Primary Headaches: An In-Depth Review

Primary headaches occurdue toabnormal overactivity in the chemistry of the brain, which may result from vascular irritation, stimulation, muscle stretch, spasm, genetic causes, or simply from analgesic overuse. The most common type of primary headache is a tension headache, which can be caused by stress, medication, insomina, and poor posture. This headache’s pain usually arises graduallyin the middle of the day and its symptoms involve a constant dull pain in both sides of the head which can be either episodic or chronic. A second most common type of primary headache is a migraine headache, which is often triggered by the environment, certain food, menstruation, and family history. Its characteristic symptom is unilateral pulsating, throbbing pain, and it’s usually episodic in nature and associated with lightheadedness, photophobia, visual stigmata. Migraines are often proceeded with aura and accompanied with nausea and vomiting, lasting from a few hours to 2-3 days. The frequency of migraine headache episodes varies from once a week to once a year [1,2]. 

Other primary headache types include cluster headaches and medication overuse headaches (rebound headache). A cluster headache is more common in men and is generally aggravated by stress. It may last from 15 minutes to 3 hours, up eight times a day, and typically occurs for 4-12 weeks, then disappears. Cluster headachestake place around the same times every day, and there are no symptoms in the interim. These headaches are usually associated with severe pain around one eye with tearing or redness and sometimes drooping eyelid, runny nose, and sweating, and remission may last months or even years. Medication overuse headache (or rebound headache) occurs if a patient uses opiate-based medications to treat headaches too often. These headaches are associated with restlessness, neck pain, nasal congestion, and poor sleep [3].

Usually, having a headache is not a cause for concern, but there are alarming signs that necessitate medical attention. Patients need to seek quick medical advice and be evaluated in an emergency setting if they are over 50 years old and their headache is severe, persistent, and does not improve with medication. Additionally, other signs involve a major change in the pattern of your headaches, increase with cough, changing positions, getting worse associated with personality changes, confusion, fever, neurological changes such as visual disturbances, slurred speech, weakness, numbness, or seizures or neck stiffness or painful red eye. Additional red flags include from new headaches that are increasing in frequency and intensity or a major change in headache patterns. These concerning risk factors and symptoms necessitate a comprehensive neurological exam, neuroimaging including head CT or MRI, and stereological evaluation [4].

If the headache is severe in intensity, there are multiple treatment options that a patient can consider. The main treatments for headaches are rest and analgesic medications such as nonsteroidal anti-inflammatory, acetaminophen, and aspirin. Second order therapies include opioid medications and preventive therapies for migraines. For medication overuse headaches, limiting or stopping the involved drug is the mainstay approach. There are also integrative therapies such acupuncture, cognitive behavioral therapy, herbal products, hypnosis, and meditation. Prior work suggests magnesium oxide 400-500 milligrams per day and Vitamin D can help prevent migraine episodes. Additionally, avoiding stressors, eating regular healthy meals, sleeping well, maintaining good sleep hygiene, using heat or ice packs, exercising regularly, and decreasing or limiting alcohol consumptionhave been shown to help reduce headaches [5]. 

For migraine headaches, triptans block pain pathways in the brain and can have side effects such as precipitating strokes or heart attacks in high-risk patients. In drug trials, Lasmiditan significantly improved pain as well as nausea and sensitivity to light and sound, but its side effects include sedation and dizziness and is contraindicated with alcohol. Moreover, Ubrogepant, a calcitonin gene-related peptide receptor antagonist is approved for the treatment of acute migraines, with or without aura in adults. It is the first drug of this type approved for migraine treatment [6]. In drug trials, Ubrogepant was more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it. Common side effects included dry mouth, nausea, and excessive sleepiness. These effects can be contraindicated with strong CYP3A4 inhibitor drugs. Lastly, opioid medications and anti-nausea drugs, reserved for patients who cannot take other migraine medications because of their addiction tendency, can help if the migraine with aura is accompanied by nausea and vomiting and is usually given with pain medications, respectively [7]. Lastly, preventative migraine medications aim to reduce the frequency, severity, and length of migraine headaches. Examples includebeta-blockers, calcium channel blockers, botox injections, Calcitonin Gene-Related Peptide (CGRP) monoclonal antibodies, antidepressants, and anti-seizure drugs. A list of the most used medications and possible side effects is provided below table 1 [8-15]. 

Table 1: Most common used medications and possible side effects.