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What Type of Headache do I

have?
David M. Biondi, DO
Director, Headache Management Programs
Spaulding Rehabilitation Hospital
Consultant, Massachusetts General Hospital
Instructor in Neurology, Harvard Medical School
Boston, MA

The Headache Dilemma

Migraine
Tension

Sinus
Treatment

Headache in the Population


99% of women and 93% of men have had
headache during their lifetime
25% of women and 8% of men in the United
States have had migraine headache
18% of women and 6% of men have had migraine
over the previous year
Prevalence is highest between age 25 55 years
An estimated 30 million have migraine and up
to 10 million have chronic daily headache (> 15
headache days per month) in the U.S.

Headache History
Headache attacks
How it begins
Precipitating event, illness, injury

Headache attack descriptions


Frequency and patterns
Any significant changes

Location
Time to peak intensity
Duration
Quality and intensity
Warning symptoms and aura
Associated symptoms and level of disability
Triggers and aggravating or relieving factors

Tension Headache or Migraine?

Tension-type Headache or Migraine?


Migraine is 6.3x more common than TTH
80
70

TTH is 1.5x
more common
than migraine

TTH is 3.3x
more common
than migraine

75

60

Population

50

Percent 40
(%)
30

40

Waiting Room

44
29

20
10
0

12
Tension-Type Headache

Significant
Headaches*

12
Migraine

* People who want to talk to the doctor about their headaches or who
have headaches that interfere with daily activities.
Lipton RB et al. Neurology. 2003;61:375-385.

Episodic Tension-type Headache


A. Number of days with such headache < 180/year (<15/month)
B. Headache lasting from 30 minutes to 7 days
C. At least 2 of the following:
Pressing/tightening (non-pulsating) quality
Mild or moderate intensity (may
inhibit, but does not prohibit activities)
Bilateral location
No aggravation by walking stairs
or similar routine physical activity
D. Both of the following:
No nausea or vomiting (anorexia may occur)
Photophobia and phonophobia are absent, or one but not
the other is present
E. At least 10 previous headache episodes fulfilling these criteria
F. No evidence of organic disease

Migraine Without Aura


A. Headache lasting from 4 to 72 hours
B. At least 2 of the following

Unilateral location
Pulsating quality
Moderate or severe intensity
Aggravation by routine physical activity

C. At least 1 of the following:

Nausea and/or vomiting


Photophobia and phonophobia

D. At least five attacks fulfilling these criteria


E. No evidence of organic disease

Tension-type Headache or Migraine


Mild
Moderate
Severe
Unilateral
Bilateral
Photophobia
Nausea

Aura
Vomiting
Aggravated
by Activity

Throbbing
Pressure
Tension-Type

Migraine
2002 Primary Care Network

Migraine Aura
Positive Neurological Symptoms
Reversible brain/neurological symptoms
Visual flashes, spots, or zig-zag lines
Traveling tingling sensations

Gradual development over >4 minutes


Resolves within 1 hour

Negative Neurological Symptoms


Reversible brain/neurological symptoms

Visual blind spots


Numbness
Speech or word finding problems
Trouble thinking

Resolves within 1 hour

Even My Hair Hurts


(allodynia)

Cutaneous allodynia
Hair hurts
Painful when:

Shaving
Combing hair
Touching scalp
Resting head on pillow
Pulling hair back (wearing
a ponytail)
Wearing eyeglasses or
contact lenses
Wearing hat or head band

Other painful events


Water hitting head or
face while showering
Breathing through nose
especially cold air
Cooking over a hot
stove
Rubbing the neck or
shoulders
Hanging head down or
bending over

Neck Pain During Migraine


Prevalence
75% of subjects

Descriptions

69% - tightness
17% - stiffness
5% - throbbing
5% - other

82% had previously been


given a diagnosis of
tension-type headache
Kaniecki R. Neurology. 2002;58(Suppl 6):S15-S20.

92%

100%
80%

61%

60%

41%

40%
20%
0%

Prodrome

Postdrome
Migraine
Phase

Migraine Pain Intensity


and Disability
9% Function Normally

>75% Report Severe to


Extremely Severe Pain
50
40

53%
Severe
Impairment
or Bed Rest
Required

39%

Patients

30

Some
Impairment

(%)

20
10
0

Mild

Moderately
Severe

Severe

Extremely
Severe

Lipton RB et al. Headache. 2001;41:638-645.

Dilemmas in Diagnosing Migraine


Visual aura
only 15-20% of migraineurs

Head pain can be non-throbbing


in ~40% of patients

Head pain can be bilateral


in ~ 43% of patients1

Sinus pain and pressure, stuffiness, rhinorrhea &


weather association is often present
in up to 97% of migraine attacks2

Neck pain is often present


in up to 75% of migraine attacks3
1. Data on File. GlaxoSmithKline.
2. Cady RK, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.
3. Kaniecki RG, et al. Poster presented at:10th IHC; June 29-July 2, 2001; New York NY.

Sinus Headache or Migraine?

Myth
Headaches that are triggered by weather or
are associated with sinus symptoms are not
migraines.

Fact
Up to 50% of migraine patients report their
headaches are influenced by weather 1
45% of migraine patients report sinus
symptoms including2
Lacrimation
Nasal congestion
Rhinorrhea
1. Raskin NH. Headache. 2nd ed. New York: Churchill Livingstone; 1998.
2. Barbanti P et al. Cephalalgia. 2001;21:295.

Headache:
A Minor Criteria in AAO-HNS Sinusitis
Headache is a minor factor in the diagnosis of
rhinosinusitis, according to AAO-HNS*

Major factors
Purulence in nasal cavity on
exam
Facial pain/pressure/congestion*
Nasal obstruction/blockage/
discharge
Fever (in acute only)
Hyposmia/anosmia

Minor factors

Fever (chronic)
Halitosis
Headache
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness

* Facial pain/pressure alone does not constitute a suggestive history for


rhinosinusitis in the absence of another major nasal symptom or sign.
* American Academy of Otolaryngology-Head and Neck Surgery Lanza et al. Otolaryngol Head Neck Surg 1997.117(pt 2): S1-S7.

Sinus Symptoms Are Common in

the Presentation of Migraine

97%
89%
85%

Moderate/Severe Pain
Pulsatile
Worsened by Activity

84%
82%
79%

Sinus Pressure
Sinus Pain
Photophobia

67%
63%

Phonophobia
Nasal Congestion

40%
38%

Runny Nose
Watery Eyes

29%
27%

Aura
Itchy Nose

Sinus Symptoms

25%

Vomiting

N = 2424

IHS Migraine Symptoms

0%

20%

40%

60%

80%

Schreiber C. Poster presented at: American Headache Society Meeting; June 21-23, 2002;Seattle, WA.

100%

Sinus Headache in Primary Care


Migraine w/o or
with Aura

82%

IHS 1.1, 1.2

8%

Migrainous
IHS 1.7

n=2520
10%

Other
0%

20%

40%

60%

Percentage of Subjects
Source: SUMMIT Study

80%

100%

One Nerve Pathway:


Multiple Symptoms of Migraine

Summary
Tension-type headaches are very common in the
general population
Migraine headaches are also common but are more
common than tension-type headaches in medical
clinics because of greater severity and disability
True sinus headaches are uncommon
Sinus symptoms and neck pain are very common
symptoms of migraine
Most cases of recurrent sinus headaches are
migraine especially if there is a family history of
recurrent or chronic headaches

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