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After reading the article you should be able to:

1. Differentiate between primary and secondary headaches.
2. Compare and contrast tension-type, migraine, and cluster headaches.
3. Discuss nursing and medical management for a patient experiencing headaches.

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By JULIE A. WATSON, RN, MNSc, APN, CPNP-PC

JULIE A. WATSON is a certified pediatric nurse practitioner with Bentonville Pediatrics, P.A., in Bentonville, AR. During her 10 years as a nurse, she's worked with a variety of neurology patients. The author has no financial relationships to disclose. STAFF EDITOR: CATHERINE M. RADWAN

One of the most common types of pain known to mankind is the headache—nearly 90% of men and 95% of women have had at least one.² Furthermore, 25% of Americans report frequent and severe headaches, and an estimated 1% to 2% of emergency department visits are due to headache symptoms.^3,4

About one in 10 American adults use prescription and/or nonprescription headache relief products per week.³ In the United States alone, headache complaints cost billions of dollars annually due to the expenses incurred from medical care, lost productivity, and work absences.⁵ Because headache symptoms are so prevalent and disabling, nurses must be knowledgeable about headache disorders so that they can assess a client's pain, intervene effectively, and teach clients how to find relief.

According to the International Headache Society (IHS), there are 14 basic types of headache disorders.⁴ Most headaches (with a few exceptions, including the neuralgias and neuropathies) are classified as either primary or secondary.⁶ Primary headaches are headaches that are not caused by any underlying disorder, whereas secondary headaches occur as a result of some abnormal pathology, such as head trauma, increased intracranial pressure, tumors, or infection.⁶

It is imperative to be able to recognize the potentially life-threatening symptoms of secondary headaches so that emergency care can be provided when necessary. A key indicator of a secondary headache is the patient's complaint that his or her pain is "the worst headache of my life." Other symptoms include: sudden onset of headache pain; changes in a usual headache pattern; headaches that always occur on the same side of the head; onset after age 50; headache precipitated by Valsalva maneuver; change in level of consciousness; weakness in extremities or facial muscles; face or jaw pain; difficulty in speaking or swallowing; change in pupil size or shape; neck stiffness; hearing impairment; fever; developing rash; or seizures.^4,7,8,9

Once you've determined that a headache is not likely to be the secondary type, you then can assist the patient in finding relief for primary headache symptoms. Of the primary headaches, at least 97% can be classified as tension-type, migraine, or cluster.⁸ Typical characteristics of these three primary headache types are found in the chart, and the common pharmacologic and nonpharmacologic treatments for each in the chart.

Tension-type headache

This is by far the most common type of primary headache, with a lifetime incidence of approximately 80%.⁶ Tension-type headaches usually begin before middle age and affect women more often than men. Current science indicates that tension-type headaches are likely to be caused by an imbalance of serotonin, norepinephrine, and endorphins in the brain.⁸

Sufferers of tension-type headaches usually describe the pain as a dull ache that can be felt on both sides of the head, often as though a tight band is squeezing the head. Other symptoms that present may include muscle stiffness in the neck and shoulders, soreness in the muscles of the scalp, fatigue, depression, anxiety, and sleep problems.⁸ Unlike migraine headache, people with tension-type headaches usually keep up their normal activities and typically do not have any nausea, vomiting, visual changes, or sensitivity to light or noise.

Tension-type headaches are classified as episodic, chronic, or frequent.⁸ Episodic tension-type headaches may be referred to as "stress headaches" and occur less than once per month. Triggers are temporary anxiety, stress, anger, or fatigue. Pain relief results from avoiding stressors, relaxing for a relatively brief period, or taking over-the-counter analgesics. Non-opioid analgesics such as acetaminophen (Tylenol) typically are the first drugs recommended for tension-type headaches, although nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) also are used.

Chronic tension-type headache is diagnosed when the patient has a tension-type headache at least 15 days per month for at least six consecutive months. Treating chronic tension-type headache consists of preventive therapy in addition to abortive therapy. Prevention includes nonpharmacologic interventions such as the application of heat and/or cold, massage, relaxation techniques, stress management, counseling, eating balanced meals, getting adequate rest and sleep, and maintaining good posture.³ A tricyclic antidepressant such as amitriptyline (Elavil) may be prescribed as preventive therapy for a patient with chronic tension-type headache, even if the patient does not have symptoms of depression.¹⁰ Interestingly, some recent studies have shown that botulinum toxin injections into the cranial muscles can prevent tension-type headache, although this is controversial.¹¹

