1. 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

3. 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.

4. 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

5. Tension Headache or Migraine?

6. 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:

7. 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

8. 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

9. 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

10. 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

11. “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

12. 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.

13. 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:

14. 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.

15. Sinus Headache or Migraine?

16. 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.

17. 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 (pt 2): S1-S7.

18. 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.

19. “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

20. One Nerve Pathway: Multiple Symptoms of Migraine

21. 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