Tension headache and migraine are the main types of “Primary headaches”, which are headaches without obvious cause.

Tension Headaches

Tension headaches are the most common type of headaches among adults. In a study it was estimated that about 78% people suffer from tension Headache at least once. These are also referred to as muscle contraction headaches or stress headaches.

A tension headache may appear periodically ("episodic," less than 15 days per month) or daily ("chronic," more than 15 days per month). An episodic tension headache may be described as a mild to moderate constant band-like pain or pressure. These headaches may last from 30 minutes to several days. Episodic tension headaches usually begin gradually, and often occur in the middle of the day.

The severity of a tension headache increases significantly with its frequency. Chronic tension headaches come and go over a prolonged period of time. The pain is usually throbbing and affects the front, top or sides of the head. Although the pain may vary in intensity throughout the day, the pain is almost always present. Chronic tension headaches do not affect vision, balance or strength.

About 30%-80% of the adults suffer from occasional tension headaches. Women are twice as likely to suffer from tension-type headaches as men. Most people with episodic tension headaches have them no more than once or twice a month, but the headaches can occur more frequently.

Approximately 3% suffer from chronic daily tension headaches. It also tends to be more common in females. Many people with chronic tension headaches have usually had the headaches for more than 60-90 days.

Causes of Tension Headaches

There is no single cause for tension headaches. This type of headache is not an inherited trait that runs in families. In some people, tightened muscles in the back of the neck and scalp cause tension headaches. Inadequate rest, poor posture, and emotional or mental stress, including depression and unknown factors, may cause this muscle tension

Some type of environmental or internal stress usually triggers tension headaches. The most common sources of stress include family, social relationships, friends, work and school. Some of stressors include problems at home, difficult family life, having no close friends, losing a job, deadlines at work, preparing for tests or exams, competing in sports or other activities, being a perfectionist, being involved in too many activities/organizations and not getting enough sleep.

Episodic tension headaches are usually triggered by an isolated stressful situation or a build-up of stress. Daily stress, such as from a high-pressured job, can lead to chronic tension headaches.

Symptoms of Tension Headaches

Severity/Intensity of Pain: The pain of episodic tension headaches is described as mild to moderate, constant band-like pain, pressure or throbbing. The "severity" of a tension headache increases significantly with its frequency. Chronic tension headaches may vary in intensity throughout the day, but the pain is almost always present.

Location of Pain: Tension headaches affect the front, top or sides of the head.

Frequency of Headaches: A tension-type headache may appear periodically (episodic, less than 15 days per month) or daily (chronic, more than 15 days per month).

Duration of Pain: Episodic tension headaches usually begin gradually, and often occur in the middle of the day. These headaches may last from 30 minutes to several days. Chronic tension headaches come and go over a prolonged period of time.

Other symptoms include sleep disturbances, chronic fatigue, irritability, disturbed concentration, mild sensitivity to light or noise and aching of muscles.

There are no associated neurological symptoms (such as muscle weakness, or blurred vision) in people with tension headaches. In addition, severe sensitivity to light or noise, stomach pain, nausea and vomiting are not symptoms usually associated with tension headaches.

Migraines

A migraine headache occurs with changes in the size and pulsation of the arteries within and outside of the brain. It was estimated that about 16% of the population suffers from migraine. More women than men get migraines and a quarter of all women with migraines suffer four or more attacks a month; 35% experience 1-4 severe attacks a month, and 40% experience one or less than one severe attack a month. Each migraine can last from four hours to three days.

The exact causes of migraines are unknown, although they are related to changes in the brain as well as to genetic causes. People with migraines may inherit the tendency to be affected by certain migraine triggers, such as fatigue, bright lights, weather changes, hormonal changes and others.

There is a migraine "pain centre" in the brain. A migraine begins when hyperactive nerve cells send out impulses to the blood vessels, causing them to clamp down or constrict, followed by dilation (expanding) and the release of several substances that cause the pulsation to be painful.

Triggers of Migraine

Many migraines seem to be triggered by external factors. Possible triggers include:

Emotional Stress :This is one of the most common triggers of migraine headache. During stressful events, certain chemicals in the brain are released to combat the situation .The release of these chemicals can provoke vascular changes that can cause a migraine. Repressed emotions surrounding stress, such as anxiety, worry, excitement, and fatigue can increase muscle tension and dilated blood vessels can intensify the severity of the migraine.

Sensitivity to chemicals and preservatives in foods. Certain articles such as aged cheese, alcoholic beverages, and food additives such as nitrates (in pepperoni, hot dogs etc.) and monosodium glutamate (MSG, commonly found in Chinese food) may be responsible for triggering up to 30% of migraines.

Caffeine :Excessive caffeine consumption in beverages or medicines and withdrawal can cause headaches. The blood vessels seem to become sensitized to caffeine, and when caffeine is not ingested, a headache may occur. Caffiene is useful in treating acute migraine attacks.

Weather conditions. Walking in the sun, changes in barometric pressure, strong winds, or changes in altitude can all trigger a migraine.

