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{{ClinPsy}}
 
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{{Infobox Symptom
 
{{Infobox Symptom
 
|Name = Headache
 
|Name = Headache
|Image = Headache.jpg
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|Image = Migraine.jpg
|ICD10 = {{ICD10|R|51||r|50}}
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|Caption = Woman with a headache
|ICD9 = {{ICD9|784.0}}
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|ICD10 = {{ICD10|G|43||g|40}}-{{ICD10|G|44||g|40}}, {{ICD10|R|51||r|50}}
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|ICD9 = {{ICD9|339}}, {{ICD9|784.0}}
 
|DiseasesDB = 19825
 
|DiseasesDB = 19825
 
|MedlinePlus = 003024
 
|MedlinePlus = 003024
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|MeshID = D006261
 
|MeshID = D006261
 
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{{otheruses}}
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A '''headache''' or '''cephalalgia''' is [[pain]] anywhere in the region of the [[head]] or [[neck]]. It can be a [[symptom]] of a number of different conditions of the head and neck.<ref>{{DorlandsDict|four/000047369|headache}}</ref> The [[brain tissue]] itself is not sensitive to pain because it lacks [[nociceptors|pain receptors]]. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Nine areas of the head and neck have these pain-sensitive structures, which are the cranium (the [[pericranium|periosteum of the skull]]), [[muscles]], [[nerves]], [[arteries]] and [[veins]], [[subcutaneous tissue]]s, [[Human eyes|eyes]], [[ears]], [[sinuses]] and [[mucous membranes]].
A '''headache''' ('''[[wiktionary:cephalalgia|cephalalgia]]''' in medical terminology) is a condition of pain in the [[head]]; sometimes [[neck]] or upper back pain may also be interpreted as a headache. It ranks amongst the most common local pain complaints and may be frequent for many people.
 
   
The vast majority of headaches are benign and self-limiting. Common causes are [[tension headache|tension]], [[migraine]], [[eye strain]], [[dehydration]], low blood sugar, [[mastication|hypermastication]] and [[sinusitis]]. Much rarer are headaches due to life-threatening conditions such as [[meningitis]], [[encephalitis]], [[cerebral aneurysm]]s, [[hypertensive emergency|extremely high blood pressure]], and [[brain tumor]]s. When the headache occurs in conjunction with a [[head injury]] the cause is usually quite evident. A large percentage of headaches among women are caused by ever-fluctuating [[estrogen]] during [[menstruation|menstrual]] years. This can occur prior to, or even during midcycle menstruation.
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There are a number of different classification systems for headaches. The most well-recognized is that of the [[International Headache Society]]. Headache is a [[non-specific symptom]], which means that it has many possible causes. Treatment of a headache depends on the underlying [[etiology]] or cause, but commonly involves [[analgesics]].
   
Treatment of an uncomplicated headache is usually symptomatic with [[Over-the-counter drug|over-the-counter]] [[analgesic|painkillers]] such as [[aspirin]], [[paracetamol]] (acetaminophen), or [[ibuprofen]], although some specific forms of headaches (e.g., [[Migraine|migraines]]) may demand other, more suitable treatment. It may be possible to relate the occurrence of a headache to other particular triggers (such as stress or particular foods), which can then be avoided.
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==Classification==
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Headaches are most thoroughly classified by the [[International Headache Society]]'s International Classification of Headache Disorders (ICHD), which published the second edition in 2004.<ref name=ICHD2>{{cite web |url=http://216.25.100.131/ihscommon/guidelines/pdfs/ihc_II_main_no_print.pdf |title=216.25.100.131 |format=PDF |work=the Headache Classification Subcommittee of the International Headache Society |accessdate=|archiveurl=http://web.archive.org/web/20040613165925/http://216.25.100.131/ihscommon/guidelines/pdfs/ihc_II_main_no_print.pdf|archivedate=2004-06-13}}</ref> This classification is accepted by the [[WHO]].<ref>Olesen et al., p. 9&ndash;11</ref>
   
