Migraine Without Aura
Migraine Without Aura
Migraine is a primary headache disorder which is the third most common disorder in the world and is the third highest cause of disability in the under 50 population. Migraine can be split into two distinct types - Migraine without aura and Migraine with aura.
Migraine without aura is described as a recurring headache condition which will typically last 4-72 hours and is characterised by the following:
- Headache which is at least two of the following:
- Unilateral (one sided)
- Pulsating in quality
- Moderate to severe intensity
- Aggravated by usual physical activity (e.g. walking)
- Headache associated with one or more of the following:
- Nausea and/or vomiting
- Light sensitivity and sound sensitivity (Olesen et al., 2018)
Migraine without aura
Migraine With Aura
Migraine With Aura
Also known as ‘classic migraine’ and is characterized by headache which is preceded or accompanied by a collection of transient focal neurological symptoms known as an aura. The most common aura is visual disturbance and affects around 90% of classic migraine sufferers. Patients experiencing visual auras often describe sensations of:
- Bright/flashing lights
- Fogginess/haziness
- Zig-zags
- Partially or entirely diminished visual clarity
Sensory changes such as pins and needles or numbness in different parts of the body like the left or right side of the body, the face and/or the tongue are the second most common aura. Speech disturbances can also occur but are less frequent than the previous two types of aura. It is also not uncommon for patients who experience one aura to experience another type of aura during the same episode or in different episodes. Thankfully, these focal neurological signs are completely reversible and usually last a few minutes to an hour.
Patients may also experience various symptoms in the hours or days leading up to their migraine including fatigue, neck stiffness, difficulties concentrating, light, smell and/or sound sensitivities, nausea. It is also not uncommon for patients to experience fatigue or a depressed mood for days after the migraine has subsided (Olesen et al., 2018).
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Tension Type Headache
Tension Type Headache (TTH)
Tension type headache is very prevalent throughout the community affecting up to 78% of Australians at some point in their lifetime.
TTH is thought to arise from an increased responsiveness of our upper cervical (neck) pain nerves to stimulation which results in a condition named brainstem sensitization leading to headache (Olesen et al., 2018) (Watson and Drummond, 2012).
TTH can be divided into 2 groups -
- Episodic tension type headache
- Frequent episodic tension type - at least 10 headache episodes on less than 15 days per month for longer than 3 months. Episodes typically last 30 minutes to 7 days.
- Infrequent episodic headache - headaches occurring less than once a month on average over the course of 1 year. Episodes typically last 30 minutes to 7 days.
- Chronic tension type headache
- Headaches occurring more than 15 days per month for longer than 3 months.
- Episodes last hours to days, or are unremitting (Olesen et al., 2018).
Typical features of TTH according to International Classification of Headache Disorders (ICHD-3)
- Bilateral location
- Pressing, tightening or vice like quality
- Mild to moderate intensity
- Headache is not aggravated by routine physical activity e.g. walking
Patients won’t experience the following
- Vomiting or nausea
- Light sensitivity and noise sensitivity at the same time (Olesen et al., 2018)
Cervicogenic Headache
Cervicogenic Headache
Is a very common type of secondary headache disorder which arises from musculoskeletal (bony, disc and/or soft tissue components) dysfunctions in the upper three joints in the neck.
The upper cervical nerves are connected to the brainstem via a group of nerves called the trigeminocervical nucleus (TCN) (Bondi, 2001). Chronic dysfunctions in these upper three cervical joints leads to an upregulation of the TCN, meaning it has a diminished capacity to tolerate stimulation which results in headache.
Typical features of cervicogenic headache include:
- Unilateral location which can alternate during an episode or between episodes
- Headache induced by improper postures, external pressures on neck structures and specific maneuvers stressing particular neck structures (Chua et al., 2012)
- Decreased range of motion in the neck or feelings of restriction
- Generalized pain and stiffness in the neck or the feeling of tight muscles (Olesen et al., 2018)
Chronic Daily Headaches
Chronic Daily Headaches
Chronic daily headaches (CDH) is a collective term to describe headache conditions that occur on more than 15 days per month with the vast majority being attributed to chronic migraine, chronic tension type headache, medication overuse headache and new daily persistent headache (Ahmed et al., 2012).
