Headache

Typically, the patient is a woman (migraine is 3 times more common in women than men) who has a visual disturbance before some or all of her headaches. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It may look like: blurred vision, small dots which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car, or like through a kaleidoscope, seeing holes or blind spots, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being unable to express ideas. A headache usually follows shortly after the aura ends, and that headache may be milder than one in a patient who does not have an aura (migraine without aura).

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It may be located on one side of the head, in or behind an eye or in the forehead or temple . Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients may have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body, called allodynia during which a touch can even be painful. The entire migraine attack lasts from 4 hours to 3 days, but if untreated or unsuccessfully treated, typically lasts 12-24 hours. It can occur a few times per year or several times per month, but must have occured 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it is more common in women.

Treatment

Most patients do best with a combination of behavioral medicine, changes in life style, and medication.

Behavioral medicine includes biofeedback training, relaxation techniques, cognitive therapy, and keeping a detailed headache calendar of their headaches and treatment results.

Lifestyle changes include eating and sleeping on a regular schedule and doing aerobic exercise daily. Some patients benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, , Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, classical Chinese Medicine and complementary medicine.
Acute treatment with medication is best when a triptan, nonsteroidal anti-inflammatory (NSAID) or ergot such as DHE is taken early in the course of the headache, not usually during the aura and no more than 2 days per week. In mild cases, over the counter medicines may be helpful. We prefer to avoid opiates, butalbital-containing medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given if triptans do not control the nausea.

If there are too many headache days per week (3 or more days) or if the headaches are very disabling and do not respond to acute medications, then daily preventive medication should be considered. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. nortriptyline amitriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

This headache is similar to typical aura with migraine headache but is missing one criterion (such as there is no nausea or only one of sensitivity to light and sound, so a definite diagnosis of migraine cannot be made. Typically, the patient is a woman (migraine is 3 times more common in women than men) who has a visual disturbance before some or all of her headaches. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It may look like: blurred vision, small dots which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car, or like through a kaleidoscope, seeing holes or blind spots, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being unable to express ideas. A headache usually follows shortly after the aura ends, and that headache may be milder than one in a patient who does not have an aura (migraine without aura).

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It may be located on one side of the head, in or behind an eye or in the forehead or temple . Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients may have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body, called allodynia during which a touch can even be painful. The entire migraine attack lasts from 4 hours to 3 days, but if untreated or unsuccessfully treated, typically lasts 12-24 hours. It can occur a few times per year or several times per month, but must have occured 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it is more common in women.

Treatment

Most patients do best with a combination of behavioral medicine, changes in life style, and medication.

Behavioral medicine includes biofeedback training, relaxation techniques, cognitive therapy, and keeping a detailed headache calendar of their headaches and treatment results.

Lifestyle changes include eating and sleeping on a regular schedule and doing aerobic exercise daily. Some patients benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, , Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, classical Chinese Medicine, and complementary medicine.
Acute treatment with medication is best when a triptan, nonsteroidal anti-inflammatory (NSAID) or ergot such as DHE is taken early in the course of the headache, not usually during the aura and no more than 2 days per week. In mild cases, over the counter medicines may be helpful. We prefer to avoid opiates, butalbital-containing medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given if triptans do not control the nausea.

If there are too many headache days per week (3 or more days) or if the headaches are very disabling and do not respond to acute medications, then daily preventive medication should be considered. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. nortriptyline amitriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

Typically, the patient is a woman (migraine is 3 times more common in women than men) who does not have a visual disturbance (called aura) or other neurologic symptoms before her headaches. This headache is often more severe than a headache that follows an aura.

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It may be located on one side of the head, in or behind an eye or in the forehead or temple. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients may have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body, called allodynia during which a touch can even be painful. The entire migraine attack lasts from 4 hours to 3 days, but if untreated or unsuccessfully treated, typically lasts 12-24 hours. It can occur a few times per year or several times per month, but must have occured 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it is more common in women.

Treatment

Most patients do best with a combination of behavioral medicine, changes in life style, and medication.

Behavioral medicine includes biofeedback training, relaxation techniques, cognitive therapy, and keeping a detailed headache calendar of headaches and treatment results.

Lifestyle changes include eating and sleeping on a regular schedule and doing aerobic exercise daily. Some patients benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, classical Chinese Medicine, and integrative medicine.
Acute treatment with medication is best when a triptan, nonsteroidal anti-inflammatory (NSAID) or ergot such as DHE is taken early in the course of the headache, not usually during the aura and no more than 2 days per week. In mild cases, over the counter medicines may be helpful. We prefer to avoid opiates, butalbital-containing medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given if triptans do not control the nausea.

If there are too many headache days per week (3 or more days) or if the headaches are very disabling and do not respond to acute medications, then daily preventive medication should be considered. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. nortriptyline amitriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made.

