This is the most common type of headache with the clinical features as:
- Constant pain spreading all over the skull
- Pain radiating forward from the occipital region
- Feeling ‘dull’, ‘tight’ or like pressure.
- Sometimes, continuous pain for weeks without interruption
- The severity of pain varies individually.
- There is no photophobia.
- No complaint of vomiting
- Pain increases as the day goes on.
Diagnosis of tension headache is mainly clinical. Your doctor can diagnose your headache from a description of your pain. Therefore, never forget to include all the details, such as pain characteristics, pain intensity, pain site, etc. In most cases, your physician will diagnose tension headache based upon the above clinical feature. However, he may run some imaging tests in certain cases to rule out an underlying serious problem. Following are the most important imaging tests in this regards:
- MRI (Magnetic Resonance Imaging) Brain
- CT (Computed Tomography) Scan Brain
Management of this type of pain is mainly based on discussion with patients about the causes of this type of disease and the explanation that this is not a serious disease. Many medications both OTC and prescription, are available to reduce the cluster headache, including:
- Pain relievers: Simple over-the-counter (OTC) pain relievers are the first line of treatment for tension headache. These OTC medications include aspirin, naproxen, and ibuprofen.
- Prescribed drugs for tension headaches include naproxen, ketorolac and indomethacin.
- Combination drugs: Aspirin or acetaminophen or both can be combined with caffeine or a sedative drug to form a single medication. These drugs can be more effective. Some of these combinations are available over the counter.
- Triptans can be used in persons suffering from both migraines and episodic tension headaches because they are effective against the pain of both headaches.
Your doctor may advise you on some medications to minimize the frequency and intensity of tension headache. This is especially important when you suffer from frequent or chronic headaches that aren’t easy to go away. Preventive medicines include:
- Tricyclic antidepressants such as amitriptyline and protriptyline, are widely used drugs to prevent tension headaches. Beware of the side effects of the drugs.
- Anticonvulsants and muscle relaxant such as Topiramate may prevent tension headaches.
Preventive medications can take several weeks or more to build up in your body before they take effect. So, you have to wait before seeing their effects.
- Ice packs
- Adopt coping strategies to manage your stress
- Maintain a good posture.
The following alternative treatment options may help:
- Gentle massage
- Deep breathing
- Behavioural therapies
Migraine affects 20% of women and 6% of men at some point in their lives. Its causes remain largely unknown. The following factors are associated with migraine:
- Family history, suggesting a genetic predisposition.
- Hormonal influences can also exacerbate it.
- Medications such as oral contraceptives and vasodilators
- Sensory stimulation
- Foods such as aged cheeses and salty and processed foods
Prodromal symptoms that appear before the attack are:
- Mood changes
- Swift Food cravings
- Neck rigidity
- Increased urination
- Excessive thirst
- Frequent yawning
Symptoms of migraine aura include:
- Visual hallucinations
- Flash Of light in front of eyes
- Temporary loss of vision
- Pin and limb sensation in their limbs.
- Abnormal body moves
- Difficulty in speaking
In around 20% of patients, migraine begins with aura (previously called ‘classical’ migraine). Shimmering, silvery zigzag lines (fortification spectra) start appearing across the visual fields for up to 40 mins, sometimes. This can sometimes cause temporary blindness. Another 80% of patients suffer from migraine without aura. Following are the characteristics of a migraine attack:
- Severe and throbbing pain
- Irritation to noise or even voice
- Pain exacerbated by movement
- Limbs weakness
Doctors, particularly expert in headaches (neurologists), can diagnose migraines based on your history, clinical features, and general physical and neurological examination. Your doctor may advise the following tests to rule out any serious underlying disease:
- MRI. It can help a doctor diagnose any tumour, stroke, bleeding in the brain, infections, and other problems.
- CT scan. A series of X-rays created through a CT scan creates a detailed image of the brain.
- Simple analgesia with aspirin or paracetamol
- Antiemetic medications to stop the vomiting if there is any
- Triptans such as sumatriptan are used to treat the severe attacks of migraine.
- Ubrogepant: This oral calcitonin gene-related peptide receptor antagonist has been recently approved for the treatment of acute migraine with or without aura in adults. I
- Opioid medications can be used in individuals who can’t take other drugs due to any reason.
- Avoidance of identified triggers or exacerbating factors.
- If frequent, try calcium channel blockers
- Beta-blockers such as propranolol
- Antidepressants, particularly tricyclic antidepressants (amitriptyline) can prevent migraines.
- Anti-seizure drugs such as Valproate and topiramate
- Botox injections. Injections about every 3 months offer protection against migraine in some adults.
- New drugs such as calcitonin gene-related peptide (CGRP) monoclonal antibodies
Other treatment options:
- Cognitive behavioural therapy.
- Herbs, vitamins and minerals.
