Headaches and migraines – diagnosis and treatment

Migraine is the technical name for headache. It consists of pain or discomfort in the region of the head including the face. Headaches vary widely in their different characteristics: location, type of pain, intensity, frequency, duration and associated symptoms. For this reason, more than 300 different types are considered by the International Headache Society.

Migraine is a type of pain that, in addition to the headache, also presents additional symptoms: nausea, and/or vomiting, and/or photophobia/phonophobia, with severe and incapacitating intensity. The symptoms can last up to 72 hours.

Migraines may have several phases, however not all patients experience them in the same sequence: prodrome (mood/ behavior change), aura (visual, sensory or speech alterations), migraine itself (intense pain, usually throbbing on one or both sides of the head, and may be associated with nausea, vomiting, photophobia and/or phonophobia) and resolution phase.

It is important to emphasise that patients can often have more than one type of associated headache. It is common for the same patient to complain of migraine and tension-type headaches, for example.

Headaches may be the result of a structural change (nerves, muscles or blood vessels) or the consequence of a specific pathology (head trauma, sinusitis, hypertension, sleep apnea, among others). However, most headaches do not have a direct cause, such as a tension-type headache and a migraine headache, where the reason is attributed to stress and muscle tension.

Although the symptoms may be varied, tension-type headaches and migraine headaches have the following symptoms in common: the onset is slow, pain on both sides of the head; the pain is described as a tightness (like a tight helmet); pain may be felt at the back of the head or neck; intensity is mild to moderate, usually not associated with nausea, vomiting or sensitivity to light (photophobia).

The diagnosis of the type of headache is essentially made by the medical history and physical/neurological examination and, if necessary, complementary diagnostic exams (in case there is a secondary cause). However, the medical history is determinant in reaching a diagnosis and also in identifying the type of headache. For this reason, the patient must describe all the symptoms and characteristics of his headaches as clearly as possible: at what time of the day they occur, where the pain is located, type of pain, duration, associated symptoms, triggering factors or previous history of head trauma.

Specific treatment for a headache is based on the patient’s age, medical history, type of headache(s), frequency and severity, and also the patient’s tolerance to specific medications, procedures and therapies.

General measures may be recommended to help prevent a headache and avoid triggering factors, such as certain foods and beverages (alcohol, chocolate, cured cheese, beverages containing caffeine, nitrates, monosodium glutamate present in some Asian food), sleep deprivation and fasting.

During the acute phase of the headache, the patient should always have with them an “SOS Kit” with the prescribed medication which they know will be effective. In addition, taking a rest in a quiet and dark place (in the case of migraines) is recommended. Learning to deal with stress (e.g. yoga practice) is also recommended in the acute phase.

If your doctor decides to start with prophylactic treatment, this means that for a few months you will need to take medication daily, in order to reduce the frequency and severity of each crisis, ideally until no further headaches are experienced.

The efficacy and necessity of further medication will be evaluated in the consultation. A crisis calendar is recommended to identify the profile of the headaches.

There are other specific and targeted treatments for particular headaches; an occipital nerve block, application of botulinum toxin or the most recent treatment for migraine prophylaxis (+4 days per month), a monthly injection of monoclonal human antibody of the CGRP receptor.

By Dr Leandro Valdemar
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Dr Leandro Valdemar is a neurologist and neurophysiologist at the HPA Health Group