A typical patient is just like the patient with migraine without aura but one diagnostic criterion is missing (such as there is no nausea or vomiting and only one of sensitivity to light and sound, so a definite diagnosis of migraine cannot be made). Typically, the patient is a woman (migraine is 3 times more common in women than men) who has no visual disturbance or other neurologic symptoms before her headaches.
A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It may be located on one side of the head, in or behind an eye or in the forehead or temple . Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients may have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body, called allodynia during which a touch can even be painful. The entire migraine attack lasts from 4 hours to 3 days, but if untreated or unsuccessfully treated, typically lasts 12-24 hours. It can occur a few times per year or several times per month, but must have occured 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it is more common in women.

Treatment

Most patients do best with a combination of behavioral medicine, changes in life style, and medication.

Behavioral medicine includes biofeedback training, relaxation techniques, cognitive therapy, and keeping a detailed headache calendar of headaches and treatment results.

Lifestyle changes include eating and sleeping on a regular schedule and doing aerobic exercise daily. Some patients benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, classical Chinese Medicine, and integrative medicine.
Acute treatment with medication is best when a triptan, nonsteroidal anti-inflammatory (NSAID) or ergot such as DHE is taken early in the course of the headache, not usually during the aura and no more than 2 days per week. In mild cases, over the counter medicines may be helpful. We prefer to avoid opiates, butalbital-containing medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given if triptans do not control the nausea.

If there are too many headache days per week (3 or more days) or if the headaches are very disabling and do not respond to acute medications, then daily preventive medication should be considered. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. nortriptyline amitriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made.

A typical patient has an aura as described below but the headache that follows is not a migraine, rather a tension-type headache or other type. Tension-type headaches are usually on both sides of the head, mild to moderate in intensity, steady and pressing in nature, without nausea, vomiting, or sensitivity or light or sound.

The aura lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It may look like: blurred vision, small dots which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car, or like through a kaleidoscope, seeing holes or blind spots, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being unable to express ideas.

Treatment

Aura without headache is not usually treated. If it occurs so frequently that the patient needs preventive treatment, a medication which blocks cortical spreading depression such as as lamotrigine can be considered. If the headache is usually a tension-type headache it can be treated acutely with analgesics or nonsteroidal anti-inflammatory medications. Biofeedback training can be helpful. If they occur more than twice per week, a daily tricyclic antidepressant such as nortriptyline can be tried.

A typical patient has an aura but no headache follows. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It may look like: blurred vision, small dots which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car, or like through a kaleidoscope, seeing holes or blind spots, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being unable to express ideas. As migraineurs get over the age of 50 they may have more auras without headache, or the headache may be very mild. If the aura is always on the same side, neurologic testing should be done to be sure there are are no abnormailities in the back of the brain in the occipital lobe.

Treatment

Aura is not usually treated by itself unless it occurs very frequently. Various medications can be tried, lamotrigine being one of the most effective.

A typical patient is a woman with a history of migraine and for more than 3 months has had headaches at least 15 days per month and sometimes daily or almost daily. Each headache can be milder tension-type headaches without migraine features, or more severe and typical of migraine. There should be at least 8 days per month that are migraine days, or would have been that severe but were effectively treated by triptans or ergots. The migraine headache usually has a gradual onset and builds to moderate to severe intensity and is located often on one side of the head, often in or behind the eye or on the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement. Patients have various triggers that set off their pain and prefer to lie quietly in a dark, quiet area without stimulation. They may have increased sensitivity of the scalp, face, and skin on any part of their body (allodynia). The entire attack often lasts most of the day or even longer, if not treated or effectively treated.

On non-migraine headache days the pain is milder and similar to tension-type headache (on both sides of the head or in any distribution, with a pressing or squeezing quality and not associated with nausea, vomiting, sensitivity to light or sound and there may be no worsening with movement.

Treatment

Chronic migraine is complex and disabling and can be difficult to treat. Patients often see many doctors with little benefit. Most patients with Chronic Migraine may benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and patients should keep a calendar of their headaches, treatments and treatment results. Patients should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, classical Chinese Medicine and integrative medicine.

Acute treatment is best when a triptan or ergot is taken early in the course of the headache, not usually during the aura, no more than 2 days per week. A nonsteroidal anti-inflammatory medicine (NSAID) may also be helpful but use must also be limited. In mild cases, over the counter medicines may be helpful. We prefer to avoid opiates, butalbital-containing medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given if triptans to not control the nausea.
By definition there are too many headache days per month (15 or more), so preventive medicine should be given. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

The best scientific evidence for treating chronic migraine is with topiramate and onabotulinumtoxin-A (Botox) by injection. The later is the only drug approved for treatment of chronic migraine. In severe situations, some patients will benefit from other techniques such as nerve blocks and chronic occipital nerve stimulation.

