Cefalea Ptes

Migraine headaches
Highlights
Migraine Symptoms
A typical migraine attack lasts anywhere from 4 - 72 hours and produces symptoms that
may include:
Throbbing pain on one side of the head

Pain worsened by physical activity
Nausea, sometimes with vomiting
Visual symptoms
Facial tingling or numbness
Extreme sensitivity to light and noise
Looking pale and feeling cold
Migraines attacks are often preceded by symptoms that may include:
Sensitivity to light or sound

Changes in appetite
Thirst
Fatigue and drowsiness
Mood changes
Sensory disturbances (auras)
Migraine Triggers
Migraines can be triggered by many everyday things. Different people respond to

different triggers, so it is important to track your migraine patterns to help avoid
migraine attacks. Common migraine triggers include:
Emotional stress
Intense physical exertion
Abrupt weather changes
Bright or flickering lights
High altitude
Travel motion
Lack of sleep
Skipping meals
Odors
Certain types of foods and beverages (aged cheese, chocolate, red wine, beer,
coffee, and many others)
Food additives or preservatives (such as nitrates, nitrates, and monosodium
glutamate)
Migraine Treatment Approaches

Migraines need a two-pronged approach: Treatment and prevention. Treatment uses
medications that provide quick pain relief when attacks occur. These drugs include pain
relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs), triptans such as
sumatriptan (Imitrex), and ergotamine drugs.
Preventive strategies begin with non-drug approaches, including behavioral therapies

and lifestyle changes. If headache attacks continue to occur on a weekly basis, your
doctor may recommend you try preventive medication. Drugs currently approved for
migraine prevention include the beta-blocker drugs propanolol (Inderal) and timolol
(Blacadrene), and the anti-seizure drugs divalproex (Depakote) and topiramate
(Topamax).
Introduction
The pain from a headache does not start from inside the brain. (The brain itself cannot
feel pain.) Instead, headache pain begins in other locations, such as the tissues covering
the brain or muscles, blood vessels, or nerves around the scalp face and neck.
A headache is generally categorized as primary or secondary.
Primary Headache. A headache is considered primary when a disease or other medical

condition does not cause it.
Tension headache is the most common primary headache and accounts for
almost all headaches. [For more information, see In-Depth Report # 11: Tension
headaches.]
Neurovascular headaches are the second most common primary headaches. This
type includes migraines and cluster headaches. [Fore more information, see In-
Depth Report # 99: Cluster headaches.] Such headaches are caused by an
interaction between blood vessel and nerve abnormalities.
Headaches may be caused by muscle tension, vascular problems, or central nervous

system disorders.
Secondary Headache. Secondary headaches are caused by other medical conditions,

such as sinusitis, neck injuries or abnormalities, and stroke. About 2% of headaches are
secondary headaches caused by abnormalities or infections in the nasal or sinus
passages.
It is not uncommon for someone to experience a combination of headache types.
Migraine Headaches
Migraine is the most common form of disabling headache that prompts patients to seek
care from doctors. Migraines are sometimes classified as occurring with aura
(previously called classic migraine) or without aura (previously called common
migraine).
There may be up to four phases to a migraine: prodrome phase, auras, the attack, and
the postdrome phase. These phases may not occur in every patient or every headache.
Prodrome. The prodrome phase is a group of vague symptoms that may precede a
migraine attack by several hours, or even a day or two. Prodrome symptoms include:
Sensitivity to light or sound

Changes in appetite, including decreased appetite or food cravings
Thirst
Fatigue and drowsiness
Mood changes, including depression, irritability, or restlessness
Auras. Auras are sensory disturbances that occur before the migraine attack in 1 in 5
patients. Visually, auras are referred to as being positive or negative:
Positive auras include bright or shimmering light or shapes at the edge of the
field of vision called scintillating scotoma. They can enlarge and fill the line of
vision. Other positive aura experiences are zigzag lines or stars.
Negative auras are dark holes, blind spots, or tunnel vision (inability to see to
the side).
Patients may have mixed positive and negative auras. This is a visual experience
that is sometimes described as a fortress with sharp angles around a dark center.
Other neurologic symptoms may occur at the same time as the aura, although they are
less common. They include:
Speech disturbances
Tingling, numbness, or weakness in an arm or leg
Perceptual disturbances such as space or size distortions
Confusion
Migraine Attack. If untreated, attacks usually last from 4 - 72 hours. A typical migraine
attack produces the following symptoms:
Throbbing pain on one side of the head. The word migraine, in fact, is derived
from the Greek word hemikrania, meaning "half of the head" because the pain of
migraine often occurs on one side. Pain also sometimes spreads to affect the
entire head.
Pain worsened by physical activity
Nausea, sometimes with vomiting
Visual symptoms
Facial tingling or numbness
Extreme sensitivity to light and noise
Looking pale and feeling cold
Less common symptoms include tearing and redness in one eye, swelling of the eyelid,
and nasal congestion, including runny nose. (Such symptoms are more common in
certain other headaches, notably cluster headaches.)
Postdrome. After a migraine attack, there is usually a postdrome phase, in which
patients may feel exhausted and mentally foggy for a while.
Chronic Migraine (Transformed Migraine)
In some cases, patients eventually experience on-going and chronic migraine (also
called transformed migraine). Chronic migraines typically begin as episodic headaches
when patients are in their teens or 20s, which then increase in frequency over time.
Headaches generally occur at least 50% of the days over a month, and often on a daily
or near-daily basis.
The majority of chronic migraines are caused by overuse of analgesic migraine

medications, both prescription pain reliever drugs and over-the-counter analgesic
medications. Medication overuse headaches are also called rebound headaches. Obesity
and caffeine overuse are other factors that may increase the risk of episodic migraine
transforming to chronic migraine.
Chronic migraines can resemble tension headaches and it is sometimes difficult to

differentiate between them. Both types of headaches can co-exist. In addition to
throbbing pain on one side of the head, chronic migraine is marked by gastrointestinal
symptoms such as nausea and vomiting. Many patients with chronic migraine also
suffer from depression.
Other Migraine Variations
Although migraine is considered to be a specific chronic illness, it has various

presentations that occur in different individuals.
Menstrual Migraines. Migraines are often tied to a woman's menstrual cycle, typically
in the first days preceding or beginning menstruation. Estrogen and progesterone
fluctuations may play a role. About half of women with migraines report an association
with menstruation. Compared to migraines that occur at other times of the month,
menstrual migraines tend to be more severe, last longer, and not have auras. Triptan
drugs can provide relief and may also help prevent these types of migraines.
Basilar Migraine. Considered a subtype of migraine with aura, this migraine starts in
the basilar artery, which forms at the base of the skull. It occurs mainly in young people.
Symptoms may include vertigo (the room spins), ringing in the ears, slurred speech,
unsteadiness, possibly loss of consciousness, and severe headaches.
Abdominal Migraine. This migraine tends to occur in children who have a family
history of migraine. Periodic migraine attacks are accompanied by abdominal pain, and
often nausea and vomiting.
Ophthalmoplegic Migraine. This very rare headache tends to occur in younger adults.
The pain centers around one eye and is usually less intense than in a standard migraine.
It may be accompanied by vomiting, double vision, a droopy eyelid, and paralysis of
eye muscles. Attacks can last from hours to months. A computed tomography (CT) or
magnetic resonance imaging (MRI) scan may be needed to rule out an aneurysm (a
rupture blood vessel) in the brain.
Retinal Migraine. Symptoms of retinal migraine are short-term blind spots or total
blindness in one eye that lasts less than an hour. A headache may precede or occur with
the eye symptoms. Sometimes retinal migraines develop without headache. Other eye
and neurologic disorders must be ruled out.
Familial Hemiplegic Migraine. This is a very rare inherited genetic migraine disease. It
can cause temporary paralysis on one side of the body, vision problems, and vertigo.
These symptoms occur about 10 - 90 minutes before the headache.
Status Migrainosus. This is a serious and rare migraine. It is so severe and lasts so long
that it requires hospitalization.
Causes
Until recently, abnormalities of blood vessel (vascular) systems in the head were
thought to be mainly responsible for migraines. Now, however, doctors tend to believe
that migraine starts with an underlying central nervous system disorder. When triggered
by various stimuli, this disorder sets off a chain of neurologic and biochemical events,
some of which subsequently affect the brain's vascular system. No experimental model
fully explains the migraine process.
There is certainly a strong genetic component in migraine with or without auras.

Researchers have located a single genetic mutation responsible for the very rare familial
hemiplegic migraine, but several genes are likely to be involved in the great majority of
migraine cases.
Numerous chemicals, structures, nerve pathways, and other players involved in the
process are under investigation. These include:
Peptides. Stress or some unknown factor triggers the release of certain protein
fragments called peptides (Substance P, calcitonin gene-related peptide, and
others). These peptides dilate blood vessels and produce an inflammatory
response that triggers over-excitation of the nerve cells in the trigeminal
pathway. [This nerve pathway runs from the brain stem to the head and face.
These nerves spread to the meninges (the membrane covering of the brain.)]
Abnormal Calcium Channels. Some migraines may be due to abnormalities in
the channels within cells that transport the electrical ions calcium, magnesium,
sodium, and potassium. Calcium channels appear to play a particularly critical
role in migraine.
Serotonin and Other Neurotransmitter Levels. Neurotransmitters are chemical
messengers in the brain. Serotonin is a neurotransmitter (chemical messenger in
the brain) that is important for sleep, well-being, and other factors that affect
quality of life. Abnormalities in serotonin levels have been observed in both
tension-type and migraine headache sufferers. Altered levels of other
neurotransmitters, importantly dopamine and stress hormones, also occur with
migraine and tension-type headaches, and could trigger the events in the brain
leading to migraine.
Reduced Magnesium Levels. Magnesium deficiencies have been observed in
people with both tension-type and migraine headaches. Reduced levels could be
a destabilizing factor, causing the nerves in the brain to misfire, possibly even
accounting for the auras that many sufferers experience.
Nitric Oxide. Other research suggests that nitric oxide may be important in
triggering in most primary headaches (tension-type, cluster, and migraines).
Estrogen Fluctuations in Women. Tension-type headaches and migraine
headaches are slightly more common in females during adolescence and
adulthood. Most likely hormone fluctuations, rather than whether levels are
elevated or low, trigger headaches.
Migraine Triggers
A wide range of events and conditions can alter conditions in the brain that bring on
nerve excitation and trigger migraines. They include, but are not limited to:
Emotional stress
Intense physical exertion (such as exercise, lifting, or even bowel movements or
sexual activity)
Abrupt weather changes
Bright or flickering lights
Odors
High altitude
Travel motion
Lack of sleep
Skipping meals
Certain types of foods, and chemicals contained in them. More than 100 foods
and beverages may potentially trigger migraine headache. Caffeine is one such
trigger. Caffeine withdrawal can also trigger migraines in people who are
accustomed to caffeine. Red wine and beer are also common triggers.
Preservatives and additives (such as nitrates, nitrites, and MSG) can also trigger
attacks. Doctors recommend that patients keep a headache diary to track which
foods trigger migraine.
Risk Factors
Gender
About 75% of all migraine sufferers are women. Migraine is more prevalent among
women throughout the world and in every culture. Although the incidence of migraine
is similar for boys and girls during childhood, it increases in girls after puberty.
Migraine most commonly affects women between the ages of 20 - 45.
Fluctuations of female hormones, such as estrogen and progesterone, appear to increase

the risk for migraines and their severity in some women. About half of women with
migraines report headaches associated with their menstrual cycle. For some women,
migraines also tend to be worse during the first trimester of pregnancy, but improve
during the last trimester.
Age
Migraine headaches typically affect people between the ages of 15 - 55. However,
migraine also affects about 5 - 10% of all children. Unlike migraine in adults, migraines
in children occur equally in boys and girls. Studies indicate that many children with
migraine eventually stop having attacks when they reach adulthood or transition to less
severe tension-type headaches. Children with a family history of migraine may be more
likely to continue having migraines.
Family History
Migraines tend to run in families. About 70 - 80% of patients with migraine have a
family history of the condition.
Medical Conditions Associated with Migraines
Many people with migraine have or have a history of depression, anxiety, stroke,
epilepsy, irritable bowel syndrome, or high blood pressure. These conditions do not
necessarily increase the risk for migraine, but they are associated with it.
Prognosis
For many people, migraines eventually go into remission and sometimes disappear
completely, particularly as they age. Estrogen decline after menopause may be
responsible for remission in some older women.
Complications
Risk for Stroke and Heart Disease. Migraine or severe headache is a risk factor for
stroke in both men and women, especially before age 50. Research indicates that
migraine may also increase the risk for other types of heart problems.
Migraine with aura appears to carry a higher risk for stroke than migraine without aura,
especially for women. Because of this, it is very important that women with migraine
avoid other stroke risks such as smoking and possibly birth control pills. Some studies
suggest that people who have migraine with aura are more likely than people without
migraine to have cardiovascular risk factors (high cholesterol, high blood pressure) that
increase the risk for stroke. [For more information, see In-Depth Report #45: Stroke.]
Emotional Disorders and Quality of Life. Migraines have a significant negative impact
on quality of life, family relations, and work productivity. Studies indicate that people
with migraines have poorer social interactions and emotional health than patients with
many chronic medical illnesses, including asthma, diabetes, and arthritis. Anxiety
(particularly panic disorders) and major depression are also strongly associated with
migraines.
A National Headache Foundation-sponsored survey of migraine sufferers reported that:
90% of people with migraines could not function normally on the day of a
migraine attack
80% experienced abnormal sensitivity to light and noise
75% experienced nausea and vomiting
30% required bed rest
25% missed at least 1 day of work due to migraine in past 3 months
Diagnosis
Anyone, including children, with recurring or persistent headaches should consult a

doctor. There are no blood tests or imaging techniques that can be used to diagnose
migraine headaches. A diagnosis will be made on the basis of medical history and
physical exam, and, if necessary, tests may be necessary to rule out other diseases or
conditions that may be causing the headaches. It is important to choose a doctor who is
sensitive to the needs of headache sufferers and aware of the latest advances in
treatment.
Diagnostic Criteria for Migraine
A diagnosis of migraine is usually made on the basis of repeated attacks (at least 5) that
meet the following criteria:
Headache attacks that last 4 - 72 hours

Headache has at least two of the following characteristics: Location on one side
of the head; throbbing pain; moderate or severe pain intensity; pain worsened by
normal physical activity (walking, climbing stairs)
During the headache, the patient experiences one or both of the following
characteristics: Nausea or vomiting; extreme sensitivity to light or sound
The headache cannot be attributed to another disorder
Headache Diary
The patient should try to recall what seems to bring on the headache and anything that
relieves it. Keeping a headache diary is a useful way to identify triggers that bring on
headaches, as well as to track the duration and frequency of headache attacks. Some tips
include:
Note all conditions, including any foods eaten, preceding an attack. Often two or
more triggers interact to produce a headache. For example, a combination of
weather changes and fatigue can make headaches more likely than the presence
of just one of these events.
Keep a migraine record for at least three menstrual cycles. For women, this can
help to confirm or refute a diagnosis of menstrual migraine.
Track medications. This is important for identifying possible medication-overuse
(rebound) headache or chronic (transformed) migraine.
Attempt to define the intensity of the headache using a number system, such as:
1 = Mild, barely noticeable
2 = Noticeable, but does not interfere with work/activities
3 = Distracts from work/activities
4 = Makes work/activities very difficult

