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Headaches
Headache office of GK Neiroklīnika is one of the infrequent specialised headache offices in Latvia. Comprehensive headache care performed by experienced neurologists and physiotherapists is offered here. A multiple-profile therapy plan is drawn up for the patient, which contains individually adjusted changes in lifestyle, occupations and medicinal therapy.
What are headaches
Headaches arise in the head or cervical spine. The pain arises in tissue and structures that surround the cervical spine, skull or brain. Neither the brain, nor spinal cord contain nerves that cause painful sensations, therefore the tissue that surrounds the cranial bones and muscles, paranasal sinuses, ears, eyes, as well as tissue that covers the surface of brain and spinal cord, arteries, veins and nerves is causing pain. Headaches can be sharp, dull, pulsating, homogeneous, light or intensive.
Primary and secondary headaches are differentiated.
- Primary headaches are headaches that lack a specific explanation and treatable cause, for instance, migraine, tension or cluster headaches.
- Secondary headaches are based on another treatable or transitory disease, for instance, influenza with elevated body temperature, inflammation of nasal mucous membrane, eye inflammation, inflammation of the blood vessels of the head or inflammation of the teeth.
Nowadays not only secondary headaches can be treated by treating the specific cause of headaches, but also primary headaches – headaches that do not have a specific explicable cause.
Therapy methods
Evaluation of the general neurological status, which provides insight on the potential causes of the headaches and preferable therapy options to the physician, lies at the basis of therapy.
- Medication therapy. Individualised medication therapy recommendations are provided on the basis of the diagnosis, history of the use of medicinal products, as well as recommendations of European Pain Federation (EFIC) and clinical experience of physician specialising in headaches.
- Physiotherapy. The physiotherapist of the headache unit of GK Neiroklīnika will prescribe physiotherapy that will enable you to improve your well-being and balance your body movements. Our physiotherapist will determine a set of therapeutic exercises suitable for you in particular.
- Therapy of headaches caused by medications or detoxification. We offer to receive specialised infusions of medicinal products to treat drug-induced headaches.
If required, medication blocks of painful points (trigger points), neuromodulation of trigeminal nerve with Cefaly ® device and, in special cases of chronic migraine therapy – onabotulinum toxin blocks are performed.
TRIPTANS
What are Triptans?
Triptans are specific anti-migraine agents, that can be used as an alternative, when nonprescription painkillers are ineffective.
How do Triptans work?
Triptans are not painkillers; they are based on the release of a chemical in the brain called serotonin, which causes the blood vessels in the brain to narrow. This effect on the blood vessels is important, as the widening of blood vessels is considered to be one of the components of the migraine attack process.
How should Triptans be used?
Triptans are only effective, if taken as soon as possible.
The most common mistakes that are made: the drug is already used during the migraine aura, as well as taken too late.
If required, a second Triptan pill can be used, but only if the first has had an effect, and no sooner than 2-4 hours later.
Triptans, like other medicines, should not be used too often as there is a risk of a medication overuse headache. Talk to your doctor, if you take Triptans more than 2-3 times per week.
What are the main side effects?
Like all medications, Triptans can cause side effects. The most common side effects: nausea, dizziness, instability, sleepiness, dry mouth.
Feeling hot, tingling, flushing and heaviness in the face, arms, legs and sometimes in the chest.
Remember, if any of the medications in this group cause side effects, you can switch to another that is right for you and will not cause side effects!
In what cases is the use of Triptans not recommended?
Triptans are not recommended, if you have a history of: coronary heart disease, myocardial infarction, uncontrolled arterial hypertension, cerebral infarction or transient ischemic attack, renal or hepatic insufficiency.
Triptans should be used with caution in patients 65+ years of age because of their increased cardiovascular risks.
The use of Triptans during pregnancy is not recommended and should only be considered in special cases.
During lactation it is recommended to avoid breast-feeding for 24 hours after taking Triptans.
NON-STEROID ANTI-INFLAMMATORY DRUGS (NSAIDs)
What are Non-Steroid Anti-Inflammatory Drugs?
NSAIDs are a group of painkillers that act as first choice medication for headaches.
How do Non-Steroid Anti-Inflammatory Drugs work?
NSAIDs block the effects of the chemically active substance (enzyme) called cyclooxygenase (COX). COX is required for the activation of chemicals such as prostaglandins. In turn, prostaglandins are involved in causing pain and inflammation. By preventing the activation of prostaglandin, pain and inflammation are reduced.
How do you use Non-Steroid Anti-Inflammatory Drugs?
