406 ‒ Migraine, cluster headache, and tension headache: symptoms, causes, prevention, and treatment

KEYPOINTS

• 01

  Headache has over 300 types and causes; the first split is primary versus secondary.

  Grosberg, a headache neurologist, says the differential is one of the longest in medicine. Primary headaches (migraine, tension-type, cluster) are disorders in themselves; secondary headaches stem from something else, which is why red flags matter.

• 02

  Migraine has specific diagnostic criteria, and it isn't always one-sided.

  At least five lifetime attacks lasting 4–72 hours untreated, plus two of: one-sided, throbbing, moderate-to-severe, worse with activity—along with nausea or light and sound sensitivity. Up to 40% have pain on both sides. Tension-type headache lacks nausea and can last 30 minutes to a week.

• 03

  Migraine is common, disproportionately female, and badly under-served.

  About 45 million Americans, roughly 18% of women, with a female ratio of about 3:1. Only around 50 fellowship-trained headache neurologists graduate per year. Episodic migraine is under 15 headache days a month; chronic is 15+ and affects 1–2% of the population.

• 04

  Hormones matter: the speed of estrogen decline is a key trigger.

  Studies since the 1970s link migraine to the late-luteal estrogen drop; newer work shows it's the faster rate of decline that's distinctive in women with migraine. Pure menstrual migraine occurs in under 10% of women. Perimenopause often worsens it; about two-thirds improve after menopause, but 10–20% continue or worsen. Migraine without aura improves in about 47% of women in the first trimester and 80–87% in the second and third.

• 05

  A migraine has phases, and aura is only in a minority.

  Premonitory symptoms can precede the attack; aura evolves gradually over 5–60 minutes; then the headache and a postdrome. Some attacks build over hours, others wake people at 3 a.m. Light sensitivity is present in about two-thirds to 70%.

• 06

  Cluster headache is among the most severe pains known and is often misdiagnosed.

  Attacks peak in 5–15 minutes, last 15 minutes to 3 hours, and are stabbing or boring around one eye. About 97% have same-side eyelid droop, tearing, redness or nasal congestion—often mistaken for sinusitis or allergies—and about 90% are restless. One patient likened it to giving birth to 100 babies without an epidural. The male:female ratio is now about 3–4:1.

• 07

  Migraine is a neurovascular disorder, not just a blood-vessel problem.

  The 1940s vascular theory was too simple. Pain signals from the dura and its blood vessels travel along the first branch of the trigeminal nerve to the trigeminal nucleus caudalis in the brainstem—where C2–C3 neck nerves also converge, explaining neck pain in migraine. Neuropeptides such as CGRP and an inflammatory response are involved; serotonin was noted to fall in blood during attacks decades ago.

• 08

  Many more people qualify for prevention than receive it.

  About 40% of people with migraine are medically eligible for preventive therapy, but only 16–17% receive it. Low-dose amitriptyline or nortriptyline are used at doses well below those for depression, which Grosberg explains to reduce stigma.

• 09

  CGRP drugs changed treatment, with roughly 60% responding.

  Monthly CGRP monoclonal antibodies (and oral gepants) work in up to about 60% of patients, with response defined as at least a 50% drop in headache days; Grosberg also counts patients whose severity or acute-drug response improves. U.S. prices are often 3–10x what other countries pay.

• 10

  Triptans transformed acute care; injections are fastest for cluster.

  Ergotamines came first; triptans arrived in the mid-1990s, targeting 5-HT1B/1D receptors. For cluster, injectable sumatriptan has a median time to relief around 9 minutes. Botox for chronic migraine uses the PREEMPT protocol of injections in the forehead, sides and back of head, neck and shoulders; verapamil is used for cluster, sometimes at very high doses.

• 11

  Tension-type headache is the most common primary headache, and neck pain is a shared feature.

  Like migraine, it is split into episodic (under 15 days a month) and chronic (15+ days). Because neck nerves converge on the same brainstem nucleus as the trigeminal system, neck and shoulder pain can be referred pain rather than the cause. Peter asks whether responding to 1,000 mg of acetaminophen implies tension-type; Grosberg cautions that response to a simple analgesic doesn't by itself settle the diagnosis.