Highlights of the 5th Annual Association of Family Practice Physician Assistants (AFPPA) Conference: Headache Management -- Evaluation and Treatment

San Antonio, Texas; November 19-23, 2003

Jim Meeks, PA-C


February 12, 2004

In This Article

Headache Classifications

Schuman identified 2 types of headache: primary and secondary. Primary headaches include those not caused by other medical conditions, specifically tension-type, cluster, and migraine headaches. Secondary headaches are the symptom of another disease or disorder, such as a tumor, infection, uncontrolled hypertension, diseases of the brain, eye, ear, or nose, or disorders related to circulation, such as a clot and aneurysm. Less than 2% of headaches are secondary headaches.[3,5]

The National Headache Foundation has categorized headaches into 3 specific groups: tension-type, neurovascular, and organically caused. Migraine and cluster headaches are considered to be neurovascular. Secondary headaches are those that are classified as organically caused, according to this categorization.[5]

Tension-type headache can be episodic, and is either a randomly occurring event that may be triggered by temporary conditions (such as stress, anxiety, fatigue, or anger), or is chronic in nature. Chronic tension-type headache typically presents as a daily or continual headache. The headache is often variable in intensity, but is almost always present.[7] Tension headaches are the most common type of primary headache, affecting nearly 80% of the adult population at some point in life.[7,8]

The International Headache Society criteria for headaches include the following characteristics for tension-type headaches: a pressing/tightening (nonpulsating) quality; mild or moderate intensity; bilateral location; and an absence of response to physical exertion or routine physical activity (ie, going up a flight of stairs).[9] A patient must have at least 2 of these criteria to be diagnosed with tension-type headache. Other criteria include the absence of nausea and vomiting, and evidence of either phonophobia or photophobia, but not both at the same time.

Migraines are a neurologic disorder and migraineurs are considered to have a hypersensitive nervous system.[2] Migraines begin with stimulation of the nervous system by various events (stress, foods, odors, hormonal changes, weather changes, depression, anxiety, sleep deprivation, etc.) that provoke neurochemical changes in the nervous system. These changes affect branches of the trigeminal nerve, resulting in release of vasoactive amines and substances that lead to inflammation of meningeal arteries and stretching of the trigeminal afferent branches. If not terminated early in the migraine event, this can initiate a feedback loop into the trigeminal ganglia.

International Headache Society diagnostic guidelines define a migraine headache as an occasional headache lasting 4-72 hours, involving any 2 of the following: unilateral location; throbbing; pain worsened by movement; or pain that is moderate or severe in nature. Also required for diagnosis is the presence of nausea with vomiting, or phonophobia and photophobia. Five episodes with symptoms that meet the aforementioned criteria are required to make the diagnosis of migraine.[9] Schuman[1] emphasized that there is no such thing as a "first migraine" based on these criteria. Migraine is only one element in the list of possible diagnoses. Other entities must be considered and ruled out first.

Only about 1 in 5 migraineurs experience aura. Aura is an electrical event. Nett[2] described it as a spreading depolarization that starts in the occipital cortex and spreads cephalically at a rate of 3 mm per minute. This was postulated as long ago as the 1950s and has now been verified by PET scan studies.

Aura presents as a visual disturbance -- blinking or brightly colored lights -- seen by the patient prior to onset of headache.[3] Visual disturbances may also present as a halo effect seen around lights or bright objects. Other aura presentations may include episodes of dizziness, confusion, syncope, dysarthria, diplopia, and vomiting, all occurring before onset of the actual headache.[4]

Cluster headaches are the least common type of headache, affecting approximately 1 million individuals annually in the United States, 20% of whom have chronic cluster headaches.[7] Men and women are affected at a ratio of 9:1, respectively. Adults aged 20-40 years most frequently suffer from cluster headaches.[8] Attacks can be triggered by consumption of alcohol, and an associated history of heavy smoking and drinking is common.[3]

A typical cluster headache has a sudden onset with little warning of the impending attack. Some sufferers describe a feeling of discomfort or a mild unilateral burning sensation prior to headache onset.[7] The headache often occurs in the middle of the night, at about the same time. Associated symptoms may include unilateral pain around the eye, tearing and inflammation of the same eye, and nasal congestion on the affected side.[3]

The pain associated with cluster headache is much shorter than that of a migraine or tension-type headache. Although it typically lasts for 30-45 minutes, it can last from a few minutes to several hours. Once the pain has resolved, it will often return later the same day. One to 4 headaches per day during the cluster cycle are common. A cluster headache cycle can last for weeks to months, followed by a headache-free period that may last from months to years.[7,8]


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