Take the prescribed dose as soon as possible after the onset of symptoms. If the medication is taken soon enough and at an adequate dose, it often reduces or stops the headache entirely.
If required, the dose can be repeated after 4 hours.
Non-steroidal anti-inflammatory drugs should not be used too often. If you need to take medication for headaches more than 15 times per month, talk to your doctor, as there is a high risk of developing medication overuse headaches.
What are the main side effects?
The most common side effects are: diarrhoea, dyspepsia, nausea, vomiting, sleepiness, tinnitus, dizziness. In rare cases: gastric ulcer, gastrointestinal bleeding, myocardial infarction, worsening of heart failure, aplastic anaemia, aseptic meningitis, cognitive impairment, psychosis, cerebral infarction, interstitial nephritis, bronchospasms, severe allergic reactions.
In what cases is the use of Non-Steroid Anti-Inflammatory Drugs not recommended?
NSAIDs should not be used by patients with gastrointestinal bleeding, asthma patients, and in the case of coagulopathies. The use of this group of medications should be especially considered for patients with inflammatory bowel diseases, heart, liver and kidney failure.
Use with caution for elderly patients. It is not recommended during the last trimester of pregnancy. Caution is advised during lactation.
ANTIDEPRESSANTS
What are Antidepressants?
Antidepressants are a group of medications that are widely used to relieve headaches and other neuropathic pains. Optional antidepressants for headache prevention are tricyclic antidepressants (Amitriptyline, Nortriptyline) and Selective Serotonin Reuptake Inhibitors (Fluoexetins) and Serotonin-Norepinephrine Reuptake Inhibitors (Venlaflaxin, Duloxetine).
How Do Antidepressants work?
Antidepressants affect serotonin and/or norepinephrine, which play an important role in mood changes, as well as in the onset mechanism of pain.
How should Antidepressants be used?
Antidepressants should be taken once per day at certain times or in the morning or evening, depending on the antidepressant you are prescribed. Increase the medication dose gradually as recommended by your doctor.
Non-addictive doses of medications are used to prevent headaches, so do not be afraid to take them.
What are the main side effects?
Tricyclic antidepressants: sleepiness, blurred vision, dry mouth, urinary retention, weight gain, heart rate problems.
Serotonin reuptake inhibitors: nausea, vomiting, constipation, loss of appetite, increased sweating, fatigue, sleep disturbances, sexual dysfunction.
When is the use of Antidepressants not recommended?
Antidepressants are not recommended for patients with heart rate problems, uncontrolled arterial hypertension, hepatic and renal impairment, angle-closure glaucoma, epilepsy, mania.
Use with caution for elderly patients. It is recommended to avoid the use of antidepressants during pregnancy. Venlafaxine is considered a relatively safe antidepressant during lactation.
ANTICONVULSANTS/ANTI-EPILEPTIC DRUGS
What are Anticonvulsants?
Anticonvulsants or anti-epileptic drugs are a group of medications used to prevent epileptic seizures, but medications of this group are also effective in preventing headaches.
How do Anticonvulsants work?
It is not clear how Anticonvulsants prevent headaches. It is possible that they act on neurons in the brain that are overly agitated in the case of a headache.
How should Anticonvulsants be used?
Anticonvulsants are used for the prophylactic treatment of headaches and should not be used in the event of an acute attack. Medication is taken regularly once a day, slowly increasing the dose as instructed by your doctor.
What are the main side effects?
Common side effects: decreased/increased appetite, weight loss/increase, changes in taste, difficulty concentrating, nausea, vomiting, burning or tingling sensation, sleepiness, tiredness.
Rare side effects: changes in body temperature, bleeding, pancreatitis, liver failure.
In what cases is it not recommended to use Anticonvulsants?
Must not be used during pregnancy, therefore warn your doctor, if you are planning pregnancy.
BETA BLOCKERS
What are Beta Blockers?
Beta Blockers are cardiovascular drugs that lower blood pressure and affect heart rhythm. Beta-blockers are one of the most common migraine prevention medications.
How do Beta Blockers work?
Beta Blockers reduce vascular dilation, stabilise serotonin levels, affect hypothalamic activity, reduce anxiety, which can be considered as migraine triggers.
How should Beta Blockers be used?
Beta Blockers are used for the prophylactic treatment of migraines to reduce the frequency of migraine attacks. The medication should be taken regularly once or twice per day.
It is not recommended to stop taking Beta Blockers suddenly. If you observe any side effects, consult your doctor.
What are the main side effects?
Common side effects: tiredness, dizziness, feeling cold or tingling in the feet and hands, sexual dysfunction, weight gain.
