Understanding and Managing Headaches: A Clinical Overview

The headache itself can be remembered using the mnemonic POUND:

• Pulsatile (throbbing)
• Over several hours
• Unilateral (one-sided)
• Nausea/Vomiting
• Disabling

Patients also frequently exhibit photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

Pharmacological Management

Management is divided into two distinct strategies:

1. Abortive Therapy (Acute Treatment) Used to stop an active headache attack:

• Triptans: Serotonin ($5\text{-HT}_{1\text{B/1D}}$) agonists that inhibit trigeminal activity. Because they cause vasoconstriction, they are contraindicated in patients with vascular disease (e.g., coronary artery disease, stroke history) or uncontrolled hypertension.
• Lasmiditan: A newer $5\text{-HT}_{1\text{F}}$ agonist that provides migraine relief without the risk of vasoconstriction, making it suitable for patients with vascular contraindications.
• Antiemetics: Dopamine antagonists like metoclopramide, chlorpromazine, or prochlorperazine are used to treat nausea and can also provide sedation to help the patient rest.

2. Prophylactic Therapy (Preventative Treatment) Indicated if attacks occur more than 3 times per month:

• Anticonvulsants: Topiramate or valproate.
• Beta-blockers: Propranolol.
• Antidepressants: Amitriptyline or venlafaxine.

Exam Tip: Topiramate Side Effects Topiramate is highly effective but can cause "mental dulling" (sedation/foggy feeling). It is also a weak carbonic anhydrase inhibitor, which increases urinary calcium excretion and raises the risk of kidney stones; patients should be advised to maintain high hydration.

Special Populations

• Pregnancy: For abortive therapy, acetaminophen is the safest option. For prophylaxis, propranolol is preferred. Avoid anticonvulsants like valproate due to teratogenicity (neural tube defects).
• Oral Contraceptives: Women who experience migraines with aura should avoid estrogen-containing oral contraceptives due to a significantly increased risk of stroke.

Trigeminal Autonomic Cephalalgias

This group includes rare, excruciatingly painful headaches that are often unilateral and associated with autonomic symptoms.

Cluster Headaches

Cluster headaches are rare, severe, and often occur in "clusters" following a circadian rhythm (e.g., daily attacks at the same time of day for weeks). They are characterized by intense pain behind the eye and autonomic dysfunction, including:

• Lachrymation (tearing)

• Rhinorrhea (runny nose)

• Ptosis (drooping eyelid)

• Miosis (constricted pupil)

• Management: Acute treatment includes oxygen (which may induce vasoconstriction or inhibit trigeminal activation) and triptans. Prophylaxis is managed with verapamil.

Paroxysmal Hemicrania

This disorder is very similar to cluster headaches but has distinct clinical features:

• Frequency: Much higher ($>15$ attacks per day).
• Duration: Much shorter ($\approx 15$ minutes).
• Response: It shows a distinct, positive response to indomethacin, whereas cluster headaches do not.

Medication Overuse Headache (MOH)

MOH occurs when patients use abortive medications—such as NSAIDs, triptans, or opioids—for 15 or more days per month. This can worsen a pre-existing headache disorder, creating a cycle where the patient feels they need more medication to manage the increasing pain. The primary treatment is the discontinuation of the overused medication.

Low Pressure Headache

A low pressure headache results from a drop in cerebrospinal fluid (CSF) pressure, often following a lumbar puncture or epidural anesthesia. The hallmark is a postural headache: pain that worsens when sitting or standing and improves when lying flat.

• Management: NSAIDs or an epidural blood patch, where venous blood is injected into the epidural space to create a clot that seals the CSF leak.