‘Tension Headache’ or ‘Migraine Without Aura’ or ‘Mixed’ Headache?

October 12, 2009 by dean · Leave a Comment 

Diagnosis cannot be done from symptoms alone

Diagnosis cannot be done from symptoms alone

This study from Spain demonstrates that diagnosing headache and migraine cannot be done from symptoms alone.

One hundred and five GPs were asked to examine and treat a patient who was considered (according to the International Headache Society’s diagnostic criteria) to be suffering migraine without aura.

Forty six diagnosed migraine correctly, 41 diagnosed the patient as tension-type headache, whilst 17 concluded ‘mixed’ headache and one GP was unable to diagnose the patient. One hundred and three recommended anti inflammatory medication as symptomatic treatment. Triptans were recommended by 67 GPs (including 15 of the 41 who had diagnosed the patient as tension-type headache). Preventive treatment was not considered by 30 GPs. A total of 66 GPs would prescribe beta-blockers (13 of the 41 who diagnosed tension-type headache), 35 amitriptyline (of whom 23 diagnosed tension-type headache) and the remaining 9, other treatments.

I have always maintained that a ‘diagnosis’ is not particularly useful – this study supports my clinical experience – what is the point of a diagnosis. The key to successful management is finding the source of the sensitisation; whilst the triptans may decrease the sensitisation they do not remove the source.

A skilled examination of the structures of the upper neck can identify relevant disorders – this involves temporary reproduction (and easing as the technique is sustained) of familiar head pain.

Cheers

Dean

(Pascual J, Sanchez A, Castillo J Dif?culties for diagnosing and treating migraine among general practitioners Cephalalgia 2009;29(Suppl. 1):1–166)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

The Enormous Amount of Research

September 6, 2009 by dean · Leave a Comment 

Despite the enormous amount of research into the various forms of headache and migraine their cause remains a mystery.

To help you, the headache or migraine sufferer know the source of you pain as precisely as possible, latest research into headache and migraine is summarised on this website.

This includes research into migraine, tension-type headache, cluster headache, paroxysmal headache, hemicrania continua, post-traumatic headache, menstrual migraine, sinus headache and cervicogenic (neck) headache.

Cheers

Dean

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Paroxysmal Hemicrania Related to Menstruation

August 15, 2009 by dean · Leave a Comment 

Here we go again – another headache type that occurs within the menstrual period!  Last count it was migraine, tension-type headache, cluster headache …

This case study describes a 43 year old woman who initially had menstrual related migraine which later developed into a typical paroxysmal hemicrania (similar to cluster headache). So here we have menstrual migraine and menstrual paroxysmal hemicrania in the one person, both of which responded to the ‘triptans’.

Just further evidence supporting that headache and migraine develops from one condition – sensitisation of the brainstem (remember that the ‘triptans’ desensitise the brainstem).

Cheers

Dean

(Maggioni F. Menstrual paroxysmal hemicrania, a possible new entity? Cephalalgia 2007;27:1085-1087)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Menstrual Tension-type Headache?

August 14, 2009 by dean · Leave a Comment 

Menstrual headaches can vary in severity from one cycle to the next

Menstrual headaches can vary in severity from one cycle to the next

Now we have menstrual tension-type headache described. When will it all end – the last thing we need now is another headache type!

The authors interviewed 165 women with menstrual related headache and found that the characteristics of tension-type headache were evident in 21.

Isn’t this what some authorities are saying – that all headache and migraine arises from the same disorder?

Menstrual tension-type headache is just a less severe expression of menstrual migraine.

Don’t get me wrong, this is my clinical experience also. I see women whose menstrual headaches vary in severity from one cycle to the next, and some women whose headaches are less severe than those in other women, so Yes, it can present as what is considered a tension-type headache (but its not tension!).

What is needed is to determine the source of the sensitisation – and basic neuro anatomy and research tells us that neck disorders have the potential to sensitise the brainstem.

Cheers

Dean

(Arjona A et al. Menstrual Tension-Type headache: Evidence for Its Existence. Headache 2007;47:100-103)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Migraine, Sinusitis and Recurring Headache in Children

August 8, 2009 by dean · Leave a Comment 

Examine the upper necks of children before sinus surgery

Examine the upper necks of children before sinus surgery

Given what we know about ‘sinus’ headache in adults, it is not surprising that a recent survey has concluded that children with recurrent headaches are misdiagnosed as sinus headache and receive unnecessary Xrays and sinus treatment.

Of 214 patients, approximately 40% of patients with migraine and 60% with tension-type headache had been misdiagnosed as ‘sinus’ headache; treatment of sinuses had no effect in 60%; and of those 53% patients who had had Xrays, 50% were normal.

