WHAT IS A HEADACHE?
A headache is one of the most common health complaints; almost everyone experiences headaches to some degree at some point in their lives. Every 10 seconds, a person in the United States visits the emergency room due to head pain. Through the Global Burden of Diseases, Injuries, and Risk Factors (GBD) studies, headache has emerged as a major global public health concern. Overall, there are two main types of headache:
The most common subtypes of primary headaches are tension headaches and migraines. Between these two, migraine causes its sufferers to seek medical care, since it is the more severe headache of the two. On the other hand, not every severe headache is migraine. Almost 3 billion individuals were estimated to have a migraine or tension-type headache.
Headache, and in particular, migraine, is one of the main causes of disability worldwide, particularly in young adults and middle-aged women. In GBD 2016, migraine was the second cause of disability after lower back pain.
Primary headache has numerous subtypes, but in practice, the majority of patients with primary headache who seek medical attention suffer from migraine.
Migraine is the 3rd most prevalent illness in the world, which can occur in children which usually goes undiagnosed. About 10% of school-age children suffer from migraine, and up to 28% of adolescents between the ages of 15-19 are affected by it. Half of all migraine sufferers have their first attack before the age of 12. However, its peak incidence is between the ages of 20-50 years. Since more than 90% of sufferers are unable to work or function normally during their migraine episodes, it places a huge burden on the community. In a UK study, migraine was the first cause of disability in persons under the age of 50. This shows that migraine patients have not been properly diagnosed and treated. In the United States, two large studies showed that “73.3% of episodic migraine patients and 95.5% of chronic migraine patients do not get appropriate treatment for their condition.” The reason for this issue is lack of education in both the medical and patient communities:
- Medical community: A remarkable percentage of healthcare providers are unaware that Headache Fellowship training within the subspecialty of neurology exists, despite the fact that the Headache subspecialty has been an established field for well over a decade. The American Headache Society, beginning in 2003, advanced the original idea for a formal headache fellowship. The United Council for Neurologic Subspecialties (UCNS) led to the introduction of the neurologic subspecialty of Headache Medicine in 2005. Since then the number of academic facilities that have developed headache fellowship programs has increased, and as of 2020 there are 44 programs offering Headache fellowships in the United States. It is important that healthcare providers be aware of physicians who have completed this specific training in Headache medicine within their communities in order to refer patients to the proper specialist. Also, there is a misconception within the medical community that any severe headache is migraine, and that any neurologist can treat the headache.
- Patient community: A majority of patients suffering from headache and migraine are unaware of the differences between neurological subspecialties, such as headache specialists, pain specialists, and general neurologists. Sometimes patients are even unaware that neurology is different from neurosurgery. Most patients select their providers using online forums such as patient groups on Facebook or other social media platforms, a general Google search, or through targeted advertisements, for which there is no oversight. Instead, patients should refer to reliable websites such as the American Headache Society or National Headache Foundationwhen searching for a provider. Most simply, patients who are seeking management for their headache can review a provider’s biography to identify whether the practitioner has been trained in an accredited headache program. It is also noteworthy for patients to take into account the fact that fellowship training and board certification in pain medicine is an anesthesiology subspecialty and differs from headache medicine training and board certification. It is crucial for patients to not only research the different treatment options available to them but also the treating physician’s qualifications. This background knowledge can tremendously help the patient stay informed and make better, more informed decisions regarding their treatment and longitudinal headache management.
Non-neurological etiologies for secondary headaches are usually underestimated since the majority of patients seek treatment from a neurologist for their headache symptoms. Some causes of non–neurological headache include disorders of spine (particularly cervical spine), disorders of the nose and sinuses, and even of the heart or kidneys. In addition, inflammatory and autoimmune disorders such as lupus can cause headache or trigger the underlying headache, particularly migraine. Therefore, it is critical that providers treating headache patients incorporate a broad view and have requisite knowledge in medicine beyond neurology. This is the reason that some of the best headache experts in the US and around the world are not neurologists. It is especially important for patients with headache to see the proper specialist, particularly if there is a possibility of secondary headache disorder.
In practice, the most common type of secondary headache and the number one reason for most visits in tertiary headache clinics is medication overuse headache, also known as “rebound headache”. Rebound headaches occur when a headache patient takes any abortive medication more than the recommended doses, which varies according to the drug. Rebound headaches can result from taking excessive doses of prescription or over-the-counter medicines, particularly Excedrin. When a migraine patient develops an overlapping rebound headache, this makes treatment more challenging.