== Pathophysiology ==
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Other classification systems exist. One of the first published attempts was in 1951.<ref>{{cite journal |author=BROWN MR |title=The classification and treatment of headache |journal=Med. Clin. North Am. |volume=35 |issue=5 |pages=1485–93 |year=1951 |month=September |pmid=14862569 |doi= |url=}}</ref> The [[National Institutes of Health]] developed a classification system in 1962.<ref>{{Cite journal
The [[brain]] in itself is not sensitive to [[pain]], because it lacks [[nociceptor]]s. Several areas of the head can hurt, including a network of nerves which extend over the scalp and certain nerves in the face, mouth, and throat. The [[meninges]] and the blood vessels do have pain perception. Headaches often result from traction to or irritation of the meninges and blood vessels. The membrane surrounding the brain and spinal cord, called the [[dura mater]], is innervated with nociceptors. Stimulation of these dural nociceptors is thought to be involved in producing headaches. Similarly the muscles of the head may be sensitive to pain.
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|journal= JAMA
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|author=Ad Hoc Committee on Classification of Headache
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|title= Classification of Headache
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|volume=179
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|pages=717–8
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|year=1962
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|doi= 10.1001/jama.1962.03050090045008
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|issue= 9 }}</ref>
   
== Types ==
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===ICHD-2===
{{Unreferencedsection|date=October 2008}}
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{{Main|International Classification of Headache Disorders}}
There are five types of headache: vascular, myogenic (muscle tension), cervicogenic, traction, and inflammatory.
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The [[International Classification of Headache Disorders]] (ICHD) is an in-depth [[hierarchical]] classification of headaches published by the [[International Headache Society]]. It contains explicit (operational) [[diagnostic criteria]] for headache disorders. The first version of the classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in 2004.<ref>{{cite book|title=The Headaches|edition=3|publisher=Lippincott Williams & Wilkins|year=2005|isbn=0-7817-5400-3|author=Jes Olesen, Peter J. Goadsby, Nabih M. Ramadan, Peer Tfelt-Hansen, K. Michael A. Welch}}</ref>
=== Vascular ===
 
{{main|vascular headache}}
 
The most common type of vascular headache is ''[[migraine]]''. Migraine headaches are usually characterized by severe pain on one or both sides of the head, an upset stomach, and, for some people, disturbed vision. It is more common in women. While vascular changes are evident during a migraine, the cause of the headache is [[neurological]], not vascular. After migraine, the most common type of vascular headache is the [[Toxic headache|"toxic" headache]] produced by fever.
 
   
Other kinds of vascular headaches include ''[[cluster headache]]s'', which are very severe recurrent short lasting headaches, often located through or around either eye and often wake the sufferers up at the same time every night. Unlike migraines, these headaches are more common in men than in women.
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The classification uses numeric codes. The top, one-digit diagnostic level includes 13 headache groups. The first four of these are classified as primary headaches, groups 5-12 as secondary headaches, [[Human cranium|cranial]] [[neuralgia]], central and primary facial pain and other headaches for the last two groups.<ref>{{cite book|title=Comprehensive Review of Headache Medicine|publisher=Oxford University Press US|year=2008|isbn=0-19-536673-5|author=Morris Levin, Steven M. Baskin, Marcelo E. Bigal}}</ref>
   
=== Muscular/myogenic ===
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The ICHD-2 classification defines [[migraine]]s, tension-types headaches, [[cluster headache]] and other [[trigeminal]] autonomic cephalalgias as the main types of primary headaches.<ref name="A">{{cite web|url=http://www.textbookofpain.com/storedfiles/McMahon%20Ch54.pdf?CFID=8547982&CFTOKEN=15628127 |title=Headache: classification |date=|accessdate=2010-08-06}} {{Dead link|date=November 2010|bot=H3llBot}}</ref> Also, according to the same classification, stabbing headaches and headaches due to [[cough]], exertion and sexual activity ([[coital cephalalgia]]) are classified as primary headaches. The daily-persistent headaches along with the hypnic headache and thunderclap headaches are considered primary headaches as well.
Muscular (or myogenic) headaches appear to involve the tightening or tensing of facial and neck muscles; they may radiate to the forehead. [[Tension headache]] is the most common form of myogenic headache.
 
