Primary headaches (tension, migraine, and cluster): Clinical sciences

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Introduction 0:00–0:34

Primary headache is a type of headache that is not caused by another condition or injury. The underlying pathophysiology is not well understood, but it involves release of neurotransmitters, such as calcitonin gene-related peptide in migraines, and increased sensitization of pain pathways including sensory inputs from the trigeminal and upper cervical nerves.
The most common types of primary headache are tension-type headache, cluster headache, and migraine. Now, if a patient presents with a headache, you should first obtain a focused history and physical examination, including a fundoscopic exam.

Focused H&P 0:34–2:03

History typically reveals a patient younger than 50 years of age who reports episodes of recurrent headaches that are similar in quality and progression and completely resolve between attacks.
They also report that the intensity of headaches doesn’t require regular use of painkillers. Primary headaches are not positional, meaning that the quality of the headache does not change with positioning, such as when the patient is laying down versus standing up.
Also, the headache is not worse with Valsalva maneuvers, such as sneezing, coughing, or straining for a bowel movement; or with jaw movement, such as chewing or talking.
While obtaining history, be sure to rule out secondary causes of headaches. First, ask the patient if they have started any new medications recently because some headaches can be an adverse effect of medications.
Also, the patient should report no history of head trauma, systemic symptoms such as fever, malignancy, or immunodeficiency.
If any of these are present, think of secondary headaches. Finally, the physical exam reveals a normal neurologic exam in between episodes of headache; with normal appearance of the optic nerves on the fundoscopic exam.
With these findings, diagnose a primary headache. The next step is to ask your patient about the laterality of their headaches.

Tension-type headache 2:03–3:58

If their headaches are bilateral, suspect tension-type headaches and assess the criteria for tension-type headaches. This type of headache can last minutes to days and must meet at least two of the following four characteristics.
First, these headaches are associated with a pressing or tightening sensation. Sometimes, your patient will describe this feeling as having a non-pulsating band of pressure around the head.
Next, headaches should be bilateral and mild to moderate in intensity, but they should not worsen by routine physical activity, such as walking.
Finally, tension type headaches are usually not associated with nausea, vomiting, photophobia, or phonophobia. However, some patients might present with either photophobia or phonophobia, but not both.
If your patient meets these criteria, diagnose tension-type headaches. Management of all primary headaches, including tension-type headaches, should start with lifestyle modifications, such as stress reduction, improved sleep schedule, adequate hydration, and regularly scheduled meals.
Also, encourage the patient to track their headaches and use a diary to identify potential stressors and triggers. During an acute episode of a tension-type headache, options for abortive medications include nonsteroidal anti-inflammatory drugs, or NSAIDs; aspirin; acetaminophen; and caffeine.
For patients with frequent episodes, consider starting a preventive medication. Options include tricyclic antidepressants, such as amitriptyline, and serotonin-norepinephrine reuptake inhibitors (SNRI), like venlafaxine.
Alright, let’s go back and focus on individuals who report unilateral headaches. In this case, you should suspect migraine or cluster headaches, so your next step is to assess whether the headache is associated with either restlessness or ipsilateral autonomic features, such as lacrimation and rhinorrhea.

Cluster headache 3:58–6:30

If either of those characteristics is present, suspect cluster headaches and assess the criteria to confirm the diagnosis.
The patient should describe headaches as severe, unilateral pain in the orbital, supraorbital, or temporal region that typically lasts 15 minutes to 3 hours.
These headaches are frequent and occur at least every other day, sometimes multiple times a day. Headaches should be associated with restlessness or agitation, causing the patient to pace around or rock back and forth in a chair during an episode; and/or at least one of the ipsilateral autonomic features.
These include conjunctival injection or lacrimation; nasal congestion or rhinorrhea; eyelid edema; forehead and facial sweating; and miosis or ptosis.
If the patient meets these criteria, diagnose cluster headache, which falls under a broader category of headaches known as trigeminal autonomic cephalalgias.
The term “cluster” is used because patients tend to have clustered headache attacks that last for weeks to months, with periods of remission in between.
Interestingly, most patients have a circadian pattern to their headaches, with symptoms starting around the same time each day.
Management involves lifestyle modifications. Some known triggers for cluster headaches include alcohol, nitroglycerin, and heat, so patients should avoid these triggers.
Acute headache treatment involves oxygen administration and triptans, such as subcutaneous or nasal sumatriptan, or nasal zolmitriptan.
To bridge the patients until preventive medications kick in, you can use corticosteroids orally or as an injection targeting the greater occipital nerve.
Finally, preventive medications include verapamil, lithium, and galcanezumab, which is a monoclonal antibody against the calcitonin gene-related peptide receptor, or the CGRP receptor.
Now, let’s go back and look at individuals with unilateral headaches reporting no restlessness or ipsilateral autonomic features.