- A high dose of riboflavin (vitamin B-2)
Cluster headache (migrainous neuralgia)
This is much less common than migraine. Males predominate 5: 1, and onset is usually in the third decade of life. A cluster headache is called so because it generally lasts for several weeks to months. Moreover, it tends to occur seasonally, such as every spring or every fall. A cluster headache happens quickly, usually without any warning signs. Some people might experience migraine-like nausea and aura. Common signs and symptoms of cluster headache are:
- Excruciating pain generally in, behind (retro-orbital) or around one eye
- Radiating to other parts of the face
- Unilateral pain
- Excessive tears
- Redness of your eye on the affected side
- The runny nose on the affected side
- Profuse sweating on the affected side
- Drooping eyelid
The exact cause and mechanism of cluster headache are unknown. But the cluster pattern of this type of headache suggests that it has something to do with the body’s biological clock (hypothalamus). Unlike other types of jeans, it is not associated with any particular food item. Other medications such as nitroglycerin are thought to trigger cluster headaches.
Your doctor can diagnose cluster headaches due to the characteristic nature of the headache and the pattern of how it attacks. A detailed description of the attacks, location and severity of your pain and details of any associated symptoms will help your doctor diagnose it. Based on your signs and symptoms, doctors will perform a general physical examination and neurological examination to assess your brain functions. Hev may advise some blood tests Moreover, imaging tests such as MRI and CT scan of the brain can be done as the last test to diagnose this headache or rule our tiger serious conditions.
There is no permanent treatment for cluster headaches. Medications are used to decrease the intensity of pain, shorten the headache period and prevent further attacks. Following treatments are given to solve the acute attack of cluster headache:
- Local anesthetics such as lidocaine ‘
Moreover, the following medication can be used to prevent cluster headaches.
- Calcium channel blockers such as verapamil
- Corticosteroids such as prednisone
- Lithium carbonate.
- Occipital nerve block
In rare cases, when the cluster headache doesn’t go away, the doctor may have to advise surgical options which include:
- Sphenopalatine ganglion stimulation
- Noninvasive vagus nerve stimulation (VNS)
Potential future treatments
Following treatment are under research and can be used in future:
- Occipital nerve stimulation
- Deep brain stimulation
- Unilateral lancinating facial pains
- Severe, very brief but repetitive pain
- It causes the patient to flinch as it happens with motor tic.
- It can be triggered by touch.
- It can appear and disappear again and again
Trigeminal neuralgia usually resolves with medicines. However, if it does not, surgery may be performed. Following medicines are approved time used against trigeminal neuralgia.
- Anticonvulsant such as carbamazepine oxcarbazepine lamotrigine, phenytoin, clonazepam, and gabapentin
- Antispasmodic agents. such as baclofen
- Botox injections
Following are the Surgical options for trigeminal neuralgia:
- Microvascular decompression
- Brain stereotactic radiosurgery (Gamma knife)
- Glycerol injection
- Balloon compression
- Radiofrequency thermal lesioning
The Takeaway Message:
If you’re suffering from any type of headache that is not getting relieved by over-the-counter (OTC) medications, it would be the best idea to consult your doctor. He can listen to your signs and symptoms, can examine you, run some test and can formulate an effective personalized treatment plan for your headache.
Burch R. Migraine and Tension-Type Headache: Diagnosis and Treatment. Med Clin North Am. 2019;103(2):215-233. doi:10.1016/j.mcna.2018.10.003
Robbins MS. Diagnosis and Management of Headache: A Review. JAMA. 2021;325(18):1874-1885. doi:10.1001/jama.2021.1640
Kahriman A, Zhu S. Migraine and Tension-Type Headache. Semin Neurol. 2018;38(6):608-618. doi:10.1055/s-0038-1673683
Diener HC. Headache: insight, understanding, treatment and patient management. Int J Clin Pract Suppl. 2013;(178):33-36. doi:10.1111/ijcp.12049
Chowdhury D. Acute management of migraine. J Assoc Physicians India. 2010;58 Suppl:21-25.
Gallagher RM, Cutrer FM. Migraine: diagnosis, management, and new treatment options. Am J Manag Care. 2002;8(3 Suppl):S58-S73.
Wei DY, Khalil M, Goadsby PJ. Managing cluster headache. Pract Neurol. 2019;19(6):521-528. doi:10.1136/practneurol-2018-002124
Suri H, Ailani J. Cluster Headache: A Review and Update in Treatment. Curr Neurol Neurosci Rep. 2021;21(7):31. Published 2021 May 5. doi:10.1007/s11910-021-01114-1
Rozen TD. Antiepileptic drugs in the management of cluster headache and trigeminal neuralgia. Headache. 2001;41 Suppl 1:S25-S32. doi:10.1046/j.1526-4610.2001.01154-5.x
Jensen RH. Tension-Type Headache – The Normal and Most Prevalent Headache. Headache. 2018;58(2):339-345. doi:10.1111/head.13067
Scripter C. Headache: Tension-Type Headache. FP Essent. 2018;473:17-20.