Examination of the upper neck in children with recurrent (and ‘suspected’ sinus) headache is as important as it is in adults. This is relatively inexpensive and does not involve radiation ….

Cheers

Dean

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

(Senbil N et al. Sinusitis in children and adolescents with chronic or recurrent headache: a case-controlled study. J Headache Pain 2008 Feb;9(1):33-6)

Migraine and Sinus Headache

August 6, 2009 by dean · Leave a Comment 

Sinus Pain

Sinus Pain

Of 2991 patients with a self-described or physician diagnosis of ‘sinus’ headache, an overwhelming 88% were diagnosed as migraine!

Clearly, as the researchers concluded, migraine (not to mention tension-type headache) should be considered and indeed the most likely cause of facial pain.

Cheers

Dean

(Schreiber CP et al. Prevalence of migraine in patients with a history of self reported or physician-diagnosed “sinus” headache. Arch Intern Med 2004 Sep 13;164(16):1769-72)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Triggers of Tension Headache and Migraine Are No Different

July 14, 2009 by dean · Leave a Comment 

After comparing the triggers of migraine, tension headache and combined tension-type headache/migraine, no differences were found. In this research, patients, irrespective of their diagnosis, reported that emotional, dietary, physical, environmental, and hormonal factors were equally likely to trigger their headache or migraine … more evidence of a single headache and migraine process.

Can you imagine the delight of my patients when, having for years avoided chocolate or red wine (fancy living a life without chocolate or a glass of red wine!), and after treatment, chocolate, red wine, cheese etc no longer triggered headache or migraine. Clearly, neck disorders were sensitising their brainstem.

One authority suggests that dietary factors alone are not sufficient to trigger headache or migraine – that they probably act on a pre-existing condition.

Cheers

Dean

(Amery WK, Van den Bergh V. What can precipitating factors teach us about the pathogenesis of migraine? Headache. 1987;27:146-150

Scharff L, Tirk DC, Marcus DA. Triggers of headache episodes and coping responses of headache diagnostic groups. Headache 1995;35(7):397-403)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

How Many More Headaches or Migraines Are We Going to See?

July 13, 2009 by dean · Leave a Comment 

Bath Related Headache

Bath Related Headache

I read with some frustration of a new headache type being reported – ‘Bath-related headache’!

There is not one year that goes by when another headache is described and introduced to the headache and migraine mass! In the last couple of years, pony-tail headache and chewing gum headache have been recognised – when will it stop!

All headache and migraine lie on a continuum with ‘migraine’ representing severe headache at one end of the spectrum and the relatively mild tension-type headache at the other end of the spectrum. As one authority has explained, using ‘migraine’ to describe acute headache in this way is similar to using the term ‘hypertension’ to report the extreme end of the blood pressure continuum.

Headache and migraine is becoming unnecessarily complicated and it need not be!

Cheers

Dean

(Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes – prolonged effects from a single injection. Pain 2006; 122:126-9) 2009

Anderson CD, Franks RA. Migraine and tension headache: is there a physiological difference? Headache 1981; 21:63-71

Cady R, Schreiber C, Farmer K, Sheftell F. Primary headaches: a convergence hypothesis. Headache 2002; 42:204-16

Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 1985; 25:194-8

Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 1985; 25:194-198

Marcus DA. Migraine and tension-type headaches: the questionable validity of current classification systems. Clin J Pain 1992; 8:28-36

Marcus D, Scharff L, Mercer S, Turk D. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache 1999; 39:21-27

Mercer S, Marcus DA, Nash J. Cervical musculoskeletal disorders in migraine and tension-type headache. Paper presented at the 68th Annual Meeting of the American Physical Therapy Association; 1993; Cincinatti, Ohio

Nelson CF. The tension headache, migraine headache continuum: A hypothesis J Manipulative Physiol Ther 1994; 17:156-167

Tanaka M, Okamoto K. Bath-related headache: a case report. Cephalalgia 2007;27:563-565

Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: A descriptive study. J Manipulative Physiol Ther 1992; 15:418-429)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Sumatriptan Effective in a Range of Headache and Migraine

July 12, 2009 by dean · Leave a Comment 

One hundred and fourteen patients were diagnosed as migraine, 76 as tension-type headache, and 42 were not able to be classified according to the International Headache Society’s diagnostic criteria.

Ninety six per cent of migraineurs responded to sumatriptan, whilst it was effective in 97% and 95% of tension headache sufferers and unclassifiable headaches respectively .

This response clearly demonstrates that there is a common underlying mechanism for a range of headache and migraine conditions – and the recent research suggests that it is a sensitised brainstem – and the action of sumatriptan? It desensitises the brainstem.