Uncommon: shortness of breath, depression, sleep disturbances.
In what cases are Beta Blockers not recommended?
Not recommended for patients with low blood pressure, diabetes, asthma, chronic obstructive pulmonary disease.
CGRP ANTAGONISTS AND INHIBITORS (Monoclonal antibodies).
What are CGRP Antagonists and Inhibitors?
The latest specific prophylactic drug in the treatment of migraine – monoclonal antibodies.
How do CGRP Antagonists/Inhibitors work?
During a migraine the blood vessels and nerves in the brain release chemically active substances, including CGRP. This neuropeptide causes intense inflammation of the lining of the brain, leading to migraine attacks. CGRP also acts as a vasodilator. Monoclonal antibodies either inactivate the CGRP molecule or block its receptor, thereby inhibiting the activity of CGRP and preventing the migraine attack.
How should CGRP Antagonists/Inhibitors be used?
Depending on the frequency of migraine attacks, 1-2 injections per month or one injection every 3 months are required, depending on the choice of monoclonal antibody.
What are the main side effects?
Monoclonal antibodies are currently well tolerated and no significant side effects have been identified.
The side effects that are currently being noted are local and related to the injection site: bleeding, blistering, burning sensation, skin discolouration, hives, itching, soreness, tingling sensation, swelling.
Very rare: muscle cramps and constipation.
When is the use of CGRP Antagonists/Inhibitors not recommended?
During pregnancy or if pregnancy is planned, as the effects on the foetus have not been adequately studied.
Tension-type headache
What is a tension-type headache?
Tension-type headache is the most common of the primary headaches. Headaches are experienced by almost everyone, but they are more common in women. Although the intensity of a tension-type headache is mild, it can sometimes affect your daily activities.
Episodic tension-type headache is felt by 70% of the population. An episode of headache can last from a few hours to a few days, but does not occur more often than 15 days per month.
1-3% of adults suffer from a chronic tension-type headache and experience more days with a headache per month than headache-free days.
Tension-type headache is characterised by….
Headache feels depressing and is bilateral. The intensity of a headache is usually moderate to mild, but can often disturb daily activities. Rarely, sensitivity to light or noise can be observed.
What causes a tension-type headache?
The causes are varied, but emotional tension associated with stress or anxiety and musculoskeletal problems in the neck are considered a significant factor.
What is the possible therapy?
Nonprescription analgesics such as Ibuprofen, Aspirin, Naproxen are used for acute medical treatment. When taking these medications, special attention should be paid to how many pills are taken per day, as well as the frequency of use, because too frequent use of these painkillers can lead to medication overuse headaches. Do not use painkillers regularly, and do not use them more often than 3 days per week!
What to do, if painkillers do not help or have to be used often?
Your doctor may recommend preventive treatment. Effective prophylactic medications are antidepressants, anti-epileptic drugs, as well as muscle relaxants. These medications should be taken daily!
Recommended non-drug therapy: physiotherapist classes, physiotherapy procedures (TENS), relaxing therapy, acupuncture, but the most suitable for your case will be recommended by your doctor, as each case is individual.
What can I do myself to avoid headaches?
⦁ Relax, take a break from work, enjoy a massage, change your daily habits.
⦁ Engage in regular physical activities, prefer walking instead of moving around in a vehicle.
⦁ Fight stress through breathing and relaxation exercises.
Are special tests required?
There are no specific tests to confirm the diagnosis of a tension-type headache. The diagnosis is made based on your description of the headache and the doctor’s examination. Therefore it is important to accurately describe the symptoms of the headache, the medications you take in the case of headaches, and how often you have to take painkillers.
COMPLETE THE HEADACHE DIARY TO BETTER UNDERSTAND YOUR HEADACHES.
Migraine
What is a migraine?
Migraine is the most common neurological disease, ranking in seventh place of all disabling diseases.
Migraine is characterised by a severe headache, nausea, sensitivity to light and sound. Migraine occurs in an attack-like manner and the patients feel completely healthy between the attacks. The duration of an attack varies from 4 h up to 3 days, in the frequency from once a year to several times a month.
Every seventh adult in the world has migraines. Women suffer from migraines up to three times more often than men. Migraines can start in childhood, but the highest frequency of attacks occurs at the age of 35-49 years old. Women experience the onset of migraine attacks most often at the age of puberty.
What are the types of migraines?
The most common is migraine without aura, but 1/3 of migraine cases occur with aura. It should be noted that there may be cases of migraine attacks both with and without aura, but these are rare. For elderly people migraine attacks are only possible with aura without a subsequent headache.
Migraine is characterised by….
