 180/year (<15/month)

B. Headache lasting from 30 minutes to 7 days

C. At least 2 of the following:• Pressing/tightening (non-pulsating) quality• Mild or moderate intensity (may inhibit, but does not prohibit activities)• Bilateral location• No aggravation by walking stairs or similar routine physical activity

        D. Both of the following:• No nausea or vomiting (anorexia may occur)• Photophobia and phonophobia are absent, or one but not the other is present

        E. At least 10 previous headache episodes fulfilling these criteria

F. No evidence of organic disease

Migraine Without Aura

A. Headache lasting from 4 to 72 hoursB. At least 2 of the following

• Unilateral location• Pulsating quality• Moderate or severe intensity• Aggravation by routine physical activity

C. At least 1 of the following:• Nausea and/or vomiting• Photophobia and phonophobia

D. At least five attacks fulfilling these criteriaE. No evidence of organic disease

Tension-type Headache or Migraine

Tension-Type Migraine

Mild

Moderate

Severe

Unilateral

Bilateral

Photophobia

Nausea

Throbbing

Pressure

Aura

Vomiting

Aggravated by Activity

© 2002 Primary Care Network

Migraine Aura• Positive Neurological Symptoms

– Reversible brain/neurological symptoms• Visual flashes, spots, or zig-zag lines• Traveling tingling sensations

– Gradual development over >4 minutes– Resolves within 1 hour

• Negative Neurological Symptoms– Reversible brain/neurological symptoms

• Visual blind spots• Numbness• Speech or word finding problems• Trouble thinking

– Resolves within 1 hour

“Even My Hair Hurts”(allodynia)

• Cutaneous allodynia– “Hair hurts”– Painful when:

• Shaving• Combing hair• Touching scalp• Resting head on pillow• Pulling hair back (wearing

a ponytail)• Wearing eyeglasses or

contact lenses• Wearing hat or head band

• Other painful events– Water hitting head or

face while showering– Breathing through nose

especially cold air– Cooking over a hot

stove– Rubbing the neck or

shoulders– Hanging head down or

bending over

Neck Pain During Migraine

• Prevalence – 75% of subjects

• Descriptions – 69% - tightness

– 17% - stiffness

– 5% - throbbing

– 5% - other

61%

92%

41%

0%

20%

40%

60%

80%

100%

Prodrome Postdrome

Migraine Phase

Kaniecki R. Neurology. 2002;58(Suppl 6):S15-S20.

82% had previously been 82% had previously been given a diagnosis of given a diagnosis of tension-type headachetension-type headache

Migraine Pain Intensity and Disability

0

10

20

30

40

50

Mild ModeratelySevere

Severe ExtremelySevere

>75% Report Severe to >75% Report Severe to Extremely Severe PainExtremely Severe Pain

Lipton RB et al. Headache. 2001;41:638-645.

Patients Patients

(%)(%)

39% 39%

Some Some ImpairmentImpairment

9% Function Normally9% Function Normally

53% 53%

Severe Severe Impairment Impairment or Bed Rest or Bed Rest

RequiredRequired

Dilemmas in Diagnosing Migraine• Visual aura

– only 15-20% of migraineurs• Head pain can be non-throbbing

– in ~40% of patients• Head pain can be bilateral

– in ~ 43% of patients1 • Sinus pain and pressure, stuffiness, rhinorrhea &

weather association is often present – in up to 97% of migraine attacks2

• Neck pain is often present – in up to 75% of migraine attacks3

1. Data on File. GlaxoSmithKline.2. Cady RK, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.3. Kaniecki RG, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.

Sinus Headache or Migraine?

MythMythHeadaches that are triggered by weather or Headaches that are triggered by weather or are associated with sinus symptoms are not are associated with sinus symptoms are not migraines.migraines.

FactFact Up to 50% of migraine patients report their Up to 50% of migraine patients report their

headaches are influenced by weatherheadaches are influenced by weather11

45% of migraine patients report sinus 45% of migraine patients report sinus symptoms includingsymptoms including22

–– LacrimationLacrimation

–– Nasal congestionNasal congestion

–– RhinorrheaRhinorrhea1. Raskin NH. Headache. 2nd ed. New York: Churchill Livingstone; 1998. 2. Barbanti P et al. Cephalalgia. 2001;21:295.

• Major factors – Purulence in nasal cavity on

exam – Facial pain/pressure/congestion*– Nasal obstruction/blockage/

discharge– Fever (in acute only) – Hyposmia/anosmia

* Facial pain/pressure alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign.

* American Academy of Otolaryngology-Head and Neck Surgery Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7.

Headache: A Minor Criteria in AAO-HNS Sinusitis

• Minor factors – Fever (chronic) – Halitosis – Headache – Fatigue – Dental pain – Cough – Ear pain/pressure/fullness

Headache is a minor factor in the diagnosis of rhinosinusitis, according to AAO-HNS*

N = 2424N = 2424

“Sinus” Symptoms

Are Common in the Presentation of Migraine

0% 20% 40% 60% 80% 100%

27%Itchy Nose

38%Watery Eyes

40%Runny Nose

63%Nasal Congestion

82%Sinus Pain

84%Sinus Pressure

25%Vomiting

29%Aura

67%Phonophobia

79%Photophobia

85%Worsened by Activity

89%Pulsatile

97%Moderate/Severe Pain

IHS Migraine Symptoms

Schreiber C. Poster presented at: American Headache Society Meeting; June 21-23, 2002;Seattle, WA.

“Sinus Symptoms”

“Sinus” Headache in Primary Care

10%

8%

82%

0% 20% 40% 60% 80% 100%

Percentage of Subjects

10%

8%

82%

0% 20% 40% 60% 80% 100%

Percentage of Subjects

Migraine w/o or with AuraIHS 1.1, 1.2

MigrainousIHS 1.7

Other

Source: SUMMIT Study

n=2520

One Nerve Pathway:Multiple Symptoms of Migraine

One Nerve Pathway:Multiple Symptoms of Migraine

Summary• Tension-type headaches are very common in the

general population

• Migraine headaches are also common but are more common than tension-type headaches in medical clinics because of greater severity and disability

• True “sinus headaches” are uncommon

• Sinus symptoms and neck pain are very common symptoms of migraine

• Most cases of recurrent “sinus headaches” are migraine especially if there is a family history of recurrent or chronic headaches