5 = Incapacitating
Medical and Personal History
The patient should report any other conditions that might be associated with headache,
including:
Any chronic or recent illness and their treatments

Any injuries, particularly head or back injuries
Any uncharacteristic dietary changes
Any current medications or recent withdrawals from any drugs, including over-
the-counter or natural remedies
Any history of caffeine, alcohol, or drug abuse
Any serious stress, depression, and anxiety
The doctor will also need a general medical and family history of headaches or diseases,
such as epilepsy, that may increase their risk. Migraine tends to run in families.
Physical Examination
In order to diagnose a chronic headache, the doctor will examine the head and neck and
will usually perform a neurologic examination, which includes a series of simple
exercises to test strength, reflexes, coordination, and sensation. The doctor may ask
questions to test short-term memory and related aspects of mental function.
Differentiating Between Migraine and Other Types of Headaches
Differentiating Between Migraines and Tension Headaches. Migraines and tension

headaches have some similar characteristics, but also some important differences:
Migraine pain is throbbing, while tension-type headache pain is usually a steady

ache
Migraine pain may affect only one side of the head while tension-type headache
pain typically affects both sides of the head
Migraine pain, but not tension-type pain, worsens with head movement
Migraine headaches, but not tension-type headaches, may be accompanied by
nausea or vomiting, sensitivity to light and sound, or aura
[For more information, see In-Depth Report #11: Tension-type headache.]
Differentiating Between Migraines and Sinus Headaches. Many primary headaches,

including migraine, are misdiagnosed as sinus headaches, causing patients to be treated
inappropriately with antibiotics. Many patients who think they have sinus headaches
may actually have had a migraine. Sinus headaches occur in the front of the face,
usually around the eyes, across the cheeks, or over the forehead. They are usually mild
in the morning and increase during the day and are usually accompanied by fever, runny
nose, congestion, and general debilitation. It is also possible for patients to have
migraines with sinus symptoms.
A real sinus headache is a sign of an acute sinus infection, which responds to treatment
with decongestants. Patients who do not respond or who have severe sinusitis should
receive antibiotics. If sinus headaches seem to recur, the patient is likely experiencing
migraines.
Imaging Tests
The doctor may order a computed tomography (CT) scan or magnetic resonance
imaging (MRI) test of the head to check for brain abnormalities that may be causing the
headaches. Imaging tests of the brain may be recommended if the results of the history
and physical examination suggest neurologic problems such as:
Changes in vision
Muscle weakness
Fever
Stiff neck
Changes in the way someone walks
Changes in someone's mental status (disorientation)
Imaging tests may also be recommended for patients with headache:
That wakes them at night

A sudden or severe headache, or a headache that is the worst headache of
someone's life
New headaches in adults over 50 years, especially in the elderly. In this age
group, it is particularly important to first rule out age-related disorders including
stroke, low blood sugar (hypoglycemia), accumulation of fluid within the brain
(hydrocephalus), and head injuries (usually from falls).
Worsening headache or headaches that do not respond to routine treatment.
A CT (computed tomography) scan is a much more sensitive imaging technique than x-

ray, allowing high definition of not only the bony structures but also the soft tissues.
Clear images of organs and structures, such as the brain, muscles, joints, veins and
arteries, as well as of tumors and hemorrhages, may be obtained with or without the
injection of contrasting dye.
Symptoms that Could Indicate a Serious Underlying Condition
Headaches indicating a serious underlying problem, such as cerebrovascular disorder or

malignant hypertension, are uncommon. (It should be emphasized that a headache is not
a common symptom of a brain tumor.) People with existing chronic headaches,
however, might miss a more serious condition by believing it to be one of their usual
headaches. Such patients should call a doctor promptly if the quality of a headache or
accompanying symptoms has changed. Everyone should call a doctor for any of the
following symptoms:
Sudden, severe headache that persists or increases in intensity over the following
hours, sometimes accompanied by nausea, vomiting, or altered mental states
(possible hemorrhagic stroke)
Sudden, very severe headache, worse than any headache ever experienced
(possible indication of hemorrhage or a ruptured aneurysm)
Chronic or severe headaches that begin after age 50
Headaches accompanied by other symptoms, such as memory loss, confusion,
loss of balance, changes in speech or vision, or loss of strength in or numbness
or tingling in arms or legs (possibility of small stroke in the base of the skull)
Headaches after head injury, especially if drowsiness or nausea are present
(possibility of hemorrhage)
Headaches accompanied by fever, stiff neck, nausea and vomiting (possibility of
spinal meningitis)
Headaches that increase with coughing or straining (possibility of brain
swelling).
A throbbing pain around or behind the eyes or in the forehead accompanied by
redness in the eye and perceptions of halos or rings around lights (possibility of
acute glaucoma)
A one-sided headache in the temple in elderly people; the artery in the temple is
firm and knotty and has no pulse; scalp is tender (possibility of temporal
arteritis, which can cause blindness or even stroke if not treated)
Sudden onset and then persistent, throbbing pain around the eye possibly
spreading to the ear or neck unrelieved by pain medication (possibility of blood
clot in one of the sinus veins of the brain)
Treatment Approaches
Migraine treatment involves both treating acute attacks when they occur and developing
preventive strategies for reducing the frequency and severity of attacks.
Treating Migraine Attacks
Many effective headache remedies are available for treating a migraine attack. Still,
many patients are treated with unapproved drugs, including opoids and barbiturates that
can be potentially addictive or dangerous.
The main types of medications for treating a migraine attack are:
Pain relievers [usually nonprescription nonsteroidal anti-inflammatory drugs

(NSAIDs) or acetaminophen]
Ergotamines
Triptans
It is best to treat a migraine attack as soon as symptoms first occur. Doctors generally
recommend:
Start with nonprescription pain relievers for mild-to-moderate attacks. If

migraine pain is severe, a prescription version of an NSAID may be
recommended.
A triptan is generally the next drug of choice.
Ergotamine drugs tend to be less effective than triptans but are helpful for some
patients.
Depending on the severity of the attacks, and accompanying symptoms, the
doctor may recommend taking a triptan or ergotamine drug in tablet, injection,
or suppository form. The doctor may also prescribe specific medications for
treating symptoms such as nausea.
Try to guard against medication overuse, which can cause a rebound effect. Nearly all
pain relief drugs used for migraine can cause rebound headache, and patients should not
take any the drugs more than 9 days per month. If you find that you need to use acute
migraine treatment more frequently, talk to your doctor about preventive medications.
Preventing Migraine Attacks
Preventive strategies for migraine include both drug treatment and behavioral therapy or
lifestyle adjustments.
Patients should consider using preventive migraine drugs if they have:
Migraines that are not helped by acute treatment drugs

Frequent attacks (more than once per week)
Side effects from acute treatment drugs or contraindications to taking them
The main preventive drug treatments for migraine are:
Beta-blocker drugs [usually propranolol (Inderal) or timolol (Blocadren)]

Anti-seizure drugs [usually divalproex (Depakote) or topiramate (Topamax)]
Tricyclic antidepressants [usually amitriptyline (Elavil)]
A preventive medication strategy needs to be carefully tailored to an individual patient,

taking into account the patient's medical history and co-existing medical conditions.
These drugs can have serious side effects.
A preventive medication is usually started at a low dose, and then gradually increased. It
may take 2 - 3 months for a drug to achieve its full effect. Preventive treatment may be
needed for 6 - 12 months or longer. Most patients take preventive medications on a daily
basis, but some patients may use these drugs intermittently (for example, for preventing
menstrual migraine).
Patients can also help prevent migraines by identifying and avoiding potential triggers,
such as specific foods. Relaxation therapy and stress reduction techniques may also
help. (See Lifestyle section in this report.)
Treatment Approaches for Children
Migraine Treatment for Children. Most children with migraines may need only mild
pain relievers and home remedies (such as ginger tea) to treat their headaches. The
American Academy of Neurology's practice guidelines for children and adolescents
recommend the following drug treatments:
For children age 6 years and older, ibuprofen (Advil) is recommended.
Acetaminophen (Tylenol) may also be effective. Acetaminophen works faster
than ibuprofen, but the effects of ibuprofen last longer.
For adolescents age 12 years and older, sumaptriptan (Imitrex) nasal spray is
recommended.
Migraine Prevention for Children. Non-medication methods, including biofeedback and

muscle relaxation techniques may be helpful. If these methods fail, then preventive
drugs may be used, although evidence is weak on the effectiveness of standard migraine
preventive drugs in children.
Withdrawing from Medications
If medication overuse causes rebound migraines to develop, the patient cannot recover
without stopping the drugs. (If caffeine is the culprit, a person may need only to reduce
coffee or tea drinking to a reasonable level, not necessarily stop drinking it altogether.)
The patient can usually stop abruptly or gradually. The patient should expect the
following:
Most headache drugs can be stopped abruptly, but the patient should talk to their
doctor first. Certain non-headache medications, such as anti-anxiety drugs or
beta-blockers, require gradual withdrawal under medical supervision.
If the patient chooses to taper off standard headache medications, withdrawal
should be completed within three days.
The patient may take other pain medicines during the first days. Examples of
drugs that may be used include dihydroergotamine (with or without
metoclopramide), NSAIDs (in mild cases), corticosteroids, or valproate.
Patients must expect their headaches to get worse after they stop taking their
medications, no matter which method they use. Most people feel better within 2
weeks, although headache symptoms can persist up to 16 weeks (and in rare
cases even longer).
If the symptoms do not respond to treatment and cause severe nausea and
vomiting, the patient may need to be hospitalized.
Medications for Treating Migraine Attacks
Many different medications are used to treat migraines. However, the Food and Drug
Administration (FDA) has specifically approved only the following types of drugs for
treating migraine attacks:
Non-prescription drugs. Excedrin Migraine, Advil Migraine, and Motrin

Migraine Pain
Prescription drugs. Triptans and ergotamine
Other types of drugs, including opioids and barbiturates, are sometimes prescribed off-
label for migraine treatment. Opioids and barbiturates have not been approved by the
FDA for migraine relief, and they can be addictive.
All FDA-approved migraine treatments are approved only for adults. No migraine
products have officially been approved for use in children.
Pain Relievers
Some patients with mild migraines respond well to over-the-counter (OTC) painkillers,
particularly if they take a full dose of the medicine at the very first sign of an attack.
OTC pain relievers, also called analgesics, include:
Nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin),

naproxen (Aleve), and aspirin. The FDA-approved migraine products Advil
Migraine and Motrin Migraine Pain both contain ibuprofen.
Acetaminophen (Tylenol). The FDA-approved migraine product Excedrin
Migraine contains acetaminophen, as well as aspirin and caffeine.
There are also prescription-only NSAIDs. These include diclofenac (Cataflam), which is
taken by mouth, and ketorolac (Toradol), which is given by injection.
NSAID Side Effects. High dosages and long-term use of NSAIDs can increase the risk
for heart attack, stroke, kidney problems, and stomach bleeding. Aspirin does not
increase the risk for heart problems, but it can cause other NSAID-related side effects.
Triptans
Triptans (also referred to as serotonin agonists) were the first drugs specifically
developed for use against migraine. They are the most important migraine drugs
currently available. They help maintain serotonin levels in the brain, and so specifically
target one of the major components in the migraine process.
Triptans are recommended as first-line drugs for adult patients with moderate-to-severe
migraines when NSAIDs are not effective. Triptans have the following benefits:
They are effective for most patients with migraine, as well as patients with
combination tension and migraine headaches.
They do not have the sedative effect of other migraine drugs.
Withdrawal after overuse appears to be shorter and less severe than with other
migraine medications
Sumatriptan. Sumatriptan (Imitrex) has the longest track record and is the most studied
of all triptans. It is available as a fast-dissolving pill, nasal spray, or injection. Injected
sumatriptan works the fastest of all the triptans and is the most effective, but it can
cause pain at the injection site. The nasal spray form bypasses the stomach and is
absorbed more quickly than the oral form. Some patients report relief as soon as 15
minutes after administration. The spray tends to work less well when a person has nasal
congestion from cold or allergy. It may also leave a bad taste. Sumatriptan is effective
for many patients, but headache recurs in 20 - 40% of people within 24 hours after
taking the drug.
Other Triptans. Newer triptans include almotriptan (Axert), zolmitriptan (Zomig),

naratriptan (Amerge), rizatriptan (Maxalt), frovatriptan (Frova), and eletriptan (Relpax).
Treximet combines in one pill both sumatriptan and the anti-inflammatory pain reliever
naproxen (Aleve, Naprosyn). Triptans are also being investigated for prevention under
certain circumstances, such as menstrual migraines, but benefits appear limited.
Although triptans, (like all migraine medications), are approved only for adults,
researchers are investigating zolmitriptan for treating migraines in adolescents.
Side Effects. Side effects of triptans may include:
Tingling and numbness in the toes

Sensations of warmth
Discomfort in the ear, nose, and throat
Nausea
Drowsiness
Dizziness
Muscle weakness
Heaviness, pain, or both in the chest. (About 40% of patients taking sumatriptan
experience these symptoms, and they are major factors in discontinuing the
drug. Newer drugs, such as almotriptan, produce fewer chest symptoms.)
Rapid heart rate
Complications of Triptans. The following are potentially serious problems.
Complications of heart and circulation. Triptans narrow (constrict) blood

vessels. Because of this effect, spasms in the blood vessels may occur and cause
serious side effects, including stroke and heart attack. Such events are rare, but
patients with an existing history or risk factors for these conditions should
generally avoid triptans.
Serotonin syndrome. Serotonin syndrome is a life-threatening condition that
occurs from an excess of the brain chemical serotonin. Triptan drugs used to
treat migraine, as well as certain types of antidepressant medications, can
increase serotonin levels. These antidepressant drugs include serotonin reuptake
inhibitors (SSRIs) -- such as fluoxetine (Prozac), paroxetine (Paxil), and
sertraline (Zoloft) -- and selective serotonin/norepinephrine reuptake inhibitors
(SNRIs), such as duloxetine (Cymbalta) and venlafaxine (Effexor). It is very
important that patients not combine a triptan drug with a SSRI or SNRI drug.
Serotonin syndrome is most likely to occur when starting or increasing the dose
of a triptan or antidepressant drug. Symptoms include restlessness,
hallucinations, rapid heartbeat, tremors, increased body temperature, diarrhea,
nausea, and vomiting. You should seek immediate medical care if you have these
symptoms.
The following people should avoid triptans or take them with caution and only with the
advisement of a doctor:
Anyone with a history or any risk factors for stroke, uncontrolled diabetes, high
blood pressure, or heart disease.
People taking antidepressants that increase serotonin levels.
Children and adolescents. They may be safe, but controlled studies are needed to
confirm this. (Triptans should not, in any case, be the first-line treatment for
children.)
People with basilar or hemiplegic migraines. (Triptans are not indicated for these
migraineurs.)
There is no evidence to date of any higher risk for birth defects in pregnant
women who take triptans. Still, women should be cautious about taking any
medications during pregnancy and discuss any possible adverse effects with
their doctors.
Ergotamine (Ergot)
Drugs containing ergotamine (commonly called ergots) constrict smooth muscles,

including those in blood vessels, and are useful for migraine. They were the first anti-
migraine drugs available. Ergotamine is available by prescription in the following
preparations:
Dihydroergotamine (DHE) is an ergot derivative. It is administered as a nasal

spray form (Migranal) or by injection, which can be performed at home.
Ergotamine is available tablets taken by mouth, tablets taken under the tongue
(sublingual), and rectal suppositories. Some of the tablet forms of ergotamine
contain caffeine.
Ergotamine's role since the introduction of triptans is now less certain. Only the rectal
forms of ergotamine are superior to rectal triptans. Injected, oral, and nasal-spray forms
are all inferior to the triptans. Ergotamine may still be helpful for patients with status
migrainous or those with frequent recurring headaches.
Side Effects. Side effects of ergotamine include:
Nausea
Dizziness
Tingling sensations
Muscle cramps
Chest or abdominal pain
The following are potentially serious problems:
Toxicity. Ergotamine is toxic at high levels.