Chronic daily headaches may arise from episodic headaches of the same type and there are certain factors which may put you at risk of developing CDH such as:
- Medication overuse
- Previous head or neck injury
- Obesity
- Snoring and sleep disturbances
- Smoking
- Caffeine consumption
- Comorbidities such as depression and anxiety (Olesen et al., 2018)
Vestibular Migraine
Vestibular Migraine
Vestibular migraine is a type of migraine in which patients will experience symptoms such as dizziness, vertigo, loss of balance/unsteadiness, pulsating unilateral headache, visual aura and sensitivity to lights and/or sounds. Patients may also experience feelings of anxiousness or lose confidence in themselves (Olesen et al., 2018).
It is considered the most common form of spontaneous episodic vertigo and the second most common form of vertigo (Bisdorff, 2011).
The duration of vestibular migraine attacks are highly variable, typically lasting from 5 minutes to 72 hours however some episodes may only last seconds and others can last a month (Olesen et al., 2018)
Medication Overuse Headache
Medication Overuse Headache (MOH)
MOH is a headache disorder which develops as a result of regular use of symptomatic headache medications. Any pain medications can cause MOH but the most common types are combination analgesics (e.g. codeine and paracetamol) which are closely followed by paracetamol. Other pain medications such as triptans, opioids and ergotamine also cause MOH but are less common (Ahmed et al., 2012).
'The International Classification of Headache Disorders (ICHD-3) diagnoses MOH with the following criteria:
- Headache occurring on 15 or more days per month in a patient with a pre-existing headache disorder
- Regular overuse (10 or more or 15 or more/days per month depending on medication type) for more than 3 months of one or more drugs taken for acute symptomatic treatment of headache (Olesen et al., 2018).
Cluster Headache
Cluster Headache
Cluster headache is a type of primary headache which falls under the umbrella of trigeminal-autonomic cephalalgias (TACs). Cluster headaches are a very debilitating type of headache affecting about 0.1% of the population (Goadsby et al., 2018).
They are diagnosed by the International Classification of Headache Disorders (ICHD-3) according to the following criteria:
- At least 5 attacks fulfilling the following criteria
- Severe or very severe one sided pain located around the eye, above the eye or in the temporal region
- Either or both of the following
- At least one of the following ipsilateral (on the same side) to the headache
- Conjunctival injection and/or lacrimation (redness/tearing of the eye)
- Nasal congestion or runny nose
- Eyelid swelling
- Forehead/facial sweating
- Forehead/facial redness
- Sensation of blocked ear
- Excessive pupil constriction or drooping of the eyelid
- Feelings agitation or restlessness
- At least one of the following ipsilateral (on the same side) to the headache
- Occurring between every second day up to 8 per day (Olesen et al., 2018)
References
Biondi, D., 2001. Cervicogenic headache: Diagnostic evaluation and treatment strategies. Current Pain and Headache Reports, 5(4), pp.361-368.
Bisdorff, A., 2011. Management of vestibular migraine. Therapeutic Advances in Neurological Disorders, 4(3), pp.183-191.
Chua, N., Wilder-Smith, O., Suijlekom, H., Wilder-Smith, O. and Vissers, K., 2012. Understanding Cervicogenic Headache. Anesthesiology and Pain Medicine, 2(1), pp.3-4.
Goadsby, P., Wei, D. and Yuan Ong, J., 2018. Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), p.3.
Olesen, J., Bendtsen, L., Dodick, D., Ducros, A., Evers, S., First, M., Goadsby, P., Hershey, A., Katsarava, Z., Levin, M., Pascual, J., Russell, M., Schwedt, T., Steiner, T., Tassorelli, C. and Terwindt, G., 2018. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 38(1), pp.1-211.
Watson, D. and Drummond, P., 2012. Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache: The Journal of Head and Face Pain, 52(8), pp.1226-1235.
