Back to Search Results

6/1/2019

Migraine, Cluster, and Tension Headaches

Author: Frederick Eruo, MD

Mentor: Adrianne Dade, MD
Editor: Julie DeCesare, MD

Registered users can also download a PDF or listen to a podcast of this Pearl.
Log in now, or create a free account to access bonus Pearls features.

Headache may be classified as primary or secondary. Primary headaches have no associated underlying pathologic abnormalities.  The principal primary headaches include cluster, migraine, and tension-type headaches.  These syndromes constitute more than 90% of primary headaches. Some patients develop analgesic-withdrawal or rebound headaches.  Secondary headaches are due to metabolic, structural, or pathologic causes such as lesions that increase intracranial pressure, vasculitis, thrombosis of brain sinuses and veins, or pseudotumor cerebri.  Diagnosis of headache requires a thorough history with a detailed physical examination. History should include the onset and description of headache, location, frequency, duration, any associated symptoms, any prodromal features or aura, family history, and medication history.

Cluster headache is usually unilateral in location and does not include an aura. Onset of the headache is frequently in the thirties or forties age groups.  It is generally orbito-temporal, excruciating, boring, or penetrating with possible ipsilateral ptosis, miosis, red eyes, nasal congestion, and sweating of the face. Patients may have a sense of restlessness, agitation with frenetic pacing, and rocking movements. Cluster headaches occur more frequently in males than females, whereas migraine headaches, and sometimes tension headaches, occur more commonly in females than males.  Triptans such as sumatriptan, especially the injectable form, are used to treat acute cluster headache. Briefly inhaling 100% oxygen provides dramatic improvement for cluster headache. Preventive medications for cluster headaches include topiramate, lithium carbonate, and calcium channel blockers such as verapamil.

Migraine headache is an intense, throbbing or pulsating sensation lasting several hours or even days. The pain may be disabling, sometimes preventing patients from various physical activities. It may be associated with menstruation and changes in mood, appetite, or energy. Migraine headache can often be associated with nausea, vomiting, photophobia, phonophobia, or behavioral changes. It may or may not include aura. Triggers for migraine headache can include stress, lack of sleep, certain medications (oral contraceptive pills, vasodilators like nitroglycerin), changes in hormones, diet, diet additives, and weather. The intensity and frequency of migraine headaches tend to decrease after menopause. Migraine headache may be treated with acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), amitriptyline, sumatriptan, ergots, codeine, butalbital, calcium channel blockers, or beta-blockers. Adjunctive treatment for migraine may include non-pharmacologic options such as exercise and avoiding precipitating factors.

Tension-type headache is usually bilateral in location, bifrontal, bioccipital or neck region. It is described as a tight aching band that is squeezing and pressing, with no prodrome or aura. Episodic tension headache usually lasts 30 minutes to a few hours; rarely it can last days.  Tension headaches are best managed with acetaminophen, NSAIDs, massage therapy, heat, and rest. Preventive measures such as smoking cessation, regular exercise, and reducing alcohol and caffeine intake may be useful.

A secondary headache is different from primary because there is usually an underlying medical condition. The differential diagnosis includes severe hypertension, tumors of the central nervous system, infection or inflammation of the head and neck region, head injury, subdural hematoma, subarachnoid hemorrhage, hydrocephalus, or pregnancy. Red flags for secondary headaches include: first or worst headache of the patient’s life, headache beginning at extremes of age (< 5 years and >50 years), headache associated with sex, exertion, cough, sneeze, or Valsalva, human immunodeficiency virus (HIV), pregnancy or headache with seizure, syncope, or the presence of cancer. Patients with any of these red flags need evaluation.

Preeclampsia should be considered in women over 20 weeks of gestation and women in the peripartum and postpartum period with new-onset headache. 

Further Reading:

[No authors listed], ACOG Committee Opinion No. 767: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol. 2019 Feb;133(2):e174-e180. doi: 10.1097/AOG.0000000000003075.

International Headache Society (IHS). www.ihs-headache.org/

Olesen J, Tfelt-Hansen P, Ramadan N, Goadsby PJ, Welch KMA. The headaches. Philadelphia: Lippincott, Williams, and Wilkins, 2006.

Initial Approval May 2019, Published June 2019

 

********** Notice Regarding Use ************

The Foundation for Exxcellence in Women’s Health, Inc (“Foundation”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The Foundation reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. The Foundation does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither the Foundation, SASGOG nor their respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2019 The Foundation for Exxcellence in Women's Health, Inc. All rights reserved.  No re-print, duplication or posting allowed without prior written consent.

 

Back to Search Results