What are the different types of headaches and their management options?

Headache: Types and Management

Primary Headache Types

Migraine

Migraine is the most disabling primary headache disorder, affecting 12% of the population and ranking as the second leading cause of years lived with disability worldwide 1.

Clinical Features

• Unilateral, throbbing pain of moderate to severe intensity that worsens with physical activity 2
• Duration of 4-72 hours if untreated 3
• Associated symptoms include nausea/vomiting, photophobia, and phonophobia 2, 3
• Patients typically prefer to lie still in a dark, quiet room 3

Acute Treatment Algorithm

1. First-line options:

   • Acetaminophen, NSAIDs, or combination products with caffeine 1
   • Triptans (5-HT1B/D agonists) eliminate pain in 20-30% of patients by 2 hours 1
   • Sumatriptan 25-100 mg orally, maximum 200 mg/24 hours 4

2. Second-line for triptan non-responders:

   • Gepants (CGRP receptor antagonists) such as rimegepant or ubrogepant eliminate headache in 20% at 2 hours 1
   • Lasmiditan (5-HT1F agonist) is safe in patients with cardiovascular risk factors 1

3. Critical contraindications to triptans:

   • Coronary artery disease or vasospasm 4
   • Uncontrolled hypertension 4
   • Stroke/TIA history 4
   • Peripheral vascular disease 4
   • Within 24 hours of ergotamines or other triptans 4
   • Screen for CAD risk factors (hypertension, hypercholesterolemia, smoking, obesity, diabetes, family history) before prescribing 3, 4

Prophylactic Treatment

• Indicated for patients with frequent or chronic headaches 5
• Options include β-blockers, tricyclics, antiepileptics (topiramate), botulinum toxin, and CGRP monoclonal antibodies 6, 5
• CGRP monoclonal antibodies reduce migraine by 1-3 days per month relative to placebo 1

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Tension-Type Headache

Tension-type headache affects 38% of the population, making it the most prevalent primary headache disorder 1.

Clinical Features

• Bilateral, pressing/tightening (non-pulsatile) pain of mild to moderate severity 2
• Not aggravated by routine physical activity 2
• Lacks nausea/vomiting (though anorexia may occur), and typically does not have both photophobia and phonophobia 2
• Missed meals can trigger attacks 2

Treatment

• NSAIDs are the mainstay for acute treatment 5
• Tricyclic antidepressants have the most evidence for prophylactic therapy 5

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Cluster Headache

Cluster headache presents with strictly unilateral, severe pain lasting 15-180 minutes with ipsilateral autonomic symptoms 2.

Diagnostic Criteria

• Five attacks required for diagnosis with frequency of 1-8 attacks daily 3
• Severe unilateral supraorbital or temporal pain lasting 15-180 minutes 3
• At least one ipsilateral autonomic symptom: lacrimation, nasal congestion, ptosis, conjunctival injection, or restlessness 2, 3

Acute Treatment

• Subcutaneous sumatriptan 6 mg is first-line with 70% achieving relief within 10 minutes 3
• 100% oxygen inhalation at 12 L/min has equal efficacy to sumatriptan 3
• Intranasal zolmitriptan 10 mg is an alternative 3
• Screen for cardiovascular risk factors before prescribing sumatriptan 3

Prophylactic Treatment

• Verapamil 360 mg/day is the prophylactic drug of choice 3
• Monitor ECG for PR interval prolongation at higher doses 3
• Oral corticosteroids or greater occipital nerve blockade can serve as bridging therapy while verapamil takes effect 3
• Galcanezumab for episodic cluster headache (not chronic) 3
• Lithium, topiramate, or divalproex sodium as add-on therapy for chronic cases 3

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Secondary Headache Red Flags

Always exclude secondary causes when "red flags" are present 2:

• Sudden onset ("thunderclap") 2
• Fever 2
• Focal neurological symptoms 2
• New onset after age 50 2
• Progressive worsening 3
• Abnormal neurological examination 3

Neuroimaging (MRI preferred) is indicated when red flags are present 3. Routine neuroimaging is not indicated for typical primary headaches without concerning features 2.

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Medication Overuse Headache

Suspect medication overuse headache in patients with frequent headaches using acute medications ≥10 days per month 7.

Management

• Medication withdrawal is necessary 6, 7
• Patients overusing opiates, barbiturates, or benzodiazepines require slow tapering and possibly inpatient treatment 7
• Patients overusing other agents (NSAIDs, triptans) can withdraw more quickly 7
• Detoxification includes withdrawal of overused drugs and treatment of withdrawal symptoms (which often includes transient worsening of headache) 4

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Comprehensive Management Approach

Address risk factors, headache triggers, and comorbid conditions (depression, anxiety, substance abuse, chronic musculoskeletal pain) that impair treatment effectiveness 7.

Incorporate both pharmacologic and nonpharmacologic strategies including behavioral health approaches, complementary integrative health interventions, and neuromodulation 6.

Regular scheduled follow-up is essential to monitor progress 7.