A thorough examination of the upper neck will either confirm of negate cervical disorders as the sensitising source.

Cheers

Dean

(Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes – prolonged effects from a single injection. Pain 2006; 122:126-9) 2009

Anderson CD, Franks RA. Migraine and tension headache: is there a physiological difference? Headache 1981; 21:63-71

Cady RK, Gutterman D, Saires JA, Beach ME. Responsiveness of non-IHS migraine and tesnion-type headache to sumatrptan. Cephalalgia 1997;17:588-90

Cady R, Schreiber C, Farmer K, Sheftell F. Primary headaches: a convergence hypothesis. Headache 2002; 42:204-16

Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 1985; 25:194-198

Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 1985; 25:194-8

Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151

Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain1996; 119:1419-28

Katsavara Z, Giffin N, Diener HC, Kaube H. Abnormal habituation of ‘nociceptive’ blink reflex in migraine – evidence for increased excitability of trigeminal nociception. Cephalalgia 2003; 23:814-819

Katsavara Z, Lehnerdt G, Duda B, Ellrich J, Diener HC, Kaube H. Sensitization of trigeminal nociception specific for migraine but not pain of sinusitis. Neurology 2002; 59:1450-1453

Kaube H, Katasavara Z, Przywara S, Drepper J, Ellrich J, Diener HC. Acute migraine headache. Possible sensitization of neurons in the spinal trigeminal nucleus? Neurology 2002; 58:1234-1238

Marcus D, Scharff L, Mercer S, Turk D. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache 1999; 39:21-27

Marcus DA. Migraine and tension-type headaches: the questionable validity of current classification systems. Clin J Pain 1992; 8:28-36

Mercer S, Marcus DA, Nash J. Cervical musculoskeletal disorders in migraine and tension-type headache. Paper presented at the 68th Annual Meeting of the American Physical Therapy Association; 1993; Cincinatti, Ohio

Milanov I, Bogdanova D. Trigemino-cervical reflex in patients with headache. Cephalalgia 2003; 23:35-38

Nardone R, Tezzon F. The trigemino-cervical reflex in tension-type headache. European Journal of Neurology 2003; 10(3):307-312

Nardone R et al Trigemino-Cervical Reflex Abnormalities in Patients with Migraine and Cluster Headache. Headache 2008; 48(4):578-585

Nelson CF. The tension headache, migraine headache continuum: A hypothesis J Manipulative Physiol Ther 1994; 17:156-167

Sandrini G, Cecchini AB, Milanov I, Tassorelli C, Buzzi MG, Nappi G. Electrophysiological evidence for trigeminal neuron sensitisation in patients with migraine. Neurosci Lett 2002; 317:135-138

Sjaastad O, Fredricksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998; 38:442-5)

Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: A descriptive study. J Manipulative Physiol Ther 1992; 15:418-429)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Blood Vessels and Migraine

June 11, 2009 by dean · Leave a Comment 

Blood Vessels of the Neck and Brain

Blood Vessels of the Neck and Brain

The medical model of headache and migraine recognizes two conditions – migraine and tension-type headache. Recently the International Headache Society introduced a third ‘group’ of headaches; this group comprises Cluster Headache, Chronic Paroxysmal Hemicrania, SUNCT, and Hemicrania Continua.

In this model, the pain of migraine is considered to be from dilating or expanding arteries inside the head – an assumption based largely on the nature of pain – a throbbing, pulsating pain.

However research has shown:

Blood vessel dilatation persists after head pain has resolved – if dilatation were the cause of the pain one would expect pain to be there if dilatation was present, but this is not the case.

Blood vessel dilatation is not present in all migraineurs during an attack – if it was the cause one would expect it to be present in all sufferers.

Blood vessel dilatation is estimated to be about nine percent – too small to cause the significant pain of migraine?

Pain leads to or causes dilatation, not dilatation first, followed by pain.

Clearly this body of research demonstrates that dilatation of arteries is not the cause of migraine pain – why is it then that some authorities and information sources perpetuate this assumption?

Cheers

Dean

(Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151

Tegeler CH, Davidai G, Gengo FM, Knappertz VA,Troost BT, Gabriel H, Davis RL. Middle cerebral artery velocity correlates with nitroglcerin-induced headache onset. J Neuroimaging 1996; 6(2): 81-6

Thomsen LL, Iverson HK, Olesen J. Cerebral bloodflow velocities are reduced during attacks of unilateral migraine without aura. Cephalalgia 1995; 15(2): 109-116

Thomsen LL. Investigations into the role of nitric oxide and the large intracranial arteries in migraine headache. Cephalalgia 1997; 17:873-95)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.