What are the different types of headaches and their treatments?

Types of Headaches and Their Treatments

The three main types of primary headaches are migraine, tension-type, and cluster headaches, each with distinct clinical features requiring specific treatment approaches based on their unique pathophysiology and symptom profiles. 1

Primary Headache Disorders

1. Migraine Headache

Migraine is characterized by:

• Diagnostic Features:

  • At least two of: unilateral location, throbbing character, moderate to severe intensity, worsening with activity
  • At least one of: nausea/vomiting, photophobia and phonophobia 1
  • May occur with or without aura (visual distortions, scotomas) 1

• Treatment:

  • Acute Treatment:

    • First-line: NSAIDs, acetaminophen, or combination products with caffeine 2
    • Second-line: Triptans (sumatriptan, rizatriptan) for moderate-severe attacks 3, 4
      • Contraindicated in patients with cardiovascular disease 4
      • Subcutaneous sumatriptan provides relief within 10-15 minutes 3
    • Newer options: Gepants (CGRP receptor antagonists) and ditans (5-HT1F agonists) 1, 2

  • Preventive Treatment:

    • Indicated when headaches occur >4 days/month or cause significant disability
    • Options include antihypertensives, antiepileptics, antidepressants, CGRP monoclonal antibodies 2
    • Botulinum toxin for chronic migraine (≥15 headache days/month) 1

2. Tension-Type Headache

Tension-type headache features:

• Diagnostic Features:

  • At least two of: pressing/tightening (non-pulsatile) quality, mild-moderate intensity, bilateral location, no aggravation by activity
  • No nausea/vomiting, may have photophobia OR phonophobia (not both) 1

• Treatment:

  • Acute Treatment:
    • Simple analgesics (acetaminophen, NSAIDs) 2
  • Preventive Treatment:
    • Amitriptyline or other tricyclic antidepressants
    • Non-pharmacological: stress management, biofeedback, physical therapy 5

3. Cluster Headache

Cluster headache is characterized by:

• Diagnostic Features:

  • Severe unilateral orbital/temporal pain lasting 15-180 minutes
  • Accompanied by ipsilateral autonomic symptoms: lacrimation, nasal congestion, rhinorrhea, ptosis, miosis, eyelid edema 1
  • Attacks occur in clusters lasting weeks to months, followed by remission periods 6

• Treatment:

  • Acute Treatment:

    • First-line: High-flow oxygen (12-15 L/min via non-rebreather mask) 6
    • Second-line: Subcutaneous sumatriptan (6 mg) 6
    • Third-line: Intranasal zolmitriptan (10 mg) 6

  • Preventive Treatment:

    • Galcanezumab for episodic cluster headache 6
    • Verapamil (≥240 mg daily) with cardiac monitoring 6
    • Non-invasive vagus nerve stimulation for episodic cluster headache 6
    • Short-term bridge therapy with corticosteroids 6

Secondary Headache Disorders

Secondary headaches result from underlying medical conditions and require identification and treatment of the primary cause:

• Major Categories:

  • Vascular disorders (stroke, arterial dissection)
  • Neoplastic causes (brain tumors)
  • Infectious diseases (meningitis, sinusitis)
  • Intracranial pressure disorders (idiopathic intracranial hypertension) 2

• Red Flags Requiring Urgent Evaluation:

  • Thunderclap headache (sudden onset)
  • New headache after age 50
  • Headache with systemic illness or focal neurological symptoms
  • Headache that changes with position
  • Headache in immunocompromised patients 1

Medication Overuse Headache

• Occurs when acute headache medications are used ≥10 days/month
• Treatment requires withdrawal of overused medications and management of withdrawal symptoms 4
• Preventive medications may be needed simultaneously 1

Treatment Approach Algorithm

1. Identify headache type based on clinical features
2. Rule out secondary causes if red flags are present
3. For migraine:
   • Mild-moderate: Start with NSAIDs/acetaminophen
   • Moderate-severe: Add triptan if no cardiovascular contraindications
   • Consider preventive therapy if ≥4 headache days/month
4. For tension-type headache:
   • Simple analgesics for acute treatment
   • Consider amitriptyline if frequent episodes
5. For cluster headache:
   • High-flow oxygen for acute attacks
   • If unavailable/ineffective, use subcutaneous sumatriptan
   • Start preventive therapy based on episodic vs. chronic pattern

Important Considerations

• Neuroimaging is only indicated when red flags suggest secondary headache 1
• Avoid opioids for headache management due to risk of dependency and medication overuse headache 6
• Patient education about trigger avoidance is crucial for all headache types 6
• Regular monitoring of treatment efficacy is essential to adjust therapy as needed 6