Hormone replacement therapy and oral contraceptives are thought to contribute to the development of tension-type headache, so patients with this headache type may want to discuss with their healthcare providers the possibility of discontinuing these medications.⁴ Muscle relaxants and drugs used for migraines have not been shown to be effective in treating or preventing tension-type headaches.³

Frequent headaches occur one to 15 days per month. These headaches often coexist with migraine. Due to the frequency of this type of headache, sufferers should use caution not to overuse analgesics for pain.⁸

Migraine headache

Migraine headache affects 18% of women and 6% of men, although this type of headache often is underdiagnosed and therefore not treated effectively.^3,5 Migraine headache often begins between 10 and 30 years of age.⁴ The exact source of a migraine is unknown, but it is believed that certain neurotransmitters become activated and cause vasodilation of cranial blood vessels.⁴ Research currently is being conducted to determine whether migraines are genetic. In fact, one gene has been identified for a type of migraine known as familial hemiplegic migraine.⁴ It is known that patients who have epilepsy, major affective disorders, asthma, chronic fatigue syndrome, stroke, hypertension, or Raynaud's phenomenon are at increased likelihood to experience migraine headache.⁹

Migraine headache often is described as a "throbbing" pain, usually located on only one side of the head, that may be accompanied by nausea, vomiting, and sensitivity to light and sound. These attacks typically last from four to 72 hours.⁸

Migraines are classified as "migraine without aura" or "migraine with aura." The IHS defines an aura as a "focal neurological disturbance manifesting as visual, sensory, or motor symptoms."¹² Auras are most often experienced as light flashes, blind spots, shimmering lights, zigzag lines, or sensations of numbness and tingling.⁸

An acute migraine headache attack can be treated in numerous ways. Many individuals will self-medicate with NSAIDs or other simple analgesics.⁹ Antiemetics such as metoclopramide (Reglan) often are used in conjunction with an analgesic. In fact, research has demonstrated that metoclopramide alone may be effective in aborting a migraine headache due to its dopamine antagonist properties.¹³

Women suffer migraines three times more frequently than men, and menstrual migraines affect 60 percent of these women. They occur during ovulation or before, during, or immediately after the period.¹⁴ When estrogen and progesterone levels change, women are more vulnerable to headaches. Because oral contraceptives influence estrogen levels, women on birth control pills may have more menstrual migraines. For treatment, triptans appear to provide acute relief and also may be useful for headache prevention.

Triptans also have shown effectiveness in stopping an acute migraine attack.⁹ Examples of triptan medications include sumatriptan (Imitrex), rizatriptan (Maxalt), and zolmatriptan (Zomig).⁹ Other drugs that have been used to stop a migraine attack include dihydroergotamine (DHE), prochlorperazine (Compazine), isometheptene (Octin), and glucocorticoids.⁹ Often, acute migraine treatment consists of a combination of these medications. For example, Midrin is a brand-name drug that is a combination of isometheptene mucate, dichloralphenazone, and acetaminophen.⁹

Migraine headache prevention involves lifestyle modification and trigger avoidance. Lifestyle modifications include regular sleeping habits, regular meals, exercise, and the avoidance of stress.⁹ Some studies have shown that patients also may find migraine relief through acupuncture, biofeedback, cognitive behavioral therapy, or transcutaneous electrical nerve stimulation (TENS).⁵ The migraine sufferer should attempt to identify and avoid any migraine triggers. Examples of triggers are listed in the chart below.

Preventive medication may be necessary if an individual has three or more migraine headaches per month or if each migraine headache lasts two or more days. Medications that prevent migraine headaches may include anticonvulsants, antidepressants, beta-blockers, calcium channel blockers, NSAIDs, hormonal therapy, and the triptans. Some patients report that multivitamins and an herbal remedy known as feverfew help decrease the severity of migraine.⁵

Cluster headache

This type of headache is much less common than a migraine or tension-type headache—the prevalence is only about five in every 10,000 adults.¹⁵ The rarity of cluster headache may explain why it takes an average of 2.6 years and at least three healthcare providers to accurately diagnose a client with this type of headache disorder.¹¹ Cluster headache is referred to as "cluster" because many headache attacks occur during a period of six to 12 weeks, which then is followed by an inactive period that lasts a few months.^15,16

In contrast to migraine and tension-type headache, men are three to four times more likely than women to experience cluster headaches.¹⁵ Smokers and individuals with a family history of cluster headache also are more likely to experience these types.⁴