Adverse effects on blood vessels. Ergot can cause persistent blood vessel
contractions, which may pose a danger for people with heart disease or risk
factors for heart attack or stroke.
Internal scarring (fibrosis). Scarring can occur in the areas around the lungs,
heart, or kidneys. It is often reversible if the drug is stopped.
The following patients should avoid ergots:
Pregnant women. Ergots can cause miscarriage.

People over age 60.
Patients with serious, chronic health problems, particularly those with heart and
circulation conditions.
Ergotamine can interact with other medications, such as antifungal drugs and some
antibiotics. All ergotamine products approved by the Food and Drug Administration
(FDA) contain a "black box" warning in the prescription label explaining these drug
interactions. The five FDA-approved ergotamine products are:
Migergot suppository (marketed by G and W Labs)

Ergotamine Tartrate and Caffeine tablets (marketed by Mikart and West Ward)
Cafergot tablets (marketed by Sandoz)
Ergomar sublingual tablets (marketed by Rosedale Therapeutics)
Opioids
If the pain is very severe and does respond to other drugs, doctors may try painkillers
containing opioids. Opioid drugs include morphine, codeine, meperidine (Demerol), and
oxycodone (Oxycontin)]. Butorphanol is an opioid in nasal spray form that may be
useful as a rescue treatment when others fail.
Opioids are not approved for migraine treatment and should not be used as first-line
therapy. Nevertheless, many opioid products are prescribed to patients with migraine,
sometimes with dangerous results. For example, following reports of several drug-
related deaths, the Food and Drug Administration has warned that the cancer pain pill
fentanyl (Fentora) should not be used to treat patients with migraine or others conditions
for which the drug is not specifically approved.
Side Effects. Side effects for all opioids include drowsiness, impaired judgment, nausea,
and constipation. There is a risk for addiction, and these drugs can become ineffective
with long-term use for chronic migraines. Doctors should not prescribe opioids to
patients at risk for drug abuse, including those with personality or psychiatric disorders.
Drugs Used for Nausea and Vomiting
Metoclopramide (Reglan) is used in combinations with other drugs to treat the nausea
and vomiting that occurs with other drugs and with migraine itself. Metoclopramide and
other anti-nausea drugs, such as domperidone (Motilium), may help the intestine better
absorb migraine medications.
Medications for Preventing Migraine Attacks
The Food and Drug Administration has approved four drugs for prevention of migraine:
Propanolol (Inderal)
Timolol (Blacadrene)
Divalproex sodium (Depakote)
Topiramate (Topamax)
Propanolol and timolol are beta-blocker drugs. Divalproex and topiramate are anti-
seizure drugs. Many other drugs are also being used or investigated for preventing
migraines.
Beta-Blockers
Beta-blockers are usually prescribed to reduce high blood pressure. Some beta-blockers,
however, are also useful in reducing the frequency of migraine attacks and their severity
when they occur. Propranolol (Inderal) and timolol (Blocadren) have been approved
specifically for prevention of migraine. Metoprolol (Toprol), atenolol (Tenormin), and
nadolol (Corgard) are also being studied for migraine prevention.
Side Effects. Side effects may include:
Fatigue and lethargy are common.

Some people experience vivid dreams and nightmares, depression, and memory
loss.
Dizziness and lightheadedness may occur upon standing.
Exercise capacity may be reduced.
Other side effects may include cold extremities, asthma, decreased heart
function, gastrointestinal problems, and sexual dysfunction.
If side effects occur, the patient should call a doctor, but it is extremely important not to
stop the drug abruptly. Some evidence suggests that people with migraines who have
had a stroke should avoid beta-blockers.
Anti-Seizure Drugs
Anti-seizure drugs, also called anticonvulsant drugs, are commonly used for treating
epilepsy and bipolar disorder. Divalproex sodium (Depakote) and topiramate (Topamax)
are the only anti-seizure drugs that are approved for migraine prevention. However, if
patients do not respond to either of these drugs, doctors may try other types of anti-
seizure medications.
Divalproex Sodium (Depakote). Divalproex sodium (Depakote) was first approved in

1996 for migraine prevention. A once-a-day formulation of divalproex (Depakote ER)
was approved in 2000. Doctors sometimes prescribe a similar drug, valproate
(Depakene). Pregnant patients should not use these drugs, as they may cause birth
defects.
Topiramate (Topamax). In 2004, the Food and Drug Administration approved

topiramate for prevention of migraines in adults. Topiramate's most common side effect
is a tingling sensation in the arms and legs. Weight loss is also a side effect.
Other Anti-Seizure Drugs Under Investigation. Researchers are studying other types of
anti-seizure drugs for migraine prevention, including levetiracetam (Keppra),
gabapentin (Neurontin), and pregabalin (Lyrica).
Side Effects. Anti-seizure medication side effects vary by drug but may include:
Nausea and vomiting

Diarrhea
Cramps
Hair loss
Dizziness
Sleepiness
Blurred vision
Weight gain
Valproate and divalproex can cause serious side effects of inflammation of the
pancreas (pancreatitis) and damage to the liver
Tricyclic and Other Antidepressants
Amitriptyline (Elavil, Endep), a tricyclic antidepressant drug, has been used for many
years as a first-line treatment for migraine prevention. It may work best for patients who
also have depression or insomnia. Tricyclics can have significant side effects, including
disturbances in heart rhythms, and can be fatal in overdose. Although other tricyclic
antidepressants may have fewer side effects than amitritpyline, they do not appear to be
particularly effective for migraine prevention.
Researchers have investigated newer types of antidepressants, including serotonin-

reuptake inhibitors (SSRIs), such as fluoxetine (Prozac). However, studies to date do not
indicate that SSRIs are helpful for migraine prevention.
Investigational Treatments for Preventing Migraines
Muscle Relaxants. Botulinum toxin A (Botox) injection, a common wrinkle treatment,

causes small muscles to relax. It is being studied as a preventive approach for reducing
the frequency of migraine attacks and patients' reliance on pain medications. To date,
there is still no proven benefit. More research is needed.
Angiotensin Converting Enzyme Inhibitors. Commonly used for treating high blood
pressure, angiotensin converting enzyme (ACE) inhibitors such as lisinopril (Prinivil)
block the production of the protein angiotensin, which constricts blood vessels and may
be involved in migraine.
Angiotensin-Receptor Blockers. Angiotensin-receptor blockers (ARBs), such as

candesartan (Atacand), are another type of high blood pressure medications being
studied for migrane prevention.
Neurostimulation Devices. Researchers are investigating a transcranial magnetic

stimulation (TMS) device to help stop migraines before they occur. The hair dryer-size
device is held to the back of the head and delivers quick magnetic pulses. The device is
used when a patient experiences the first signs of a migraine. Other types of nerve
stimulation devices are also under investigation.
Nasal Devices. New types of nasal sprays and powders are being researched. Some of
them use capsaicin, the chemical found in cayenne peppers, to help relieve pain.
Non-Drug Treatments and Lifestyle Changes
There are several ways to prevent migraine attacks. You should first try a healthy diet,
the right amount of sleep, and non-drug approaches (such as biofeedback) for
prevention.
Behavioral Treatments
Behavioral techniques that reduce stress and empower the patient may help some people
with migraines. They generally include:
Biofeedback therapy
Relaxation techniques
Cognitive-behavioral therapy
Behavioral methods may help counteract the tendency for muscle contraction and
uneven blood flow associated with some headaches. They may be particularly beneficial
for children, adolescents, and pregnant and nursing women, and anyone who cannot
take most migraine medications. Studies generally find that these techniques work best
when used in combination with medications.
Biofeedback. Many studies have demonstrated that biofeedback is effective for reducing
migraine headache frequency. Biofeedback training teaches the patient to monitor and
modify physical responses, such as muscle tension, using special instruments for
feedback.
Relaxation Therapy. Relaxation therapy techniques include relaxation response,

progressive muscle relaxation, visualization, and deep breathing. Muscle relaxation
techniques are simple and easy to learn, and can be effective. Some patients may also
find that relaxation techniques combined with applying a cold compress to the forehead
may help provide some pain relief during attacks. Some commercially available
products use a pad containing a gel that cools the skin for several hours.
Cognitive Behavioral Therapy. Cognitive-behavioral therapy (CBT) teaches patients

how to recognize and cope with stressors in their life. It can help patients understand
how their thoughts and behavior patterns may affect their symptoms, and how to change
the way the body responds to anticipated pain. CBT may be included with stress
management techniques. Research indicates that CBT is most effective when combined
with relaxation training or biofeedback.
Acupuncture
Acupuncture is a Chinese medicine technique that uses thin needles to stimulate specific
points aligned with energy pathways in the body. Studies have showed mixed results on
the benefits of acupuncture for preventing migraine.
Lifestyle Changes
Making a few minor changes in your lifestyle can make your migraines more bearable.
Improving sleep habits is important for everyone, and especially those with headaches.
What you eat also has a huge impact on migraines, so dietary changes can be extremely
beneficial, too.
Avoid Food Triggers. Avoiding foods that trigger migraine is an important preventive
measure. Common food triggers include monosodium glutamate (MSG), processed
lunch meats that contain nitrates, dried fruits that contain sulfites, aged cheese, alcohol
and red wine, chocolate, and caffeine. However, peoples responses to triggers differ.
Keeping a headache diary that tracks diet and headache onset can help identify
individual food triggers.
Eat Regularly. Eating regularly is important to prevent low blood sugar. People with
migraines who fast periodically for religious reasons might consider taking preventive
medications.
Stay Physically Active. Exercise is certainly helpful for relieving stress. An analysis of
several studies reported that aerobic exercise in particular might help prevent migraines.
It is important, however, to warm up gradually before beginning a session, since sudden,
vigorous exercise might actually precipitate or aggravate a migraine attack.
Limit Estrogen-Containing Medications. Medications that contain estrogen, such as oral

contraceptives and hormone replacement therapy, may trigger migraines or make them
worse. Talk to your doctor about whether you should stop taking these types of
medications or reduce the dosage.
Herbs and Supplements
Manufacturers of herbal remedies and dietary supplements do not need Food and Drug
Administration approval to sell their products. Just like a drug, herbs and supplements
can affect the body's chemistry, and therefore have the potential to produce side effects
that may be harmful. There have been several reported cases of serious and even lethal
side effects from herbal products. Patients should always check with their doctors
before using any herbal remedies or dietary supplements.
Riboflavin (Vitamin B2). Some studies have found that people who take vitamin B2
experience a reduction in the frequency of migraine attacks (although not on duration or
severity). Vitamin B2 is generally safe, although some people taking high doses develop
diarrhea.
Magnesium Supplements. Some studies have reported a higher rate of magnesium

deficiencies in some patients with migraine, such as those with menstrual migraines.
Magnesium helps relax blood vessels. Some patients report that magnesium
supplements help provide relief.
Feverfew. Feverfew is the most studied herbal remedy for headaches and may help in
some cases. However, like all effective headache remedies, overuse can cause a rebound
effect.
Fish Oil. Some studies suggest that omega-3 fatty acids, which are found in fish oil,
have anti-inflammatory and nerve protecting actions. These fatty acids can be found in
oily fish, such as salmon, mackerel, or sardines. They can also be obtained in
supplements of specific omega-3 compounds (DHA-EPA).
Ginger. In general, herbal medicines should never be used by children or pregnant or

nursing women without medical counsel. One exception may be ginger, which has no
side effects and can be eaten in powder or fresh form, as long as quantities are not
excessive. Some people have reported less pain and frequency of migraines while taking
ginger, and children can take it without danger. Ginger is also a popular home remedy
for relieving nausea.
Resources
www.headaches.org -- National Headache Foundation

www.achenet.org -- American Headache Society
www.aan.com -- American Academy of Neurology
www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke
www.clinicaltrials.gov -- Find clinical trials
References
Bigal ME, Lipton RB. What predicts the change from episodic to chronic migraine?
Curr Opin Neurol. 2009 Jun;22(3):269-76.
Buse DC, Andrasik F. Behavioral medicine for migraine. Neurol Clin. 2009
May;27(2):445-65.
Ebell, MH. Diagnosis of migraine headache. Am Fam Physician. 2006;74(12):2087-8.
Goadsby PJ. Pathophysiology of migraine. Neurol Clin. 2009 May;27(2):335-60.
Goadsby PJ. Recent advances in the diagnosis and management of migraine. BMJ. 2006
Jan 7;332(7532):25-9.
Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S, et al. Practice

parameter: pharmacological treatment of migraine headache in children and
adolescents: report of the American Academy of Neurology Quality Standards
Subcommittee and the Practice Committee of the Child Neurology Society. Neurology.
2004 Dec 28;63(12):2215-24.
Lewis DW, Winner P, Hershey AD, Wasiewski WW. Adolescent Migraine Steering
Committee. Efficacy of zolmitriptan nasal spray in adolescent migraine. Pediatrics.
2007 Aug;120(2):390-6.
Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF; AMPP Advisory
Group. Migraine prevalence, disease burden, and the need for preventive therapy.
Neurology. 2007 Jan 30;68(5):343-9.
Naumann M, So Y, Argoff CE, Childers MK, Dykstra DD, Gronseth GS, et al.
Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an
evidence-based review): report of the Therapeutics and Technology Assessment
Subcommittee of the American Academy of Neurology. Neurology. 2008 May
6;70(19):1707-14.
Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain.

