Headaches can take a toll on our quality of life

Headache is very common. There are many types of headaches, with the most common being migraines, tension headaches and cluster headaches. Other types of headaches include cervicogenic headache (which is due to neck problems), occipital neuralgia, sinus headache, post-trauma headaches, and medication-overuse headache. We will cover the common headache types first, followed by the others below.

Here is how to differentiate between the common types of headache:

Characteristics of common headache syndromes

Symptom	Migraine headache	Tension headache	Cluster headache
Location	One-sided in 70% of people, on both sides in 30%. Usually over the forehead.	Always on both sides of the head	Always on one side and in the area around the eye or temple
Characteristics	Slowly builds up in intensity, pulsating/throbbing, moderate to severe in intensity, made worse by normal physical activity	A sense of pressure and tightness that varies in intensity with time, usually light to moderate.	Pain comes on suddenly and reaches a climax in intensity quickly in minutes, the sensation of a boring, excruciating, explosive and continuous pain that is extremely severe.
Activity	Finds relief in lying down in a dark and quiet room	Varies. may seek rest or activity	Unable to rest
Duration	3 hours to 3 days	Variable	30 minutes to 3 hours
Other symptoms	Sensitivity to light and sound, nausea and vomiting; usually preceded by auras which represent changes in vision and hearing before the attack	None	A red-eye on the same side as the headache along with tearing, a blocked and runny nose, paleness of the face, intense sweatiness, drooping of the eyelids, and severe sensitivity to alcoholic beverages

Cervicogenic headache

This is related to bony structures or soft tissues in the neck which results in pain being transmitted and felt in the head. The small joints in the neck can become damaged through normal wear and tear or injury, and the pain sensation from these joints are transmitted through nerves which are also give sensation to other parts of the head. This leads to us feeling pain in the head even though the source is in the neck.

Treatment includes:
– Physical therapy
– Medications
– Acupuncture
– Simple steroid injections
– Radiofrequency procedures

Avoid vigorous massage or spine manipulation as this can lead to nerve and blood vessel damage, resulting in permanent paralysis or death.

In the event the offending joint(s) has severe problems that do not respond to the above treatment, the patient may need to have surgery to put in metallic implants to have the joint fused so that it does not move and cause pain.

Occipital Neuralgia

Occipital neuralgia is characterized by pain that arises at the back of the head near the occiput (that bony prominence that you can feel). The pain is like an electric shock, comes and goes, lasting moments, although there can be a lingering ache. The pain can also spread along the nerve towards the eye. The affected area can feel a bit numb, unpleasant, tender or exquisitely sensitive to touch. Other symptoms may include nausea and vomiting, difficulty with balance and slurred speech.

Treatment includes:
– Medications such as carbamazepine, gabapentin, pregabalin or tricyclic antidepressants
– Simple steroid injections
– Pulse radiofrequency procedure
– Peripheral nerve stimulator
– Open surgery to “free” the entrapped nerve

Sinusitis

This condition is often very hard to differentiate from tension headache or migraine. If the patient has nasal discharge with or without fever and tenderness of the sinus in proximity to the headache, sinus headache should be considered as a diagnosis. There is usually no nausea or vomiting or any sensitivity to light and noise.

Treatment includes:
– antibiotics to treat any infection
– seeing an ENT specialist for consideration of drainage procedures

Post-trauma headache

Post-trauma headache, also known as post-concussion headache, can be due to motor vehicle accidents, falling down, and sports injuries. Symptoms may include headache, dizziness, mood and behavioural changes, forgetfulness and difficulty concentrating on a task, insomnia, and sensitivity to sound. An MRI may be needed to ensure that there is no bleeding in the brain or a serious injury that may need an urgent operation.

Symptoms usually improve after a week, although in some cases it may take up to 3 months. Treatment will need to address sleep, as well as cognitive and behavioural changes. Specifically for the headache, the treatment will involve:

– Medications such as amitrityline and nortriptyline, propanolol or indomethacin can be tried; intravenous metoclopramide or dihydroergotamine may be beneficial for certain patients.
– Some cases may respond to Pain Interventional Procedures such as an Occipital Nerve block or radiofrequency, or a sphenopalatine block.

Medication Overuse

People with chronic headaches usually rely on long-term usage of medications in order to cope with their symptoms. Unfortunately, these medications can become a cause of headaches as well. A vicious cycle forms in which a person takes medications to help with the headache, which causes a rebound headache when the medication wears off, leading the person to keep on using the medication in order to prevent a “withdrawal” symptom, which although less severe than an opioid withdrawal can still be very problematic.

The treatment involves:
– Avoiding this problem altogether by avoiding opioid medications and bulbalbital-containing medications
– Not using the following medications for more than 9 days a month: aspirin/paracetamol/caffeine combinations, triptans
– Not using the following medications for more than 15 days a month: NSAIDs such as aspirin, indomethacin or even newer COX-II inhibitors such as etoricoxib and celecoxib.
– Using a preventive medication for Chronic Headaches such as a tricyclic anti-depressant like amitriptyline or nortriptyline for long-term control of the headache.