‘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.

Cluster Headache and Migraine Are Just Different Expressions of the Same Condition

October 9, 2009 by dean · Leave a Comment 

After examining six clinical trials in which cluster headache sufferers were treated with various ‘triptan’ medications it was concluded that the ‘triptans’ were effective in preventing the debilitating pain of cluster headache – just further evidence to support that cluster headache and migraine share a common underlying disorder.

This disorder has been demonstrated to be a sensitised brainstem and of course the ‘triptans’ de-sensitise the brainstem.

Furthermore there is a significant body of research which suggests that influencing (anaesthetising/blocking) information from structures of the upper neck prevents migraine and cluster headache. This suggests that abnormal information from disorders of these structures can sensitise the brainstem and that therefore a skilled examination of the upper neck should be included in assessment of migraine and cluster headache sufferers.

Cheers

Dean

(Akin Takmaz et al. Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. Agri. 2008 Jan;20(1):47-50

Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain 1996; 119:1419-28

Law S, Derry S, McQuay H, Moore A A systematic review of the triptan class of drugs for the treatment of cluster headache Cephalalgia 2009;29 (Suppl. 1):1–166

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

Peres MF. et al Greater occipital nerve blockade for cluster headache. Cephalalgia 2002;22:520-522

Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-928

Solomon S, Lipton RB, Newman LC. Nuchal features of cluster headache. Headache 1990;30:347-9obin J,Stephen Flitman S. Nerve Blocks: When and What to Inject? Headache 2009

Yi X et al Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3

Young et al Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122-1125

Young et al. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1139)

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

Exertional Headache, Migraine and the Neck

August 26, 2009 by dean · Leave a Comment 

"Exertional Headache"

"Exertional Headache"

‘Benign’ (or harmless) Exertional Headache is defined as headache caused by exertion such as coughing, sneezing, bending, heavy lifting, running (how is this different to headache triggered by exercise?) or when straining at stool.

It is important that if your headache history is less than 3 months and is triggered or aggravated by these activities that you consult you doctor.

These activities create similar effects on the body as do the Valsalva manoeuvers.

Recent research1 found a wide range of symptoms in Exertional Headache, some with migrainous symptoms, and the authors suggested that the ‘triptans’ might be useful. As usual there is a lot of discussion as to the actual mechanism of Exertional Headache and indeed Exercise Induced Headache, but the causes remain unknown – why?

The Valsalva manoeuver is used (and has been for years) to identify problems or injury in the nerves of the cervical spine. Upon the exertion of pressure, pain may be felt, and may indicate increased pressure on the C2-3 intervertebral disc or other part of a cervicogenic (neck) disorder.

Clearly increased headache or headache or migraine triggered by exertion or exercise is likely to be caused by a neck disorder.

Cheers

Dean

(Chen S-P, Fuh J-L, Lu S-R, Wang S-J. Exertional headache – a survey of 1963 adolescents. Cephalalgia 2008; 29:401-407

Johnson RH, Smith AC, Spalding JM (February 1969). “Blood pressure response to standing and to Valsalva’s manoeuvre: independence of the two mechanisms in neurological diseases including cervical cord lesions”. Clin Sci 36 (1): 77–86)

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

Headache and Migraine Causes

August 25, 2009 by dean · Leave a Comment 

The recent research has shown convincingly that migraine and headache is underpinned by sensitisation of the brainstem or central sensitisation.

One of the potential sources of senstisation of the brainstem is abnormal information from a disorders of structures within the head, structures which are supplied by the trigeminal nerve. It is then interesting to find that headache persists after blocking information carried by the trigeminal nerve. This clearly demonstrates that headache or migraine can come from other sources, for example neck disorders, and that the triptans act on structures other than in the head to ease headache or migraine … a sensitised brainstem … sensitised from another source … perhaps a neck disorder?

This can be easily confirmed by a skilled examination of the upper neck structures.

Cheers

Dean

(Matharu MS, Goadsby PJ. Persistence of attacks of cluster headache after trigeminal nerve root resection. Brain 2002;125(pt5):976-984)

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

Triptans, Migraine and Menstrual Migraine – Further Evidence That Hormones Are Not The Cause!

August 24, 2009 by dean · Leave a Comment 

Photophobia means sensitivity to light

Photophobia means sensitivity to light

Interesting to note that a recent study when reviewing migraine-associated characteristics including aura, allodynia-associated (excessive tenderness to touch) symptoms, photophobia (sensitivity to light), phonophobia (sensitivity to noise), and nausea were similar for both menstrual migraine and non menstrual migraine sufferers.

Furthermore the triptans were equally effective for both menstrual related migraine and non menstrual migraine patients.