Cluster headache is rare, occurring in less than one tenth of one percent of the population (compared to migraine which occurs is 12% of the population). It is one of the few headaches that is more prevalent in men than women, 3 or 4 times more in men. The typical patient with cluster headache has the episodic form of cluster and is a 20 to 50 year old male who has episodes of headache about once or twice per year called cluster periods. These periods last about 4-8 weeks and during this time patients have headache on most days, often 1-3 times per day, sometimes in the middle of the night waking them up from sleep about 1 am. The headaches usually come on suddenly and reach maximum intensity quickly, in a matter of minutes. The pain is in or around one eye, temple or upper jaw, does not usually change sides during the cluster period (or even during the next one) and is excruciatingly intense, steady, non-throbbing like an severe pressure is pushing the eye out of its socket. The pain can involve the upper teeth, the back of the head or neck. It is usually associated with some of the following symptoms, on the side of the pain: red and tearing eye, stuffed and running nostril, sweating of the forehead, small pupil, drooping of the eyelid and the patient’s behavior is often irritable and agitated. Patients cannot stay still and they walk, run, rock back and forth, or bang their head on a wall or bang an ice pack on their forehead. Luckily the pain is relatively brief, about 45 – 60 minutes in duration, but can last up to 3 hours and be as short as 15 minutes. Between attacks the patients is either pain free or has a mild, constant pain in the same distribution. During the cluster period the patient will not drink alcohol as it triggers a headache, as does taking a nap. About 10-20% of cluster patients have chronic cluster, with attacks continuing on most days of the week for years, with cycles of lessening or worsening of the pain. Cluster headache can start at any age, but usually begins between 25- 40.

Treatment

Acute treatment is best with injections of sumatriptan or the use of a nasal spray of a triptan or DHE. Breathing 100% oxygen at 12 Liters/minute flow through a rebreathing mask over the nose and mouth is usually effective in stopping a cluster headache and it has no side effects.

At the start of a cluster period some patients benefit from transitional or bridge therapy with steroids, DHE, triptans or ergots daily till preventive therapy kicks in and begins to be effective. Prevention is started at the same time and begins to work over several days as the bridge therapy is tapered off. The best preventive to start with is usually verapamil, either at regular or higher than usual migraine doses. Other preventives include other other calcium channel blockers, topiramate, indomethacin, gabapentin, lithium carbonate, etc. Rarely, patients with intractable, severe, chronic cluster which is unresponsive to all therapies will need occipital nerve blocks, chronic occipital nerve stimulation or deep brain stimulation into the area of the posterior hypothalamus (see Chronic Cluster Headache).

Cluster headache is rare, occurring in less than one tenth of one percent of the population and it is one of the few headaches that is more prevalent in men than women. Only 20% of cluster patients have the chronic form. Some patients start with episodic cluster headaches and convert to chronic. Others start with chronic and either stay chronic or can convert to episodic.

The typical patient with cluster headache is a 20-50 year old man with the episodic form of cluster, who has episodes of cluster headache about once or twice per year called cluster periods. Chronic cluster patients have headache most days of the week practically every week on the year with little respit. They may have several weeks in a row where their headache are more frequent and intense and others when they are milder. They have headache on most days, often 1-3 times per day, sometimes in the middle of the night waking the patient up from sleep about 1 am. The headaches usually come on suddenly and reach maximum intensity quickly, in a matter of minutes. The pain is in or around one eye, temple or upper jaw, does not usually change sides during the cluster period (or even during the next one) and is excruciatingly intense, steady, non-throbbing like an severe pressure is pushing the eye out of its socket. The pain can involve the upper teeth, the back of the head or neck. It is usually associated with some of the following symptoms, on the side of the pain: red and tearing eye, stuffed and running nostril, sweating of the forehead, small pupil, drooping of the eyelid and the patient’s behavior is often irritable and agitated. Patients cannot stay still and they walk, run, rock back and forth, or bang their head on a wall or bang an ice pack on their forehead. Luckily the pain is usually brief, about 45 – 60 minutes in duration, but can last up to 3 hours and be as short as 15 minutes. Between attacks the patients is either pain free or has a mild, constant pain in the same distribution. These patients often will not drink alcohol as it triggers a headache, as does taking a nap. Cluster headache can start at any age, but usually begins between 25- 40.

Treatment

Acute treatment is best with injections of sumatriptan or the use of a nasal spray form of a triptan or DHE. Breathing 100% oxygen at about 12 Liters/minute flow through a rebreathing mask over the nose and mouth is usually effective in stopping a cluster headache and it has no side effects. The best preventive to start with is verapamil at either normal migraine doses or higher than usual doses. Other preventives include other calcium channel blockers, topiramate, indomethacin, gabapentin, lithium carbonate, etc. As chronic cluster is sometimes intractable with poor response to all attempts at medication treatments, some patients will need hospitalization, nerve blocks, chronic occipital nerve stimulation or deep brain stimulation into the posterior hypothalamus. Many patients end up on opiates, although we try to avoid them completely.

This is a rare type of migraine that runs in families and a typical patient presents with an aura of weakness of an arm and leg on one side, possibly with other auras, followed by a typical migraine headache. At least one close relative has to also have migraine with weakness on one side. A typical patient is a woman (migraine is 3 times more prevalent in females than males) who has weakness and possibly other auras such as a visual aberration before some or all of her headaches. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It is usually manifested by some of the following characteristics: blurred vision, small dots all over which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car or through a kaleidoscope, seeing holes or blind spots in the visual field, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being able to express ideas. At some point before the headache the patient will become weak on one side, possibly including the face, arm and leg. A headache usually follows shortly after the aura’s termination, and that headache may be milder than a migraine that is not preceded by an aura.

