Headache

Marc E. Lenaerts, MD

Assistant Professor

Headache Section

Department of Neurology

Oklahoma Health Sciences Center

Headache is a very common problem. It is believed that over 90 % of the general population suffers from headache at least at some point in their life.

Headaches can be divided into two main groups:

a) Those that are due to a recognized cause (a disease, a trauma, a toxic agent or a drug (including prescription) called secondary headaches

b) Primary headaches, which are not due to any known cause.

It is important to distinguish between a cause and a trigger:

·        a cause is necessary for the secondary headache condition to be present; meningitis is an example

·        a trigger is a factor that can cause a episode of primary headache to occur at a given time; a glass of wine is an example.

A common source of misunderstanding is sinus disease, or sinusitis: whereas it can be the cause of a secondary headache condition, i.e., a sinusitis headache, it is much more commonly a trigger for the primary headache migraine, in other words inflammation causes an exacerbation of a true migraine headache.

Among primary headaches, tension-type headache and migraine are the most frequent. Tension-type headache is actually much more prevalent, however usually not severe hence not a reason for medical attention. Mild, pressure-type pain diffusely in the head, non-disabling and without nausea or vomiting, make the usual presentation. Often it occurs a few times a month or even a year. Seldom it can become daily and then becomes of medical concern.

Migraine is, of all headaches, the one that is most frequently seen by medical professionals. It is estimated that 28 million Americans suffer from migraine, i.e., approximately one person out of eight. It takes of a toll three times heavier on women than on men.

Following are the main symptoms of migraine. Episodic headache, lasting a few hours to a few days; intense pain, often dominant on one side, with throbbing character; exacerbation by external factors such as noise (phonophobia), light (photophobia), smells (osmophobia), and by physical activity; nausea, vomiting, and even diarrhea; mood changes and decreased concentration. They are common albeit present with variable frequency and combination. Sometimes an “aura” comes with the headache, usually at the beginning. Various symptoms can make the aura: vision trouble: sensation of a veil or a heat wave, dark or bright (flashing) spots, blinding, etc...; sensation trouble: tingling, numbness, usually in the lips and hand; movement difficulty (rare): weakness on one side, ...

The treatment of migraine consists of three main components, all of which should always be considered in every patient: non-medication approach, prevention and abortive therapy.

Non-medication methods include sleep hygiene, exercise and diet, relaxation techniques including biofeedback, particularly useful in children, acupuncture, results of which are usually modest, etc…

Preventive treatments aim at decreasing the frequency and the intensity of migraine attacks. They are of different classes and often happen to be medications used for other disorders: anti-hypertensives such as Propranolol (InderalÒ) and Verapamil (CalanÒ), antiepileptics such as Valproate Sodium (DepakoteÒ), Gabapentin (NeurontinÒ) and Topiramate (TopamaxÒ), antidepressants such as Amitriptyline (ElavilÒ) or Doxepin (SinequanÒ); some are only used for migraine such as Methysergide (SansertÒ) or Riboflavin (Vitamin B2) high dose.

Finally abortive medications are taken to stop the headache attack after it started. They make the most widely used category. All symptoms of migraine deserve attention. Therefore while plain analgesics such as Aspirin or Ibuprofen are effective and often used, they do not help the nausea and vomiting often associated with the attack; an antiemetic drug (against vomiting) has to then be combined, such as Metoclopramide (ReglanÒ) or Prochlorperazine (PhenerganÒ). Over the last fifteen years there has been tremendous research in migraine abortive medications, leading to a new class, the “Triptans”: while the first in 1991 was Sumatriptan (ImitrexÒ), there are now six more drugs, namely Naratriptan (AmergeÒ), Zolmitriptan (ZomigÒ), Rizatriptan (MaxaltÒ), Frovatriptan (FrovaÒ), Eletriptan (RelpaxÒ) and Almotriptan (AxertÒ). All are very effective medications not only on the pain but also on several other symptoms including nausea, vomiting, photo- and phonophobia. Sumatriptan comes as a subcutaneous self-administered injection, the most efficient of all but also associated with a higher cost and more side effects, and a nasal spray. All the others are available in oral forms only. While there are certain advantages of some over the others in some of their qualities, those differences remain modest.

The Department of Neurology of the University of Oklahoma is particularly devoted to the study and care of headaches, withy the Chairman Dr James Couch, MD, PhD, a world leader in the field and past president of the American Headache Society (AHS), and myself, trained in Belgium with another leader in the field. Several associates in the Department also actively devote their time to the field.

Our research is mostly clinical, i.e., directly applies to patient care. Among the different projects both ongoing and future, we experiment the “Triptans” in new indications (I am currently at a meeting for this at the time of my writing this note!), study the epidemiology –the science behind the prevalence of diseases in the population- of migraine symptoms and of its comorbidity, i.e., the fact that some diseases are associated with migraine more than by chance, so that a disease process common to both, or a complex interaction between them, are suspected. Epilepsy (seizure disorder), irritable bowel syndrome (constipation or diarrhea during stress) and mitral valve prolapse or Patent Foramen Ovale (heart defects)  are some examples, and so is lupus.

Marc E. Lenaerts.

http://w3.ouhsc.edu/neuro/faculty.htm

Clinic Address:

Presbyterian Professional Office Building, Suite # 310

711, Stanton L. Young Blvd

Oklahoma City, OK 73072

Tel.: (405) 271-3635

Fax: (405) 271-2523