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Primary Headaches

Primary Headaches Quick Reference Guide

Primary headaches overview

Primary headache is the one that exists as an independent disorder in which the head pain is the cardinal feature. Primary headache is not a symptom of some other disease. There are a few features that all primary headaches inevitably share with very few exceptions.

  • Primary headache affects only quality of life but causes no brain damage or irreversible loss of function (some forms of migraine in rear instances might serve as an exception)
  • All primary headaches have associated symptoms that are headache syndrome specific (hypnic headache, cough, and sex related headaches are exceptions). For example, hypersensitivity to light is typical for migraine while tearing and unilateral runny nose are classical for cluster headache.
  • Each headache attack lasts specific period of time and might occur only limited number of times per day. Migraine can’t last just 30 minutes and then go away without medications. It lasts at least for a few hours. On the contrary, cluster headache attacks are much shorter in duration and might occur a few times per day.
  • Most of primary headaches are in the front of the head or in the upper part of the face and around the orbit. Some of them occur exclusively on one side of the head (cluster headache and paroxysmal hemicrania). The sides may sometimes switch, though. Migraine may start in the back of the head or in the neck but eventually moves to the front or involves the whole head.
  • Primary headaches are notorious for being at least moderate in intensity, like in migraine, or severe like in cluster headache. Quality of pain also matters in diagnosis. Migraine is often throbbing in quality. Cluster headache is felt as “clawing” pain in the eye. Some patients say that it is felt as if someone stuck a hot rod into the eye socket.
  • Primary headaches are sensitive to circadian rhythm. Migraine may be brought up or relieved by sleep. Nocturnal cluster headache happens exactly at the same time every night. Hypnic headache even has a second name of “alarm clock headache” because it occurs in sleep at the same time for months.
  • Some of primary headaches are gender specific. Migraine is more common and usually more severe in females. Women don’t have cluster headaches and men don’t have paroxysmal hemicrania. The last statement is my observation. Official statistics has different opinion.
  • Some primary headaches have very specific triggers, like alcohol in cluster headache. A migraine attack is often brought up by stress or excessive sleep. Birth control pills may bring up the first migraine attack or make natural history of migraine worse. Please, don’t confuse triggers with the cause. Those people who are meant to have migraine will have it no matter what. Triggers will only make the attacks more frequent.
  • Primary headache is much more than just a pain. Cluster headache is inevitably associated with specific personality traits. Almost all cluster headache sufferers are smokers. Migraine with aura is associated with increased chance of stroke, especially if combined with birth control pills.
  • In majority of primary headaches, conventional pain medications have no use. The effective medications are syndrome specific and often have no effect on other body aches. Migraine is the only primary headache that responds to conventional pain medications, such as Motrin and aspirin, but narcotics normally don’t work for migraine related headache. Frequent primary headaches are commonly managed with preventive treatment. For some, like paroxysmal hemicranias, it is the only treatment option.
  • Please note, triptans (like Sumatriptan and the rest of them) that normally help in migraine may also relieve headache due to subarachnoid hemorrhage. So, their effect on headache does not rule out this devastating condition.
  • Migraine auras may be quite bizarre, which might lead to the diagnosis of a stroke. It may present as a marching tingling sensation starting from the hand and then jumping to the face. Hemiplegic migraine may cause transient weakness, loss of speech, or confusion. Children have an “Alice in Wonderland” type of aura, or perception of distorted surrounding objects.

You probably feel confused due to large amount of details needed for diagnosis of primary headaches. For a headache professional, who keeps all the related information in the active memory, it is not a challenge but rather a day to day job.

Primary Headaches Quick Reference Guide

In this article you can glance through the cardinal features of primary headaches. Please pay attention! This information is not a precise diagnostic tool. The symptoms marked by bold italic are mandatory for each particular diagnosis. Their presence is essential, while absence of such symptoms rules out the suspected diagnosis.

  • Episodic headache; lasting from hours to a couple of days; associated with hypersensitivity; difficulty or inability to perform normal activitiesMigraine
  • Severe recurrent unilateral headache; around the orbit (felt as if the eye is being pulled out); lasting for a couple of hours; might be up to three times per 24 hours; often at night; tends to occur at the same time; associated with runny/stuffed nose and tearing on the side of the headache; maleCluster Headache
  • Recurrent unilateral moderate-to-severe “clawing” pain in the orbit/temple; lasting no more than half an hour; multiple per day; never starts in sleep; eye symptoms on the side of the headache – tearing, redness, droopy eyelid, or/and runny/stuffed nose on the same side; femaleParoxysmal Hemicrania
  • Constant mild-to-moderate pain in the same orbit/temple for moths/years; episodic exacerbations of the pain intensity to moderate-to-severe; during exacerbations of pain some eye symptoms present on the side of the headache – tearing, redness, droopy eyelid, or/and runny/stuffed nose on the same side; no headache in sleep; femaleHemicrania Continua
  • Constant mild annoying pain; in the same spot of the scalp; from months to years; this area is hypersensitive to touch; pain never changes its location; all possible imaging studies of the head and skull are normalNummular Headache
  • Repetitive, moderate-to-severe, multiple times per day, brief (seconds), shooting, burning, stabbing pain in the front of the head; associated with tearing, redness, swelling of the eye on the same side; and/or stuffed/runny nose during the attacks only – SUNCT Syndrome
  • Sudden brief stabbing pain in the frontal portion of the head; comes in single jolts or in series; lasts for a second; pain location changes from attack to attack; migraine history is typical – “Ice pick” Headache, or Primary Stabbing Headache
  • Throbbing headache in a young person during or after exercise; without associated symptoms lasting from minutes to hours – Primary Exertional Headache. Subarachnoid hemorrhage is always a concern on the first attack.
  • Repetitive; shooting or stabbing headache; for a few minutes; in a person over 50; brought up by cough, sneeze, or strain; negative diagnostic work up (work up is a must) – Primary Cough Headache
  • Dull, gradually increasing in intensity headache in the back of the head during sexual intercoursePreorgasmic Headache
  • Sudden explosive headache; turning into throbbing; during or around orgasmOrgasmic Headache. Mandatory work up for brain aneurysm is needed ASAP on the first instance of such headache.
  • Mild-to-moderate headache with onset about 1.5 hours after falling asleep; on a regular basis; after age 50; with good response to caffeine – Primary Hypnic Headache. Requires work up, since it might simulate multiple conditions.
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