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

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 Headache attack descriptions 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 TTH is 3.3x more common than migraine TTH is 1.5x more common than migraine Percent (%) * 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 Headache lasting from 4 to 72 hours At least 2 of the following Unilateral location Pulsating quality Moderate or severe intensity Aggravation by routine physical activity At least 1 of the following: Nausea and/or vomiting Photophobia and phonophobia At least five attacks fulfilling these criteria No evidence of organic disease

Tension-type Headache or Migraine Mild Moderate Severe Aura Unilateral Vomiting Bilateral Aggravated by Activity Photophobia Nausea 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 Visual blind spots Numbness Speech or word finding problems Trouble thinking

“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.

Migraine Pain Intensity and Disability 9% Function Normally >75% Report Severe to Extremely Severe Pain 53% Severe Impairment or Bed Rest Required 39% Some Impairment Patients (%) The Need for Effective Migraine Prophylaxis 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 weather1 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.

Are Common in the Presentation of Migraine “Sinus Symptoms” Are Common in the Presentation of Migraine 97% Moderate/Severe Pain 89% Pulsatile 85% Worsened by Activity 84% Sinus Pressure 82% Sinus Pain 79% Photophobia 67% Phonophobia 63% Nasal Congestion 40% Runny Nose 38% Watery Eyes 29% Aura 27% Itchy Nose IHS Migraine Symptoms “Sinus” Symptoms 25% Vomiting N = 2424 0% 20% 40% 60% 80% 100% Schreiber C. Poster presented at: American Headache Society Meeting; June 21-23, 2002;Seattle, WA.

“Sinus” Headache in Primary Care Migraine w/o or with Aura IHS 1.1, 1.2 Migrainous IHS 1.7 n=2520 Other Source: SUMMIT Study

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