2007 Mar;128(1-2):111-27. Epub 2006 Nov 2.
Pringsheim T, Davenport WJ, Dodick D. Acute treatment and prevention of menstrually
related migraine headache: evidence-based review. Neurology. 2008 Apr
22;70(17):1555-63.
Sierpina V, Astin J, Giordano J. Mind-body therapies for headache. Am Fam Physician.

2007 Nov 15;76(10):1518-22.
Silberstein SD. Preventive migraine treatment. Neurol Clin. 2009 May;27(2):429-43.
Tepper SJ, Spears RC. Acute treatment of migraine. Neurol Clin. 2009 May;27(2):417-
27.
Wilson, JF. In the clinic. Migraine. Ann Intern Med. 2007;147(9):ITC11-1-ITC11-16.
Migraine Headache in Children and Adolescents
Do children get headaches?

Yes. About four out of five children sometimes have a headache. The most common
cause is a viral infection such as a cold or the flu. Children and adolescents can also get
tension-type headaches and migraine headaches. Brain tumors can cause headaches, but
these tumors are very rare. In addition to a headache, brain tumors almost always cause
problems with coordination, balance, speech, sight and walking.
What is a migraine headache?

A migraine is usually an intense pounding headache with nausea that occurs from time
to time. The pounding or pulsing pain usually begins in the forehead, the side of the
head or around the eyes. The headache gradually gets worse. Just about any movement
or activity seems to make it hurt more. Nausea and vomiting are common. Bright lights
or loud noises make the headache worse. The headache can last for two hours or even
up to two or three days.
Some people see a pattern of lines or shadows in front of their eyes as the headache is
beginning. This is called a "warning aura." Most people with migraine do not have this.
Do many children get migraine headaches?

As many as 5 percent of children in grade school have migraine headaches. During the
high school years, about 20 percent of adolescents get migraine headaches. These
headaches are more common in girls than in boys. Boys who get migraines have them
more often when they are about 10 to 12 years old. It is not unusual for them to have
two to three migraine headaches a week.
How do children describe their migraine headaches?

"It feels like my heart is pounding in my head."
"All I want to do is throw up."
"It is like being inside a big bass drum."
"I just want to go into a dark room and lie down."
What causes migraines?

Migraine headaches seem to be caused in part by changes in the level of a body
chemical called serotonin. Serotonin plays many roles in the body, and it can have an
effect on the blood vessels. When serotonin levels are high, blood vessels constrict
(shrink). When serotonin levels fall, the blood vessels dilate (swell). This swelling can
cause pain or other problems.
Certain things that can set off migraines include the following:
Strong or unusual odors, bright lights or loud noises

Changes in weather or altitude
Being tired, stressed or depressed
Changes in sleeping patterns or sleeping time
Certain foods (see the list below), especially those that contain tyramine, sodium
nitrate or phenylalanine
Missing meals or fasting
Menstrual periods or hormones
Intense physical activity
Foods that may trigger migraines

Aged, canned, cured or processed meat, including bologna, game, ham, herring, hot dogs,
pepperoni and sausage
Aged cheese
Aspartame
Avocados
Beans, including pole, broad, lima, Italian, navy, pinto and garbanzo
Brewer's yeast, including fresh yeast coffee cake, donuts and sourdough bread
Caffeine (in excess)
Canned soup or bouillon cubes

Chocolate, cocoa and carob
Cultured dairy products, such as buttermilk and sour cream
Figs
Lentils
Meat tenderizer
Monosodium glutamate (MSG)
Nuts and peanut butter
Onions, except small amounts for flavoring
Papaya
Passion fruit
Pea pods
Pickled, preserved or marinated foods, such as olives and pickles, and some snack foods
Raisins
Red plums
Sauerkraut
Seasoned salt
Snow peas
Soy sauce
How is migraine diagnosed?

Your doctor can diagnose migraines on the basis of the symptoms your child describes.
This is called the medical history. After taking the medical history, your doctor will
perform a physical exam. Your doctor may also want to do blood tests or imaging tests,
such as an MRI or CAT scan of the brain, to be sure that there are no other causes for
the headache. Your child may also be asked to keep a "headache diary" that will help
your doctor identify any "triggers" for your child's migraines.
What can help a migraine?

When a migraine headache happens, your child should go to a cool, dark place and lie
down with a wet cloth across his or her forehead. If the doctor has given your child a
medicine for migraines, your child should take it as soon as he or she knows a headache
is starting. Don't wait! If your child feels nausea, the doctor can also prescribe a
medicine for that.
How can my child keep from having migraine

headaches?
While there are no sure ways to keep from having migraine headaches, here are some
things that may help:
Eat regularly and do not skip meals.

Keep a regular sleep schedule.
Exercise regularly.
Look for things that might trigger an attack, like certain foods, stress, too much
exercise or physical activity, certain activities or stress. Sometimes, life stresses
are a trigger. Many psychologists can teach stress management and/or
biofeedback to help your child manage stress.
Look for foods that might trigger an attack, like cheese, processed meats,
chocolate, caffeine, MSG (a preservative in many foods), nuts or pickles. About
one third of people with migraine can identify food triggers. Your child only
needs to avoid eating these foods if one of them triggers headaches.
If your child has frequent migraine headaches, your doctor may prescribe a daily
preventive medicine to try to make the headaches less frequent and less severe.
Copyright American Academy of Family Physicians 2008
Headaches - cluster
Highlights
What Are Cluster Headaches?
Cluster headaches are among the most painful types of headaches. They are marked by
excruciating stabbing and penetrating pain, which is usually centered around the eye.
Cluster headache attacks occur very suddenly and without warning, with the pain
peaking within 15 minutes. During an attack, the patient is very restless and agitated
while trying to cope with the severe pain.
Symptoms of Cluster Headache Attacks

In addition to pain, symptoms of cluster headaches may include:
Swollen or droopy eyelid

Watery, tearing eye
Stuffy or runny nose
Contracted eye pupil
Forehead and facial sweating
Intolerance to light and sound
Who Gets Cluster Headaches?
Cluster headaches are rare, affecting less than 1% of the population.

Men, usually in their 40s, are much more likely to suffer from cluster headaches
than women.
Many people who have cluster headaches have a personal or family history of
migraine headaches.
Treatment
Treatment of cluster headaches focuses on relieving pain when attacks occur, and on
preventive strategies to reduce attack duration and frequency. Oxygen therapy and
sumatriptan (Imitrex) injection are the most effective treatments for acute attacks.
Verapamil (Calan), a high blood pressure drug, is typically the first choice of medication
used for long-term prevention.
Behavioral treatments can be a helpful supplement to drug therapy. These treatments

include relaxation therapy, biofeedback, cognitive-behavioral therapy, and stress
management. Patients should also identify and avoid any triggers, such as alcohol use
and cigarette smoking, which may provoke cluster headache attacks.
Introduction
Most people have had headaches. There are many different kinds of headaches, and they
range from being an infrequent annoyance to a persistent, severe, and disabling medical
condition.
The brain is insensitive to pain, so that is not what hurts when you have a headache.
Rather, the pain occurs in the following locations:
The tissues covering the brain

The attaching structures at the base of the brain
Muscles and blood vessels around the scalp, face, and neck
Doctors categorize headaches as either primary or secondary. The category helps to

distinguish the many different kinds of headaches and to determine right treatments for
each.
Primary Headaches
A headache is considered primary when a disease or other medical condition does not
cause it. Most primary headaches fall into three main types: tension-type, migraine, and
cluster headaches.
Tension headache is the most common primary headache and accounts for 90%
of all headaches.
Migraines are the second most frequently occurring primary headaches.
Migraine is referred to as a neurovascular headache because it is most likely
caused by an interaction between blood vessel and nerve abnormalities.
Cluster headache is a less common type of primary headache. Although it is
sometimes referred to as a neurovascular headache, evidence now suggests that
its cause may lie in the hypothalamus, a region deep in the brain that regulates,
among other functions, the biologic rhythms of the body.
Headaches are usually caused by muscle tension, vascular problems, or both.
Secondary Headaches
Secondary headaches are caused by other medical conditions, such as sinus infections,
neck injuries, and strokes. About 2% of headaches are secondary to abnormalities or
infections in the nasal or sinus passages, and they are commonly referred to as sinus
headaches.
Chronic Daily Headaches
The International Headache Society has developed a classification system that includes
a category called chronic daily headaches. They may originate as tension headaches,
migraines, or a combination of these or other headache types. Chronic daily headaches
affect 4 - 5% of the population.
Chronic daily headaches are defined as any benign headache that occurs at least 15 days
a month and is not associated with a serious neurologic abnormality. Most people with
these headaches have them daily or almost daily and they can be quite debilitating.
Chronic daily headaches are, in turn, subdivided into two categories:
Short-duration headaches, or those lasting fewer than 4 hours. The most

common short-acting chronic headaches are cluster headaches.
Long-duration headaches, which last more than 4 hours. Tension-type headaches
are the most common type of long-duration chronic (recurring) headaches and,
in fact, the most common type of chronic headaches in general.
Cluster Headaches
Cluster headaches are among the most painful, and least common, of all headaches. The
pain can be so excruciating that they are sometimes referred to as "suicide headaches."
Their signature is a pattern of periodic cycles ("clusters") of headache attacks, which
may be either:
Episodic. Attacks occur regularly for 1 week to 1 year, separated by long pain-
free periods that last at least 1 month. Between 80 - 90% of patients have
episodic cycles. A significant percentage of people who experience a first cluster
attack do not have another one.
Chronic. Attacks occur regularly for more than 1 year, with pain-free periods
lasting less than 1 month. Between 10 - 20% of patients have chronic cluster
headaches. The chronic form is very difficult to treat.
Symptoms of Cluster Headaches
Cluster headaches usually strike suddenly and without warning, although some people
experience a migraine-type aura before the attack. The pain is deep, constant, boring,
piercing, or burning in nature, and located in, behind, or around the eye. The pain then
spreads to the forehead, jaw, upper teeth, temples, nostrils, shoulder or neck. The pain
and other symptoms usually remain on one side of the head.
The pain generally reaches very severe levels within 15 minutes. Patients may feel
agitated or restless during an attack and often want to isolate themselves and then move
around. Gastrointestinal symptoms are not very common.
Other typical symptoms include:
Swollen or droopy eyelid

Watery, tearing eye
Contraction of the eye pupil
Stuffy or runny nose
Forehead and facial sweating
Restlessness and agitation
Nausea and vomiting
Intolerance to light and sound
The symptoms of a cluster headache include stabbing severe pain behind or above one
eye or in the temple. Tearing of the eye, congestion in the associated nostril, and pupil
changes and eyelid drooping may also occur.
Typical Cluster Cycles
Timing of an Attack. Cluster headache attacks tend to occur with great regularity at the
same time of day. (For this reason, cluster headaches are sometimes referred to as
"alarm clock" headaches.) About 75% of attacks occur between 9 p.m. - 10 a.m. Attacks
may also peak between 1 - 3 p.m.
Duration of an Attack. A single cluster attack is usually brief but extremely painful,
lasting about 15 minutes - 1.5 hours if left untreated.
Number of Attacks per Day. During an active cycle, people can experience as few as 1
attack every other day to as many as 8 attacks a day.
Duration of Cycles. Attack cycles typically last 6 - 12 weeks with remissions lasting up
to 1 year. In the chronic form, attacks are ongoing and there is little remission. Attacks
cycles tend to occur seasonally, most often in the spring and autumn.
Primary Headaches That Resemble Cluster Headaches
Chronic Paroxysmal Hemicrania. Chronic paroxysmal hemicrania is a close relative of

cluster headache and very similar. It causes multiple, short, and severe daily headaches
with similar symptoms. Unlike cluster headaches, the attacks are shorter (1 - 2 minutes)
and more frequent (occurring an average of 15 times a day). This headache is even rarer
than cluster headache, tends to occur in women, and always responds to treatment with
the drug indomethacin (Indocin).
Hemicrania Continua. Hemicrania continua occurs mostly in women. The patient

generally experiences continuous low-level headache always on one side of the face.
Periodic attacks can last days to weeks, which can be mild to severe, and may resemble
migraines. (About 10% of patients experience remissions.) The headache can usually be
treated successfully with indomethacin, which helps differentiate it from cluster and
migraine headaches.
SUNCT Syndrome. A disorder called SUNCT syndrome (short-lasting unilateral

neuralgiform headache attacks with conjunctival injection and tearing) causes stabbing
or burning eye pain that may resemble cluster headaches, but attacks are very brief
(lasting about a minute) and may occur more than 100 times per day. Red and watery
eyes, sweating forehead, and congestion are typical. This rare headache is more
common in men and does not respond to other headache treatments.
Causes
Cluster headaches, like migraines, are likely due to an interaction of abnormalities in the
blood vessels and nerves that affect regions in the face.
Abnormalities in the Hypothalamus
Evidence strongly suggests that abnormalities in the hypothalamus, a complex structure

located deep in the brain, may play a major role in cluster headaches. Advanced imaging
techniques have shown that a specific area in the hypothalamus is asymmetrical in these
patients and is activated during a cluster headache attack.
The hypothalamus is involved in the regulation of many important chemicals and nerve
pathways, including:
Nerve clusters that regulate the body's biologic rhythms (its circadian rhythms)
Serotonin and norepinephrine. These are neurotransmitters (chemical
messengers in the brain) that are involved with well-and appetite.
Cortisol (stress hormones)
Melatonin (a hormone related to the body's response to light and dark)
Beta-endorphins (substances that modulate pain)
By some not completely understood mechanism, the trigeminal nerve is also involved.
The trigeminal nerve carries sensations from the face to the brain.
Circadian Abnormalities. Cluster attacks often occur during specific sleep stages. They
also often follow the seasonal increase in warmth and light, beginning in summer and
ending in the fall. Researchers have therefore focused attention on circadian rhythms,
and in particular small clusters of nerves in the hypothalamus that act like biologic
clocks. The hormone melatonin is also involved in the body's biologic rhythms.
Dilation of Blood Vessels
Cluster headaches are associated with dilation (widening) of blood vessels and
inflammation of nerves behind the eye.
Cluster headaches may be caused by blood vessel dilation in the eye area. Inflammation
of nearby nerves may give rise to the distinctive stabbing, throbbing pain usually felt in
one eye. The trigeminal nerves branch off the brainstem behind the eyes and send
impulses throughout the cranium and face.
What causes these events and how they relate to cluster headaches are still unclear.
Because blood vessel dilation appears to follow, not precede, the pain, some action
originating in the brain is likely to be part of the primary process.
Abnormalities in the Sympathetic Nervous System
Some evidence suggests that abnormalities in the sympathetic (also called autonomic)
nervous system may contribute to cluster headaches. This system regulates non-
voluntary muscle actions in the body, such as in the heart and blood vessels.
Prognosis
The pain of cluster headaches can be intolerable. In fact, a higher-than-average rate of

