Primary Headache Disorders

Facts

  • defined as headaches without an underlying structural or metabolic cause
  • this is generally the territory of neurologists, however neurosurgical patients with actual mass lesions have all types of headaches and you are still responsible for teasing apart and diagnosing their headaches.
 
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Tension
Migraine
Cluster
Cause
muscle tension / central sensitization
abnormal excitability and signaling within pain / neuro-vascular pathways
posterior hypothalamic activation and trigeminal–autonomic reflex dysregulation.
Location
dull-band like pressure around head, bilateral
unilateral
orbital/temporal pain, conjunctival injection, tearing, nasal congestion, facial/eyelid swelling, miosis or ptosis
Duration
30 min - several hrs
4-72 hours
up to 180 min
Change with activity
none
worsen
none
Demographics
Slight F > M
Female > Male
20-40 y.o. M
Activity preference
quiet
Rest, dark quiet room
Restlessness, pacing
Treatment
APAP / Motrin
see below
- 100% Oxygen
- Sumatriptan 6 mg SC injection – most effective; relief in 5–10 min.
- Zolmitriptan 5–10 mg nasal spray
Cluster headaches are part of a broader class of Trigeminal Autonomic Cephalalgias (TACs) which are a group of severe unilateral headaches associated with cranial autonomic symptoms (tearing, rhinorrhea, ptosis, etc.) that include:
  • Paroxysmal hemicrania – Shorter (2–30 min), more frequent, indomethacin-responsive.
  • SUNCT/SUNA – Short-lasting unilateral neuralgiform headache with conjunctival injection/tearing (SUNCT) or autonomic symptoms (SUNA).
  • Hemicrania continua – Continuous unilateral headache with exacerbations, also indomethacin-responsive.

Treatments

Mechanism
Drug Target
CGRP release
CGRP antagonists (erenumab, fremanezumab)
Serotonin modulation
Triptans (5-HT₁B/₁D agonists)
Glutamate inhibition
Topiramate
Ion channel stabilization
Valproate, beta-blockers
Neurogenic inflammation reduction
NSAIDs, steroids
Brainstem modulation
Amitriptyline, venlafaxine