Migraine symptoms appear during the migraine attack; the attack can be divided into four stages, but remember that not everyone experiences all the stages.
The warning stage – appears before any symptoms; this stage is experienced by about ½ of migraine patients. At this stage you may feel irritated, nervous, depressed, overly energetic. These feelings last for a few hours or even days before the migraine attack.
Aura, transient neurological disorders. The most common are visual symptoms such as bright or flashing light, coloured zigzag lines, blank spots in front of the eyes, usually one-sided. Rarely, there may be sensory symptoms such as a stabbing or tingling sensation in one hand with an upward character from the fingers up to one side of the face. The aura can also manifest with temporary speech disorders. The aura lasts for 10-30 minutes, but often can also be longer.
The aura is followed by a pronounced headache of a pulsating nature, usually unilateral, but possibly also bilateral. The location of a headache can differ, but is more often reported in the forehead and temples. When a headache begins, there is a desire to avoid light, sounds, as well as daily activities, which only increase the already severe headache. Nausea and vomiting may also occur at this stage.
At the moment when the headache subsides, concentration problems, irritability, fatigue, depression are possible.
Symptoms associated with migraine: nausea, vomiting, sensitivity to light, sensitivity to sounds.
What causes migraines?
Migraine occurs in the parts of the brain that are responsible for the formation mechanisms of pain and other sensations.
Migraines are often inherited from parents, grandparents.
What is the possible migraine therapy?
Treatment of acute migraine attack | |
| Non-drug therapy | Drug therapy |
| Peace, rest, sleep Cold applications or hot tub, shower. Aromatherapy Breathing, relaxation exercises Acupuncture | Analgesics: nonprescription (e.g., Ibuprofen, Naproxen, Paracetamol, Aspirin). Medication can also be used in combination with other methods, and in combination with caffeine for achieving a better effect. It is better to choose soluble, foaming and suppository forms of medication, as they act faster. Antiemetics (Metoclopramide, Domperidone). Specific migraine agents: Triptans, the drug should be taken as soon as possible, can be combined with antiemetics and analgesics. |
- Always remember to take your medication with you;
- Take medication at the moment when the first symptoms of migraine appear – DO NOT WAIT!
Do not take acute therapy painkillers regularly, and do not take them more often than 3 days per week!
What to do, if painkillers do not help or have to be used often?
If migraine attacks are frequent or severe, your doctor may recommend preventive treatment. For prophylactic treatment antihypertensive drugs, anti-epileptic drugs, as well as antidepressants are recommended. The goal of preventive therapy is to reduce the frequency and intensity of attacks, therefore these medications should be used regularly!
If the prophylactic treatment is ineffective, injections of Onabotulinum Toxin A are recommended.
The new medication for migraine prevention: CGRP receptor antibodies (Erenumab), CGRP antibodies (Fremanezumab, Eptinezumab, Galcenezumab) are injected once per month.
What can I do myself to avoid headaches?
Engage in regular physical activities. By recognising and avoiding the triggers of migraines, it is possible to reduce the activity of migraine attacks.
Migraine triggers:
- Stress – 70% of migraine patients engage in relaxing therapy, biofeedback, and if necessary, use drug therapy to reduce stress.
- Irregular sleep – observe sleep hygiene.
- External environmental conditions – avoid changes of weather conditions, strong odours, bright or flashing lights.
- Diet – caffeine and alcohol, red wine are most often mentioned as a migraine trigger, but studies show that other types of alcohol are also associated with migraine attacks. Opinions about caffeine are controversial, as there are migraine patients who report that a cup of coffee can stop a migraine attack. Food products: chocolate, cheese and other dairy products, artificial sweeteners and other products with a pronounced aroma.
- Irregular meals and dehydration can also serve as triggers.
- Hormonal factors for women – monthly periods, hormonal contraception and hormonal replacement therapy.
Are special tests required?
There are no specific tests that confirm the diagnosis of a migraine. The diagnosis is made based on your description of the headache and the doctor’s examination. Therefore it is important to accurately describe the symptoms of the headache, the medications you take in the case of headaches, and how often you have to take painkillers.
COMPLETE THE HEADACHE DIARY TO BETTER UNDERSTAND YOUR HEADACHES.
Cluster-type headache
What is a cluster-type headache?
Cluster-type headache is a very severe unilateral headache that localises in the eye area. The attack starts suddenly, without any previous warning symptoms. The attacks are short. One or more attacks can be observed per day. Attacks recur at the same time of day or night.
Cluster-type headaches are relatively rare and experienced by about one in 1000 adults; they are more common in men, who experience it about six times more often. Most often the first attack develops at the age of 20-40.