I have also mentioned before, research which demonstrates that the triptans desensitise the brainstem – a case for sensitised brainstems in menstrual migraine sufferers.

Cheers

Dean

(Diamond ML, Cady RK, Mao L, Biondi DM, Finlayson G, Greenberg SJ, Wright P. Characteristics of migraine attacks and responses to almotriptan treatment: a comparison of menstrually related and nonmenstrually related migraines. Headache 2008 Feb;48(2):248-58)

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

The ‘Triptans’ and Menstrual Migraine

August 13, 2009 by dean · Leave a Comment 

It’s interesting to read that the ‘triptans’ are also effective in managing menstrual migraine, suggesting that the underlying cause for migraine, tension headache and menstrual migraine is similar, that is, a sensitised brainstem.

One underestimated source of sensitisation are neck disorders …. tired of playing around with your hormonal levels? Perhaps it is your neck that is sensitising your brainstem – a skilled examination will either confirm or eliminate this as a possibility.

Cheers

Dean

(Mannix LK, Files J. The use of triptans in the management of menstrual migraine. CNS drugs 2005;19(11):951-972)

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

Migraine, Sinus Headache and the ‘Triptans’ – There’s More!

August 9, 2009 by dean · Leave a Comment 

Further to my comment earlier, the ‘triptans’ have been shown to be useful in differentiating migraine from sinus headache.

As in past studies patients with a self-diagnosis or physician-diagnosis of ‘sinus’ headache were assessed. An overwhelming 82% had a significant reduction in their headache symptoms.

This extraordinary response provides further (not that any more is required!) evidence that the significant majority of ‘sinus’ headaches are migraine and that the ‘triptans’ aid diagnosis.

Don’t want to take a ‘triptan’? That’s OK because a skilled examination of your upper neck will quickly tell you that it isn’t ‘sinus’ headache, but an unrecognised cervicogenic (neck) headache.

Cheers

Dean

(Kari E, DelGaudio JM. treatment of sinus headache as migraine: the diagnostic utility of triptans. Larygoscope 2008 Dec;118(12):2235-9)

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

The Triptans, Migraine and Sinus Headache

August 7, 2009 by dean · Leave a Comment 

It has been claimed that the effectiveness of the triptans in someone experiencing facial pain does not exclude a diagnosis of ‘sinus’ headache because it has been shown that the ‘triptans’ do relieve the pain of sinusitis. Whilst this is true (because abnormal information from a diseased, infected sinus will sensitise the brainstem and the ‘triptans’ desensitise the brainstem), the relief from pain will not continue once the effect of the ‘triptans’ has worn off if the facial pain were coming from an infectious condition – the triptans are not an antibiotic.

But why take a ‘triptan’ when an examination of the neck will confirm in most cases, in my clinical experience of over 13000 hours, a neck disorder as the sensitising source in the headache and migraine process?

Cheers

Dean

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

Kari E, DelGaudio JM. Treatment of sinus headache as migraine: the diagnostic utility of triptans. Laryngoscope 2008 Dec;118(12) :2235-9

Kim H. The characteristics of sinus headache resembling the primary headaches. Nippon Rinsho 2005 Oct;63(10):1771-6)

Chronic Sinusitis is Uncommon

August 4, 2009 by dean · Leave a Comment 

Neck disorders sensitise the brainstem

Neck disorders sensitise the brainstem

Over 90% of diagnosed sinus headaches present in the same way as migraine headache and that given that the majority of ‘sinus’ headaches respond to the ‘triptans’, they can be classified as migraine. Why then are 61% of patients given antibiotics for a non-infectious condition?!

It is more responsible to identify the source of the sensitisation and …. neck disorders sensitise the brainstem! All that is required is for a competent headache practitioner to examine your neck.

Cheers

Dean

(Cady RK, Schreiber CP. Sinus headache: a clinical conundrum. Otolaryngol Clin North Am 2004 Apr;37(2):267-88

Goldhammer L. Second cervical root neurofibroma and ipsilateral migraine headache. Cephalalgia 1993; 13:132

Jansen J, Markakis E, Rama B, Hildebrandt J. Hemicranial attacks or permanent hemicrania – a sequel of upper cervical root compression. Cephalalgia 1989; 9:123-30

Tepper SJ. New thoughts on sinus headache. Allergy Asthma Proc 2004 Mar-Apr;25(2):95-96 ;

Ward TN, Levine M. Headache caused by a spinal cord stimulator in the upper cervical spine. Headache 2000; 40:689-91)

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

Menstrual Migraine

July 31, 2009 by Dean Watson · Leave a Comment 

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