Headaches

Lilia C. Lovera

Walter M. Jay

M. Susan Jay

Recurrent headaches are a frequent problem in adolescents and young adults (AYAs), accounting for numerous physician visits and lost days at school and work. By age 15, over 50% of adolescents have experienced at least one headache episode.¹ Most recurrent headaches are not associated with severe organic pathology. In contrast, the single, severe acute headache may be due to significant central nervous system (CNS) or systemic disease, particularly when it occurs in a patient without prior headache history.

EPIDEMIOLOGY

The prevalence of headaches by age 15 is 57% to 82%.¹,² Most are infrequent and not disabling.

Migraine headaches have a prevalence of 8% to 23% among individuals 11 to 15 years old.³,⁴ Half of those with migraine headaches develop symptoms before age 25.⁵ In a large US-based population sample, the prevalence of chronic migraine among AYAs is 5% to 9%, with increasing prevalence throughout adolescence.⁶ In general, headaches are more common in prepubertal males. After puberty, they are more common in females.¹,²

HEADACHE TYPES

Headaches may be due to a primary headache disorder or secondary to another condition. The vast majority of headaches in AYAs are primary headache disorders including migraine (with or without aura), tension-type headache (TTH), and chronic daily headache. Primary headaches present with multiple acute attacks and complete remission between attacks. Commonly, secondary headaches may be due to systemic disease such as a viral illness or sinusitis.

CHARACTERISTICS

See Table 24.1 for characteristics of common primary and secondary headaches.

Primary Headache Disorders

These include (A) migraine, (B) TTH, (C) trigeminal autonomic cephalgias (TACs), and some forms of (D) chronic daily headache.

TABLE 24.1
Common Headache Presentations

Type of Headache	Onset	Location	Pain Quality
Migraine without aura	Gradual	Unilateral or bilateral (especially in those <18 years old)	Throbbing, pulsating
Migraine with aura	Gradual	Unilateral	Throbbing, pulsating
Tension-type	Variable, usually afternoon	Bilateral, band-like	Steady pressure, dull
Cluster	2-3 a.m., abrupt	Unilateral, orbital, or temporal	Burning, boring, excruciating
Intracranial mass lesions	Gradual or sudden, but usually recent	Focal or general	Varied, often dull ache
Idiopathic intracranial hypertension	Variable	Vertex or diffuse	Dull

Migraine

Migraine without aura, formerly “common migraine”

These are the most common, accounting for 60% to 85% of migraine headache cases.⁷ See Table 24.2 for criteria according to the International Headache Society (IHS). Common features include:

Symptoms that are often relieved by sleep or rest
Family history of migraines
Childhood history of motion sickness or cyclic vomiting
History of relief with triptans or ergot compounds is supportive of the diagnosis.
Pattern of headaches that varies over time, with exacerbations or onset that may be precipitated by puberty, college, or other life stressors

In some, episodes may be triggered by certain foods, including chocolate, tyramine-containing cheeses, red wines, and foods containing monosodium glutamate (MSG), nitrates, or nitrites.⁸

TABLE 24.2 IHS Criteria for Migraine without Aura

At least five attacks that fulfill criteria in B to D
Headache attacks that last 4 to 72 h (untreated or unsuccessfully treated)^a
Headache has at least two of the following characteristics:
1. Unilateral site^b
2. Pulsating quality
3. Moderate to severe intensity
4. Aggravation by or causing avoidance of routine physical activity (e.g., climbing stairs)
During headache, at least one of the following symptoms:
1. Nausea or vomiting (or both)
2. Photophobia and phonophobia
Not attributed to another disorder

^aIn patients aged under 18 y, duration may be 2-72 h.

^bIn patients aged under 18 y, headaches are more often bilateral.

From the Headache Classification Committee of the International Headache Society.

The International Classification of Headache Disorders, 3rd edition (beta version). Cephalagia 2013;33(9):629-808.

Migraine headaches in children and adolescents under 18 years of age tend to be more often bilateral and become unilateral in late adolescence and young adulthood.⁹

Migraine with aura, formerly “classic migraine”

An aura is a unilateral, fully reversible, visual, sensory, or other focal neurologic symptom that develops gradually and is followed by a headache and associated migraine symptoms. Given the paroxysmal neurologic symptoms, further evaluation and imaging may be required to rule out a transient ischemic attack especially at initial presentation.