suicide has been reported in men with these headaches. Eventually, as people age, the
attacks cease, but doctors cannot predict when or how they will end.
Effects on Mental and Emotional Functioning
Anxiety and depression are common among people with cluster headaches, which can
affect functioning and quality of life.
Auras and Medical Risks
About 14% of patients with cluster headaches have migraine-like aura. Recent research
suggests that headaches that are accompanied by aura may increase the risk of stroke or
transient ischemic attack (TIA). TIA symptoms are similar to those of stroke, but last
only briefly. A TIA is often a warning sign that a person is at risk for having a more
severe stroke. Headaches with auras may also increase the risk for eye retinal damage
(retinopathy). Aura-related headaches may affect the small blood vessels in the brain
and the eyes, thereby increasing the risks for stroke and retinopathy.
Risk Factors
Cluster headaches are rare, affecting less than 1% of the population.
Age and Gender
Cluster headaches can affect all ages, from children to the elderly, but are most common
from young adulthood through middle age. Men are 2 - 3 times more likely to have
cluster headaches than women, with the peak age of onset occurring during their 40s. In
women, age of onset tends to be in the 60s.
Unlike with migraines, fluctuations in estrogen and other female hormones do not
appear to influence the onset of attacks in women.
Lifestyle Factors
Lifestyle factors, including smoking, alcohol abuse, and stress (in particular stressful
work situations), appear to play a very strong role in cluster headaches. Smoking or
alcohol use can trigger attacks. (However, quitting smoking generally does not have an
effect on the disease course.) Alcohol, most commonly red wine, may trigger an attack.
Family History and Genetic Factors
Cluster headaches tend to run in families, suggesting a genetic component may be

involved in some cases.
History of Migraine
About half of people with cluster headache have a personal or family history of
migraine. Studies have reported that about 15% of patients have both kinds of headache.
Head Injury
Head injury with brain concussion appears to increase the risk of cluster headaches,
although a causal relationship has not been proven.
Sleep Apnea and Other Sleep Disorders
Cluster headaches tend to occur during specific sleep stages and have been associated
with several sleep disorders, including narcolepsy, insomnia, and sleep apnea.
Sleep apnea, a disorder in which a person stops breathing during the night, perhaps
hundreds of times, is of particular interest. In some people, apnea may trigger a cluster
headache during the first few hours of sleep, making patients susceptible to follow-up
attacks during the following midday to afternoon periods. Treating patients who have
both disorders with a device called CPAP, which opens the airways, may help improve
both conditions. [For more information, see In-Depth Report #65: Sleep apnea.]
Cluster Headache Triggers
The following conditions and substances might trigger cluster attacks:
Alcohol and cigarette smoking

High altitudes (trekking, air travel)
Bright light (including sunlight)
Exertion
Heat (hot weather, hot baths)
Foods high in nitrites (such as bacon and preserved meats)
Certain medications (including those that cause blood vessel dilation, such as
nitroglycerin, and various blood pressure medications)
Cocaine
Triggers usually have an effect only during active cluster cycles. When the disorder is in
remission, such triggers rarely set off the headaches.
Diagnosis
Many patients report a delay of 1 - 6 years in the diagnosis of their cluster headaches.
Migraine-like symptoms (light and sound sensitivity, aura, nausea, vomiting) are major
reasons for the frequent misdiagnosis by primary care doctors. In some cases, patients
are inappropriately treated for other types of headaches or health conditions (including
having sinus surgery).
Cluster headache is diagnosed by medical history, including the pattern of recurrent

attacks, and by typical symptoms (swollen eyelid, watery eye, runny nose). Keeping a
headache diary to record a description of attacks can help the doctor make an accurate
diagnosis. The patient should describe to the doctor:
Frequency of attacks (if keeping a diary, record the date and time of each attack)
Description of pain (stabbing, throbbing)
Location of pain
Duration of pain
Intensity of pain (using a number scale like the one below)
Associated symptoms (tearing eyes, nausea and vomiting, sweating)
Any measures that bring relief (applying pressure, going out for fresh air)
Any events that preceded or may have triggered the attack
Any medications you are taking
Behaviors during a headache (restlessness, agitation)
Snoring, sleep disturbances, or daytime sleepiness (these could relate to sleep
apnea, which is sometimes associated with cluster headache)
Pain may be indicated by using a number system:
2 = Noticeable, but does not interfere with work or activities

3 = Distracts from work or activities
4 = Makes work or activities very difficult
5 = Incapacitating
To diagnose a chronic headache, the doctor will examine the head and neck and perform
a neurologic examination, which includes a series of simple exercises to test strength,
reflexes, coordination, and sensation. The doctor may also examine the eyes. The doctor
may ask questions to test short-term memory and related aspects of mental function.
Imaging Tests
The doctor may order a computed tomography (CT) scan or magnetic resonance
imaging (MRI) test of the head to check for brain abnormalities that may be causing the
headaches.
Ruling Out Other Headaches and Medical Disorders
As part of the diagnosis, a doctor should rule out other headaches and disorders. If the
results of the history and physical examination suggest other or accompanying causes of
headaches or serious complications, extensive imaging tests are performed.
Migraines. Cluster headaches are often misdiagnosed as migraines but they are quite
different:
Frequency and Duration. Cluster headaches generally last 15 minutes to a few

hours and can occur several times a day. A single migraine attack is continuous
over the course of one or several days.
Behavior. Cluster headache sufferers tend to move about while migraine
sufferers usually want to lie down.
Nevertheless, in both cases, the headache suffers can be highly sensitive to light and
noise, which may make it difficult to distinguish between them.
Other Headaches. Other headaches that resemble migraines include SUNCT (short-
lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing)
and chronic paroxysmal hemicrania, which are other primary headaches, and some
secondary headaches notably trigeminal neuralgia (TN), temporal arteritis, and sinus
headaches. Cluster symptoms, however, are usually precise enough to rule out these
other types of headaches.
Tear in the Carotid Artery. A tear in the carotid artery (which leads to the brain) can
cause pain that resembles a cluster headache. People with this condition may even
respond to sumatriptan, a drug used to treat a cluster attack. Doctors should consider
imaging tests for patients with a first episode of cluster headache in which this event is
suspected.
Orbital Myositis. An unusual condition called orbital myositis, which produces swelling
of the muscles around the eye, may mimic symptoms of cluster headache. This
condition should be considered in patients who have unusual symptoms such as
protrusion of the eyeball, painful eye movements, or pain that does not dissipate within
3 hours.
Headache Symptoms that Could Indicate Serious Underlying Disorders

malignant hypertension, are uncommon. (It should be emphasized that a headache is not
a common symptom of a brain tumor.) People with existing chronic headaches,
however, might miss a more serious condition believing it to be one of their usual
headaches. Such patients should immediately call a doctor if the quality of a headache
or accompanying symptoms has changed. Everyone should call a doctor for any of the
following symptoms:
(possible indication of hemorrhagic stroke, which is also called brain
hemorrhage).
(possible indication of brain hemorrhage or a ruptured aneurysm).
Chronic or severe headaches that begin after age 50.
or tingling in arms or legs (possibility of small stroke in the base of the skull).
(possibility of brain hemorrhage).
Headaches accompanied by fever, stiff neck, nausea and vomiting (possibility of
spinal meningitis).
swelling).
acute glaucoma).
firm and knotty and has no pulse; scalp is tender (possibility of temporal
arteritis, which can cause blindness or even stroke if not treated).
clot in one of the sinus veins of the brain).
Managing Cluster Headaches
Management of cluster headaches focuses on:
Acute therapy for stopping an attack while it is happening

Preventive therapy for stopping or reducing attack recurrences
Treating Attacks
The most effective and best-studied treatments for a cluster attack are:
Oxygen inhalation
An injection of the triptan drug sumatriptan (Imitrex)
Relief can occur in 5 - 10 minutes. Oxygen and sumatriptan injection are sometimes
given together.
Other drugs that may be used for acute attacks are nasal sprays of dihydroergotamine or
lidocaine.
Preventing Attacks
Cluster headache attacks are usually short, lasting from 15 - 180 minutes, and the
excruciating pain may have subsided by the time a patient reaches a doctors office or
emergency room.
Because it can be difficult to treat attacks when they occur, treatment efforts focus on
the prevention of attacks during cluster cycles. Although certain drugs are standard,
preventive therapy needs to be individually tailored for each patient. The doctor may
prescribe a combination of drugs.
Verapamil (Calan), a calcium-channel blocker drug, is the mainstay preventive

treatment for cluster headaches. However, it can take 2 - 3 weeks for this drug to take
effect. During this period, corticosteroids (typically prednisone) may be used as an
initial transitional therapy. For long-term treatment of chronic cluster headaches, lithium
may be used as an alternative to verapamil.
Although they are not approved for cluster headache, anti-seizure drugs such as
valproate (Depakote), topiramate (Topamax), and gabapentin (Neurontin), are
sometimes used for preventive treatment.
Behavioral Treatments and Lifestyle Changes
Behavioral Treatments. Behavioral therapies can be a helpful accompaniment to drug

treatment. These approaches can help with pain management and enable patients to feel
more in control of their condition.
Behavioral approaches include:
Relaxation treatment combined with biofeedback

Cognitive-behavioral therapy
Lifestyle Changes. Patients should avoid the following triggers that may provoke cluster
headache attacks:
Alcohol. Heavy alcohol use is strongly associated with cluster headaches,

although it is not clear if alcohol triggers pain or is simply used as a coping
mechanism for dealing with severe pain.
Cigarette smoking. Many studies indicate that a majority of patients with cluster
headache are cigarette smokers. While studies have not shown that quitting
cigarettes will stop cluster headaches, smoking cessation should still be a goal.
Smokers who can't quit should at least stop at the first sign of an attack and not
smoke throughout a cycle.
Treatment for Acute Attacks
Oxygen Therapy
Breathing pure oxygen (by face mask, for 15 minutes or less) is one of the most
effective and safest treatments for cluster headache attacks. It is often the first choice
treatment. Inhalation of oxygen raises blood oxygen levels, therefore relaxing narrowed
blood vessels.
Triptans
Triptans are drugs that are usually used to treat migraine headaches. They can also help
stop a cluster attack. Injections of sumatriptan (Imitrex) are the standard triptan
treatment. Sumatriptan injections work within 15 minutes in about three quarters of
most cluster attacks. The nasal spray form may also be effective for some patients, and
generally provides relief within 30 minutes. The spray seems to work best for attacks
that last at least 45 minutes, although some people find it does not work as well as the
injectable form.
Newer triptans being studied for cluster headache treatment include zolmitriptan
(Zomig) in oral or nasal spray forms. Zolmitriptan may have fewer side effects than
sumatriptan.
Side Effects. Side effects of sumatriptan may include:
Nausea
Dizziness
Muscle weakness
Heaviness or pressure in the chest
Tingling and numbness in the toes
Rapid heart rate
Complications and Contradindications of Triptans. The following are potentially

serious problems with triptans:
Complications on the Heart and Circulation. Triptans narrow (constrict) blood

vessels. Because of this action, spasms in the blood vessels may occur, which
can cause stroke and heart attack. This is a rare but very serious side effect.
Patients with a history of heart attack, stroke, angina, uncontrolled high blood
pressure, peripheral artery disease, or heart disease should not use triptan drugs.
Serotonin Syndrome. Serotonin syndrome is a life-threatening condition that
occurs from an excess of the brain chemical serotonin. Triptans, as well as
certain types of antidepressant medications, can increase serotonin levels. These
antidepressant drugs include serotonin reuptake inhibitors (SSRIs) such as
fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) and selective
serotonin/norepinephrine reuptake inhibitors (SNRIs) such as duloxetine
(Cymbalta) and venlafaxine (Effexor). It is very important that patients not
combine a triptan drug with an SSRI or SNRI drug. Serotonin syndrome is most
likely to occur when starting or increasing the dose of a triptan or antidepressant
drug. Symptoms include restlessness, hallucinations, rapid heartbeat, tremors,
increased body temperature, diarrhea, nausea, and vomiting. You should seek
immediate medical care if you have these symptoms.
Ergotamine
Injections of the ergotamine-derived drug known as dihydroergotamine (DHE) can stop

cluster attacks within 5 minutes in many patients, offering benefits similar to injectable
sumatriptan. Ergotamine is also available in the form of a nasal spray, rectal
suppositories, and tablets.
Ergotamine can have dangerous drug interactions with many medications, including
sumatriptan. All ergotamine products approved by the Food and Drug Administration
(FDA) contain a "black box" warning in the prescription label explaining these drug
interactions. Because ergotamine constricts blood vessels, patients with peripheral
vascular disease should not use this drug.
Local Anesthetics
Lidocaine, a local anesthetic, may be useful in nasal-spray or nasal-drop form for

stopping cluster attacks. Reports suggest that it is helpful for most patients within about
40 minutes. It can have an unpleasant taste. Some doctors recommend that patients try a
topical application of lidocaine to see if it helps ease pain.
Capsaicin is a compound derived from hot pepper. Some patients who have not found
relief through other medications use it to treat or prevent cluster headaches by applying
it intranasally. There have been few studies to confirm its effectiveness. It can cause an
intense burning sensation.
Preventive Medications
Calcium-Channel Blockers
Calcium-channel blockers, commonly used to treat high blood pressure and heart
disease, are important drugs for preventing episodic and chronic cluster headaches.
Verapamil (Calan) is the standard calcium-channel blocker used for headache
prevention. It can take 2 - 3 weeks to have a full effect, and a corticosteroid drug may be
used in combination during this transitional period. Constipation is a common side
effect.
People taking calcium-channel blockers should not stop taking the drug abruptly. Doing
so can dangerously increase blood pressure. Overdose can cause dangerously low blood
pressure and slow heart beats. Drinking grapefruit juice or eating grapefruit with these
drugs can enhance their potency, sometimes to toxic levels that can cause heart failure
in patients with heart disease.
Lithium
Lithium (Eskalith, Lithane, Lithobid, Lethonate, Lithotabs), commonly used for bipolar
disorder, may also help prevent cluster headaches. The patient usually receives benefit
within 2 weeks of starting to take the drug, and often within the first week. Lithium may
be used alone or with other drugs. Lithium can have many side effects including
trembling hands, nausea, and increased thirst. Weight gain is a common side effect with
long-term use. [For more information, see In-Depth Report #66: Bipolar disorder.]
Corticosteroids
Corticosteroid drugs (also called steroids) are very useful as transitional drugs for
stabilizing patients after an attack until a maintenance drug, such as verapamil, begins to
take effect. Prednisone (Deltasone) and dexamethasone (Decadron) are the standard
steroid drugs used for short-term cluster headache transitional treatment. These drugs
are typically taken for a week and then gradually tapered off. If headaches return, the
patient may start taking the steroid again. Unfortunately, long-term use of steroids can
lead to serious side effects so they cannot be taken for on-going prevention.
Anti-Seizure Drugs
Anti-seizure drugs, which are used for epilepsy treatment, may be helpful for preventing
cluster headaches in some patients. They include older drugs such as valproate (valproic
acid, divalproex sodium, Depakene, Depakote) and newer drugs such as topiramate
(Topamax) and gabapentin (Neurontin). More research needs to be done to evaluate
how effective these drugs are at preventing cluster headache.
Side Effects of Valproate and Other Anti-Seizure Drugs. The side effects listed here are
mostly associated with valproate. Newer anti-seizure drugs may have fewer side effects.
In general, most side effects occur early in therapy and then subside. Those of valproate
may include:
Gastrointestinal problems (such as nausea, vomiting, and heartburn)

