Headaches and Dizziness: Difference between revisions

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=== Migraine ===
=== Migraine ===
Migraine is a recurrent headache disorder which affects around fifteen percent of the population aged 22-55 years.<ref name=":3">Burstein R, Noseda R, Borsook D. Migraine: multiple processes, complex pathophysiology. J Neurosci. 2015;35(17):6619-6629. </ref> It generally begins in childhood to early adulthood although it can start later in life for some perimenopausal / menopausal women.<ref name=":2" /> It is estimated that ten percent of children experience migraines.<ref>Rao R, Hershey AD. An update on acute and preventive treatments for migraine in children and adolescents. Expert Review of Neurotherapeutics. 2020. Published online. </ref> It affects women more than men.<ref name=":3" /> As it tends to run in families, it is considered a genetic disorder.<ref name=":3" /> It has significant personal and economic effects<ref name=":0" /> and is listed as the sixth most prevalent out of 328 diseases and injuries assessed in the Global Burden of Disease Study from 2016.<ref>GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-976. </ref>
Migraine is a recurrent headache disorder which affects around fifteen percent of the population aged 22-55 years.<ref name=":3">Burstein R, Noseda R, Borsook D. Migraine: multiple processes, complex pathophysiology. J Neurosci. 2015;35(17):6619-6629. </ref> It generally begins in childhood to early adulthood although it can start later in life for some perimenopausal / menopausal women.<ref name=":2" /> It is estimated that ten percent of children experience migraines.<ref>Rao R, Hershey AD. An update on acute and preventive treatments for migraine in children and adolescents. Expert Review of Neurotherapeutics. 2020. Published online. </ref> It affects women more than men.<ref name=":3" /> As it tends to run in families, it is considered a genetic disorder.<ref name=":3" /> It has significant personal and economic effects<ref name=":0" /> and is listed as the sixth most prevalent out of 328 diseases and injuries assessed in the Global Burden of Disease Study from 2016.<ref name=":4">GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-976. </ref>