Migraine with typical aura occurs in 15% to 30% of patients with migraine with aura.⁷

See Table 24.3 for diagnostic criteria according to IHS.
- Visual auras occur in 90% of migraines with aura, followed by sensory auras, and less frequently, speech manifestations.⁹
- Visual manifestations include blurred vision, zigzag lines, field defects, scintillations, or distortions.

Migraine with brainstem aura, formerly “basilar migraine”

Represents 3% to 19% of childhood migraine with auras and are more common in female AYAs.⁷,¹⁰

Symptoms are characterized by vertigo, ataxia, dysarthria, diplopia, and decreased level of consciousness that are fully reversible.

TABLE 24.3 IHS Criteria for Migraine with Typical Aura

At least two attacks that fulfill criteria B and C
Migraine aura is fully reversible and consists of visual, sensory, and/or speech/language symptoms. There are no motor, retinal, or brainstem symptoms
At least two of the following four features:
1. At least one aura symptom develops gradually over 5 min, and/or two or more different aura symptoms occur in succession
2. Each aura symptom lasts 5-60 min
3. At least one aura symptom is unilateral
4. There is headache either with the aura or within 60 min of the aura
Not attributed to another disorder, and transient ischemic attack has been ruled out

From the Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalagia 2013;33(9):629-808.

Hemiplegic migraine
- Aura consists of fully reversible motor weakness with visual, sensory, or speech manifestations, followed by a migrainous headache.
Retinal migraine
- Repeated attacks of a monocular visual disturbance; however, these are rare and other causes of monocular blindness should first be excluded.⁹

Migraines and Menses

The IHS, in its Appendix to the third edition, defines two clinical entities—the pure menstrual migraine (PMM) and the menstrually related migraine (MRM). PMM is a migraine without aura with attacks occurring only 2 days before to 3 days after the onset of bleeding and at no other times of the menstrual cycle. In contrast, MRM may occur perimenstrually, like PMM, and at other times during the menstrual cycle. For the diagnosis to be made, headaches have to occur in two out of three consecutive cycles.⁹ The perimenstrual migraine attack appears to be more closely linked with variations of sex hormones. Treatment options are discussed later in this chapter.¹¹,¹²

TTH, Formerly “Tension” Headache

THHs are band-like and bilateral, with nonpulsating pain, and last 30 minutes to 7 days. There is no nausea or vomiting, but either photophobia or phonophobia may be present. They are not worsened by physical activity. The onset is usually gradual and may be related to stress and fatigue. There may be associated pericranial tenderness to palpation.⁹,¹³,¹⁴

Trigeminal Autonomic Cephalgias

This group of primary headache disorders includes headaches that are usually lateralized, with associated prominent cranial parasympathetic autonomic features (lacrimation, rhinorrhea, conjunctival injection) ipsilateral to the headache. TACs include cluster headaches, paroxysmal hemicranias, hemicrania continua (HC), and short lasting unilateral neuralgiform headaches with conjunctival injection and tearing. Cluster headaches are the most common.⁹,¹⁵

Cluster Headaches:

Found in <5% of AYAs
Male predominance and usually starting in late adolescence or adulthood, typical age at presentation is between 30 and 50 years.
Pain is steady boring or burning, usually localized behind one eye. Pain onset is sudden and severe, but brief, lasting from 15 to 180 minutes.
Rhinorrhea, lacrimation, conjunctival injection, and Horner syndrome ipsilateral to the pain are common during an attack. During clusters, multiple daily episodes occur, often in early morning hours, awakening patient from sleep.

Chronic Daily Headache

Chronic daily headache in AYAs includes chronic migraine, chronic TTH, new daily persistent headaches (NDPHs), and HC.

Chronic migraine and chronic TTH usually evolve from intermittent migraine or TTH, and are defined as headaches occurring on more than 15 days a month for over 3 months.
NDPH is an acute onset of daily headache in a patient with no history of headache, which persists for many weeks to months.⁹,¹⁶
HC, a chronic form of a TAC, is rare in AYAs. These usually respond well to treatment with indomethacin.¹⁶