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It is located on one side of the head, in or behind an eye or in the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body. That is called allodynia during which a touch can feel like pain. The entire migraine attack lasts more than 4 hours and less than 3 days, but if untreated or unsuccessfully treated usually lasts 12-24 hours. It can occur a few times per year or several times per month, but must occur 2 times previously before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it becomes more a disease of women.

Treatment

This is one of the few types of migraine headache that we do not typically treat with triptans or egots due to the theoretical risk of making the patient worse. Many patients will benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and patients should keep a calendar of their headaches and treatments, should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, traditional Chinese Medicine and Complementary Medicine.

As we cannot use triptans or DHE, acute treatment is limited to nonsteroidal anti-inflammatory medicines (NSAIDs such as naproxen or diclofenac potassium for solution), steroids or pain medication in limited quantities. We prefer to avoid opiates, butalbital-containg medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given.

If there are too many headache days per week (3 or more) or if the headaches are too disabling or poorly responsive to the acute care medications listed above, daily preventive medication should be considered. There are many categories that can be tried but for this type of headache we tend to start with calcium channel blockers and aspirin (although the scientific evidence to do so is limited). Other preventives include other calcium channel blockers, antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

A typical patient is just like a patient with familiar hemiplegic migraine with one diagnostic criterion missing (such as there is no nausea or vomiting and only one of sensitivity to light and sound, so a definite diagnosis of migraine cannot be made). At least one close relative has to also have migraine with weakness on one side. A typical patient is a woman (migraine is 3 times more prevalent in females than males) who has weakness and possibly other auras such as a visual aberration before some or all of her headaches. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It is usually manifested by some of the following characteristics: blurred vision, small dots all over which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car or through a kaleidoscope, seeing holes or blind spots in the visual field, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being able to express ideas. At some point before the headache the patient will become weak on one side, possibly including the face, arm and leg. A headache usually follows shortly after the aura’s termination, and that headache may be milder than a migraine that is not preceded by an aura.

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It is located on one side of the head, in or behind an eye or in the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body. That is called allodynia during which a touch can feel like pain. The entire migraine attack lasts more than 4 hours and less than 3 days, but if untreated or unsuccessfully treated usually lasts 12-24 hours. It can occur a few times per year or several times per month, but must occur 2 times previously before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it becomes more a disease of women.

Treatment

This is one of the few types of migraine headache that we do not typically treat with triptans or egots due to the theoretical risk of making the patient worse. Many patients will benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and patients should keep a calendar of their headaches and treatments, should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, traditional Chinese Medicine and Complementary Medicine.

As we cannot use triptans or DHE, acute treatment is limited to nonsteroidal anti-inflammatory medicines (NSAIDs such as naproxen or diclofenac potassium for solution), steroids or pain medication in limited quantities. We prefer to avoid opiates, butalbital-containg medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given.

If there are too many headache days per week (3 or more) or if the headaches are too disabling or poorly responsive to the acute care medications listed above, daily preventive medication should be considered. There are many categories that can be tried but for this type of headache we tend to start with calcium channel blockers and aspirin (although the scientific evidence to do so is limited). Other preventives include other calcium channel blockers, antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

This is a rare type of migraine that does not run in families and a typical patient presents with an aura of weakness of an arm and leg on one side, possibly with other auras, followed by a migraine headache. At least one close relative has to also have migraine with weakness on one side. A typical patient is a woman (migraine is 3 times more prevalent in females than males) who has weakness and possibly other auras such as a visual aberration before some or all of her headaches. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It is usually manifested by some of the following characteristics: blurred vision, small dots all over which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car or through a kaleidoscope, seeing holes or blind spots in the visual field, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being able to express ideas. At some point before the headache the patient will become weak on one side, possibly including the face, arm and leg. A headache usually follows shortly after the aura’s termination, and that headache may be milder than a migraine that is not preceded by an aura.

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It is located on one side of the head, in or behind an eye or in the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body. That is called allodynia during which a touch can feel like pain. The entire migraine attack lasts more than 4 hours and less than 3 days, but if untreated or unsuccessfully treated usually lasts 12-24 hours. It can occur a few times per year or several times per month, but must occur 2 times previously before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it becomes more a disease of women.

Treatment

This is one of the few types of migraine headache that we do not typically treat with triptans or egots due to the theoretical risk of making the patient worse. Many patients will benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and patients should keep a calendar of their headaches and treatments, should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, traditional Chinese Medicine and Complementary Medicine.

As we cannot use triptans or DHE, acute treatment is limited to nonsteroidal anti-inflammatory medicines (NSAIDs such as naproxen or diclofenac potassium for solution), steroids or pain medication in limited quantities. We prefer to avoid opiates, butalbital-containg medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given.