Migraines are characterised as recurrent episodes of headaches associated with visual or sensory symptoms.<ref name=":2" /> In some cases of migraine, a headache will occur with no warning signs and resolve with sleep.<ref name=":3" /> However, sometimes prior to migraine, patients will experience a prodromal phase, with symptoms such as fatigue, euphoria, depression, irritability, food cravings, constipation, neck stiffness, increased yawning, and / or abnormal sensitivity to light, sound, and smell.<ref name=":3" /> Migraines can also present with transient hemiplegic episodes. These cases require further medical investigation.<ref name=":2" />
Migraines are characterised as recurrent episodes of headaches associated with visual or sensory symptoms.<ref name=":2" /> In some cases of migraine, a headache will occur with no warning signs and resolve with sleep.<ref name=":3" /> However, sometimes prior to migraine, patients will experience a prodromal phase, with symptoms such as fatigue, euphoria, depression, irritability, food cravings, constipation, neck stiffness, increased yawning, and / or abnormal sensitivity to light, sound, and smell.<ref name=":3" /> Migraines can also present with transient hemiplegic episodes. These cases require further medical investigation.<ref name=":2" />
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* Migraine without aura: will generally last from four to 72 hours. Typically, pain is unilateral and of a moderate to severe pulsing type and it is aggravated by physical activity. Nausea, vomiting, photophobia, and phonophobia often accompany it<ref name=":0" /><ref name=":2" />
* Migraine without aura: will generally last from four to 72 hours. Typically, pain is unilateral and of a moderate to severe pulsing type and it is aggravated by physical activity. Nausea, vomiting, photophobia, and phonophobia often accompany it<ref name=":0" /><ref name=":2" />
* Migraine with an aura: an aura refers to a sensory or neurological symptom that occurs before the migraine starts. It is usually visual - typically some type of a zigzagging crescent shape formation that occurs in the visual field,<ref name=":2" /> but it can also refer to sensory and / or speech or language symptoms. There is no motor weakness and it develops gradually. Each symptom typically lasts no longer than an hour<ref name=":0" />
* Migraine with an aura: an aura refers to a sensory or neurological symptom that occurs before the migraine starts. It is usually visual - typically some type of a zigzagging crescent shape formation that occurs in the visual field,<ref name=":2" /> but it can also refer to sensory and / or speech or language symptoms. There is no motor weakness and it develops gradually. Each symptom typically lasts no longer than an hour<ref name=":0" />
=== Tension Type Headaches ===
Tension type headaches (TTH) are the most prevalent of primary headaches in the general population.<ref>Jensen RH. Tension-Type Headache - The Normal and Most Prevalent Headache. Headache. 2018;58(2):339-345.</ref> There are four types of TTH:<ref name=":0" />
* Infrequent
* Frequent
* Chronic
* Probable
Lifetime prevalence rates range from 30 to 78 percent.<ref name=":0" /> TTH are ranked as the third most prevalent condition in the Global Burden of Disease Study of 2016<ref name=":4" /> and are more common in women.<ref name=":2" />
TTH are classified as recurrent episodes of headaches. The headaches may last a few minutes or continue for weeks.<ref name=":5">Chowdhury D. Tension type headache. Ann Indian Acad Neurol. 2012;15(Suppl 1):S83-S88. </ref> They usually consist of a pressing or tightening pain, that is non-throbbing in nature, of mild to moderate intensity that originate in the temporal region.<ref name=":2" /><ref name=":5" /> They are bilateral and do not get worse with activity. While nausea and vomiting are usually absent, photophobia and phonophobia can occur.<ref name=":5" /> They are usually accompanied by excessive tone of the suboccipital or neck muscles. Manual therapy is usually an effective intervention for this type of headache.<ref name=":2" />
While TTH have previously been associated with stress or psychogenic causes, there are numerous studies that suggest a neurobiological basis.<ref name=":5" /><ref name=":0" />
=== Trigeminal autonomic cephalalgias ===
Trigeminal autonomic cephalalgia (TAC) is a primary headache that occurs with pain in the trigeminal distribution unilaterally in the head. It occurs with cranial parasympathetic autonomic symptoms (such as eye watering, droopy eyelids or ptosis, nasal congestion) - these features are lateralised and ipsilateral to the headache.<ref name=":0" /><ref name=":2" /> They are typically of short duration.
There are five different types of TACs:<ref name=":0" />
* Cluster headaches
* Paroxysmal hemicranias
* Short-lasting Unilateral Neuralgiform Headache Attacks (either with conjunctival injection and tearing (SUNCT) or cranial autonomic symptoms (SUNA))
* Hemicrania continua
* Probable TAC
While the cluster headache is more common, the other three types of trigeminal autonomic cephalgia are fairly rare.<ref name=":2" />
Cluster headaches are recurrent and are characterised by severe unilateral pain, which has ipsilateral autonomic symptoms and often also causes restlessness and / or agitation.<ref>Russell MB. Epidemiology and genetics of cluster headache. Lancet Neurol. 2004;3(5):279-283. </ref><ref name=":6">Hoffmann J, May A. Diagnosis, pathophysiology, and management of cluster headache. Lancet Neurol. 2018;17(1):75-83.</ref> Due to the severity of the pain, they can have a major impact on a patient’s quality of life.<ref name=":6" /> The pain is located behind the eye and autonomic symptoms can include eye watering and nasal congestion.<ref name=":2" /> Cluster headaches can last from 15 minutes to three hours and they occur in clusters. The clusters can last from weeks to months or sometimes over a year.<ref name=":2" />
Their cause is unknown, but it is thought to involve a coordinated, abnormal activity in the hypothalamus, the trigeminovascular system and the autonomic nervous system. It appears that the hypothalamus has a major part in generating the state that initiates an episode. The attacks themselves likely also require involvement of the peripheral nervous system.<ref name=":6" />
Risk factors for cluster headaches include:<ref name=":2" />
* A history of exposure to tobacco smoke
* A family history of the condition
They can be triggered by alcohol and nitro-glycerine.<ref name=":2" />
=== New Daily Persistent Headache ===
New daily persistent headache occurs in patients who have no previous history of headache.<ref name=":0" /> In order to be classified as a new daily persistent headache, it must occur daily for more than three months. This headache generally has a lateral, cramping pressure quality, and is associated with photophobia, phonophobia and nausea. It is not aggravated by activity.<ref name=":2" /> It usually has a rapid onset from a specific time - this rapid onset has to be recalled by the patient if it is to be considered / classified as a new daily persistent headache.<ref name=":0" /> This pathogenesis of this condition is not well understood. It may be due to abnormal glial activation with persistent central nervous system inflammation. It may also be associated with patients who have a history of cervical hypermobility.<ref>Rozen TD. New daily persistent headache: an update. ''Curr Pain Headache Rep''. 2014;18(7):431.</ref>
== References ==
<references />