   
=== Cervicogenic ===
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Secondary headaches are classified based on their etiology and not on their [[symptoms]].<ref name="A"/> According to the ICHD-2 classification, the main types of secondary headaches include those that are due to head or neck trauma such as [[Whiplash (medicine) |whiplash injury]], [[intracranial hematoma]], post craniotomy or other head or neck injury. Headaches caused by cranial or cervical vascular disorders such as [[Stroke#Ischemic_stroke|ischemic stroke]] and [[transient ischemic attack]], non-traumatic intracranial hemorrhage, [[Cerebral arteriovenous malformation|vascular malformations]] or [[arteritis]] are also defined as secondary headaches. This type of headaches may also be caused by [[cerebral venous thrombosis]] or different intracranial vascular disorders. Other secondary headaches are those due to intracranial disorders that are not vascular such as low or high pressure of the cerebrospinal fluid pressure, non-infectious inflammatory disease, intracranial neoplasm, [[epileptic seizure]] or other types of disorders or diseases that are intracranial but that are not associated with the vasculature of the [[central nervous system]]. ICHD-2 classifies headaches that are caused by the ingestion of a certain substance or by its withdrawal as secondary headaches as well. This type of headache may result from the overuse of some medications or by exposure to some substances. [[HIV]]/[[AIDS]], intracranial [[infections]] and systemic infections may also cause secondary headaches. The ICHD-2 system of classification includes the headaches associated with homeostasis disorders in the category of secondary headaches. This means that headaches caused by [[dialysis]], [[high blood pressure]], [[hypothyroidism]], and cephalalgia and even [[fasting]] are considered secondary headaches. Secondary headaches, according to the same classification system, can also be due to the injury of any of the facial structures including [[teeth]], jaws, or [[temporomandibular joint]]. Headaches caused by psychiatric disorders such as [[somatization]] or [[psychotic disorders]] are also classified as secondary headaches.
Cervicogenic headaches originate from disorders of the neck, including the anatomical structures innervated by the cervical roots C1–C3. Cervical headache is often precipitated by neck movement and/or sustained awkward head positioning. It is often accompanied by restricted cervical range of motion, ipsilateral neck, shoulder, or arm pain of a rather vague non-radicular nature or, occasionally, arm pain of a radicular nature.
 
   
=== Traction/inflammatory ===
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The ICHD-2 classification puts cranial neuralgias and other types of [[neuralgia]] in a different category. According to this system, there are 19 types of neuralgias and headaches due to different central causes of facial pain. Moreover, the ICHD-2 includes a category that contains all the headaches that cannot be classified.
[[Image:PET3.jpg|right|thumb|150px|[[Positron emission tomography]] functional imaging shows activation of specific brain areas during a cluster headache.]]
 
Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection.
 
Specific types of headaches include:
 
*[[Tension headache]]
 
*[[Migraine]]
 
*[[Idiopathic intracranial hypertension]] (headache with visual symptoms due to raised [[intracranial pressure]])
 
*[[Ictal headache]]
 
*[[Cluster headache]]
 
*"[[Brain freeze]]" (also known as: ice cream headache)
 
*[[Thunderclap headache]]
 
*[[Vascular headache]]
 
*[[Toxic headache]]
 
*[[Coital cephalalgia]] (also known as: sex headache)
 
*[[Hemicrania continua]]
 
*[[Rebound headache]] (also called medication overuse headache, abbreviated MOH)
 
*[[Red wine headache]]
 
*"Spinal headache" (or: [[post-dural puncture headache]]s) after [[lumbar puncture]] or related procedure that will lower the [[intracranial pressure]]
 
*[[Hangover]] (caused by heavy alcohol consumption)
 
   
A headache may also be a symptom of [[sinusitis]].
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Although the ICHD-2 is the most complete headache classification there is and it includes frequency in the diagnostic criteria of some types of headaches (primarily primary headaches), it does not specifically code frequency or severity which are left at the discretion of the examiner.<ref name="A"/>
   