If there are too many headache days per week (3 or more) or if the headaches are too disabling or poorly responsive to the acute care medications listed above, daily preventive medication should be considered. There are many categories that can be tried but for this type of headache we tend to start with calcium channel blockers and aspirin (although the scientific evidence to do so is limited). Other preventives include other calcium channel blockers, antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

This is a rare type of migraine that does not run in families or cause any weakness. A typical patient presents with one or more unusual aura symptoms such as dizziness, vertigo (the room is spinning), double vision, numbness on both sides of the body, visual problems on both sides, garbled speech, trouble walking in a straight line and decreased level of consciousness followed by a migraine headache.

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It is located on one side of the head, in or behind an eye or in the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no sensory input. They may have increased sensitivity to touch on the scalp, face, and skin all over the body. That is called allodynia during which a touch can feel like pain. The entire migraine attack lasts more than 4 hours and less than 3 days, but if untreated or unsuccessfully treated usually lasts 12-24 hours. It can occur a few times per year or several times per month, but must occur 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it becomes more a disease of women.

Treatment

This is one of the few types of migraine headache that we do not typically treat with triptans or DHE due to the theoretical risk of making the patient worse. Most patients may benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and patients should keep a calendar of their headaches and treatments, should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus which is also called Butterbur and Melatonin), as well as Ayurvedic medicine techniques, traditional Chinese Medicine and Complementary Medicine.

As we cannot use triptans or DHE, acute treatment is limited to nonsteroidal anti-inflammatory medicines (NSAID such as naproxen and diclofenac potassium for solution), steroids or pain medication in limited quantities. We prefer to avoid opiates, butalbital containg medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given.

If there are too many headache days per week (3 or more) or if the headaches are too disabling, daily preventive medication should be considered. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

A typical patient is just like a patient with Basilar Type Migraine with one diagnostic criterion missing (such as there is no nausea or vomiting and only one of sensitivity to light and sound, so a definite diagnosis of migraine cannot be made). This is a rare type of migraine that does not run in families or cause any weakness and a typical patient presents with one or more aura symptoms such as dizziness, vertigo, double vision, numbness on both sides of the body, visual problems on both sides, garbled speech, trouble walking in a straight line and decreased level of consciousness followed by a typical migraine headache. A headache usually follows shortly after the aura’s termination, and that headache may be milder than a migraine that is not preceded by an aura.

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It is located on one side of the head, in or behind an eye or in the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no sensory input. They may have increased sensitivity to touch on the scalp, face, and skin all over the body. That is called allodynia during which a touch can feel like pain. The entire migraine attack lasts more than 4 hours and less than 3 days, but if untreated or unsuccessfully treated usually lasts 12-24 hours. It can occur a few times per year or several times per month, but must occur 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it becomes more a disease of women.

Treatment

This is one of the few types of migraine headache that we do not typically treat with triptans or DHE due to the theoretical risk of making the patient worse. Most patients may benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and patients should keep a calendar of their headaches and treatments, should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus which is also called Butterbur and Melatonin), as well as Ayurvedic medicine techniques traditional Chinese Medicine and Complementary Medicine.

As we cannot use triptans or DHE, acute treatment is limited to nonsteroidal anti-inflammatory medicines (NSAID such as naproxen and diclofenac potassium for solution), steroids or pain medication in limited quantities. We prefer to avoid opiates, butalbital containg medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given.

If there are too many headache days per week (3 or more) or if the headaches are too disabling, daily preventive medication should be considered. There are many categories that can be tried and we usually start with verapamile and sometimes aspirin. Other calcium channel blockers can be tried as well as antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

Typical aura with migraine headache (a form of migraine with aura). Typically, the patient is a woman (migraine is 3 times more common in women than men) who has a visual disturbance before some or all of her headaches. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It may look like: blurred vision, small dots which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car, or like through a kaleidoscope, seeing holes or blind spots, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being unable to express ideas. A headache usually follows shortly after the aura ends, and that headache may be milder than one in a patient who does not have an aura (migraine without aura).

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It may be located on one side of the head, in or behind an eye or in the forehead or temple . Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients may have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no stimulation. They may have increased sensitivity to touch on the scalp, face, and skin all over the body, called allodynia during which a touch can even be painful. The entire migraine attack lasts from 4 hours to 3 days, but if untreated or unsuccessfully treated, typically lasts 12-24 hours. It can occur a few times per year or several times per month, but must have occured 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it is more common in women.

Treatment

Most patients do best with a combination of behavioral medicine, changes in life style, and medication.

Behavioral medicine includes biofeedback training, relaxation techniques, cognitive therapy, and keeping a detailed headache calendar of their headaches and treatment results.

Lifestyle changes include eating and sleeping on a regular schedule and doing aerobic exercise daily. Some patients benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, , Coenzyme Q-10, petasites hybridus, which is also called butterbur, and Melatonin), as well as Ayurvedic medicine techniques, classical Chinese Medicine and complementary medicine.
Acute treatment with medication is best when a triptan, nonsteroidal anti-inflammatory (NSAID) or ergot such as DHE is taken early in the course of the headache, not usually during the aura and no more than 2 days per week. In mild cases, over the counter medicines may be helpful. We prefer to avoid opiates, butalbital-containing medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given if triptans do not control the nausea.

