Headache Treatment

Hemicrania Continua – The Challenges of Diagnosis!

yourheadachesolutions — Mon, 14 Sep 2009 17:44:41 +0000

Hemicrania continua is defined as a constant one sided (and always on the same side) headache of moderate intensity with exacerbations and which responds to Indomethacin. Other possible symptoms include redness of the eye, a watery or teary eye, a blocked or runny nostril and drooping of the eyelid.

But we have case reports which show that this supposedly one sided (always the same side) headache can occur on the other side and can also be on both sides at the same time.

Interestingly the traditional classification system of headache and migraine states that Cervicogenic (neck-related) Headache as a one sided headache (and always the same side) also. However my experience of over 21000 hours with headache and migraine patients is that a one sided headache that can occur on the other side is a Cervicogenic Headache. Does this mean that I am saying Hemicrania Continua is likely to be Cervicogenic Headache – Yes!

Cheers

Dean
Consultant Headache and Migraine Physiotherapist; Adjunct Lecturer, Masters Program, School of Physiotherapy, University of South
Australia; PhD Candidate, Murdoch University, Western Australia
Tension Headache

References:

(Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151

Marano E, Giampiero V, Gennaro DR, di Stasio E, Bonusa S, Sorge F. ‘Hemicrania continua’: a possible case with alternating sides. Cephalalgia 1994; 14:307–8.

Matharu MS, Boes CJ, Goadsby PJ. Management of trigeminal autonomic cephalalgias and hemicrania continua. Drugs 2003; 63:1637–77.

Matharu MS, Bradbury P, Swash M. Hemicrania continua: side alternation and response to topiramate. Cephalalgia 2005; 26: 341-344

Newman LC, Lipton RB, Russell M, Solomon S. Hemicrania continua: attacks may alternate sides. Headache 1992; 32:237–8.

Newman LC, Spears RC, Lay CL. Hemicrania continua: a third case in which attacks alternate sides. Headache 2004; 44:821–3.

Sjaastad O, Fredricksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998; 38:442-5)

Sensitisation in Headache and Migraine

yourheadachesolutions — Mon, 14 Sep 2009 17:24:32 +0000

I have mentioned in my previous blogs that sensitisation of the brainstem has been demonstrated in migraine, tension headache, menstrual migraine and cluster headache.

What I may not have made clear is that this sensitised state is present even when you are free of your headache or migraine, that is, your brainstem is sensitised constantly.

Then what happens is that you eat or drink something, your hormonal levels change, you smell a perfume – and this triggers your headache or migraine. These events lead to increased (but normal) activity of structures (including blood vessels) inside your head.

This increased activity is wrongly interpreted as being much more than what it actually is and pain results. If it wasn’t for your sensitised brainstem, what you eat, drink, smell or hormonal fluctuations would not result in the disabling headache or migraine.

If you are going to be free of your headache or migraine, the source of sensitisation has to be determined. Whilst the triptans desensitise the brainstem and are effective for many of you, they do not eliminate the cause of the sensitisation.

Information from neck disorders can sensitise the brainstem and of all the various investigations you may have for your headache of migraine, a skilled examination of your upper neck is relatively inexpensive and non invasive, and may change your life significantly.

Cheers

References:

(Goldhammer L. Second cervical root neurofibroma and ipsilateral migraine headache. Cephalalgia 1993; 13:132

Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain1996; 119:1419-28

Jansen J, Markakis E, Rama B, Hildebrandt J. Hemicranial attacks or permanent hemicrania – a sequel of upper cervical root compression. Cephalalgia 1989; 9:123-30

Katsavara Z, Giffin N, Diener HC, Kaube H. Abnormal habituation of ‘nociceptive’ blink reflex in migraine – evidence for increased excitability of trigeminal nociception. Cephalalgia 2003; 23:814-819

Katsavara Z, Lehnerdt G, Duda B, Ellrich J, Diener HC, Kaube H. Sensitization of trigeminal nociception specific for migraine but not pain of sinusitis. Neurology 2002; 59:1450-1453

Milanov I, Bogdanova D. Trigemino-cervical reflex in patients with headache. Cephalalgia 2003; 23:35-38

Nardone R et al Trigemino-Cervical Reflex Abnormalities in Patients with Migraine and Cluster Headache. Headache 2008; 48(4):578-585

Nardone R, Tezzon F. The trigemino-cervical reflex in tension-type headache. European Journal of Neurology 2003; 10(3):307-312

Sandrini G, Cecchini AB, Milanov I, Tassorelli C, Buzzi MG, Nappi G. Electrophysiological evidence for trigeminal neuron sensitisation in patients with migraine. Neurosci Lett 2002; 317:135-138

Ward TN, Levine M. Headache caused by a spinal cord stimulator in the upper cervical spine. Headache 2000; 40:689-91)

‘Hair Wash Headache’!

yourheadachesolutions — Mon, 14 Sep 2009 16:31:47 +0000

In recent correspondence to an acclaimed international headache journal, a doctor located in India reported on migrainous headache occurring after washing of the hair – as the author explains this has either not been noticed in other countries or it may be that similar headache presentations in other countries occur but are called something else.