Migraine headache, Migraine without aura, Migraine with aura 6:30–10:42

In this case, suspect migraine headaches and assess whether your patient meets the criteria for migraines. Migraines last hours to days and have at least two of the following four features.
First, they are unilateral in location. Second, they have pulsating quality.
Third, they have moderate to severe pain intensity; and fourth, headaches are worsened by, or cause avoidance of, routine physical activity such as walking.
Finally, in contrast to tension-type headaches, migraines are associated with nausea, vomiting, photophobia, and phonophobia.
If your patient meets the criteria, diagnose migraines. Next, assess for the presence of auras.
Think of auras as a warning sign of a migraine. They can be alterations in vision, sensation, speech, motor strength, and even level of consciousness.
Auras most commonly involve vision, so your patient will usually describe seeing flashes of white or different colors. Also, they might report zigzag lines, or a blind spot with a wavy, shimmering border, known as a scintillating scotoma.
If there are no auras, diagnose migraine without aura. On the flip side, if auras are present, then diagnose migraine with aura.
Here's a high-yield fact to keep in mind! Migraines are more common in biological females, and for many individuals, they get worse in the perimenstrual period.
Smoking and use of estrogen-containing oral contraceptives increase the risk of stroke in those with migraine with aura.
In general, treatment for migraines with or without aura is the same. As before, encourage lifestyle modifications.
Triggers for migraines include lack of sleep, strong smells, and dietary items such as chocolate, cheese, and alcohol. Migraine attacks are also associated with menstruation.
As far as medical therapy goes, there are various pharmacological options for abortive migraine treatment. Non-specific medications include NSAIDs, aspirin, acetaminophen, and caffeine, as well as anti-emetics like prochlorperazine and metoclopramide.
In the emergency room, a popular NSAID to give is ketorolac because you can administer it intravenously. Migraine-specific medications include triptans; CGRP receptor antagonists, known as gepants; a serotonin receptor agonist called Lasmiditan; and dihydroergotamine, which is a nasal spray.
You should avoid triptans and dihydroergotamine in patients with cardiovascular conditions because they can cause vasoconstriction.
There is also a wide variety of options for preventive migraine treatments. Some examples include anti-hypertensives such as beta-blockers and candesartan; antidepressants like amitriptyline and venlafaxine; and anti-seizure medications, such as sodium valproate and topiramate.
If patients do not respond to these medications or have contraindications to use them, try CGRP monoclonal antibodies like erenumab and galcanezumab; or CGRP receptor antagonists such as atogepant and rimegepant.
Finally, for patients with chronic migraines that are refractory to the previously mentioned medications, consider botox injections, more specifically, OnabotulinumtoxinA.
Here’s a clinical pearl! Migraines in children commonly involve bilateral frontal and temporal regions.
In addition, children may present with childhood periodic syndromes, including abdominal migraine, which is recurrent abdominal pain that lasts hours to days.
Alright, as a quick recap… Tension-type headaches are usually bilateral and mild to moderate in intensity. If headaches are unilateral, consider cluster headaches or migraines, which are more severe in intensity.

Review 10:42–11:09

Cluster headaches are associated with restlessness or ipsilateral autonomic features, while migraines are not. Finally, the management of primary headaches includes lifestyle modifications, and medical treatment with abortive and preventive medications.
management of primary headaches includes lifestyle modifications and
Primary headaches (tension, migraine, and cluster) | Osmosis