If there are too many headache days per week (3 or more days) or if the headaches are very disabling and do not respond to acute medications, then daily preventive medication should be considered. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressants (e.g. nortriptyline amitriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors (e.g. lisinopril), and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

This is a severe headache in a migraineur that lasts more than 72 hours and is difficult to treat. The background headaches are just like migraine with and without aura. A typical patient is a woman (migraine is 3 times more prevalent in females than males) who may have a visual aberration (aura) before some or all of her headaches. It lasts about 20 minutes on average but can last 5 to 60 minutes. It can appear on one side or both sides, and can start in the center or off to the side. It may look like: blurred vision, small dots which can be colored or black and white, zig zag lines, the sensation of looking through heat waves off a car, or like through a kaleidoscope, seeing holes or blind spots, flashes of light or other changes. Less often there can be sensory symptoms with numbness or tingling on one side of the face and body or a speech problem with trouble being understood or being unable to express ideas. A headache usually follows shortly after the aura’s termination, and this headache is severe and will last more than 3 days and be difficult to treat.

A typical migraine headache begins gradually and builds to a moderate or severe intensity over 30 minutes to several hours. It is located on one side of the head, in or behind an eye or in the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement or exertion. Patients have various triggers that can set off their pain and they usually prefer to lie quietly in a dark, quiet area with no sensory input. They may have increased sensitivity to touch on the scalp, face, and skin all over the body. That is called allodynia during which a touch can feel like pain. The entire migraine attack lasts more than 4 hours and less than 3 days, but if untreated or unsuccessfully treated usually lasts 12-24 hours. It can occur a few times per year or several times per month, but must occur 5 times before a diagnosis is made. Migraines usually begin between ages 8 and 25, sometimes earlier in boys, but can start at any age. After puberty, it becomes more a disease of women.

But if the headache on occasion lasts more than 3 days, is severe with lots of disability and poor response to medication we call it Status Migrainosis or migraine status.

Treatment

Oral triptans are usually not effective so patients need to be given an injection of sumatriptan or dihydroergotamine (DHE). A steroid alone or in combination with these medications is often helpful, as are behavioral medicine techniques such as biofeedback and various relaxation techniques. Peripheral nerve injections around the head and face can also be helpful. In rare cases especially if the patient is vomiting, hospitalization for fluids and iv medications may be necessary.

The chronic, underlying headache is treated the same way as other patients with migraine with and without aura are treated. Most patients may benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and patients should keep a calendar of their headaches and treatments, should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus which is also called Butterbur and Melatonin), as well as Ayurvedic medicine techniques, traditional Chinese Medicine and Complementary Medicine. A nonsteroidal anti-inflammatory medicine (NSAID such as naproxen or diclofenac postassium for solution) may be helpful but must be limited.

If there are too many headache days per week (3 or more) after status migrainosis is treated or if the headaches are too disabling, daily preventive medication should be considered. There are many categories that can be tried including beta blockers (e.g. propranolol, atenolol), calcium channel blockers (e.g. verapamil), antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressant (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors, and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

This occurs primarily in children and is typically manifested by recurrent episodic attacks of severe vomiting and intense nausea, usually identical each times it occurs in that patient. There are often 4 attacks of vomiting an hour for at least one hour. The attacks are associated with a pale face and lethargy. There is complete resolution of symptoms between attacks. These condition is not associated with headache, but these children often go on to develop migraine headaches some years later.

Treatment

There is no known treatment but anti-nausea medication should be tried at the time of the vomiting. Sometimes triptans are tried. It is possible that migraine preventive medications can be effective, such as antiepileptic medications and beta blockers, etc, given on a daily basis.

These are recurrent attacks of vertigo (the sensation that the room is spinning around the patient) in children lasting minutes to hours. They are sometimes associated with nausea and vomiting and the child may have a headache also.

Treatment

There is no accepted treatment, but anti-nausea medications that are also dopamine antagonists (prochlorperazine and others) can be tried during the episodes and migraine preventive medications such as the antiepileptics and beta blockers can be given on a daily basis.

A typical patient is a child with recurrent attacks of midline abdominal pain lasting 1-72 hours. The pain is periumbilical (around the area of the navel). The pain feels dull or sore and can be moderate to severe in intensity. This is often associated with nausea, vomiting, pallor of the face and anorexia (the feeling of not wanting to eat).

Treatment

There is no known treatment and triptans have been tried. If attacks are frequent, migraine preventive medications such as antiepileptic medications or beta blockers can be tried.

This is a rare condition in which a patient develops a typical visual aura in just one eye. The aura is just visual and almost always followed by a migraine headache. It lasts about 20 minutes and may consist of any of the following: blurred vision followed by seeing small dots which can be colored or black and white, zig zag lines, the feeling like one is looking through heat waves off a car or through a kaleidoscope. There may be holes in the visual field, flashes of light or other changes. A headache usually follows shortly afterwards, which may be milder than a migraine that is not preceded by an aura.

