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A 35-year-old woman presented to the office to discuss her migraines. She has episodic unilateral throbbing headaches accompanied by nausea, photophobia, and phonophobia. She used to have a migraine about every 3 months, but is now having one almost every 2 weeks. As this frequency interferes with her life, prophylactic therapy is discussed. She accepts and her migraine frequency decreases dramatically.

More than 77% of adults experience headaches during their lifetime. Headaches are either primary or secondary and the presence or absence of red flags is useful to distinguish dangerous causes of secondary headaches. The most common primary headaches are tension, migraine, and chronic daily headaches. Medication overuse can complicate headache therapy. Treatment and prognosis is dependent on type of headache.

  • Lifetime prevalence estimated to be greater than 77% in adults.1
  • Fifty-three percent of adults (61% of women and 45% of men), and 53% of children have had a headache in the past year.1 Elderly adults have a lower rate of headaches with 36% reporting a headache in the past year.
  • Episodic tension-type headache (TTH) prevalence is 62.6% in adults and 15.9% in children.1
  • Chronic (>15 days per month) TTH has a prevalence of 3.3% in adults and 0.9% in children.1
  • Migraine has a prevalence of 14.7% in adults (8% in men, 17.6% in women) and 9.2% in children.1
  • Chronic daily headache has lifetime prevalence of 4% to 5%.2
  • Medication overuse contributes to daily headache in approximately 1% of adults in the general population.1
  • Cluster headache has a lifetime prevalence of 0.2% to 0.3%.1

  • TTH etiology is uncertain, but likely caused by activation of peripheral afferent neurons in head and neck muscles.3
  • Migraine headache is thought to be caused by central sensory processing dysfunction, which is genetically influenced.4 Nociceptive input from the meningeal vessels is abnormally modulated in the dorsal raphe nucleus, locus coeruleus, and nucleus raphe magnus. This activation can be seen on positron emission tomography (PET) scan during an acute attack (Figure 229-1).
  • Cluster headache is caused by trigeminal activation with hypothalamic involvement, but the inciting mechanism is unknown.5

Figure 229-1

Imaging has helped clarify the etiology of migraine disorder. This positron emission tomography image shows activation in the dorsolateral pons, which includes the noradrenergic locus coeruleus, an area that modulates nociceptive input from the meningeal vessels. (With permission from Longo D, Fauci A, Kasper D, Hauser S, Jameson J, Loscalzo J, eds. Harrison's Principles of Internal Medicine, 18th ed. New York, NY: McGraw-Hill; 2011:116, Figure 14-2B.)

  • For migraines—Family history.
  • For medication overuse headache—Regular use of any medication used to treat acute headaches, most commonly simple analgesics and triptans.

Clinical Features

  • Red flags for dangerous secondary cause—Sudden onset; persistent headache with nausea, vomiting; worsening pattern; history ...

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