Introduction

Headache is one of the most common reasons patients seek help from primary care providers. In both the office and emergency room, migraine headaches cause more physician visits than all other types of headaches. Migraine headaches are a common disorder and affect nearly one in every four households in the United States. In fact, 18% of women and 6% of men suffer from migraine.

There are roughly 21 million American women and 7 million men with migraine headaches. Migraine headaches occur most frequently in both men and women between the ages of 25 and 55. Estimates of the prevalence of tension-type headache vary with ranges from 28% to 63% in men and 34% to 86% in women.

Classic Migraine

Frances, our next patient, has classic migraine headaches which respond to triptans.

This patient described classic migraine headaches beginning in the scalp and the right eye and then going into both eyes. She also has associated nausea, vomiting, and a scintillating scotoma. These are classic features of migraine headaches. Other symptoms include slurred speech and numbness of an extremity. These focal symptoms are what makes one decide to do a study such as an MRI or CAT scan of the brain. Another reason for doing a neurodiagnostic study is if the pattern of headaches changes, and she described that her pattern did change. She takes two types of medications. She takes an abortive medication (sumatriptan) and a preventative medication, (nortriptyline). Using the nortriptyline has reduced the frequency of her migraine headaches and she uses less triptan.

Menstrual Migraine

In our next case, Terri has menstrual migraine. This is a very specific type of migraine and it appears to be hormone-related.

Terri takes sumatriptan (Imitrex®), usually 100 mg, for her menstrual migraine headaches and she usually gets 100% relief of her symptoms. She sometimes has to take a second drug, naratriptan (Amerge®), which also helps relieve the pain. The most important aspect of menstrual migraine is that the patient knows exactly when the headache is beginning, so that it can be treated early and more effectively.

Combination Migraine and Tension-type Headaches

Regina is our next patient. She has a combination of both migraine and tension-type headaches.

Regina uses sumatriptan for both types of headaches. The Spectrum study showed that sumatriptan would work for multiple headache types, provided that one had migraine headaches.13 She also uses sumatriptan for her neck pain prior to the development of a severe headache and there is faster relief of the pain if she uses the medication early.

Migraine and Sinusitis

Our next patient is Jill. She has both migraine headaches and sinusitis masquerading as migraine and both respond to a triptan.

Jill has migraine headaches which, interestingly enough, begin behind the right ear and then move into the right side of the face. She describes the pain as always beginning behind the right ear. Many patients have pain beginning either in the neck or around the ear, and not always located around one eye, and it is a fallacy to believe that the pain is always unilateral. She tried zolmatriptan for both her migraine headaches and the sinusitis-type headaches and both were relieved within 30 minutes.

Classic Migraine Masquerading as Sinusitis

The next patient is Michael. Michael has classic migraine masquerading as sinusitis.

Michael is fairly typical of many patients who have similar symptoms and are diagnosed by their family physicians and otolaryngologists as having sinusitis and headaches associated with sinusitis. They are treated with antihistamines, antibiotics, analgesics, and antiinflammatory medications with only partial relief. Usually they are very dissatisfied with the partial relief these medications provide, and they are also dissatisfied with the diagnosis. He was tried on sumatriptan and the medication works very well. He is fairly classic in that he has migraine rather than sinusitis.

Cluster Headaches

No review of migraine would be complete without a discussion of cluster headaches. Cluster headaches are a distinct, although rare, clinical entity that occurs in 0.4% of the population. Attacks of headache occur several times a day in "clusters" for several days or weeks at a time. The headaches are shorter than migraine, last from 15 to 30 minutes and up to 2 to 3 hours. The pain is usually severe, knife-like, unilateral, and usually centered around the orbits or supraorbital area. Autonomic features such as conjunctival injection, lacrimation, nasal congestion, rhinorrhea, miosis, ptosis and eyelid edema are all part of the syndrome. Patients are then headache-free between clusters. Unlike migraine, cluster headache is predominantly a male disorder beginning between ages 20 and 50, with a male to female ratio of 4 to 1. Joe has cluster headaches which occur every 4 months or so and, usually, the headaches last anywhere from 2 to 4 weeks. A headache can last anywhere from minutes to hours.

Joe represents a typical case of cluster headaches. He has tried multiple medications in the past. He now has 100% relief from sumatriptan injections. Because cluster headaches are so brief, injectable sumatriptan or nasal sumatriptan are the only triptans which work fast enough to give the patient relief of his headaches.

Treatment of Cluster Headaches

1. Oxygen is the standard recommended treatment with 100% oxygen administered at 7 to 10 liters/minute for approximately 15 minutes. Approximately 70% of patients will get some relief from their pain.
2. Subcutaneous sumatriptan is an effective medication for acute symptoms. The medication may have to be repeated with a second dose.
3. Prednisone given in large doses during an attack will help suppress headaches.

Tension-type Headache

The next patient is a young female who has classic tension-type headaches associated with stress and her menstrual cycle.

The patient has tension-type headaches with neck pain radiating into the temples and then into the head and she describes the pain as if she has a "band around the head". There are no associated symptoms. No neurodiagnostic studies were ever done because her history is so typical. She responds to minor analgesics such as Tylenol, aspirin, or minor antiinflammatory medications.

Episodic tension-type headaches often lead to chronic tension-type headaches. Daily headaches may also develop in patients with a history of episodic tension-type headaches. These headaches are more often diffuse or bilateral, frequently involving the posterior aspect of the head and neck.

Rebound Headaches

Our final patient is Sue. Sue was diagnosed with rebound headaches.

Sue has classic rebound headaches. The headache can be stopped with minor analgesics, but soon returns and she has to use the analgesic again. This pattern may be repeated several times during the day. The only treatment for rebound headaches is to remove the offending medication, in this case Tylenol. After the medication is removed, one can use an antiinflammatory agent or steroids while the offending medication is tapered. Usually, the headache resolves. Most primary care providers are unaware of this common type of headache disorder.

NOTE: Vioxx, used in Sue's treatment, has been removed from the market.

Lymphoma of the Brain

Our next case presentation is Jerry. His diagnosis is lymphoma of the brain. He presented with a headache and on his examination had evidence of increased intracranial pressure.

This case is extremely important for a number of reasons. His headache complaints were nonspecific. He was describing bitemporal sharp pain. When he first saw his family physician, he was treated for allergies. In terms of his complaints, he mentioned that he listed to the left when he walked. This is an extremely important point and helps to separate a secondary headache disorder from a primary headache disorder. This would also suggest that an MRI of the brain or a CAT scan of the brain be done, both with and without contrast. This case shows how important it is to do a funduscopic examination on every patient with headaches, looking for papilledema. And, finally, Jerry presented with new onset headache and was over the age of 50, and I think you will find that these are key points of the history.

Tumor

In our next case, Kenneth has a tumor, a glioblastoma multiforme grade 3. He initially presented with a nonspecific headache located in the front of the scalp and was treated with sinus-related medication and antibiotics.

Kenneth is another example of a secondary headache disorder. When initially seen he had no symptoms other than the headaches, but later developed left hand contractions and urinary The Diagnosis and Treatment of Headache Disorders for Primary Health Care Providers incontinence. These are focal neurological findings and both of these would indicate that we are dealing with a secondary headache disorder. When a patient presents like this an MRI or CAT scan of the brain is indicated.