Recurrent Headache

We finished our discussion of “Acute Headache” with an extra post late last week.  Moving on to RECURRENT HEADACHES, which we’ll define as a headache that completely disappears, only to return again.  Be clear with the patient that today’s recurrence feels pretty much the same as previous episodes, because the chronic migraine sufferer is also allowed to happen to have a subarachnoid bleed, just like anyone else might.



Not Dangerous(usually)

**  Pheochromocytoma  —  Patients with recurrent headaches aren’t usually worried about life-threatening illness, because they know that whatever condition is causing pain didn’t do them in last time.  A Pheo, however, ultimately might.  But the adrenal tumor is very rare (≤1 per 100,000 population), and half of them cause sustained hypertension.  Still, for patients with new headaches which come and go, ask if generalized sweating and palpitations also occur.  If present, allow them to drop in without appointment the next time their headache recurs, in order to check their pulse and blood pressure while symptomatic.

A 37-year-old brand-new patient had been to an E.D. for headache, B/P 210/110, the day before.  I found her pressure stone normal, but fundoscopic exam revealed all of Keith-Wagener’s classic hypertensive abnormalities short of papilledema (narrow arterioles, some copper-wiring, A-V nicking, exudates, & hemorrhages).  I was sure she had a Pheo — what else could cause such chronic signs in the face of a normal B/P that day, and in a young person to boot?  Her new health insurance was about to kick in, so I gave her a copy of my clinical note to alert her next provider, but never saw her again.

Now let’s discuss common causes of recurrent headaches, especially the primary headache disorders not due to anything else.

** Migraines —  Above all, migraines are cyclical headaches.  They come, go, and recur.  An attack typically lasts more than four, & less than 72, hours.  The International Headache Society (IHS) diagnostic criteria require:

  • 2 of the following 4 characteristics: pulsating, unilateral, moderate or severe intensity, exacerbated by normal activity; and
  • 1 of the following 2 characteristics: nausea / vomiting, or photophobia plus phonophobia.

Up to 60% of patients experience a prodrome 1-2 days prior, consisting of mood changes, perhaps increased yawning.  Up to 25% have an aura, including a variety of evolving visual or sensory symptoms, lasting 5-60 minutes immediately before headache onset.

Imaging is not necessary unless you find objective neurological deficits.  The IHS requires five episodes before a diagnosis can be made; this is especially a research criterion.  For the typical cyclical migraine, a therapeutic trial of abortive therapy (i.e. triptans) may help diagnostically.

Anecdotal Pearl:  Many patients with recurrent headaches don’t fulfill diagnostic requirements, but report some of the above characteristics.  If symptoms are in any way cyclical, and occur frequently enough that the patient desires and is willing to take daily medication in the hope of an ounce of prevention, I’m fine with a trial of prophylaxis like a calcium channel blocker, beta-blocker, or tricyclic antidepressant.

Pearl about Therapeutic Trials: Aim for maximum doses, titrate up as tolerated.  These are in fact “Diagnostic” trials.  If you give a sub-optimal dose, and it doesn’t work, you’ll never know if the intervention might have helped.  [of course, if it does work, have the intellectual sincerity to keep ‘placebo effect’ as a possible explanation].

** Cluster Headaches —  This diagnosis tests the clinician’s skill at defining symptom chronology.  Cluster headaches:

  • Occur daily, or every other day, usually for 6-12 weeks [range: 1 week to 1 year], then disappear for at least a month, then recur.
  • Each attack lasts 15 minutes to 3 hours.  They may strike 1 to 8 times a day.
  • The headache is severe, unilateral, felt around the eye or temple.
  • There’s at least one other unilateral finding on the same side as the headache (ipsilateral):
  • red eye or tearing, eyelid edema, pupil constriction, or ptosis;
  • runny nose [nostril] or congestion;
  • unilateral forehead or facial sweating;
  • restlessness or agitation [this would be bilateral].

Imaging (MRI) is usually recommended, because a disproportionate number of patients with typical signs & symptoms of cluster headache happen to have CNS abnormalities, suggesting that some of these may be causal.

Cluster headaches have been categorized within a broader category “trigeminal autonomic cephalalgias.”  Other headache types mimic clusters, with shorter duration and more frequent bursts.  Since treatment may vary, consult a headache specialist.

If you diagnose cluster headaches, inquire about coping mechanisms.  There have been suicides among cluster headache sufferers.

**  Tension Headache  —  The most common of all headaches, the one with greatest socioeconomic impact, the least studied, & the most nondescript, tension headache is a diagnosis of exclusion.  The pain is bilateral, not severe, with no criteria to suggest migraine or cluster, much less anything serious.  The IHS defines it as lasting anywhere from 30 minutes to a week, and requires 10 episodes to make the diagnosis.

What else can I say?

Once again, the more disabling the recurrent headache, the more you should consider it might possibly be an atypical migraine.  Migraines may respond to triptans, which function best if taken at the onset to abort the symptoms.  Since such a therapeutic trial may be impossible if headaches are continually present, or come and go erratically, a trial of prophylaxis may be more useful.

The differential not-to-miss for tension headaches is Medication Overuse Syndrome.  The main culprit drugs seem to be opioids, combination products with the barbiturate butalbital (e.g. Fiorinal®), those with aspirin + acetaminophen + caffeine, and triptans, though even NSAIDs have been implicated.  Consider this diagnosis if a single headache medication is taken over 10 days per month, or if various meds are mixed for over 15 days.  As a therapeutic trial, discontinue all possible offending medications, and begin a migraine-prophylaxis regimen.

**  Special Headaches  —  Certain stimuli may cause brief headaches.  They include:

  •  “Ice-Cream Headache” (“brain freeze”), when enough cold hits the roof of the mouth fast enough.
  • “Cough Headache” occurs after coughing.
  • “Post-Coital Headache” occurs after sex, following orgasm; it can be emotionally traumatic.
  • “Chinese Restaurant Headache” from eating products with monosodium glutamate.
  • “Hot-Dog Headache” from foods with nitrites.

These headaches should only be diagnosed after numerous occurrences have set a pattern, not with the first episode.  Because of the intense straining, a subarachnoid hemorrhage from an aneurysm leak can also occur during sex, usually before orgasm.

See also our other postings on the topic: Acute H/A – 1 (“worst ever”), Acute H/A – 2 (masses, & the neuro exam), Acute H/A – 3 (other “not to miss”), Acute H/A – 4 (common causes), and Chronic Headaches.

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