What are the types of cluster headaches?
Episodic cluster-type headaches that are characterised by the episodic course. The most common period is 6 to 12 weeks, with a headache-free period between the episodes.
Chronic cluster-type headache attacks recur year after year without interruption.
Cluster-type headache is characterised by….
Unilateral pronounced, tearing, intolerable pain in the eye area, which always localises on the same side. Severe anxiety can be observed during the pain. During the attack, redness of the eye, tearing of eyes, narrowing of the pupil, nasal congestion, drooping eyelid can be observed. The duration of one attack lasts for 15 minutes to 3 hours, the seizures usually recur day by day for 6 to 12 weeks, followed by a free break in the attacks. In 1 out of 10 cases the attacks continue without a remission period.
What are the causes of a cluster-type headache?
The cause of cluster-type headache is still unclear. Attacks are often associated with hypothalamic hyperactivity, which results in the release of chemicals that stimulate nerve cells in the brain that cause pain and other symptoms.
What is the possible therapy?
Painkillers are not effective! During the attack 100% oxygen inhalation, as well as Sumatriptan injections are recommended.
Prophylactic therapy (Verapamil, Corticosteroids, Topiramate) plays an important role in the treatment of a cluster-type headache that should be continued for up to 14 days free of headaches, but in some cases prophylactic medication should be used in the long term.
Are special tests required?
There are no specific tests to confirm the diagnosis of a cluster-type headache. The diagnosis is made based on your description of the headache and the doctor’s examination. Therefore it is important to accurately describe the symptoms of the headache, the medications you take in the case of headaches, and how often you have to take painkillers.
COMPLETE THE HEADACHE DIARY TO BETTER UNDERSTAND YOUR HEADACHES.
MEDICATION OVERUSE HEADACHE.
What is a medication overuse headache?
Medication overuse headache is the third most common headache after migraine and tension-type headaches. This is a chronic daily headache. The frequency is 1-2%, more common in middle-aged people, women. Medication overuse headache is common in patients with pre-existing headaches, who have excessively used medication to control the attacks for at least 3 months.
Medication overuse headache is characterised by….
Medication overuse headache is not severe, but occurs almost daily or daily. The headache gets worse in the morning. Typically, the headache decreases, when the drug is ingested, but recur as the drug wears off. Other symptoms include nausea, irritability, anxiety, difficulty concentrating, memory problems and depression.
For each group of medications there is a certain frequency of use of the medication, which is considered as overuse.
- Nonprescription analgesics (Aspirin, Paracetamol, non-steroidal anti-inflammatory drugs) cause medication overuse headaches, if the recommended doses are exceeded and if they are used for more than 15 days per month.
- In the case of combined analgesics the risk of medication overuse headaches exists, if they are used more than 10 days per month.
- In the case of Triptans the risk of developing a medication overuse headache is moderate, when taken 10 or more days per month.
- In the case of opioids (Oxycodone, Tramadol, Codeine, Hydrocodeine), the risk of an addiction headache, if used more than 10 days per month.
- Caffeine, if the daily dose is more than 200 mg per day.
What is the possible therapy?
Excessive use of the medication should be discontinued. Basically combined therapy: pharmacological, non-pharmacological, biofeedback, combination of physical therapy.
During treatment, the headache may worsen; there may also be symptoms associated with withdrawal of the drug: nausea, vomiting, insomnia, anxiety, constipation.
Are special tests required?
There are no specific tests to confirm the diagnosis of a medication overuse headache. The diagnosis is made based on your description of the headache and the doctor’s examination. Therefore it is important to accurately describe the symptoms of the headache, the medications you take in the case of headaches, and how often you have to take painkillers.
COMPLETE THE HEADACHE DIARY TO BETTER UNDERSTAND YOUR HEADACHES.
INQUIRY FORM
- How many days per month have you had a headache (within the last 3 months)?
- How does the headache start?
- Suddenly
- Gradually
- Varies
- How long does one episode of headache last?
- What is the intensity of the headache?
- Light
- Moderate
- Severe
- Unbearable
- Where is the headache located?
- Headache is …
- Unilateral
- Bilateral
- Headache could be described as …
- Pulsating
- Compressing
- Stabbing
- Burning
- Dull
- Are any of the following symptoms characteristic during the headache?
- Nausea
- Vomiting
- Sensitivity to light
- Sensitivity to noise
- Tearing of eyes
- Congested nose
- What medications are you using to treat your headache?
- How many pills do you take to treat a single attack?
- Are all headache episodes the same?
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