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Migraine Headaches and Tension Headaches

 

Presentation

Migraines usually have moderate to severe intensity with a throbbing and pulsating sensation. Other symptoms might include patients complaining of nausea, vomiting, and sensitivity to noise and smells. Also, there is an occurrence of special paroxysmal symptoms like abdominal pain or vertigo in childhood and largely an absence of autonomic signs in the elderly (Andreou & Edvinsson, 2019). Tension-type headaches on the other hand are very common among people and do not usually require people to seek medical attention. Patients with tension-type headaches diffuse mild to moderate pain in their heads that is often described as feeling like a tight band around the head and do not throb. They also experience tenderness on the scalp, neck and shoulder muscles. However, unlike migraines, tension-type headaches are not aggravated by physical activity. Tension-type headache patients will also not have symptoms of vomiting and nausea. In addition to that, tension-type headaches might cause a light or noise sensitivity but not both. Technically migraines are associated with severe pain and might require medical management to improve the quality of life.

 

Pathophysiology

Migraine is a recurrent, disabling neurological disorder and may have auras that exhibit several hours before the migraine occurs. Pathophysiological mechanisms of migraine are associated with genetic factors that may influence susceptibility to the disease and functional and anatomical changes during the progression of a migraine attack (Andreou & Edvinsson, 2019). Auras are correlated to four different aspects of the brain namely, the hypothalamus, brainstem, cortex, and limbic system. Migraines begin in areas of the brain that are capable of initiating an aura but headaches occur from the consequential activation of the meningeal nociceptors (Burstein et. al., 2015). On the other hand, tension-type headaches are associated with nociceptors as well but the pain receptors are found in the peri-cranial myofascial tissues. Patients with tension-type headaches experience muscular pain that tends to be dull and poorly localized. Migraines and tension-type headaches are similar in the sense that the activation of nociceptors causes pain in both but the location of these pain receptors causes different intensities of pain.

 

Assessment

Assessing migraines and tension-type headaches would include a neurological examination in both cases. It is not challenging to differentiate between a migraine and a tension-type headache based on a patient’s presentation. The healthcare provider should ask for things such as when the headache first began, if there has been any trauma and if there is family history of migraines. Besides, obtaining history about the onset of the headache, duration, characteristics, severity, and treatment is important. It is also important to ask patients about their mental health, sleep patterns, the current medication they are taking and their social history. Also, it is crucial to observe how the patients are walking in terms of gait, posture, speed and coordination, and their facial symmetry, speech and use of language. Examination of symptoms that are most commonly described by patients point to the potential involvement of the hypothalamus such as fatigue, muscle tenderness and neck stiffness, smell and depression in the prodromal phase of a migraine attack (Burstein et. al., 2015). In addition, ask about associated symptoms such as nausea, vomiting, photophobia, conjunctival injection, rhinorrhea. Check blood pressure and fundoscopy. Inquire about precipitating factors such as posture, cough, stress, straining, foods, or drinks. Ask the patient which medications or treatments were tried, response and side effects (Becker et al., 2015).

 

Diagnosis

Is it a primary headache or secondary headache (headache being a symptom of another health problem? Red flags which are considered emergencies: fever with signs of meningitis, thunderclap onset, cognitive changes, papilledema. Once secondary headache is ruled out we can then focus on diagnosing the type of headache. Diagnosis of migraine and tension headaches is based on history and symptoms.

Migraines without aura 2 of the following symptoms are needed: Nausea during the attack, light sensitivity during the attack, some attacks interfere with daily activity.

Tension headaches: If not related to nausea and at least 2 of these: bilateral headache, non-pulsating pain, mild to moderate intensity, not worsened by activity (Becker et al., 2015).

 

 

 Treatment

Inquire about the presence of coexisting symptoms that might affect the treatment choice such as history of stroke, insomnia, depression, anxiety, cardiac arrhythmias, or asthma (Becker et al., 2015).

First line of treatment for migraine headaches, acute: Ibuprofen 400mg, Naproxen 500-550mg, Acetaminophen 1000mg. Second line: Triptans (Sumatriptan 100mg, Rizatriptan 10mg, Zolmitriptan 2.5mg). Third line: Naproxen 500mg in combination with a Triptan. Prophylactic: Propanolol 20mg BID. Titration dose increase 40mg/week. Max: 120 BID. Metoprolol 50mg BID, titration 50mg/week. Max: 100mg/BID. Nadolol 40mg/day. Titrate 20mg/week. Max: 160 daily. Beta blockers to be avoided with asthma. Amitriptyline or Nortriptyline 10mg at bedtime. Titrate at 10mg/week. Consider if depression, anxiety or insomnia (Becker et al., 2015).

Second line prophylactic: Topimarate 25mg/day. Titrate 25mg/week. Max: 50mg BID. Consider as first line option if overweight. Candesartan 8mg daily. Titrate 8mg/week. Max: 16mg/day. Gabapentin 300mg/day. Titrate 300mg q3-7 days. Max: 1800 day divided in 3 doses.

First line treatment for tension type headaches, acute: Ibuprofen 400mg, aspirin 1000mg, Naproxen 500-550mg, Acetaminophen 1000mg.

Prophylactic first line: Amitriptyline or Nortriptyline 10mg at bedtime. Titrate at 10mg/week. Consider if depression, anxiety or insomnia.

Lifestyle management for the prevention of migraine headaches includes: avoiding triggers, do not skip meals, irregular or little sleep, caffeine, stress (Becker et al., 2015).

 

References

Andreou, A. P., & Edvinsson, L. (2019). Mechanisms of migraine as a chronic evolutive condition. The journal of headache and pain, 20(1), 1-17.

Becker, W. J., Findlay, T., Moga, C., Scott, N. A., Harstall, C., & Taenzer, P. (2015). Guideline for primary care management of headache in adults. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541429/

Burstein, R., Noseda, R., & Borsook, D. (2015). Migraine: multiple processes, complex pathophysiology. Journal of Neuroscience, 35(17), 6619-6629.