Revision as of 11:57, 7 September 2020

Introduction[edit | edit source]

Headaches and dizziness have numerous causes and there are many different types. This page will explore some of the key types of headaches and causes of dizziness that may be encountered in clinical practice, as well as highlighting red flags and other signs / symptoms which warrant referral.

Headache Classification[edit | edit source]

Headaches are grouped into three main areas:[1]

  • Primary headaches
  • Secondary headaches
  • Neuropathies, facial pain and other headaches

Primary Headache[edit | edit source]

Primary headaches are the most common headache type.[2] These headaches, which include migraines, tension headaches, trigeminal autonomic cephalgias, and other primary headache disorders.[3][1] They are not caused by other anatomical or physiological abnormalities. Nor are they related to inflammation or infections.[2]

Migraine[edit | edit source]

Migraine is a recurrent headache disorder which affects around fifteen percent of the population aged 22-55 years.[4] It generally begins in childhood to early adulthood although it can start later in life for some perimenopausal / menopausal women.[3] It is estimated that ten percent of children experience migraines.[5] It affects women more than men.[4] As it tends to run in families, it is considered a genetic disorder.[4] It has significant personal and economic effects[1] and is listed as the sixth most prevalent out of 328 diseases and injuries assessed in the Global Burden of Disease Study from 2016.[6]

Migraines are characterised as recurrent episodes of headaches associated with visual or sensory symptoms.[3] In some cases of migraine, a headache will occur with no warning signs and resolve with sleep.[4] However, sometimes prior to migraine, patients will experience a prodromal phase, with symptoms such as fatigue, euphoria, depression, irritability, food cravings, constipation, neck stiffness, increased yawning, and / or abnormal sensitivity to light, sound, and smell.[4] Migraines can also present with transient hemiplegic episodes. These cases require further medical investigation.[3]

Migraine headaches are usually unilateral, have a pulsating quality and are aggravated by activity. They last from a few hours up to a few days.[4] Migraines in children are generally bilateral frontal temporal headaches. It has been considered a red flag symptom if they occur in the occipital region,[3] but this has been disputed in some recent research.[7]

Migraines can occur with or without aura.

  • Migraine without aura: will generally last from four to 72 hours. Typically, pain is unilateral and of a moderate to severe pulsing type and it is aggravated by physical activity. Nausea, vomiting, photophobia, and phonophobia often accompany it[1][3]
  • Migraine with an aura: an aura refers to a sensory or neurological symptom that occurs before the migraine starts. It is usually visual - typically some type of a zigzagging crescent shape formation that occurs in the visual field,[3] but it can also refer to sensory and / or speech or language symptoms. There is no motor weakness and it develops gradually. Each symptom typically lasts no longer than an hour[1]

Tension Type Headaches[edit | edit source]

Tension type headaches (TTH) are the most prevalent of primary headaches in the general population.[8] There are four types of TTH:[1]

  • Infrequent
  • Frequent
  • Chronic
  • Probable

Lifetime prevalence rates range from 30 to 78 percent.[1] TTH are ranked as the third most prevalent condition in the Global Burden of Disease Study of 2016[6] and are more common in women.[3]

TTH are classified as recurrent episodes of headaches. The headaches may last a few minutes or continue for weeks.[9] They usually consist of a pressing or tightening pain, that is non-throbbing in nature, of mild to moderate intensity that originate in the temporal region.[3][9] They are bilateral and do not get worse with activity. While nausea and vomiting are usually absent, photophobia and phonophobia can occur.[9] They are usually accompanied by excessive tone of the suboccipital or neck muscles. Manual therapy is usually an effective intervention for this type of headache.[3]

While TTH have previously been associated with stress or psychogenic causes, there are numerous studies that suggest a neurobiological basis.[9][1]

Trigeminal autonomic cephalalgias[edit | edit source]

Trigeminal autonomic cephalalgia (TAC) is a primary headache that occurs with pain in the trigeminal distribution unilaterally in the head. It occurs with cranial parasympathetic autonomic symptoms (such as eye watering, droopy eyelids or ptosis, nasal congestion) - these features are lateralised and ipsilateral to the headache.[1][3] They are typically of short duration.