Visual disturbances
Ringing in the ear
Hair loss
Weight changes (weight gain is a significant problem with valproate, while
weight loss occurs with topiramate)
Agitation
Odd movements
In women, menstrual irregularities and a higher risk for polycystic ovary
syndrome (PCOS)
Very serious side effects are rare but include the following:
Liver damage
Convulsions
Coma
Pancreatitis (inflammation of pancreas) in adults and children
Significant increase in risk for birth defects in pregnant women
Investigational Drugs
Botulinum. Botulinum toxin A (Botox) injections are typically used to smooth wrinkles.
Botox is also being studied for treatment of headaches, including the prevention of
cluster headaches. Research is still preliminary and there is not sufficient evidence to
support its efficacy.
Melatonin. Small reports indicate that melatonin, a brain hormone that helps to regulate
the sleep-wake cycle, may help prevent episodic or chronic cluster headaches.
Melatonin supplements are sold in health food stores, but as with most natural remedies,
the quality of different preparations varies, and they have not been rigorously tested for
safety or effectiveness. More studies are needed.
Surgery
In rare cases, surgical intervention may be considered for patients with chronic cluster
headaches that do not respond to treatments. Patients whose headaches have not gone
into remission for at least a year may also be candidates for surgery. Most surgical
approaches for cluster headache are still considered experimental, and have only been
tested on a relatively small number of patients. Surgery has shown limited success and
can have distressing side effects. However, some surgical techniques, such as deep brain
electrical stimulation, are showing promise.
Deep Brain Electrical Stimulation
Deep brain stimulation (also called neurostimulation) may relieve chronic cluster
headaches in some patients who do not respond to drug therapy. A similar technique is
approved for treating the tremors associated with Parkinson's disease. The surgeon
implants a tiny wire in a specific part of the hypothalamus. The wire receives electrical
pulses from a small generator implanted under the collarbone.
Although only a small number of patients have been treated, results to date are
promising. Some patients have remained completely free of pain for an average of more
than 7 months when the electrode is switched on. When the device is turned off,
headaches reappear within days to weeks. The procedure is reversible and appears to be
generally safe, although a few cases of fatal cerebral hemorrhage have occurred.
Occipital Nerve Stimulation
Occipital nerve stimulation is being investigated as a less invasive and less risky
alternative to deep brain hypothalamus stimulation. Recent studies have reported
promising results in a small group of patients with cluster headaches. Some patients
became pain-free, while others had reduced frequency of headache attacks.
Vagus Nerve Stimulation
The vagus nerve runs between the brain and the abdomen. Vagus nerve stimulation
(VNS) is a surgical procedure in which a small generator is placed under the skin on the
left side of the chest. A surgeon makes a second incision in the neck and connects a wire
from the generator to the vagus nerve. A doctor programs the generator to send mild
electrical pulses at regular intervals. These pulses stimulate the vagus nerve.
VNS is sometimes used to treat epilepsy and depression that does not respond to drugs.
It is also being investigated as a possible treatment for chronic migraine and cluster
headaches.
Procedures to Block or Remove Facial Nerves That Cause Pain
Percutaneous Radiofrequency Retrogasserian Rhizotomy. Percutaneous radiofrequency

retrogasserian rhizotomy (PRFR) generates heat to destroy pain-carrying nerve fibers in
the face. Unfortunately complications are common and include numbness, weakness
during chewing, changes in tearing and salivation, and facial pain. In severe, but rare,
cases, complications include damage to the cornea and vision loss.
Percutaneous Retrogasserian Glycerol Rhizolysis. Percutaneous retrogasserian glycerol

rhizolysis (PRGR) is a less invasive technique than PRFR and has fewer complications.
It involves injections of glycerol to block the facial nerves that cause the pain. Cluster
headaches usually recur.
Microvascular Decompression of the Trigeminal Nerve. Microvascular decompression

frees the trigeminal nerve from any blood vessels that are pressing against it. The
procedure is risky, and possible complications include nerve and blood vessel injury and
spinal fluid leakage. There is reasonably good evidence that it is not effective for
treatment of cluster headaches.
Resources
www.i-h-s.org -- International Headache Society

www.ouch-us.org -- Organization for Understanding Cluster Headaches
www.clusterheadaches.com -- Support group for people with cluster headaches
References
Ailani J, Young WB. The role of nerve blocks and botulinum toxin injections in the
management of cluster headaches. Curr Pain Headache Rep. 2009 Apr;13(2):164-7.
Bartsch T, Paemeleire K, Goadsby PJ. Neurostimulation approaches to primary

headache disorders. Curr Opin Neurol. 2009 Jun;22(3):262-8.
Beck E, Sieber WJ, Trejo R. Management of cluster headaches. Am Fam Physician.

2005; 71(4): 717-24.
Burns B, Watkins L, Goadsby PJ. Treatment of medically intractable cluster headache

by occipital nerve stimulation: long-term follow-up of eight patients. Lancet. 2007 Mar
31;369(9567):1099-106.
Cittadini E, May A, Straube A, Evers S, Bussone G, Goadsby PJ. Effectiveness of
intranasal zolmitriptan in acute cluster headache: a randomized, placebo-controlled,
double-blind crossover study. Arch Neurol. November 2006. [Epub ahead of print 11
September 2006]
Grover PJ, Pereira EA, Green AL, Brittain JS, Owen SL, Schweder P, et al. Deep brain
stimulation for cluster headache. J Clin Neurosci. 2009 Jul;16(7):861-6. Epub 2009 Apr
23.
Institute for Clinical Systems Improvement. Diagnosis and treatment of headache.

Ninth edition. March 2009.
Leone M, Bussone G. Pathophysiology of trigeminal autonomic cephalalgias. Lancet

Neurol. 2009 Aug;8(8):755-64.
Magis D, Allena M, Bolla M, De Pasqua V, Remacle JM, Schoenen J. Occipital nerve

stimulation for drug-resistant chronic cluster headache: a prospective pilot study. Lancet
Neurol. 2007 Apr;6(4):314-21.
May A. Cluster headache: pathogenesis, diagnosis, and management. Lancet. 2005;

366(9488): 843-55.
Rapoport AM, Mathew NT, Silberstein SD, Dodick D, Tepper SJ, Sheftell FD, Bigal
ME. Zolmitriptan nasal spray in the acute treatment of cluster headache: a double-blind
study. Neurology. 2007 Aug 28;69(9):821-6.
Rose KM, Wong TY, Carson AP, Couper DJ, Klein R, Sharrett AR. Migraine and retinal
microvascular abnormalities: the Atherosclerosis Risk in Communities Study.
Neurology. 2007 May 15;68(20):1694-700.
Schurks M, Kurth T, de Jesus J, Jonjic M, Rosskopf D, Diener HC. Cluster headache:

clinical presentation, lifestyle features, and medical treatment. Headache. 2006
Sep;46(8):1246-54.
Silberstein SD, Young WB. Headache and facial pain. In: Goetz CG, eds. Textbook of
Clinical Neurology. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 53.
Tyagi A, Matharu M. Evidence base for the medical treatments used in cluster headache.
Curr Pain Headache Rep. 2009 Apr;13(2):168-78.
Review Date: 10/27/2009

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Headaches - tension
Highlights
What Are Tension-Type Headaches?
Tension-type headaches are the most common type of headache, accounting for about
half of all headaches. The pain is usually mild-to-moderate in intensity, with a steady
pressing or tightening quality (like a vise being squeezed around the head). The
headache is not accompanied by nausea or vomiting, and the pain is not increased by
routine physical activity such as walking or climbing stairs. A tension-type headache
attack can last anywhere from 30 minutes to an entire week.
Who Gets Tension-Type Headaches?
Women are more likely to get tension-type headaches than men. Nearly everyone will
have at least one tension-type headache at some point in their lives. Many people who
have migraine headaches also have tension-type headaches.
What Is The Difference Between Tension-Type Headaches and Migraine

Headaches?
Migraines and tension headaches have some similar characteristics, but also some
important differences:
Migraine pain is usually throbbing and while tension-type headache pain is

usually a steady ache
Migraine pain often affects only one side of the head while tension-type
headache pain typically affects both sides of the head
nausea or vomiting, sensitivity to both light and sound, or aura
Treatment
Treatment of tension-type headache focuses on relieving pain when attacks occur, and
preventing recurrence of attacks. Most tension-type headache attacks respond to simple
over-the-counter pain relievers such as aspirin, ibuprofen (Advil), or naproxen (Aleve).
Patients who have two or more tension-type headache attacks each month should talk to
their doctors about preventive therapy. This may include a tricyclic antidepressant, such
as amitriptyline (Elavil), combined with behavioral therapies. Behavioral treatment
approaches include relaxation therapy, biofeedback, stress management, and cognitive-
behavioral therapy.
Introduction
Most people are familiar with headaches, the all too common affliction marked by
throbbing, piercing, or vise-like pain around much or a part of the head. There are many
different kinds of headaches, and they range from being an infrequent annoyance to a
persistent, severe, and disabling medical condition.
The brain itself is insensitive to pain, so that is not what hurts when a headache arises.
The pain, instead, occurs in the following locations:
The tissues covering the brain

The attaching structures at the base of the brain
Muscles and blood vessels around the scalp, face, and neck
Doctors categorize headaches as either primary or secondary, which helps to distinguish

the many different kinds of headaches and to determine appropriate treatments for each.
Primary Headaches. A headache is considered primary when a disease or other medical

condition does not cause it. Tension headache is the most common type of primary
headache. Other primary headaches include migraine and cluster headaches. [See In-
Depth Report #97: Migraine headaches and In-DepthReport #99: Cluster headaches.]
Headaches are usually caused by muscle tension, vascular problems, or both. Migraines
are vascular in origin, and may be preceded by visual disturbances, loss of peripheral
vision, and fatigue. Over-the-counter pain medications can relieve most headaches.
Secondary Headaches. Secondary headaches are caused by other medical conditions,

such as sinus infections, neck injuries, and strokes. About 2% of headaches are
secondary to abnormalities or infections in the nasal or sinus passages, and they are
commonly referred to as sinus headaches.
Chronic Daily Headaches. The International Headache Society's classification system

includes a category called chronic daily headaches. They may originate as tension
headaches, migraines, or a combination of these or other headache types. Tension-type
headaches are the most common type of long-duration chronic (recurring) headaches.
Long-duration headaches last more than 4 hours.
Tension-Type Headaches
Tension-type headaches, also called muscle contraction headaches or simply tension
headaches, are the most common of all headaches. Tension-type headaches tend to have
the following characteristics:
The pain is commonly described as a tight feeling, as if the head were in a vise.
It usually occurs on both sides of the head and is often experienced in the
forehead, in the back of the head and neck, or in both regions. Soreness in the
shoulders or neck is common.
The pain is of mild-to-moderate intensity and is steady, not throbbing or
pulsating
The headache is not accompanied by nausea or vomiting
The pain is not worsened by routine physical activity (climbing stairs, walking)
Some patients may have either sensitivity to light or sensitivity to noise, but not
both
Types of Tension Headache. Tension-type headaches are divided into four

classifications:
Frequent episodic tension-type headache. Headaches occur at least once but not
more than 15 days per month for at least 3 months (a minimum of 12 days but
not more than 180 days per year). Headaches last from at least 30 minutes to 7
days.
Infrequent episodic tension-type headache. At least 10 episodes of headache that
occur less than 1 day per month (12 days per year). Because these headaches
occur infrequently, they do not impact a patient's quality of life as severely as
frequent episodic headaches and may not require attention from a medical
professional.
Chronic tension-type headache. Headaches occur at least 15 days per month for
at least 3 months (180 days per year). The headache persists for hours at a time
and may be continuous.
Probable tension-type headache. Probable tension headaches may be classified
as probable frequent episodic, probable infrequent episodic, or probable chronic.
They have most, but not all, of the symptoms of tension-type headaches and are
not attributed to migraine without aura or other neurological disorders. Probable
chronic tension-type headache may be related to medication overuse.
Causes
The causes of tension-type headache are still uncertain. Although tension-type

headaches were once thought to be primarily due to muscle contractions, this theory has
largely been discounted. Instead, researchers think that tension-type headaches occur
due to an interaction of different factors that involve pain sensitivity and perception, as
well as the role of brain chemicals (neurotransmitters). Genetic factors are likely be
involved in chronic tension-type headache, whereas environmental factors (physical and
psychological stress) may play a role in the physiologic processes involved with
episodic tension-type headache.
Pain Sensitivity and Perception