Management of Headache
There are over 50 different subtypes of primary headache disorder. Since tension type headaches and migraines together are by far the most common headache type, we will focus on these:
Tension Type Headache
Managing a tension headache is often a balance between fostering healthy habits, finding effective non-drug based treatments, and using medications appropriately. Medication has a much less significant role in the management of a tension headache. Most patients use over-the-counter analgesic, which, as long as it is not in excess of two days a week, is usually sufficient. Acupuncture and biofeedback are also highly effective in management of tension headache.
Since a migraine is not just simply a headache, its management requires more expertise from physicians and patient education. Medical treatment is only a part of migraine management. Other vital components include developing a regular and adequate sleep and nutrition regimen, diet modification, regular exercise, sufficient hydration, relaxation techniques, yoga, and meditation. These lifestyle considerations are just as important, if not more important, than medication alone. Therefore, a proper migraine treatment program involves assembling a multidisciplinary team that can consist of a dietitian, nutritionist, physical therapist, acupuncturist, and massage therapist. Medical treatment of migraine includes the use of both abortive and preventive treatments:
- Abortive treatment: Abortive treatments are medications that all migraine patients need to use when they have a migraine headache (as needed). Although over-the-counter pain medications such as Tylenol, Advil, or Aleve can sometimes alleviate headaches in migraine patients, it is more appropriate that migraine patients use proper headache medication rather than pain medication. All migraine headache medications are prescriptions, and in order to properly use them migraine patients should be seen by a healthcare provider. There are many abortive treatment options available, which are based on migraine type, patient age, and other medical condition(s). Healthcare providers decide which option is best for each patient. It is therefore critical that the treating physician spend adequate time to go over a detailed history, and that the patient discusses all their other medical conditions. Abortive treatments may come in the form of a pill (tablet), nasal spray, dissolvable powder, or injection. Other delivery methods, including skin patches, have been in the market in the past and are currently in development.
- Preventive treatment: Some patients require preventative treatment due to an excess of monthly migraine episodes. Migraine patients who use an abortive treatment more than one day a week should consider the use of a preventive option. Patients that regularly take abortive medications more than two days a week should discuss preventive treatment options with their physician. Patients with more than 15 headaches a month (more days with headache than without) are considered to have chronic migraine and should be seen by a headache specialist.
Secondary headache management requires addressing unique causes in each individual patient by a related specialist. However, patients need to ensure they have received a correct diagnosis, since treatment of some secondary headaches may require major surgery. The variations of Secondary Headaches include:
A majority of patients who are labeled as having “sinus headaches” in fact have migraine or other types of primary headache disorder, such as cluster headache. If a patient is misdiagnosed with sinus headache and undergoes surgical intervention by an Ear/Nose/Throat (ENT) surgeon, not only will they see no improvement in their headache condition, but it will become more likely their headaches will worsen and become intractable to medical treatment. Considering sinus surgery is a relatively major procedure, it is certainly concerning that some patients undergo such an unnecessary and relatively invasive surgery. Therefore, all patients who plan to undergo surgery on the nose or sinus area for headache management must be seen and evaluated by a headache specialist prior to proceeding with surgery, and avoid a direct referral to ENT from a primary care provider or non-headache physician. It is crucial to know the difference between a headache that is directly caused by sinus or nose disease (an extremely rare condition), and a patient with migraine who has a nose and sinus disease that triggers their migraine headache (a relatively common condition). Obtaining a comprehensive history with detailed attention paid to the location of the headache and its trigger(s) can differentiate between these two conditions.
Within the last decade, there has been an increase in the overutilization of CT scans and MRI in headache medicine. It is very unfortunate that the number of patients with migraine who get MRI and CT scans has escalated tremendously. Patients should be aware that the diagnosis of migraine is a clinical diagnosis based on detailed history and examination, and that there is no role for any scan or MRI in the diagnosis of migraine. Considering advancement of imaging technology, it is not uncommon that in patients with migraine who obtain imaging scans, some “incidental” lesions are discovered. Lesions such as meningioma, arachnoid cyst, pineal cyst, pituitary cyst or even tumor, cavernous malformation, capillary telangiectasia and much more can be found during scan of any healthy individual, and so in migraine patients. These incidental lesions are almost never the cause of headache, but unfortunately patients sometimes end up having unnecessary brain surgery for these lesions. Even if these patients do not undergo unnecessary surgery, they often obtain annual follow up scans, which place a strain on healthcare utilization and can cause constant worry and fear over these incidental lesions.