As reported by this doctor, the crucial factor here is that many ladies from India have long hair that is plaited and it is time consuming to dry their hair (it is uncommon to use a hairdryer). Consequently many women do not wet their hair daily. On the days that they wash their hair however they describe throbbing headache developing within 10’-15’ ; their history of these headaches is usually quite long; this is the only headache they get; usage of perfumes or shampoos is uncommon … therefore the author (doctor) considers there are no other triggering factors …..

Are you thinking what I’m thinking? Imagine the weight on the back of the head of all the wet hair pulling the upper neck backwards – the stress on the neck structures would be significant …. could this be an unrecognised cervicogenic headache?

Cheers

Dean
Consultant Headache and Migraine Physiotherapist; Adjunct Lecturer, Masters Program, School of Physiotherapy, University of South Australia; PhD Candidate, Murdoch University, Western Australia
Menstrual Migraine

References:

(Ravishanka K. ‘Hair-wash headache’—an unusual trigger for migraine in Indian patients Cephalalgia 2005;(25)12:1184-1185

Ravishanka. Unusual Indian migraine trigger factors. Headache World 2000. Poster Presentation. Cephalalgia 2000; 20:359)

Chronic Paroxysmal Hemicrania, Hemicrania Continua and Cluster Headache – All From The Same Disorder?

yourheadachesolutions — Mon, 14 Sep 2009 16:01:53 +0000

In recent times the International Headache Society has added a third primary group of headache(s) to the two primary headache types – migraine and tension-type headache.

This third primary group includes Cluster headache, Chronic Paroxysmal Hemicrania, and SUNCT (Short lasting Unilateral Neuralgia form headache attack with Conjunctival injection and Tearing!) and Hemicrania Continua.

Chronic Paroxysmal Hemicrania is very similar to Cluster Headache and is often described as the female equivalent of Cluster Headache (Cluster Headache is more frequent in males).

It is interesting to note a report demonstrating that both chronic Paroxysmal Hemicrania and Hemicrania Continua (thought to be two different types of headache) respond to the same medication – Indomethacin. (Indomethacin is a non steroidal anti inflammatory drug used to reduce pain)

I have written before that Cluster Headache and Hemicrania Continua respond to blocking or injecting of the greater occipital nerve i.e. a feature of Cervicogenic (neck-related) Headache – just more evidence to support the role of neck disorders in many different headache forms …..

Cheers

References:

(Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151

Sjaastad O, Antonaci F. Paroxysmal Hemicrania (CPH) and Hemicrania Continua: Transition From One Stage to Another. Headache 1993;(33)10:551-554)

Hemicrania Continua and Cervicogenic (neck-related) Headache – Are They The Same Condition?

yourheadachesolutions — Wed, 09 Sep 2009 19:25:32 +0000

Interesting to note a case study reporting that the head pain of a patient suffering hemicrania continua was temporarily reproduced and resolved by neck movements and later by blocking or injecting the greater occipital nerve. These two features are key diagnostic signs of cervicogenic or neck related headache and indeed this respected researcher concludes this.

Cheers

References:

(Rothbart P. Unilateral Headache with Features of Hemicrania Continua and Cervicogenic Headache – A Case Report. Headache 1992;(32)9;459-60)

Hemicrania Continua – What Is It?

yourheadachesolutions — Wed, 09 Sep 2009 19:09:02 +0000

I have mentioned Hemicrania Continua a few times in my blogs assuming that you are familiar with this condition.

Hemicrania Continua is a headache characterised by constant pain on one side of the head (and always on the same side), of moderate severity, with episodes of aggravation. Hemicrania responds to the medication known as Indomethacin.

Hemicrania Continua is included (along with Cluster headache, Chronic Paroxysmal Hemicrania, and SUNCT) in the third primary group of headache classified by the International headache Society.

As with all of the headache and migraine types, Hemicrania Continua is based on a set of signs and symptoms with no indication as to the cause.

Cheers

References:

(Peres MFP, Siow HC, Rozen TD. Hemicrania continua with aura. Cephalalgia 2002;22:246-248)

Migraine and Headache After Trauma – Post Traumatic Headache (PTH)

yourheadachesolutions — Wed, 09 Sep 2009 18:09:41 +0000

Headache is the most common symptom after a head injury. Post traumatic headaches, like non traumatic migraine and tension headache for some reason pose a significant challenge for clinicians and are surrounded by controversy. Because the neurological examination after mild head injury is normal and standard tests as well as imaging studies (such as MRI or CT of the head) fail to reveal abnormalities, it is often thought that the symptoms following mild head injury are psychological.

