Questions and Answers

Primary headache disorders are idiopathic disorders such as migraine and tension-type headache. The latter are warning symptoms of other diseases, such as sinusitis, tumour or cerebral bleeding. Although there are many different possible causes of symptomatic headaches, primary headache disorders are much more frequent, accounting for about 95% of all headaches.

To make the correct diagnosis, the physician needs a detailed account of the headache characteristics. He will ask you to describe the headache location (on one side or both sides of the head), headache intensity, type of pain (dull, stabbing, throbbing) and accompanying symptoms (e.g., nausea, increased sensitivity to light or sounds, fatigue, red eyes). The duration of attacks, triggering factors (e.g., stress, menstruation), attack frequency (daily, two times per month, etc.), headache history (new headache vs. long-standing headache) and present and previous treatment (during attacks, prophylactic) are also important.

Some patients suffer from more than one type of headache. When headaches are long-standing, keeping a headache diary for some weeks may be useful before an appointment at the doctor’s.

A physical examination is performed before making a diagnosis. In primary headaches, the physical examination is usually normal, or (abnormal) findings are not related to the headache. If headache symptoms are typical for a primary headache type (e.g. migraine) and physical examination is normal, no further examinations (e.g. electroencephalography, imaging of the brain) are necessary.

Additional investigations, as recommended by the doctor, are only necessary when a symptomatic headache is suspected. Not all symptomatic headaches can be diagnosed using computed tomography or magnetic resonance imaging of the brain. Sometimes blood tests, ultrasound examinations or a spinal tap are required.

Many types of headache are unproblematic and can be treated with over-the-counter drugs as long as they occur only occasionally. When headaches occur on a regular basis, or do not respond satisfactorily to analgesics or increase in frequency, a doctor should be consulted. Headache patients that regularly take painkillers on more than 8 to 10 days per month should also make a doctor’s appointment.

A symptomatic headache is suspected when a new headache occurs on a daily or almost daily basis from the beginning, when the character of pre-existing headaches changes, or when fever or neurological symptoms occur (e.g. muscle weakness or palsy, sensory disturbances, changes in personality). Extremely intense headaches that reach their maximum within seconds or minutes indicate an emergency that requires immediate medical attention. The same is true when headache occurs together with meningism, significant fever, epileptic seizures or other disturbances of consciousness or acute neurologic deficits.

Tension-type headache may be episodic or chronic. In the chronic form, headaches are present on 15 days or more per month for at least three months. In the episodic form, the number of headache days is less than 15 per month. In chronic tension-type headache, slight nausea or increased sensitivity to light or sounds may occur. Vomiting or worsening by physical activity are typical migraine symptoms, which are not present in tension-type headache. Episodic tension-type headache is very frequent. Normally, it does not cause significant impairment in daily life and is well controlled by standard painkillers. In contrast, chronic tension-type headache is rare and, in most cases, develops from the episodic form. An important risk factor for the development of chronic tension-type headache is regular intake of painkillers. It is therefore important to rule out medication overuse before making the diagnosis and starting the treatment (see below).

Moreover, genetic factors may play a role in the development of chronic tension-type headache. The risk of developing chronic tension-type headache is three times higher in families with other affected members. Epidemiologic studies have shown that persons with chronic tension-type headache suffer from comorbid depression, anxiety or panic attacks more often than persons without headache. It is not clear if there is a causal relationship here. On the one hand, depression increases the risk of suffering from headache. On the other hand, frequent headaches and concomitant reduction of quality of life also lead to an increased risk of depression.

Simultaneous occurrence of migraine and tension-type headache is a frequent diagnostic problem. In these cases it is often not clear if the less severe, bilateral, dull or pressing headache indeed corresponds to a tension-type headache or instead to a less severe migraine attack. There are several arguments in favour of this view. First, the presumed tension-type headache may evolve into a full migraine attack within hours. Second, application of migraine-specific drugs (triptans) is often successful in these headaches but not in true tension-type headache.

Although tension-type headache is a frequent affliction, its origin is not clear. Possibly, there are several different factors that lead to a common type of headache described as tension-type headache. The most common hypothesis is that increased tension of the neck muscles leads to increased sensitisation of pain-processing centres in the brain if continuously present. No alteration of the muscles themselves has been found.

When alteration of the central pain processing structures has set in, tension-type headache is more difficult to treat. The ongoing muscle tension further reinforces these mechanisms, resulting in a vicious circle. However, these mechanisms are not dangerous and physical damage is not encountered.

If possible, the diagnosis of tension-type headache should be made by a headache specialist. The diagnosis is supported by the typical history and a normal physical examination that does not give reason to suspect other causes of headache. There is no further examination that might corroborate the diagnosis of tension-type headache. Additional examinations such as a computed tomography or magnetic resonance imaging are necessary only if it is suspected that there is another disorder underlying the headache.

Treatment of the acute headache attack has to be differentiated from preventive treatment. Most common painkillers, such as acetylsalicylic acid 500 mg, paracetamol 500 mg or ibuprofen 400 mg are effective in tension-type headache. Alternatively, essential oils such as peppermint oil can be used. The oil should be spread generously on the forehead, temples and neck. A major problem is that frequent intake of painkillers on more than 10 days per month can lead to an exacerbation of headache; thus it is recommended that painkillers are used restrictively, especially in chronic tension-type headache. Therefore, it is important to keep track of the number of medication days per month.