The typical patient with a migraine headache will have the gradual onset of a headache which build to moderate to severe intensity and is located often on one side of the head, often in or behind the eye or on the frontal or temporal area. Migraine can affect any part of the face or head and can be on both sides. The pain is often throbbing or pounding and associated with disability, nausea more than vomiting, sensitivity to light and sound and can be worsened with movement. Patients have various triggers that set off their pain and prefer to lie quietly in a dark, quiet area. They may have increased sensitivity of the scalp, face, and skin. The entire attack lasts more than 4 hours, usually 12-24 hours if not effectively treated. I can occur a few times per year or several times per month. Migraines usually begin between ages 8 and 30.

Treatment

Most patients may benefit from behavioral medicine treatments, non-pharmacological treatments and changes in life style, as well as medication. These include biofeedback training, relaxation techniques, cognitive therapy, and they should keep a calendar of their headaches and treatments, should eat and sleep on time and do aerobic exercises regularly. Some may benefit from specific vitamins, minerals, herbs and additives (such as Vitamin B2, magnesium, feverfew, Coenzyme Q-10, petasites hybridus which is also called Butterbur and Melatonin), as well as Ayurvedic medicine techniques, traditional Chinese Medicine and Complementary Medicine.

Acute treatment is best when a triptan or ergot is taken early in the course of the headache, not usually during the aura, no more than 2 days per week. A nonsteroidal anti-inflammatory medicine (NSAID such as naproxen or diclofenac postassium for oral solution) may also be helpful but must also be limited. In mild cases over the counter medicines may be helpful. We prefer to avoid opiates, butalbital-containg medicine (like Fiorinal) and other pain medicines. Anti-nausea medicine may be given if triptans do not control the nausea.

If there are too many headache days per week (3 or more) or if the headaches are too disabling, daily preventive medication should be considered. There are many categories that can be tried but we often start with verapamil in this situation. We can also try other calcium channel blockers, antiepileptics (e.g. topiramate, divalproex sodium, zonisamide), tricyclic antidepressant (e.g. amitriptyline, nortriptyline), angiotensin receptor blockers (e.g. candesartan), ACE inhibitors, and others. These medications should be started in small doses and slowly increased and should be given for at least two months at adequate doses before a decision on effectiveness is made. When aura is present we tend not to use beta blockers.

This is the most common headache in the general population and most people have experienced one of these on occasion. Depending on its frequency it is called infrequent (less than 1 day per month), frequent (1-14 days per month) or chronic (15 to 30 days per month). A typical tension-type headache is a mild to moderate intensity, squeezing or pressing (non-throbbing) pain, usually on both sides of the head. It can be in or over the eyes, on the top, in the back or like a band around the head. It is rarely on one side. There is usually no nausea, vomiting, sensitivity to light or sound or worsening of the headache with movement or exertion. Some patients have sensitivity to just light or sound. Some patients prefer to exercise with this headache, but would not do so with migraine.

In the chronic form, which can be daily, mild nausea is sometimes present but the pain is usually similar. There may be some patients whose tension-type headache is at times more intense without actually having enough symptoms to be classified as migraine.

Treatment

Episodic tension-type headache is usually easily treated acutely with over the counter analgesics, both simple ones and combination ones, over the counter nonsteroidal anti-inflammatory medicine (Advil, Aleve) or getting out of stressful situations or going to exercise.

When it occurs too frequently (more than 2 days per week), or causes too much disability, it is often treated with tricyclic antidepressants (nortriptyline).

This is an uncommon form of headache. A typical patient is a man or woman in the teens to 40s with a headache 15 days per month or more. The pain is of mild to moderate intensity, squeezing or pressing (non-throbbing) usually on both sides of the head. It can be in or over the eyes, on the top, in the back or like a band around the head. It is rarely on one side. There is usually no nausea, vomiting, sensitivity to light or sound or worsening of the headache with movement or exertion. Having sensitivity to just light or sound is sometimes seen, but not both. Some patients prefer to exercise with it, but would not do so with migraine.

In this chronic form, which can be as frequent as every day, mild nausea is sometimes present. There may be some patients whose tension-type headache is at times more intense without actually having enough symptoms to be classified as migraine.

Treatment

Chronic tension-type headache is often treated with tricyclic antidepressants (nortriptyline) in low doses or various other drugs.

There is an intermittent form with long breaks for weeks or months, and a chronic form that goes on daily for years. A typical patient is a woman with frequent, severe, brief pain in or around one eye. The headaches usually come on suddenly and reach maximum intensity quickly, in a matter of minutes. The pain does not usually change sides and is a severe, steady, non-throbbing pain in one eye. It is usually associated with some of the following symptoms on the side of the pain: red and tearing eye, stuffed and running nostril, sweating of the forehead, small pupil, drooping of the eyelid and the patient’s behavior is often irritable and agitated. Luckily the pain is brief, about 5-30 minutes, typically shorter than cluster headache pain, which is otherwise similar. Patients have 5 or more headaches per day, often up to 10-20.

