Most commonly seen primary headaches are migraines, tension type headaches, and cluster headaches. Other less seen primary headaches are primary cough headache, primary exercise headache, primary headache associated with sexual activity, primary thunderclap headache, primary stabbing (“ice pick”) headache, hypnic headache, external-pressure headache, primary stabbing headache, nummular headache and new daily persistent headache.
In a given year, migraine has a prevalence of 17.1% in women and 5.6% in men. The median age of onset is 25 years. In children, approximately 8% of boys and 11% of girls have migraine.
The prodrome or premonitory phase occurs in about 80% of migraineurs and may precede the attack by hours or up to 1 or 2 days. Symptoms include depression, hyperactivity, irritability, or drowsiness, photophobia, phonophobia, and yawning, and stiff neck, food cravings, diarrhea, or constipation. Second phase is aura phase and seen in about 30%. Third phase is headache seen in most but not everyone. Resolution phase or postdrome symptoms include changes in mood, weakness, tiredness, anorexia, irritability, and poor concentration.
Any part of the head or face may be affected. Pain is unilateral in 60% of cases and bilateral in 40%. Throbbing pain is present in 85% of episodes of migraine. As many as 75% of migraineurs report unilateral or bilateral tightness, stiffness, or throbbing pain in the posterior neck along with head pain. Migraines last 4 to 72 hours if left untreated. Usually increased by physical activity or movement, the pain is associated with nausea in about 80% of episodes, vomiting in about 30%, photophobia in about 90%, and phonophobia in about 80%.
Migraine triggers are present in 76% of migraineurs. One study reported the following triggers from affected patients: stress, female hormones, not eating, weather, physical exhaustion or travel, sleep disturbance, perfume or odor, bright lights, neck pain; alcohol, smoke, sleeping late, heat, food and exercise.
A 25% of all migraineurs suffer four or more severe attacks a month, 35% have one to four severe attacks per month, 38% experience one or fewer severe attacks per month. About 70% of migraineurs have an affected first-degree relative.
The prevalence of migraine with aura is 5.3% in women and 1.9% in men. As many as 81% of those having migraine with aura also have attacks of migraine without aura. The visual aura is the most common, occurring in 99% of attacks, sensory (typically unilateral numbness, tingling, or pins and needles in the hand, which may spread to the face or either alone, can have unilateral tongue paresthesias) in 30%, and dysphasia (if the dominant hemisphere or can have slurred speech) in 20%. Usually the duration of the aura is 5 to 60 minutes. Usually the aura phase is preceding the headache but it can occur during the headache. The aura may follow the headache in 3% to 8% of cases. Sometimes the aura can occur without headache. In these circumstances, other causes may need to be excluded.
Migraine treatment involves acute attack and preventives measures. Recurring migraines that significantly interfere with daily routine, despite acute treatment is indication for preventive treatment.
Chronic daily headaches are the primary headache disorders in which patients experience headaches lasting 4 or more hours per day (without treatment), 15 or more days a month for 3 or more months. This disorder affects 3% to 5% of the worldwide population. These headaches include chronic migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua.
Risk factors for transformation include medication overuse, high caffeine consumption, female gender, stressful life events, anxiety, depression, baseline high-attack frequency, lifetime injuries to the head or neck, obesity, snoring, arthritis, and presence of cutaneous allodynia.
Chronic migraine, or transformed migraine, is a complication of intermittent migraine, with 2.5% progressing yearly from episodic to chronic migraine. It may occur with or without medication overuse. The pain is often mild to moderate and not always associated with photophobia, phonophobia, nausea, or vomiting and may resemble a mixture of migraine and tension-type headaches with intermittent severe migraine-type headaches. Depression is present in 40% and anxiety in 30%. Preventive medication is different for chronic migraine than for episodic migraine. Recently, botulinum toxin A has been approved for chronic migraine.
The 1 year prevalence of the episodic type is 38% and chronic (15 or more days per month for 3 or more months) is 2%. The typical headache is a bilateral mild to moderate intensity, non-throbbing headache described as dull, pressure, a tight cap, band, or a heavy pressure without associated symptoms. The headache is unilateral in 10% and occasionally pulsating. Stress is a common trigger.
Like migraine treatment, it involves acute attack and preventive measures.
Trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterized by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features. TACs include cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA), and hemicrania continua.
The lifetime prevalence is about 0.1% with a male to female ratio of 4:1. Onset is typically from ages 20 to 40 years. Five to 20% have a family history. The risk of CH for first-degree relatives is increased by 14- to 39-fold. Up to 85% of patients are chronic cigarette smokers. The strictly unilateral pain is behind the eye in about 90%, over the temple in 70%, and over the maxilla in 50% although the pain may be in the occipital neck region. The pain is usually severe in intensity and is sharp, stabbing, piercing, burning, or pulsating in quality. Most have one to three attacks per day. Untreated, each headache lasts 15 to 180 minutes. About 97% have ipsilateral cranial autonomic symptoms such as conjunctival injection, lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, ptosis, and miosis.
Like migraine treatment, it involves acute attack and preventive measures. Triptans are the mainstay of acute treatment. Verapamil is the drug of choice for preventive treatment.