Headache & Migraine

Headache is one of the common disorder that needs medical attention by a neurologist as well as a pain physician. Here is no one on this earth who did not suffer from any type of headache in his lifetime. More than 90% would have never gone to a specialist for treatment. Either rest or over the counter medication might have solved the problem. Fortunately, most kinds of headaches are benign or harmless in nature. There are only a few kinds of headaches, which are serious. Thank god, they are really very rare. Probably you are not suffering from such.

If you notice any of the following symptoms, it may be serious. Consult your doctor.

  • Sudden onset of severe headache.
  • It is a new type of headache that you have never felt before.
  • Your headache is taking bad shape quickly.
  • Headache is associated with other symptoms like projectile vomiting, visual problems, weakness of one or both sides of the face/body, fever, etc.
  • Your headache is increasing with bending forward.
  • New kind of headache starting at an older age.

    • With these symptoms, CT-scan or MRI-scan is required.

    Types of headache:

    There are two broad types of headache:

    1) Primary – where exact reasons are not known. There are many hypotheses, postulations, but the exact cause of these types of headaches is still not understood. The common headaches of these categories are following:
    • Tension-type headache
    • Migraine
    • Cluster headache
    2) Secondary – where the headache is a symptom of some other diseases. Like a common cold, fever, eye strain, cervical spondylosis, or, rarely cancer. Below are few common types of secondary headaches:
    • Cervicogenic headaches due to pathologies in the neck
    • Occipital Neuralgia (Third occipital neuralgia is one of them)
    Tension Type Headache

    Tension-type headache is the most common type of primary headache. It is a pain or discomfort in the head, scalp or neck and is often associated with muscle tightness in these areas.

    For most of the population, the first onset of TTH is before the second decade of life. The peak prevalence appears to be between 30-39 years of age. The lifetime prevalence ranges between 30%-78%. It is seen in both sexes with female preponderance. The studies show that there is a slight decrease in the occurrence with advancing age.

    Classification
    • Episodic TTH (ETTH):- Infrequent episodic, Frequent episodic
    • Chronic TTH (CTTH)
    • Associated with peri cranial tenderness
    • Not associated with peri cranial tenderness

    Interventional
    Local injections
    1.Greater and lesser occipital nerve injections using local anesthetic with or without corticosteroids give a positive effect and short-term relief of CEH. Many authors consider entrapment of the greater occipital nerve to be one of the major underlying causes of CEH.
    2. Injection into the atlanto-axial joint with a local anesthetic andcorticosteroid, in patients with CEH, can be done ifclinical picture is suggestive of atlantoaxial joint pain. There was nostatistically significant difference after 6 months in this retrospectivestudy.’
    3. C2-3 zygapophysial joint, investigators from one study reported that some patients could obtain relief from intra-articular injection of steroids.’ Third occipital nerve block with local anaesthetic and/or steroid can be given for C2-C3 facet joint.
    4. Local injection of the ramus medialis of the cervicalramus dorsalis (cervical medial branch block) can also be done for diagnostic purpose
  • If positive response to diagnostic block of cervical medial branch block is seen, then radiofrequency ablation of nerve can be done for longer pain relief.

    • 2. In a prospective study in patients with CEH according to the criteria of Sjaastad, receiving RF treatment of the ramus medialis (medial branch) of the cervical ramus dorsalis, the results were outstanding to good in 65%, average in 14%, and no improvement was seen in 21% of the patients, with an average follow-up of 16.8 months.

  • A case report of pulsed radiofrequency for the treatment of intractable occipital headache reported 70% relief for 4 months followed by an additional 5 months of 70% relief with repeat pulsed radiofrequency.
  • RF and pulsed radiofrequency (PRF) treatment of the cervical ganglion spinale (DRG) level C2–C3 can be considered.
    • Surgical treatments

    Microsurgical decompression of the C2 ganglion spinale. During microsurgical decompression of the ganglion spinale (DRG), ligament structures and veins around the ganglion were “removed” by means of electrocoagulation.

    Cervicogenic Headache
    Cervicogenic headache (CGH) is a chronic unilateral dull headache with ipsilateral shoulder and arm pain with a restricted range of movements of the neck, classified under secondary headache by International Headache Society(IHS). Essentially it is referred pain from certain pathologies of the cervical region. It is a rare entity occurring in men and women equally in their early 30’s. It accounts for 1-4% of all headaches.

    Types
    Three different aspects of cervicogenic headaches can be described according to the area of reference of pain
    (a) occipital
    (b) Occipital temporal maxillary form.
    (c) supraorbital form . They overlaps frequently.

    Secondary Headaches
  • Headache attributed to head and/or neck trauma
  • Headache attributed to cranial or cervical vascular disorder
  • Headache attributed to non-vascular intracranial disorder
  • Headache attributed to a substance or its withdrawal
  • Headache attributed to infection
  • Headache attributed to disorder of homoeostasis
  • Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure
  • Headache attributed to psychiatric disorder

    • Diagnosis of Cluster Headache

    It is a primary headache, so there is no blood test or imaging to diagnose it. Instead, a neurologist or pain specialist only diagnoses it based on clinical features. But the patient might need to do some blood tests and imaging of the head (CT or MRI) to rule out other causes of secondary headache.

    Treatment Of Cluster Headache
  • Abortive medication:
  • Giving 100% oxygen at the beginning of the headache episode will relieve pain.
  • Tryptophan medication like sumatriptan and rizatriptan relieves headaches by constricting the blood vessel of the head.
  • Local application of capsaicin cream in the affected area of the head gives pain relief.
  • Dihydroergotamine (DHE) injection gives pain relief within 5 minutes. However, it should not be given with the triptan group of the drug.

    • Pathophysiology Of Cluster Headache
    The nerve from the base of the brain gets triggered because of a signal from the hypothalamus. Hypothalamus is the headquarter of the autonomic nervous system of our body. The hypothalamus is present inside the brain and is the home of the “internal biological clock,” which has the leading role in controlling the sleep and wake cycle. The nerve, triggered in cluster headache, is the trigeminal nerve, which has three branches that give sensory and motor supply in the face. First, which is upper branch is usually involved in cluster headache. The upper branch mainly provides supply to the forehead, scalp, and eye region. That’s why a cluster headache is also called a trigeminovascular headache.