The most common headache disorder leading to a neurological referral is actually migraine. I believe it is important for patients to have some understanding of what migraine is and how attacks can often be avoided.
About 10% of us experience migraines, occurring more often in women than in men. Once believed that migraines were due to changes in blood vessels within the brain, it is now believed that the attack involves various nerve pathways and chemicals within the brain itself. Generally migraine represents no significant threat to your overall health; but the attacks can be disabling and cause significant difficulties in your day to day function/activities.
- Migraine Symptoms
- What causes Migraine – Triggers?
- Other Types of Headaches
- Need for a Brain Scan?
- Headache Treatment
- The Local Headache Service with National Links
Migraine Symptoms
Migraines can last from 4 to 72 hours and occur in ‘attacks’ of headache that can be worse on one side of the head. Other symptoms can include nausea, vomiting and sensitivity to light, noise and strong smells and movement.
Approximately 1 in 3 patients have migraine with aura. This means that they have a focal neurological warning symptom (aura) before the headache begins – this can include seeing stars or zigzag lines, tunnel vision or a temporary blind spot as well as tingling in the hand or face or transitory speech and cognitive disturbances. These symptoms usually last minutes and can signal the onset of migraine.
Symptoms can linger once a migraine attack is over including feeling mentally dull, fatigue and neck pain.
What causes Migraine – Triggers?
Most migraine attacks occur for no apparent reason, however some people get migraine after a ‘trigger’. These are categorized into Behavioural, Environmental, Infectious, Dietary, Chemical or Hormonal Trigger Factors.
Migraine Trigger Examples:
Bright Lights, Loud Noises, Certain Odours or Perfumes ~ Physical or Emotional Stress ~ Changes in Sleep Pattern ~ Smoking or Exposure to Smoke ~ Skipping Meals ~ Lack of Water (Dehydration) ~ Alcohol or Caffeine ~ Menstrual Cycle Fluctuations, Birth Control Pills ~ Neck pain ~ Foods Containing Tyramine (red wine, smoked fish, aged cheese, chicken livers, figs and some beans), Monosodium Glutamate (MSG), or Nitrates (like bacon, hot dogs and salami) ~ Other Foods such as Peanut Butter, Avocado, Banana, Citrus, Onions, Dairy Products and Fermented/Pickled Foods.
Patients often report more than one trigger factor and so patients are recommended to keep a ‘migraine diary’ to note when, where and what they were doing when the attack started. From this a pattern may emerge and it may be possible to avoid potential ‘trigger factors’.
There is no specific cure for migraine, so it is best to try and reduce exposure to triggers.
Other types of headaches
Headaches can be thought of as being ‘primary’ (where no underlying cause can be identified) or ‘secondary’ to some underlying pathology. The more common types of primary headache disorders seen are: Migraine, Cluster Headache, Tension Headache and forms of Trigeminal Neuralgia.
Headaches may not be just due to problems within the head but may also be as a result of injury or tension within the muscles of the scalp and neck, or related to problems with ENT/dental or vision.
Headaches may also be due to underlying medical disorders, problems with sleep and mood or medications taken. Therefore one has to take a detailed medical history before coming to a final diagnosis.
I believe that the most important factor in coming to a diagnosis of headache is carefully listening to the patient’s symptoms followed by a thorough neurological examination.
Need for a brain scan?
For the vast majority of patients with headaches, no sinister cause is ever identified. Thus in most cases a scan cannot be used to diagnose the cause of the headache. Although brain tumours can present with headache, this rarely occurs in isolation and patients will also manifest seizures and/or focal neurological symptoms and signs which should be picked up after carefully listening to the medical history and performing a neurological physical examination.
Although a ‘normal brain scan’ may seem reassuring, it may not exclude all serious causes of headache (eg Benign Intracranial Hypertension, Small Brain Aneurysms, Giant Cell Arteritis, Cerebral Venous Sinus Thrombosis). There are many different ways of imaging the brain and the type of scan requested should reflect the patient’s symptoms and the clinicians concerns.
Furthermore, it is important that the scans are arranged by clinicians who are able to interpret the subsequent results. I work as part of a Multi-Disciplinary Team, consisting of Neurosurgeons and Neuroradiologists and I am able to regularly discuss the results of any scans performed in light of the clinical context.
Headache Treatment
It is important to try where possible to identify triggering or exacerbating factors and sometimes this may need to be done by the means of a headache diary. For example in some patients poor sleep, dehydration, skipping meals, alcohol and the menstrual cycle may be triggering factors for their headaches and addressing these factors would be important in managing their headaches.
The commoner types of primary headache disorders seen are: migraine, cluster headache, tension headache and forms of trigeminal neuralgia. In each case the drug treatment and management is very different. Broadly speaking drug treatment can be split into medication you take when you have a headache (symptomatic or abortive) and medication taken regularly to reduce the frequency and severity of headaches (prophylactic or preventative). In my opinion, there are no hard and fast rules regarding what medication to take as individual factors will determine the precise management approach.
Unfortunately, over-the-counter pain-killers may be ineffective for some forms of headache and, even if effective initially, if taken frequently over long periods of time, could lead to headaches in themselves (medication overuse headaches).
The Local Headache Service with National Links
At Brighton and Sussex University Hospitals NHS Trust, we are fortunate to have a GP with a specialist interest in Headache Disorders (Dr Susan Lipscombe). She has a wealth of experience treating patients with headaches and is part of the Association of British Headache Specialists. Together we run a combined Headache/Neurological Disorders Clinic with our combined skills offering a comprehensive approach to patients with headache disorders. Both of us are active in training and education having given talks for the Migraine Trust as well as other organisations. We are also actively engaged in clinical trials for patients with migraine and have established links with the specialist headache clinics both in London and Oxford.
For more information about Migraine and other headache disorders (including cluster headache and trigeminal neuralgia) see my Quick Links webpage