Preventive treatment first includes general measures such as ensuring that the day is structured, with breaks and sufficient sleep and the reduction of stress factors. Moreover, regular exercise, e.g. cycling, swimming, running or Nordic walking, if possible three times per week for at least 30 min is recommended as well as relaxation techniques such as progressive muscle relaxation (PMR) that is effective in both migraine and tension-type headache.

When there is a continuous increase of headache days, with the risk of a previously episodic headache becoming chronic, preventive medication should be started in addition to the general measures described above. Preventive drugs are not direct painkillers. In contrast, they are supposed to act on pain processing in the brain and thereby lead to a reduction of tension-type headache. The exact mechanism of action is not known. Preventive medication has to be taken regularly, i.e. daily. Its action sets in only after about 4-6 weeks. In tension-type headache, mainly antidepressant drugs are used that act not only on headache but also on other types of pain. For preventive treatment of headache, lower doses are used compared to the treatment of depression. The first choice is amitriptyline, alternatively other types of antidepressants such as mirtazapine or venlafaxine can be used. Tizanidine and valproate are used as drugs of second choice, they are not antidepressant drugs. Botulinum toxin is not effective in chronic tension-type headache.

All of these drugs are prescription drugs and blood tests or ECG controls are required during the initial dosing phase. If the dose is increased slowly, these drugs are usually well tolerated. If there is a significant reduction of headache days and severity, the preventive drug is maintained for at least 6-9 months.

There are also non-pharmacological methods of tension-type headache treatment, including the general measures described above (regular structure of the day, stress reduction and stress coping, physical exercise and relaxation techniques). Most of the time, a combination of pharmacological and non-pharmacological methods is more effective than only using a pharmacological method. Acupuncture can be tried; however, results vary between studies and are less pronounced than with the methods described above.

It is only partially understood how overuse of analgesics and triptans leads to headache exacerbation and increase in headache frequency. Both modification of neurobiological pain processing and psychological factors seem to contribute. Especially the strong effect of triptans on migraine headache may induce an accelerated learning process that may lead to more and more frequent intake of the medication. Studies have shown that triptans may cause medication overuse headache more rapidly and in lower dosages than other drugs. However, medication overuse headache is usually not a dependence disorder as is the case with illicit drugs.

With medication overuse, the pre-existing headache, most often a migraine, often changes in character. The headache may be more often bilateral, more dull than throbbing, and less frequently accompanied by additional symptoms such as nausea, vomiting and increased sensitivity to light and sounds. Sometimes the headache may thus resemble a tension-type headache or a combination of migraine and tension-type headache. To make the diagnosis it is important that the headache has developed from a primary headache disorder, with an increasing headache frequency, eventually exceeding 15 days per month, and during frequent, sometimes even prophylactic intake of acute headache medication that shows an increasing lack of effect.

Some analgesics, if taken very frequently, can impair normal body functions (impairment of kidney function, high blood pressure) or interact with other drugs (e.g. impair the blood thinning effect of acetylsalicylic acid). Moreover, the effect of acute headache medication in patients suffering from medication overuse headache is often unsatisfactory. In addition, the high cost of triptans may be a problem for patients buying these drugs over the counter.

It was long thought that preventive drugs do not work as long as the patient is overusing acute headache medication. In contrast, several studies have shown that withdrawal of the overused acute pain medication leads to a marked improvement in headache. However, recent studies now show that certain preventive migraine medicines (topiramate, botulinum toxin for chronic migraine) are effective even in the presence of medication overuse. It is currently not clear if this is true for all preventive migraine treatments. Therefore, the current standard procedure is to recommend withdrawal and at the same time start patients on a preventive medication. For patients who do not tolerate withdrawal, preventive medication should be started anyway.

When stopping the overused acute headache medication, withdrawal symptoms can occur. There may be an exacerbation of headache for some days, possibly with increased accompanying symptoms such as nausea and fatigue. In addition, autonomic symptoms such as restlessness, sweating and heart palpitations can occur. In most cases, these symptoms recede within a few days and patients are then markedly improved. Withdrawal of acute headache medication is usually done in an out-patient or day-clinic setting. An in-patient treatment should be reserved for patients who need special support because of psychosocial constellations (e.g. high stress load at work or at home), or who have psychological comorbidities such as depression or anxiety disorders, or who overuse not only simple analgesics and triptans but also opioids and tranquilizers or if previous attempts to withdraw acute headache medication were not successful.

One third of the patients who successfully terminate medication overuse relapse within one year. Therefore, treatment by a headache specialist should be continued even after an initially successful withdrawal. In this way, medication intake can be monitored and adapted to the patient’s needs. In addition, the patient may then benefit from other therapeutic options, including patient education and treatment of concomitant disorders. Non-pharmacological approaches and integration of these measures into daily life are important. These include training in a relaxation technique, regular sleeping times, regular breaks and physical activity. In this way, patients acquire additional strategies for managing their headache disorder, learn to use their acute headache medication responsibly, and are able to recognize impending medication overuse.

However, the most important message is that medication overuse headache can be treated effectively. In over 80% of the patients who successfully stop their overuse of acute headache medication, headache improves significantly. In most cases, after stopping medication overuse, headache reverts to its original pattern with isolated headache attacks that can be treated effectively with acute headache medication.