Like other types of pain, headaches can serve as warning signals of more serious disorders. This is particularly true for headaches caused by [[inflammation]], including those related to [[meningitis]] as well as those resulting from diseases of the sinuses, spine, neck, ears, and teeth.
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=== NIH ===
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{{Main|NIH classification of headaches}}
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The NIH classification consists of brief definitions of a limited number of headaches.<ref name="Levine et al., p 60"/>
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<!--It outlines five types of headache: vascular, myogenic (muscle tension), cervicogenic, traction, and inflammatory.-->
   
== Diagnosis ==
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The NIH system of classification is more succinct and only describes five categories of headaches. In this case, primary headaches are those that do not show organic or structural etiology. According to this classification, headaches can only be vascular, [[myogenic]], cervicogenic, traction and inflammatory.
While, statistically, headaches are most likely to be harmless and self-limiting, some specific headache syndromes may demand specific treatment or may be warning signals of more serious disorders. Some headache subtypes are characterized by a specific pattern of symptoms, and no further testing may be necessary, while others may prompt further diagnostic tests.
 
   
Headache associated with specific symptoms may warrant urgent medical attention, particularly sudden, severe headache or sudden headache associated with a [[neck stiffness|stiff neck]]; headaches associated with [[fever]], [[convulsion]]s or accompanied by confusion or [[loss of consciousness]]; headaches following a blow to the head, or associated with pain in the eye or ear; persistent headache in a person with no previous history of headaches; and recurring headache in children.
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==Cause==
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There are over 200 types of headaches, and the causes range from harmless to life-threatening. The description of the headache, together with findings on [[neurological examination]], determines the need for any further investigations and the most appropriate treatment.<ref name=SIGN>{{cite book | author=Scottish Intercollegiate Guideline Network | title=Diagnosis and management of headache in adults | location=Edinburgh | date=November 2008 | isbn=978-1-905813-39-1 | url=http://www.sign.ac.uk/guidelines/fulltext/107/}}</ref>
   