Menstrual Periods

Excessive fatigue
Skipping meals
Changes in normal sleep pattern

Migraines and other Medical conditions

Some medical conditions occur more commonly in migraine sufferers

Asthma
Chronic Fatigue Syndrome
High Blood Pressure 
Stroke
Sleep Disorders

Migraines have a tendency to run in families. 80% of migraine sufferers have a family history of migraines. If one parent has a history of migraines, the child has a 50% chance of developing migraines, and if both parents have a history of migraines, the risk jumps to 75%.

Types of Migraines

Symptoms that signal the onset of a migraine are used to describe two types of migraine.

Migraine with aura (known as "classic" migraine)
Migraine without aura (known as "common" migraine)

Premonitory Symptoms

These are generally classified as excitatory or inhibitory in origin. The excitatory symptoms are irritability, elation, hyperactivity, yawing, food craving, intolerance of light or sound and increased bowel or bladder activity. Inhibitory symptoms are mental slowing, poor concentration, word finding difficulty, weakness, fatigue, constipation, abdominal bloating and poor appetite

"Aura" is a warning sign that a migraine is about to begin. Auras occur in about 20%-30% of migraine sufferers. An aura can occur one hour before the attack of pain and last from 15 to 60 minutes. The symptoms always last less than one hour. Visual auras include:

Bright flashing dots or lights
Blind spots
Distorted vision
Temporary vision loss
Wavy or jagged lines

There are also auras that can affect the other senses. These auras can be described simply as having a "funny feeling," or the person may not be able to describe the aura. Other auras may include ringing in the ears, or having changes in smell (such as strange odours), taste or touch.

Migraine headaches can occur in various combinations.

Type of Pain: The headache often begins as a dull ache and develops into throbbing pain. The pain is usually aggravated by physical activity. The pain of a migraine can be described as mild, moderate, or severe.

Location of Pain: The pain in many cases is one sided but can shift to the other side of the head, or it can affect the front of the head or feel like it's affecting the whole head.

Duration of Pain: Most migraines last about 4 hours although severe ones can last up to a week.

Frequency: The frequency of migraines varies widely among individuals. It is common for a migraine sufferer to get 2-4 headaches per month. Some people, however, may get headaches every few days, while others only get a migraine once or twice a year.

Other symptoms that can occur with migraine include:

Sensitivity to light, noise, and odours
Nausea and vomiting, stomach upset, abdominal pain
Loss of appetite
Sensations of being very warm or cold
Paleness
Fatigue
Dizziness
Blurred vision
Diarrhea
Fever (rare)

Postdrome : In the post headache phase 70% have mood changes, 50% have muscular weakness or tiredness and 30% have reduced appetite.

Rare migraine conditions include these types of neurological auras:

Hemiplegic migraine: temporary paralysis or nerve or sensory changes on one side of the body (such as muscle weakness). The onset of the headache may be associated with temporary numbness, dizziness, or vision changes.

Retinal migraine: temporary loss of vision in one eye, along with a dull ache behind the eye that may spread to the rest of the head.

Basilar artery migraine: dizziness, confusion or loss of balance can precede the headache. The headache pain may affect the back of the head. These symptoms usually occur suddenly and can be associated with the inability to speak properly, ringing in the ears, and vomiting. This type of migraine is strongly related to hormonal changes and primarily affects young women.

Status migrainosus: a rare and severe type of migraine that can last 72-hours or longer. The pain and nausea are so intense that people who have this type of headache sometimes need to be hospitalised. Certain medications, or medication withdrawal, can cause this type migraine syndrome.

Ophthalmoplegic migraine: pain around the eye, including paralysis in the muscles surrounding the eye. This is an emergency medical condition, as the symptoms can also be caused by pressure on the nerves behind the eye or an aneurysm. Other symptoms of ophthalmoplegic migraines include droopy eyelid, double vision, or other vision changes. Fortunately, this is a rare form of migraine.

Symptoms of Migraines Without Aura

Migraines without auras are more common, occurring in 80%-85% of migraine sufferers. Several hours before the onset of the headache, the person can experience vague symptoms, including:

Anxiety
Depression
Fatigue or tiredness

The chances of a person with migraine having a serious underlying neurological disease though very low shouldnot be ignored

Usually Tension Headache and Migraine can be diagnosed from the symptoms and examination by the doctor and no expensive investigation is required. Where clinical presentation is atypical and the possibility of an underlying cause is high, investigations like EEG, CT Scan or MRI may be required.

Some of the symptoms which call for further testing are

Sudden onset of severe headache with or without vomiting ( Thunderclap Headache)
Headaches beginning in middle age.
Symptoms like fever, muscular pain, weight loss
Presence of other diseases like malignancy, AIDS
Changes in headache pattern
Neurological signs or changes in mental functions or alertness.

Migraine and Tension Headaches can be preveted to a large extend through medicines and non pharmacologial means. The next article would deal with treatment and prevention of these headaches.

Dr. Daisy Noble
German Medical Care
Jleeb Al Shyouk, Kuwait 

Dr. Noble Zachariah
Specialist Physician
ACFMS, Jahra