Research indicates that patients with tension-type headache may have abnormalities in
the central nervous system, which includes the nerves in the brain and spine, that
increase their sensitivity to pain.
Tension-type headaches may also be linked to myofascial trigger points in the neck and
shoulder muscles. Myofascial pain involves the fascia (connective tissue) and muscles.
Trigger points are knots in the muscle tissue that can cause tightness, weakness, and
intense pain in various areas of the body. For example, a trigger point in the shoulder
may result in headache.
Brain Chemicals (Neurotransmitters)
Neurotransmitters are chemical messengers in the brain. Several types of

neurotransmitters have been identified as playing a role in increasing activity in pain
pathways in the brain and affecting how the brain reacts to pain stimulation. In
particular, serotonin (also called 5-HT) and nitric oxide are thought to be involved in
these chemical changes. Release of these chemicals may activate nerve pathways in the
brain, muscles, or elsewhere and increase pain.
Triggers for Tension-Type Headache
In addition to stress, many different factors can trigger or aggravate tension-type

headaches:
Medication and Substance Overuse. About a third of persistent headaches -- whether

chronic migraine or tension-type -- are medication-overuse headaches. These are the
result of a rebound effect caused by the regular overuse of headache medications.
Nearly any headache medication can produce this effect. Headaches can also occur after
withdrawing from caffeine, nicotine, or alcohol.
Poor Posture and Work Conditions. Working or sleeping in an awkward position can
contribute to posture problems (especially those that affect muscles in neck and
shoulders) that trigger headaches. Eyestrain caused by overwork can also play a role.
Fatigue. Lack of sleep and tiredness from overwork are also headache triggers.
Foods and Beverages. Rapid consumption of ice cream or other very cold foods or
beverages is the most common trigger of sudden headache pain, which may be
prevented by warming the food or drink for a few seconds in the front of the mouth
before swallowing. Not eating on time is also a trigger for headache.
Physical Activity. Intense physical exertion (including athletics or sexual activity) as

well as lack of physical activity can trigger headaches. However, tension-type headache
pain is not worsened by routine physical activity.
Dental Problems. Jaw clenching or teeth grinding, especially during sleep, are signs of
temporomandibular joint dysfunction (TMJ, also known as TMD). TMJ pain can occur
in the ear, cheek, temples, neck, or shoulders. This condition often coexists with chronic
tension headache. Some patients with TMJ may see improvement in tension-type
headaches from procedures or exercises therapies that specifically address the dental
condition.
Physical Trauma. Whiplash or head or neck injury can lead to headaches.
Hormonal Changes. Hormonal changes, such as those that occur during the menstrual
cycle or perimenopause, can affect headache occurrence.
Causes of Secondary Headaches
About 90% of people seeking help for headaches have a primary headache. The rest are
secondary headaches, caused by an underlying disorder that produces headache as a
symptom. More than 300 conditions can cause headaches. These can range from sinus
conditions to brain tumor. While fear of brain tumor is common among people with
headaches, headache is almost never the first or only sign of a tumor. Changes in
personality and mental functioning, vomiting, seizures, and other symptoms are more
likely to appear first.
Risk Factors
Tension-type headaches are the most common type of headache. Nearly everyone has at
least one tension-type headache during their lifetime. Episodic tension-type headaches
are far more common than chronic tension-type headaches.
Headaches in Adults
Gender. Tension-type headaches are more common among women than men.
Age. Tension-type headaches are most likely to occur among people in their 40s. The
prevalence of tension-type headaches declines as people become older.
Headaches in Children
Headaches are rare before age 4 but increase in prevalence throughout childhood,
reaching a peak around age 13. Many children with tension-type headache episodes also
suffer from some form of emotional disorder.
Psychosocial factors associated with childhood tension-type headaches include:
Sleep problems. Many children who experience chronic daily headaches suffer
from sleep disturbances, especially difficulty falling asleep.
Moderate or severe depression.
Emotional rigidity in a child and more repressed anger than their peers.
Family stress. This includes maternal illness or separation, family bereavement,
relationship problems, mental illness in a family member, and other stressful
family events.
Problems at school. According to a National Headache Foundation survey,
nearly 30% of children miss school because of headaches. For many children,
the start of the school season can be a particularly stressful time.
The National Headache Foundation recommends these tips for parents:
Keep a diary of your child's headaches noting time of onset, length and intensity
of attack, location of pain, and food triggers.
Make sure your child gets plenty of sleep at regular times.
Avoid changes in child's eating routing (hunger and eating at irregular times can
trigger headaches).
Discuss any headache concerns with child's doctor.
Prognosis
Both episodic tension-type headache and chronic daily headache affect quality of life.
Tension-type headache episodes are rarely disabling, however, and rarely require
emergency treatment. If they do, there is usually a migraine component occurring with
the tension-type headache.
Nevertheless, although they are not medically dangerous and occur relatively rarely,
chronic tension headaches can have a negative impact on quality of life, families, and
work productivity. Several studies have reported lower quality of life with any chronic
daily headache compared to those no headaches or only episodic ones. Many people
with chronic tension-type headaches also suffer from anxiety and depression.
Tension-type headaches can, in most cases, be treated and prevented. Episodes of these
headaches can also resolve over time. In one study, nearly half of patients with frequent
or chronic tension-type headache were not experiencing headaches when examined 3
years later. Patients who have both tension-type and migraine headaches may face
steeper challenges in recovery.
Diagnosis
Diagnosing the cause of persistent daily headache can be difficult. Studies report that
people who visit the emergency room with disabling headache are often misdiagnosed
as tension-type headaches instead of migraines. It is important to choose a doctor who is
sensitive to the needs of headache sufferers and is aware of the latest advances in
treatment.
Extensive testing may be advised for anyone with a chronic, daily headache. Tracking
times of medications, withdrawal, and headache, using the headache diary, is usually
very helpful in diagnosis.
According to the International Headache Society, a diagnosis of tension-type headache

is suggested by the following symptoms:
Pressing or tightening (but non-pulsating) feeling

Mild-to-moderate pain on both sides of the head
Not aggravated by routine physical activity (such as walking or climbing stairs)
In episodic tension-type headaches:
No nausea or vomiting
Photophobia (intolerance of light) or phonophobia (intolerance of sound) may be
absent or one of these symptoms (but not both) may be present
In chronic tension-type headaches:
No vomiting
No moderate or severe nausea
No more than one of the following symptoms: Mild nausea, photophobia, or
phonophobia
Some types of chronic tension headache may include tenderness upon manual
palpitation of the head (pericranial tenderness).
Differentiating Medication-Overuse (Rebound) Headache from Tension-Type

Headache.
About a third of persistent headaches are the result of the rebound effect caused by the
overuse of headache medications.
Usually in such cases, medications have been taken on an ongoing basis for more than 3
days each week. If patients stop taking these drugs, the headaches come back. The
patient then starts taking the drugs again. Eventually the headache simply persists and
medications are no longer effective. Even after successful medication withdrawal,
relapse is common, particularly with drugs that contain caffeine, so doctors should
check for this type of headache even in patients who have previously been treated.
Medications implicated in medication-overuse headache include barbiturates, sedatives,

narcotics, and migraine medications, particularly those that also contain caffeine.
(Heavy caffeine use can also cause this condition.) Simple painkillers, such as aspirin or
ibuprofen, are less likely causes of medication-overuse headaches.
Differentiating Tension Headaches from Chronic Migraines
Migraines and tension headaches have some similar characteristics, but also some
important differences:
Migraine pain is usually throbbing, while tension-type headache pain is usually

a steady ache
Migraine pain often affects only one side of the head, while tension-type
headache pain typically affects both sides of the head
nausea or vomiting, sensitivity to light and sound, or aura
Some research suggests that migraine and tension headaches may be related. [For more
information, see In-Depth Report #97: Migraine headaches.]
For an accurate diagnosis, the patient should describe the following:
Duration and frequency of headaches

Recent changes in their character
Location of the pain
Type of pain (throbbing or steady pressure)
Intensity of the headache
Associated symptoms, such as visual disturbances or nausea and vomiting.
(These are seen most often with migraines.)
Behaviors during a headache. Different behaviors may help distinguish between
migraine and tension headaches. People with tension headaches tend to relieve
pain by massaging the scalp, temples, or the nape of the neck. People with
migraines are more likely to compress the forehead and temples (tying a scarf
around the head) or to apply cold to the area. They also tend to isolate
themselves, lie down, induce vomiting, and use more pillows than usual. (None
of these maneuvers do much good in relieving either headache, unfortunately.)
The patient should also report any other conditions that might be associated with
headache, such as any:
Chronic or recent illness and their treatments

Injuries, particularly head or back injuries
Dietary changes
Current medications or recent withdrawal from any drugs, including over-the-
counter or natural remedies
History of caffeine, alcohol, or drug abuse
Serious stress, depression, and anxiety
The doctor will also need the patient's general medical and family history, particularly
concerning headaches or other neurological diseases.
Headache Diary to Identify Triggers
Keeping a headache diary is a useful way to identify triggers that bring on headaches,
and to help the doctor differentiate between migraine and tension-type headache. Be
sure to include all events preceding an attack. Often two or more triggers interact to
produce a headache.
In general, similar stimuli seem to trigger all primary headaches, although people with
migraines may be more sensitive to some of them (weather, certain smells, light, and
smoke) than people with tension headaches.
Tracking medications is an important way of identifying medication-overuse headache

or transformed migraine.
Be sure to attempt to define the intensity of the headache. There are different scoring
symptoms available that help communicate the severity of the pain to the doctor. For
instance, the following is a number system that can be helpful:
2 = Noticeable, but does not interfere with work/activities

3 = Distracts from work/activities
4 = Makes work/activities very difficult
5 = Incapacitating
In order to diagnose a chronic headache, the doctor will examine the head and neck to
check for muscle tenderness. The doctor may also perform a neurologic examination,
which includes a series of simple exercises to test strength, reflexes, coordination,
sensation, and mental function. The doctor may also recommend an eye examination.
Imaging Tests
Imaging tests used for severe or persistent headache include computed tomography
(CT) scan and magnetic resonance imaging (MRI). Imaging tests of the brain may be
recommended under the following circumstances:
If the results of the history and physical examination suggest neurologic

problems
Changes in vision
Muscle weakness
Fever
Stiff neck
Changes in the way someone walks
Changes in mental status including signs of disorientation
Imaging tests may also be recommended for:
Patients with headache that wakes them at night

A sudden or severe headache, or a headache that is the worst headache of
someone's life
For patients with history of cancer or weakened immune system
For new headaches in adults over 50 years, especially in the elderly. In this age
group, it is particularly important to first rule out age-related disorders, including
stroke, low blood sugar (hypoglycemia), fluid accumulation in the brain
(hydrocephalus), and head injuries (usually from falls).
For patients with worsening headache or headaches that do not respond to
routine treatment
Headache Symptoms that Could Indicate Serious Underlying Disorders

malignant hypertension, are uncommon. (It should again be emphasized that a headache
is not a common symptom of a brain tumor.) People with existing chronic headaches,
however, might miss a more serious condition believing it to be one of their usual
headaches. Such patients should immediately call a doctor if the quality of a headache
or accompanying symptoms has changed. Everyone should call a doctor for any of the
following symptoms:
(possible hemorrhagic stroke)
(possible indication of hemorrhage or a ruptured aneurysm)
Chronic or severe headaches that begin after age 50
or tingling in arms or legs (possibility of small stroke in the base of the skull)
(possibility of hemorrhage)
Headaches accompanied by fever, stiff neck, nausea, and vomiting (possibility
of spinal meningitis)
swelling)
acute glaucoma)
firm and knotty and has no pulse; the scalp is tender (possibility of temporal
arteritis, which can cause blindness or even stroke if not treated).
clot in one of the sinus veins of the brain)
Treatment
Management of tension-type headaches focuses in the short term on treating acute

attacks, and in the long term on preventing recurrent episodes of headache. In general,
short-term treatment of tension-type headache involves drugs (mainly pain relievers)
while long-term preventive measures include both drug and non-drug approaches. With
medications, relaxation training, lifestyle changes, and other therapies, nearly all
patients can be helped.
Treatment for Acute Attacks of Tension-Type Headaches
Most acute attacks of tension-type headaches get better without any treatment. Simple
over-the-counter pain relievers such as acetaminophen or non-steroidal anti-
inflammatory drugs (NSAIDs) can treat mild symptoms. Aspirin or ibuprofen (generic,
Advil, other brands) are usually the first choices, followed by naproxen (generic,
Aleve). Some patients may also find helpful medications that combine a pain reliever
with caffeine.
Some people find massage therapy helpful for treating acute episodes of tension-type
headache.
Treatment and Prevention of Frequent and Chronic Tension-Type Headaches
Daily preventive treatment is recommended for patients who experience at least two
headache attacks a month. Preventive treatments do not work as well when patients are
overusing pain-relief medication, so doctors may recommend stopping and withdrawing
from analgesics before beginning preventive approaches.
The goals of preventive treatment are to reduce the frequency and severity of headache
attacks, and to improve the response to pain medication.
Preventive treatment for tension-type headache includes:
Drug treatment with an antidepressant, usually the tricyclic antidepressant

amitriptyline
Relaxation training and biofeedback
Stress management through cognitive-behavioral therapy
Studies indicate that best results are achieved when drug treatment is combined with
relaxation or stress-management training.
Withdrawing from Medications after Medication-Overuse Headaches
If headaches develop because of medication overuse, the patient cannot recover without
stopping the drugs. (If caffeine is the culprit, a person may only need to reduce coffee or
tea drinking to a reasonable level, not necessarily stop drinking it altogether.) The
patient usually has the option of stopping abruptly or gradually and should expect the
following course:
Most headache drugs can be stopped abruptly, but the patient should be sure to
check with the doctor before withdrawal. Certain non-headache medications,
such as anti-anxiety drugs or beta-blockers, require gradual withdrawal under
medical supervision.
If the patient chooses to taper off standard headache medications, withdrawal
should be completed within 3 days or less. Otherwise, the patient may become
discouraged.
No matter which approach is used for stopping medication, the patient must
expect a period of worsening headache for a few days afterward. Alternative
pain relievers may be administered during the first days to help withdrawal.
Most people feel better within 2 weeks, although headache symptoms can persist
up to 16 weeks (and in rare cases even longer).
Medications
The standard treatments for tension-type headaches are non-steroidal anti-inflammatory

drugs (NSAIDs) such as aspirin and ibuprofen, and tricyclic antidepressants, usually
amitriptyline (Elavil).
Due to the risks of overuse and dependence, opoids, opoid-like drugs, and sedative
hypnotics are not recommended for treatment of tension-type headaches.
Pain Relievers
Several pain relievers are helpful for mild-to-moderate headaches. They cannot prevent
headaches, however.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). NSAIDs are common pain relievers
that block prostaglandins, substances that dilate blood vessels and cause inflammation
and pain. NSAIDs are usually the first drugs tried for almost any kind of headache.
There are dozens of NSAIDs. Common NSAIDs include:
Over-the-counter NSAIDs. Aspirin, ibuprofen (generic, Advil, other brands),

naproxen (generic, Aleve), ketoprofen (Actron, Orudis KT)
Prescription NSAIDs. Diclofenac (Voltaren, Cataflam, Solaraze), tolmetin
(Tolectin), indomethacin (Indocin)
Patients should be aware that long-term use of high-dose NSAIDs may increase the risk
for stomach bleeding and heart problems, including heart attack and stroke.
Acetaminophen. Acetaminophen (Tylenol) is a good alternative to NSAIDs when

stomach distress, ulcers, or allergic reactions prohibit their use. A high dose (1,000 mg),
however, is needed for this drug to be effective for headaches. Midrin (a combination of
a drug that narrows blood vessels, a mild sedative, and acetaminophen) may also be
helpful for tension-type headaches.
Acetaminophen does have some adverse effects, however, and the daily dose should not
exceed 4 grams (4,000 mg). Patients who take high doses of this drug for long periods
are at risk for liver damage, particularly if they drink alcohol and do not eat regularly.
Acetaminophen may cause serious kidney problems in people who already have kidney
disease. It also may interact with certain medications, including the blood thinner
warfarin.
Tricyclics and Other Antidepressants
Antidepressants known as tricyclics are most often used for prevention of severe
chronic tension-type headaches. Newer selective serotonin-reuptake inhibitors (SSRIs)
antidepressants are also sometimes used in milder cases.
Tricyclic Antidepressants. Tricyclics are not only useful for depression but also appear
to help relieve muscle pain and improve sleep. They are sometimes classified in one of
two categories: tertiary or secondary amines:
Tertiary amines include amitriptyline (Elavil) and imipramine (Tofranil).