Treatment

Most patients respond well to indomethacin taken 2 or 3 times daily in moderately high doses. Many other medications can be tried.

SUNCT is very rare and can occur in either gender and at any age. A typical patient presents with very frequent, brief, severe stabbing or pulsating pains in or around one eye or temple, accompanied by a red and tearing eye on the same side as the pain. The headaches usually come on suddenly and reach maximum intensity quickly, in a matter of seconds. The pain does not change sides and is excruciating, steady and non-throbbing. Patients have 3-200 attacks per day lasting 5 to 240 seconds. This is much shorter and more frequent than either cluster headache or paroxysmal hemicrania, but is otherwise similar.

Treatment

There is no known treatment that is usually effective. Daily, preventive medications should be tired and many can work including the antiepileptic drugs lamotrigine and topiramate.

A typical patient notices transient, localized, brief, irregular jabs of sharp pain in any part of the head, which can occur one at a time in a series of jabs for several seconds. In some patients they are limited to the same place in the head, but they usually move around to different areas, most often in or around the eye, temple or parietal area behind the temple or higher up on the head. A jab or stab rarely lasts longer than 3 seconds. They are more frequent in patients with migraine and cluster headache, often felt in the painful area involved in those headaches. They can be severe and worrisome, but are very brief and not associated with underlying medical problems.

Treatment

If the patient has coexisting cluster or migraine headache, those conditions should be treated more aggressively. If not, no treatment is usually necessary and reassurance often suffices.

This is a headache that occurs only when the patient coughs or strains as though moving their bowels. It can last 1 second to 30 minutes and is usually on both sides of the head. About 40% of the time it can be related to structural problems in the brain, so appropriate diagnostic testing should be performed.

Treatment

If no secondary causes are found, preventive treatment with indomethacin is often successful.

The typical patient has a throbbing headache brought on by and occurring during or after exertion. It can last between 5 minutes and 48 hours. If often occurs at high altitudes or in hot weather.

Treatment

Acute or preventive therapy with indomethacin or other NSAIDs is usually effective.

A typical patient has a dull ache in the head and neck associated with an awareness of neck and/or jaw muscle contraction. It occurs during sexual activity and increases with sexual excitement.

Treatment

If neurological investigations are normal, indomethacin or other NSAIDs can be taken prior to sexual activity or preventively on a daily basis.

A typical patient has a sudden, severe headache at the time of orgasm. It can last between one minute and 3 hours. The first time it occurs the patient should be taken to the emergency room for testing to exclude neurological problems. The benign type often starts spontaneously for no apparent reason and weeks to months later it disappears.

Treatment

If neurological investigations are normal, the patient can be given indomethacin or another NSAID prior to sexual activity or preventively on a daily basis.

A typical patient is over the age of 50 and has mild to moderate headaches on both sides of the head at least 15 days a month that begin during sleep, awaken them and last 15 to 180 minutes. The pain is only occasionally severe and the patient can usually get back to sleep after walking around for a while.

Treatment

Lithium and caffeine have been known to be helpful preventive medications.

A typical patient has the sudden onset of severe headache that reaches maximum intensity within one minute (and often in 1-5 seconds) and lasts from one hour to 10 days. It can occur in any part of the head and be steady or throbbing. The headache may recur within the first week. The patient must undergo an immediate spinal tap and imaging studies of the head. The search for an underlying neurological cause should be quick and exhaustive.

Treatment

There is no agreed on treatment if no secondary cause is found. Steroids and DHE may be effective and in certain cases pain medications and NSAIDs can be used briefly.

A typical patient has a one sided, daily, continuous moderately severe headache for more than 3 months. At times it may intensify during which time there can be one or several autonomic signs such as a red or tearing eye, stuffed or running nostril, small pupil, drooping eyelid or sweating over the eyebrow, all on the side of the pain. Sometimes the eye feels as though there is a foreign object in it. The pain is usually continuous but can be intermittent

Treatment

Daily, preventive indomethacin is usually helpful but other NSAIDs can be tried.

A typical patient has a mild to moderate, headache on both sides that is pressing or tightening in quality and becomes unremitting within 3 days of onset. It often starts as a mild, typical headache that does not concern the patient, but it never goes away. The patient often remembers exactly when it started and what was happening at that time. If the patient does not describe it as starting and becoming constant within 3 days, it might be considered a chronic tension-type headache. Many patients may have some days during which the headache is much worse and would be considered a migraine. The headache can be any type or affect any area of the head. The key to recognizing this headache is that it occurs either in a patient without headache or it shows up as a new type of headache that starts one day and becomes constant quickly. Some patients will have a history of recent infection or other minor illness, although this does not always occur. Patients should be investigated for various neurological problems, including spinal fluid pressure abnormalities and medication overuse. Prognosis is either favorable with the headache disappearing over time or unfavorable with the headache continuing incessantly without response to any preventive medication.

Treatment

There is no known effective treatment although many medications and behavioral therapies have been tried. Sometimes clonazapam can be effective. When it occurs in young adolescent girls, it can be a frustrating type of headache to treat, with little response to therapy.