Why is it then that in the presence of any abnormal findings the focus on the head continues?

It is important that after a blow to the head an intracranial (within the head) cause of headache or migraine be ruled out. However once an intracranial cause has been eliminated, why then does the source of the headache or migraine become such a mystery?

If the head hits the windscreen for example, the body keeps moving; it is the neck which connects the head to a moving body and absorbs a significant amount of stress.

It is very important then that a skilled examination of the upper three spinal segments be performed and that prior to examination of the upper neck, assessment of crucial ligaments be undertaken – this is mandatory.

An examination of this nature may prevent years of frustration and unnecessary medication.

Cheers

References:

(Packard RC. Chronic Post-traumatic headache: Associations with mild traumatic brain injury, concussion, and post-concussive disorder. Current Pain and Headache Reports 2008; (12)1:67-73

Treleaven J, Jull G, Atkinson L. Cervical musculoskeletal dysfunction in post-concussional headache. Cephalalgia 1994;14:273-9)

Neck X-Rays, Headache and Migraine

yourheadachesolutions — Tue, 08 Sep 2009 18:49:00 +0000

Generally routine neck xrays are uninformative for headache or migraine sufferers. However, this does not exclude neck disorders as the source of headache or migraine.

Therefore xrays as a form of diagnosis are not highly regarded. Nevertheless it is very important that neck xrays be undertaken in the event of any significant head or neck trauma or injury.

It is information from structures supplied by the upper three cervical nerves which have access to the brainstem and therefore the potential to sensitise the brainstem. Consequently abnormalities seen on neck xrays, involving spinal segments below C3 (third cervical vertebra) are likely to be irrelevant. This is why it is crucial that when having a CT or MRI scan of your neck for headache that the upper 3 spinal segments are included.

Degenerative changes or spondylosis of C5-6 for example is irrelevant to the sensitisation process; information from this level does not have direct access to the brainstem.

Cheers

References:

(Goldhammer L. Second cervical root neurofibroma and ipsilateral migraine headache. Cephalalgia 1993; 13:132

Jansen J, Markakis E, Rama B, Hildebrandt J. Hemicranial attacks or permanent hemicrania – a sequel of upper cervical root compression. Cephalalgia 1989; 9:123-30

Ward TN, Levine M. Headache caused by a spinal cord stimulator in the upper cervical spine. Headache 2000; 40:689-91)

Migraine, Headache And The Brainstem

yourheadachesolutions — Tue, 08 Sep 2009 18:35:35 +0000

There is clear clinical and experimental evidence that the BRAINSTEM plays a pivotal role in the migraine process.

Migraine and headache are conditions in which normal light is unpleasant, normal sound uncomfortable, and where there is an abnormal interpretation of activity – one in which normal pulsing of arteries is felt as pain.

Information from the visual and auditory systems along with activity of structures from inside the head are transmitted through the brainstem to the cortex where it is interpreted – it seems as though the cortex is misled by a sensitised or hyper excitable brainstem.

The key to successful treatment is determining the source of the sensitisation of the brainstem – information from neck disorders is neglected by traditional medicine as a potential source. Whilst it is important and responsible that other possibilities be investigated, given the clinical and experimental evidence, it is irresponsible that the neck not be considered.

Cheers

References:

(Goadsby PJ. Migraine pathophysiology: The brainstem governs the cortex. Cephalalgia 2003;23:565-566

Knight Y. Brainstem modulation of caudal trigeminal nucleus: A model for understanding migraine biology and future drug targets. Headache Currents 2005 Vol. 2, No. 5:108-118)

Migraine In 1888 – The Same As In 2009!

yourheadachesolutions — Tue, 08 Sep 2009 18:17:29 +0000

Amazing! I have just come across a gentleman who in 1888 who described the migraine process in this way: “… we must not ascribe too much significance to throbbing of the increase in the pain by the cause of vascular distension; these may be due merely to the over sensitiveness of the central structures.” In other words expansion of the blood vessels is unlikely to be the cause of pain; it may be that expansion of blood vessels is misinterpreted by a sensitised central nervous system.

This information from the blood vessels has to pass through the BRAINSTEM on the way to the cortex … and what has been shown to be the disorder in headache and migraine? … a SENSITISED BRAINSTEM.

A man 120 years before his time – Bravo!

Cheers

References:

(Gowers WR. Diseases of the brain and cranial nerves. General and functional diseases of the nervous system. A Manual of Diseases of the Nervous System, 1st Ed. Vol. 2 London: Churchill, 1888)