Amitriptyline is the tricyclic most commonly used for tension-type headache.
These drugs tend to cause more drowsiness than secondary amines, which may
be helpful for patients with sleep problems.)
Secondary amines include desipramine (Norpramin) and nortriptyline (Pamelor,
Aventyl). Secondary amines may have fewer side effects than tertiary amines,
but they are just as toxic in high amounts.
A tricyclic antidepressant is usually started at a lower dose and then slowly increased. A
headache diary can help the patient and the doctor assess the effectiveness of the
treatment. In general, patients should remain on preventive drug treatment for at least 6
months. After that time, the doctor will slowly reduce the dose while continuing to
monitor the frequency of headache attacks.
Side effects are fairly common with these medications. Drowsiness is the most
common, but may vary by specific drug. In addition, side effects most often reported
include dry mouth, constipation, blurred vision, sexual dysfunction, weight gain, trouble
urinating, heart rhythm problems, and dizziness. Blood pressure may also drop suddenly
when sitting up or standing.
Tricyclics can have serious, although rare, side effects, including heart rhythm
problems, which can be dangerous for some patients with certain heart diseases. These
drugs can be fatal with overdose.
Other Antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) work by

increasing levels of serotonin in the brain. SSRIs used for tension-type headache
preventive treatment include paroxetine (Paxil) and citalopram (Celexa). Other
antidepressants used for tension-type headache are mirtazapine (Remeron) and
venlafaxine (Effexor), which target both serotonin and norepinephrine.
Although these antidepressants have fewer side effects than tricyclics, they do not
appear to be as effective for preventive treatment of tension-type headaches.
Investigational Drugs
Tizanidine. Tizanidine (Zanaflex) is a muscle relaxant that is being studied as a possible

preventive drug for chronic tension-type headaches.
Botulinum Toxin. Botulinum toxin A (Botox) injections are now widely used to relax
muscles and reduce skin wrinkles. Botox is also becoming popular as a treatment for
chronic daily headaches, which include tension-type headache. However, at present
there is little scientific evidence to support its use. Botox is not approved for headache
treatment.
Nitric Oxide Synthase Inhibitors. Nitric oxide synthase inhibitors block nitric oxide,
which may play a role in increasing nerve activity that leads to headache. Drugs are
currently being investigated in clinical trials for migraine treatment, and may also be
studied for tension-type headache.
Lifestyle Changes
Psychological and behavioral techniques, and lifestyle changes, can have a beneficial
effect on tension-type headaches. These therapies can also enhance the effects of drug
treatments. To date, relaxation training and biofeedback have the strongest evidence for
improvement in tension-type headache outcomes.
Relaxation Training and Biofeedback
Relaxation training uses breathing exercises, guided imagery, and other techniques to
help relax muscles and relieve stress. Biofeedback uses a device to record a patients
bodily responses (heart rate, surface skin temperature, muscle tension). This information
is then fed back to the patient through a sound or visual image. Through this
feedback, patients learns to control their physical responses. In clinical studies,
relaxation training and biofeedback, both alone and in combination, have led to
improvements in tension-type headache.
Stress Management and Behavioral Training
Cognitive-behavioral therapy (CBT) teaches patients how to recognize and cope with
stressors in their life. It can help patients understand how their thoughts and behavior
patterns may affect their symptoms, and how to change the way the body responds to
anticipated pain. CBT is often included in stress management techniques. Research
indicates that CBT and stress management is most effective when combined with
relaxation training or biofeedback.
Massage, Spinal Manipulation, and Physical Therapy
Massage can help relax tense muscles, and may be helpful during acute headache
attacks, although there is little evidence for long-term benefits. Although some small
studies have suggested that spinal manipulation by chiropractors or osteopaths may
have some benefits for preventing tension-type headaches, there is insufficient evidence
overall to confirm their effectiveness for tension-type headache pain reduction.
Evidence is somewhat stronger on the benefits of spinal manipulation for patients with
headaches originating from nerve or muscular problems in the neck. Some researchers
believe that tension-type headaches relieved by spinal manipulation are probably really
caused by neck problems.
There has been little research evaluating the benefits of physical therapy for tension-
type headache. Still, a physical therapist may be helpful in teaching specific exercises
for strengthening and stretching muscles or improving posture. A physical therapist may
also be able to advise on ergonomic changes to the patients workplace environment.
Acupuncture
Several reviews of clinical trials of acupuncture suggest that it may have some benefit
for tension headache.
Acupuncture, hypnosis and biofeedback are all alternative ways to control pain.
Acupuncture involves the insertion of tiny sterile needles, slightly thicker than a human
hair, at specific points on the body.
Diet and Exercise
Good health habits -- including adequate sleep, healthy diet, regular exercise-- are
helpful for reducing stress.. Quitting smoking is important in reducing the risks for all
headaches.
Home Remedies
Heat or cold packs may be helpful. An ancient remedy for tension headaches uses
pressure applied to the head (such as a headband or a towel wrapped around the head)
plus either heat or cold. Some people report more relief with cold, others with heat.
Packs can either be frozen or heated.
Herbal and Other Natural Remedies
Numerous herbal remedies are promoted for tension-type headache. It is important that
anyone taking herbal or so-called natural remedies be aware of the lack of regulations
governing their quality and effectiveness. Generally, manufacturers of herbal remedies
and dietary supplements do not need approval from the Food and Drug Administration
(FDA) to sell their products. Just like a drug, herbs and supplements can affect the
body's chemistry, and therefore have the potential to produce side effects that may be
harmful. Always check with your doctor before using any herbal remedies or dietary
supplements.
Essential Oils. Some patients find relief using two drops of peppermint, eucalyptus, or
lavender oil added to one cup of water. The patient soaks a cloth in the solution and
applies it as a compress to the head.
Magnesium. Some patients report that magnesium supplements can help prevent
migraine headache attacks, but there is little evidence that magnesium is helpful for
tension-type headaches.
Herbs. Feverfew and valerian are two popular herbal remedies for headache relief.
There have been few studies to confirm the effectiveness of these or other herbs for
headache treatment.
The following are special concerns for people taking these herbs:
People who have a bleeding or blood clot disorder, or who take blood-thinning
medications such as coumadin (Warfarin), should not take feverfew. Feverfew
can interfere with these medications and can affect the time it takes blood to
clot. Pregnant women or women hoping to become pregnant should not take this
herb, as it may potentially harm the fetus.
Valerian has sedative properties but can cause dizziness and drowsiness. High
doses of valerian may cause blurred vision, excitability, vivid dreams, and
changes in heart rhythm.
Resources

www.i-h-s.org -- International Headache Society
References
Antttila P. Tension-type headache in childhood and adolescence. Lancet Neurol. 2006
Mar;5(3):268-274.
Bigal ME, Rapoport AM, Hargreaves R. Advances in the pharmacologic treatment of

tension-type headache. Curr Pain Headache Rep. 2008 Dec;12(6):442-6.
Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA.

Myofascial trigger points and their relationship to headache clinical parameters in
chronic tension-type headache. Headache. 2006 Sep;46(8):1264-72.
Fernandez-de-Las-Penas C, Cuadrado ML, Pareja JA. Myofascial trigger points, neck

mobility, and forward head posture in episodic tension-type headache. Headache. 2007
May;47(5):662-72.
Fumal A, Schoenen J. Tension-type headache: current research and clinical

management. Lancet Neurol. 2008; 7(1): 70-83.
Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for

tension-type headache. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587.
Loder, E. and P. Rizzoli. Tension-type headache. BMJ. 2008; 336(7635): 88-92.
Naumann M, So Y, Argoff CE, Childers MK, Dykstra DD, Gronseth GS, et al.
Assessment: Botulinum neurotoxin in the treatment of autonomic disorders and pain (an
evidence-based review): report of the Therapeutics and Technology Assessment
Subcommittee of the American Academy of Neurology. Neurology. 2008 May
6;70(19):1707-14.
Rosen NL. Psychological issues in the evaluation and treatment of tension-type

headache. Curr Pain Headache Rep. 2008 Dec;12(6):425-32.
Silver, N. Headache (chronic tension-type). Am Fam Physician. 2007; 76(1): 114-6.
Stovner Lj, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, et al. The global
burden of headache: a documentation of headache prevalence and disability worldwide.
Cephalalgia. 2007 Mar;27(3):193-210.
Vargas BB. Tension-type headache and migraine: two points on a continuum? Curr
Pain Headache Rep. 2008 Dec;12(6):433-6.
Review Date: 10/27/2009

Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine,
Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by
David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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Rebound Headaches
What are rebound headaches?

Rebound headaches happen every day or almost every day. They may be caused by
using too much pain medicine. These headaches usually begin early in the morning. The
pain can be different each day. People who have rebound headaches also may have
nausea, anxiety, irritability, depression or problems sleeping.
What kinds of medicine can cause rebound headache?

Prescription and over-the-counter medicine for migraines (such as aspirin and
acetaminophen) can cause rebound headaches if you take them too often. These
medicines should not be taken more than 2 days per week. Sedatives, tranquilizers and
ergotamine medicines also can cause rebound headaches. Talk with your doctor to find
out if you should stop taking these medicines or should not take as much of them.
Should I stop taking certain medicines?

Talk to your doctor about the medicines you are taking. You can safely stop taking some
medicines right away. Other medicines may need to be stopped gradually over time.
Once you stop taking the medicine that is causing your rebound headaches, your
headaches may get worse for a couple of weeks. This is normal. If you have any
concerns, be sure to talk to your doctor.
What effect does caffeine have on headaches?

Some headache medicines contain caffeine. Caffeine can make your headache feel
better for a little while. But if you take medicine that has caffeine in it every day, you
might get more headaches. The same is true if you drink beverages that contain caffeine
every day. If your headache gets worse when you stop having caffeine, the caffeine may
be causing some of your headaches.
What can I do to help my headaches?
A headache diary can help you and your doctor know exactly when you are getting
headaches and what helps relieve the pain.
There are several medicines that can be used to prevent headaches. They have to be
taken every day. These medicines include the following:
Tricyclic antidepressants, such as amitriptyline (brand name: Elavil) and

nortriptyline (brand names: Aventyl, Pamelor)
Antiepileptic drugs, such as valproic acid (brand names: Depakene, Depakote,
Depacon), gabapentin (brand name: Neurontin) and topiramate (brand name:
Topamax)
Beta blockers, such as propranolol (brand names: Inderal, InnoPran)
These medicines can help you get fewer headaches. They will not stop every headache.
It can take 6 weeks or more for the medicine to start working. Talk to your doctor about
whether one of these medicines is right for you. It is important to follow your doctor's
instructions when you take these medicines.
Following a regular daily pattern can also help. Eat meals at regular hours. Do not skip
breakfast. Fasting is a common cause of headache. Go to bed and get up at the same
time every day. Regular aerobic exercise can be helpful. Try to exercise for at least 30
minutes a day, 4 days a week. Yoga, meditation and relaxation therapy can also relieve
headaches.
How should I use medicine for my daily headaches?

Take medicine only as directed by your doctor. Always carry your medicine with you in
case you get a headache.
What about alternative therapies and herbal health

products?
Some patients try alternative therapies (such as acupuncture or chiropractic treatments)
for headache relief. If you are considering an alternative therapy, talk to your doctor
about the potential risks and benefits of these treatments.
If you are considering taking an herbal health product for headache relief, keep in mind
that these products aren't tested to be sure they're safe. You should check with your
doctor before taking any herbal health product, especially if you take any prescription
medications.
Copyright American Academy of Family Physicians 2008

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Migraine headaches

Throbbing pain on one side of the head

Migraines attacks are often preceded by symptoms that may include:

Sensitivity to light or sound

Migraines can be triggered by many everyday things. Different people respond to

Migraine Treatment Approaches

Preventive strategies begin with non-drug approaches, including behavioral therapies

A headache is generally categorized as primary or secondary.

Primary Headache. A headache is considered primary when a disease or other medical

Headaches may be caused by muscle tension, vascular problems, or central nervous

Secondary Headache. Secondary headaches are caused by other medical conditions,

It is not uncommon for someone to experience a combination of headache types.

Sensitivity to light or sound

Chronic Migraine (Transformed Migraine)

The majority of chronic migraines are caused by overuse of analgesic migraine

Chronic migraines can resemble tension headaches and it is sometimes difficult to

Other Migraine Variations

Although migraine is considered to be a specific chronic illness, it has various

There is certainly a strong genetic component in migraine with or without auras.

Fluctuations of female hormones, such as estrogen and progesterone, appear to increase

Medical Conditions Associated with Migraines

A National Headache Foundation-sponsored survey of migraine sufferers reported that:

Anyone, including children, with recurring or persistent headaches should consult a

Diagnostic Criteria for Migraine

Headache attacks that last 4 - 72 hours

1 = Mild, barely noticeable

2 = Noticeable, but does not interfere with work/activities

3 = Distracts from work/activities

4 = Makes work/activities very difficult

Medical and Personal History

Any chronic or recent illness and their treatments

Differentiating Between Migraine and Other Types of Headaches

Differentiating Between Migraines and Tension Headaches. Migraines and tension

Migraine pain is throbbing, while tension-type headache pain is usually a steady

[For more information, see In-Depth Report #11: Tension-type headache.]

Differentiating Between Migraines and Sinus Headaches. Many primary headaches,

Imaging tests may also be recommended for patients with headache:

That wakes them at night

A CT (computed tomography) scan is a much more sensitive imaging technique than x-

Symptoms that Could Indicate a Serious Underlying Condition

Headaches indicating a serious underlying problem, such as cerebrovascular disorder or

Treating Migraine Attacks

The main types of medications for treating a migraine attack are:

Pain relievers [usually nonprescription nonsteroidal anti-inflammatory drugs

Start with nonprescription pain relievers for mild-to-moderate attacks. If

Preventing Migraine Attacks

Patients should consider using preventive migraine drugs if they have:

Migraines that are not helped by acute treatment drugs

The main preventive drug treatments for migraine are:

Beta-blocker drugs [usually propranolol (Inderal) or timolol (Blocadren)]

A preventive medication strategy needs to be carefully tailored to an individual patient,

Treatment Approaches for Children

Migraine Prevention for Children. Non-medication methods, including biofeedback and

Withdrawing from Medications

Medications for Treating Migraine Attacks

Non-prescription drugs. Excedrin Migraine, Advil Migraine, and Motrin

Nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin),

Other Triptans. Newer triptans include almotriptan (Axert), zolmitriptan (Zomig),

Side Effects. Side effects of triptans may include:

Tingling and numbness in the toes

Complications of Triptans. The following are potentially serious problems.

Complications of heart and circulation. Triptans narrow (constrict) blood

Drugs containing ergotamine (commonly called ergots) constrict smooth muscles,