What are the distinctive features and specific treatments for migraine, cluster, and tension headaches?

Distinctive Features and Treatments for Migraine, Cluster, and Tension Headaches

For effective headache management, NSAIDs are first-line for migraine, oxygen and sumatriptan for cluster headaches, and analgesics with muscle relaxation techniques for tension headaches. 1

Migraine Headache

Distinctive Features

• Throbbing, pulsating pain (often unilateral)
• Associated symptoms: nausea, vomiting, photophobia, phonophobia
• Duration: 4-72 hours if untreated
• May be preceded by aura (visual disturbances, sensory symptoms)
• Aggravated by routine physical activity
• Often disabling, requiring rest in dark, quiet environment

Treatment

Acute Treatment

1. First-line: NSAIDs

   • Ibuprofen 400-600mg
   • Naproxen sodium 500-550mg 1
   • Combination therapy (acetaminophen + aspirin + caffeine) has good evidence for effectiveness 1

2. Second-line: Triptans

   • Sumatriptan 50mg orally for most patients (maximum 200mg/24 hours)
   • Sumatriptan 6mg subcutaneously for severe attacks or significant nausea/vomiting 1, 2
   • Rizatriptan 10mg orally for adolescents weighing ≥40kg 1

   Caution: Triptans are contraindicated in uncontrolled hypertension, cardiovascular disease, or basilar/hemiplegic migraine 1, 2

3. Additional options:

   • Antiemetics (metoclopramide) even if vomiting is not present 1
   • CGRP receptor antagonists (rimegepant, ubrogepant) 1
   • Rescue medications: opioids or butalbital-containing compounds for severe attacks unresponsive to first/second-line treatments 1

Preventive Treatment

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
• Topiramate, beta blockers (propranolol), tricyclic antidepressants (amitriptyline) 1
• Non-pharmacological: regular aerobic exercise, strength training, regular sleep schedule, adequate hydration, trigger avoidance 1

Cluster Headache

Distinctive Features

• Excruciating unilateral pain (typically around the eye)
• Autonomic symptoms: ipsilateral tearing, nasal congestion, rhinorrhea, conjunctival injection, ptosis, miosis
• Short duration: 15-180 minutes per attack
• High frequency: 1-8 attacks per day
• Circadian pattern: often occurs at the same time each day, commonly at night
• Restlessness during attacks (unlike migraine where rest is preferred)
• Episodic pattern: clusters lasting weeks to months separated by remission periods 3, 4, 5
• Chronic form: attacks continue without significant remission periods 5

Treatment

Acute Treatment

1. First-line:

   • Oxygen therapy (100% oxygen at 12-15 L/min via non-rebreather mask)
   • Sumatriptan 6mg subcutaneously (provides relief within 15 minutes in 74-75% of patients) 3

2. Second-line:

   • Intranasal lidocaine (less effective) 6
   • Dihydroergotamine (DHE) 4

Preventive Treatment

1. First-line:

   • Prednisone (short-term use to break cycle) 4
   • Verapamil (for longer-term prevention)

2. Second-line:

   • Lithium 4
   • Methysergide 4
   • Ergotamine 4

Tension Headache

Distinctive Features

• Bilateral, pressing/tightening (non-pulsating) pain
• Mild to moderate intensity
• Not aggravated by routine physical activity
• No nausea or vomiting (mild photophobia or phonophobia may be present)
• Duration: 30 minutes to 7 days
• Described as a constant, tight, pressing, or bandlike sensation in frontal, temporal, or occipital areas 4
• Associated with muscle tenderness and contraction of scalp muscles 4

Treatment

Acute Treatment

1. First-line:

   • Simple analgesics: acetaminophen, NSAIDs 4
   • Combination analgesics (with caffeine) for more severe cases

2. Non-pharmacological approaches:

   • Heat application
   • Massage
   • Muscle stretching 4

Preventive Treatment

1. First-line:

   • Amitriptyline 4
   • Muscle relaxants 4

2. Non-pharmacological approaches:

   • Stress management
   • Relaxation training
   • Biofeedback 4, 5
   • Cognitive-behavioral therapy 1

Important Considerations

• Medication overuse: Limit use of acute medications to prevent medication overuse headache:

  • Triptans: no more than 9 days per month
  • OTC medications: no more than 14 days per month
  • NSAIDs: no more than 15 days per month 1

• Patient education: Encourage use of headache diaries to track frequency, severity, triggers, and response to treatment 1

• Trigger identification: Help patients recognize and avoid personal triggers (alcohol, caffeine, certain foods, stress, fatigue, perfumes, fumes, glare, flickering lights) 1