The pathophysiology of cluster headache may be due to inflammation disrupting signals from the trigeminal nerve.⁸ Recent studies have found that cluster headache may occur as a result of abnormalities in the hypothalamus, although the specific abnormality is yet to be determined.¹⁵ Since cluster headache is a relatively rare phenomenon, a client with this possible diagnosis should be referred to an experienced neurologist for management.⁴

The pain of a cluster headache begins suddenly, is always one-sided, and has been described as an excruciating sensation of burning or throbbing around one eye.^4,8 The affected eye usually becomes red, watery, and swollen, and may droop.⁴ Often the nose will become congested, and nasal discharge may occur on the same side as the headache pain.⁸ Cluster headache sufferers also may experience excessive sweating and facial flushing on the same side as the headache pain.⁸ The pain of a cluster headache typically lasts from 15 minutes to three hours, with most headaches persisting for less than one hour.¹⁵ Cluster headaches occur from one to four times per day during the cluster period, and often begin in the first three hours after falling asleep at night.^15,16

Abortive therapy for an acute episode of cluster headache most often consists of sumatriptan (Imitrex) given subcutaneously and the inhalation of 100% oxygen by face mask for 15 to 25 minutes.¹⁷ Preventive therapy for cluster headache may consist of a calcium channel blocker such as verapamil, antiepileptic medications such as valproic acid or topiramate, melatonin, and/or lithium carbonate.¹⁸

In conclusion, headache pain can be caused by numerous factors and may affect anyone at any time. Knowing the common characteristics of headache types can make nurses better equipped to assess the patient and ask questions that will assist the healthcare team in determining how to manage the headache pain. By working together, the nurse, the patient, and the healthcare team can create a treatment plan that will effectively reduce the impact of headache pain on their patients' quality of life.

REFERENCES

1. The cost of headaches: $4.3 billion spent on migraines and headaches each year, report says. Pharmaceutical Executive. (2006, May 1).

2. Yale University School of Medicine. (2005, Oct. 28). Nervous System Disorders, Headache. http://ymghealthinfo.org/content.asp?page=P00784

3. Kaniecki, R. (2003). Headache assessment and management. The Journal of the American Medical Association, 289(11), 1430-1433.

4. Welch, E. (2005). Headache. Nursing Standard, 19(24), 45-52.

5. Lawrence, E. C. (2004). Diagnosis and management of migraine headaches. Southern Medical Journal, 97(11), 1069-1077.

6. Levin, M. (2006). Classification of primary headaches: Concepts and controversies. Continuum, 12(6), 32-51.

7. Holcomb, S. S. (2005). Guidelines for migraine treatment. The Nurse Practitioner, 30(7), 12-15.

8. National Headache Foundation. (2004). Categories of Headache. Accessed online August 6, 2008, at www.headaches.org/press/NHF_Press_Kits/Press_Kits_-_Categories_of_Headache

9. Wright, W., Diamond, S., Matthews, C., & Schumann, E. (2005). New insights into the pathophysiology and management of migraine headaches. The Clinical Advisor, April 2005(Suppl. 1), 3-22.

10. Tommaso, M. Shevel, E., et al. (2006). Intra-oral orthosis vs amitriptyline in chronic tension-type headache: a clinical and laser evoked potentials study [Electronic version]. Head and Face Medicine 2(15) www.head-face-med.com/content/2/1/15

11. Diener, H. C. (2005). Headache. Current Opinion in Neurology, 18(3), 279-282.

12. Goadsby, P. J. (2006). Pathophysiology of migraine. Continuum, 12(6), 52-66.

13. Colman, I. Brown, M. D., Innes, G. D., Grafstein, E., Roberts, T. E., & Rowe, B. H. (2004). Parenteral metoclopramide for acute migraine: meta-analysis of randomized controlled trials. British Medical Journal, 329 (7479), 1369-1371.

14. Brandes, J. L. (2006). The influence of estrogen on migraine. JAMA, 295, 1824-1830.

15. McGeeney, B. E. (2005). Cluster headache pharmacotherapy. American Journal of Therapeutics, 12(4), 351-358.

16. Kernich, C. A. (2005). Cluster headaches. The Neurologist, 11(4), 255-256.

17. Evers, S. & Frese, A. (2005). Recent advances in the treatment of headaches. Current Opinion in Anaesthesiology, 18(5), 563-568.

18. May, A. & Leone, M. (2003). Update on cluster headaches. Current Opinion in Neurology, 16(3), 333-340.

TYPICAL CHARACTERISTICS OF TENSION-TYPE, MIGRAINE, AND CLUSTER HEADACHE

TREATMENTS FOR HEADACHES

MIGRAINE TRIGGERS