Introduction to Types of Headaches and Lecture Objectives
Peace be upon you. In this lecture and the next one, God willing, we will discuss the topic of headaches. This lecture aims to discuss the warning signs "Red Flags", the difference between primary headaches and secondary headaches, as well as how to take a medical history, clinical examination, and diagnosis. Today, we will focus on primary headache disorders, while the next lecture will be dedicated to secondary headaches.
Case Study: Secondary Headache (Temporal Arteritis)
I will start by presenting a case of a patient I saw recently; she is 55 years old, suffering from diabetes, hypertension, and high blood lipids. She came complaining of a headache on the right side that started three weeks ago. She described it as a new onset and intermittent headache. She visited the emergency center, and they performed a CT scan of her brain, which was normal, and she was initially diagnosed with trigeminal neuralgia and given the drug "Carbamazepine" at a dose of 100 mg twice daily, but the headache continued.
Upon examining her in the neurology clinic, I noticed three important signs:
- New onset headache at the age of 55.
- Severe headache in the temporal area.
- Presence of joint pain.
During the clinical examination, the neurological examination was normal, but there was pain upon touching the right temporal area. Here, I suspected a secondary headache called "temporal arteritis." I requested blood tests (ESR, CRP, CBC) and prescribed a high dose of steroids (Prednisolone 60 mg). The results showed a significant increase in ESR and CRP, confirming the high probability of the diagnosis, and she was referred to the hospital for further treatment with intravenous steroids and a biopsy of the temporal artery.
The Difference Between Primary and Secondary Headaches
The idea behind presenting this case is to distinguish between the two types:
- Primary Headache: Accounts for about 90% of cases. It is usually not life-threatening and does not cause permanent problems. It includes migraines, tension headaches, and cluster headaches. In this type, tests and scans are normal (Negative).
- Secondary Headache: Accounts for about 10-12%, but it can be life-threatening or vision-threatening. It is caused by another organic cause such as subarachnoid hemorrhage, brain tumors, or temporal arteritis.
Warning Signs (Red Flags)
When receiving a headache patient, you should look for the following signs that require in-depth tests:
- Sudden onset: Such as "thunderclap headache."
- Neurological symptoms: Presence of weakness on one side, speech problems, or double vision.
- Fever and stiff neck: May indicate meningitis.
- Age: New onset headache for a person over the age of fifty.
- Positional change: Headache that worsens with a change in body position or coughing (Valsalva).
- Change in pattern: A patient with chronic headache but its nature has suddenly changed in terms of severity or frequency.
Diagnosis of Primary Headache Disorders
If the warning signs are negative, we proceed to diagnose primary headache based on a detailed medical history:
1. Tension-type Headache
This is the most common type and is characterized by:
- It lasts from 30 minutes to 7 days.
- It is on both sides of the head (Bilateral).
- It is described as pressure or a "band" around the head.
- Its severity is mild to moderate and does not increase with physical activity.
- It is not accompanied by nausea or vomiting.
2. Migraine
It is characterized by:
- It lasts from 4 to 72 hours.
- It is usually on one side (Unilateral).
- It is described as throbbing or pulsating.
- Its severity is moderate to severe and increases with physical activity.
- It is accompanied by nausea, vomiting, sensitivity to light (Photophobia), or sound (Phonophobia).
- About 15-20% of cases are preceded by "aura."
3. Cluster Headache
This is less common and more prevalent among men:
- It is characterized by very severe attacks that last from 15 minutes to 3 hours.
- It is concentrated around the eye.
- It is accompanied by symptoms on the same side such as eye redness, tearing, runny nose, or drooping eyelid (Ptosis).
- It is characterized by long periods of activity and inactivity (Headache-free periods).
Treatment Strategies
Treatment of Migraine Attacks (Abortive Treatment)
- Triptans: Such as "Sumatriptan." It works by constricting blood vessels.
- Contraindications: Patients with heart disease, strokes, or uncontrolled hypertension.
- Pain relievers: Such as ibuprofen, naproxen, and paracetamol (Tylenol).
Preventive Treatment
This is given if the patient suffers from 4 or more attacks per month:
- Medications: "Amitriptyline," "Topiramate," and "Propranolol."
- Drug selection: Depends on the patient's condition; for example, "Topiramate" is preferred for those suffering from obesity as it reduces weight, while "Propranolol" is avoided for asthma patients.
Treatment of Cluster Headache
- Immediate treatment: 100% oxygen or sumatriptan injections.
- Preventive treatment: "Verapamil" is the first choice.
Treatment of Tension Headache
- Acute treatment: If the attacks are less than 15 days per month, we use non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or acetaminophen (Tylenol).
- Preventive treatment: If the headache is chronic (more than 15 days per month), we use "Amitriptyline" in low doses, or sometimes selective serotonin reuptake inhibitors (SSRIs) such as "Fluoxetine" if there is accompanying tension or anxiety.
Discussion of Questions and Clinical Cases
First Case: Heart Patient and Smoker
A 50-year-old patient suffering from high blood pressure, high cholesterol, and a smoker who does not adhere to his medication. He came with a severe migraine attack.
- Question: What is the "least optimal" treatment choice for him?
- Answer: "Sumatriptan."
- Reason: Because the patient has cardiovascular risk factors and uncontrolled blood pressure, and triptans cause vasoconstriction, which may pose a risk to him. A comprehensive cardiac evaluation should be conducted before prescribing it in such cases.
The Second Condition: A Patient Suffering from Obesity and Asthma
A 24-year-old woman suffering from obesity, asthma, and chronic constipation complains of an increase in the frequency of migraine attacks (3 attacks per week).
- Question: What is the best preventive treatment for her?
- Answer: "Topiramate" (Topiramate).
- Reason:
- It helps in weight loss, which is suitable for her condition.
- We avoid "Propranolol" because it is prohibited for asthma patients.
- We avoid "Amitriptyline" because it causes weight gain.
- We avoid "Verapamil" because it may worsen her constipation problem.
Audience Questions and Final Answers
1. Headache Caused by Tumors (e.g., Neurofibromatosis)
One of the attendees asked about headaches caused by neurofibromatosis. We explained that this type of headache is considered a secondary headache. It does not necessarily follow a specific pattern like migraines or tension headaches but is caused by tumor compression or increased intracranial pressure. The primary diagnosis here depends on magnetic resonance imaging (MRI).
2. Menstrual Migraine
A question about how to deal with migraines that occur only with the menstrual cycle.
- Answer: These are often linked to hormonal changes. If the attacks are limited to the menstrual period, we focus on acute treatment (Abortive) such as triptans or ibuprofen.
- Supplements like "magnesium" or "riboflavin" (Vitamin B2) can be used as simple prevention throughout the month or before the expected menstrual period to reduce the severity of attacks without the need for strong preventive drugs if the attacks are not frequent during the rest of the month.
3. Sensitivity to Light and Sound (Photophobia & Phonophobia)
A question about whether triptans treat these symptoms.
- Answer: Yes, these symptoms are part of a migraine attack and not independent diseases. When triptans treat the attack and stop the headache, the sensitivity to light and sound accompanying it disappears automatically.
4. Use of Antidepressants (SSRIs) in Tension Headaches
We confirmed that drugs like "Fluoxetine" may help in cases of chronic tension headaches, especially if the patient is suffering from psychological stress or sleep problems, where the drug is chosen based on the patient's condition (e.g., choosing a sedating drug if they suffer from insomnia, or a stimulating drug if they suffer from lethargy).
With this, we have covered the basics of primary headaches, and we will meet in the next lecture to discuss secondary headaches in detail, God willing. Thank you.