There are five different types of TACs:[1]

  • Cluster headaches
  • Paroxysmal hemicranias
  • Short-lasting Unilateral Neuralgiform Headache Attacks (either with conjunctival injection and tearing (SUNCT) or cranial autonomic symptoms (SUNA))
  • Hemicrania continua
  • Probable TAC

While the cluster headache is more common, the other three types of trigeminal autonomic cephalgia are fairly rare.[3]

Cluster headaches are recurrent and are characterised by severe unilateral pain, which has ipsilateral autonomic symptoms and often also causes restlessness and / or agitation.[10][11] Due to the severity of the pain, they can have a major impact on a patient’s quality of life.[11] The pain is located behind the eye and autonomic symptoms can include eye watering and nasal congestion.[3] Cluster headaches can last from 15 minutes to three hours and they occur in clusters. The clusters can last from weeks to months or sometimes over a year.[3]

Their cause is unknown, but it is thought to involve a coordinated, abnormal activity in the hypothalamus, the trigeminovascular system and the autonomic nervous system. It appears that the hypothalamus has a major part in generating the state that initiates an episode. The attacks themselves likely also require involvement of the peripheral nervous system.[11]

Risk factors for cluster headaches include:[3]

  • A history of exposure to tobacco smoke
  • A family history of the condition

They can be triggered by alcohol and nitro-glycerine.[3]

New Daily Persistent Headache[edit | edit source]

New daily persistent headache occurs in patients who have no previous history of headache.[1] In order to be classified as a new daily persistent headache, it must occur daily for more than three months. This headache generally has a lateral, cramping pressure quality, and is associated with photophobia, phonophobia and nausea. It is not aggravated by activity.[3] It usually has a rapid onset from a specific time - this rapid onset has to be recalled by the patient if it is to be considered / classified as a new daily persistent headache.[1] This pathogenesis of this condition is not well understood. It may be due to abnormal glial activation with persistent central nervous system inflammation. It may also be associated with patients who have a history of cervical hypermobility.[12]

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 International Headache Society. International Classification of Headache Disorders (ICHD-3). Available from https://ichd-3.org/classification-outline/ (accessed 7 September 2020).
  2. ↑ 2.0 2.1 Manzoni GC, Stovner LJ. Epidemiology of headache. Handb Clin Neurol. 2010;97:3-22. 
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 Dent D. Headaches and Dizziness Course. Physioplus. 2020.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Burstein R, Noseda R, Borsook D. Migraine: multiple processes, complex pathophysiology. J Neurosci. 2015;35(17):6619-6629.
  5. ↑ Rao R, Hershey AD. An update on acute and preventive treatments for migraine in children and adolescents. Expert Review of Neurotherapeutics. 2020. Published online.
  6. ↑ 6.0 6.1 GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2018;17(11):954-976.
  7. ↑ Genizi J, Khourieh-Matar A, Assaf N, Chistyakov I, Srugo I. Occipital Headaches in Children: Are They a Red Flag?. J Child Neurol. 2017;32(11):942-946.
  8. ↑ Jensen RH. Tension-Type Headache - The Normal and Most Prevalent Headache. Headache. 2018;58(2):339-345.
  9. ↑ 9.0 9.1 9.2 9.3 Chowdhury D. Tension type headache. Ann Indian Acad Neurol. 2012;15(Suppl 1):S83-S88.
  10. ↑ Russell MB. Epidemiology and genetics of cluster headache. Lancet Neurol. 2004;3(5):279-283.
  11. ↑ 11.0 11.1 11.2 Hoffmann J, May A. Diagnosis, pathophysiology, and management of cluster headache. Lancet Neurol. 2018;17(1):75-83.
  12. ↑ Rozen TD. New daily persistent headache: an update. Curr Pain Headache Rep. 2014;18(7):431.
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