The most important step in diagnosing a headache is for the physician to take a careful history and to examine the patient. In the majority of cases the diagnosis will be a "primary headache" which means that the headache, whilst unpleasant is not occurring as a manifestation of a more serious condition. The main types of primary headache are tension headache, migraine, and the trigeminal autonomic cephalalgias of which cluster headache is an example. As it is often difficult for patients to recall the precise details regarding each headache, it is often useful for the sufferer to fill-out a "headache diary" detailing the characteristics of the headache. When the headache does not clearly fit into one of the recognized primary headache syndromes or when atypical symptoms or signs are present then further investigations are justified.<ref>Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA 2006;296:1274–83</ref> [[Computed tomography]] (CT/CAT) scans of the brain or sinuses are commonly performed, or [[magnetic resonance imaging]] (MRI) in specific settings. [[Blood test]]s may help narrow down the [[differential diagnosis]], but are rarely confirmatory of specific headache forms.
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===Primary headaches===
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The most common types of headache are the "primary headache disorders", such as [[Tension headache|tension-type headache]] and [[migraine]]. They have typical features; migraine, for example, tends to be pulsating in character, affecting one side of the head, associated with [[nausea]], disabling in severity, and usually lasts between 3 hours and 3 days. Rarer primary headache disorders are [[trigeminal neuralgia]] (a shooting face pain), [[cluster headache]] (severe pains that occur together in bouts), and [[hemicrania continua]] (a continuous headache on one side of the head).<ref name=SIGN/>
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===Secondary headaches===
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Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). [[Medication overuse headache]] may occur in those using excessive painkillers for headaches, paradoxically causing worsening headaches.<ref name=SIGN/>
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A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes; some of these may be life-threatening or cause long-term damage. A number of "red flag" symptoms therefore means that a headache warrants further investigations, usually by a specialist. The red flag symptoms are a new or different headache in someone over 50 years old, headache that develops within minutes ([[thunderclap headache]]), [[paresis|inability to move a limb]] or abnormalities on [[neurological examination]], [[mental confusion]], being woken by headache, headache that worsens with changing posture, headache worsened by exertion or [[Valsalva manoeuvre]] (coughing, straining), [[visual loss]] or visual abnormalities, [[claudication#Jaw|jaw claudication]] (jaw pain on chewing that resolves afterwards), [[meningism|neck stiffness]], [[fever]], and headaches in people with [[HIV]], [[cancer]] or risk factors for [[thrombosis]].<ref name=SIGN/>
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"Thunderclap headache" may be the only symptom of [[subarachnoid hemorrhage]], a form of [[stroke]] in which blood accumulates around the brain, often from a ruptured [[Intracranial berry aneurysm|brain aneurysm]]. Headache with fever may be caused by [[meningitis]], particularly if there is meningism (inability to flex the neck forward due to stiffness), and confusion may be indicative of [[encephalitis]] (inflammation of the brain, usually due to particular [[virus]]es). Headache that is worsened by straining or a change in position may be caused by increased [[intracranial pressure|pressure in the skull]]; this is often worse in the morning and associated with vomiting. Raised intracranial pressure may be due to [[brain tumor]]s, [[idiopathic intracranial hypertension]] (IIH, more common in younger overweight women) and occasionally [[cerebral venous sinus thrombosis]]. Headache together with weakness in part of the body may indicate a [[stroke]] (particularly [[intracranial hemorrhage]] or [[subdural hematoma]]) or brain tumor. Headache in older people, particularly when associated with visual symptoms or jaw claudication, may indicate [[giant cell arteritis]] (GCA), in which the [[vasculitis|blood vessel wall is inflamed]] and obstructs blood flow. [[Carbon monoxide poisoning]] may lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and blurred vision. [[Glaucoma|Angle closure glaucoma]] (acute raised [[Intraocular pressure|pressure in the eyeball]]) may lead to headache, particularly around the eye, as well as visual abnormalities, nausea, vomiting and a red eye with a dilated pupil.<ref name=SIGN/>
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== Pathophysiology ==
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The [[Human brain|brain]] itself is not sensitive to [[pain]], because it lacks [[nociceptor|pain receptors]]. However, several areas of the [[head]] and [[neck]] do have nociceptors, and can thus sense pain. These include the extracranial arteries, large veins, cranial and spinal nerves, head and neck muscles and the [[meninges]].<ref name=ACEP2008/>
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Headache often results from traction to or irritation of the meninges and blood vessels. The nociceptors may also be stimulated by other factors than head trauma or tumors and cause headaches. Some of these include [[Stress (biology)|stress]], dilated [[blood vessels]] and muscular tension. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts.<ref>{{cite web|url=http://www.experiencefestival.com/a/Headache_-_Pathophysiology/id/1292096| title=Headache - Pathophysiology|date=|accessdate= June 21, 2010}}</ref>
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It has been suggested that the level of [[endorphins]] in one's body may have a great impact on how people feel headaches{{Citation needed|date=March 2012}}. Thus, it is believed that people who suffer from chronic headaches or severe headaches have lower levels of endorphins compared to people who do not complain of headaches.
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Primary headaches are even more difficult to understand than secondary headaches. Although the pathophysiology of migraines, cluster headaches and tension headaches is still not well understood, there have been different theories over time which attempt to provide an explanation of what exactly happens within the brain when individuals suffer from headaches. One of the oldest such theories is referred to as the vascular theory which was developed in the middle of the 20th century.<ref>{{cite journal |author=Goadsby PJ |title=The vascular theory of migraine--a great story wrecked by the facts |journal=Brain |volume=132 |issue=Pt 1 |pages=6–7 |year=2009 |month=January |pmid=19098031 |doi=10.1093/brain/awn321 |url=http://brain.oxfordjournals.org/content/132/1/6.full}}</ref> The vascular theory was proposed by Wolff and it described the intracranial vasoconstriction as being responsible for the [[Aura (symptom)|aura]] of the migraine. The headache was believed to result from the subsequent rebound of the dilatation of the blood vessels which led to the activation of the perivascular nociceptive nerves. The developers of this theory took into consideration the changes that occur within the blood vessels outside the [[Human cranium|cranium]] when a migraine attack occurs and other data that was available at that time including the effect of vasodilators and vasoconstrictors on headaches.
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The neurovascular approach towards primary headaches is currently accepted by most specialists. According to this newer theory, migraines are triggered by a complex series of neural and vascular events. Different studies concluded that individuals who suffer from migraines but not from headache have a state of neuronal hyperexcitability in the [[cerebral cortex]], especially in the [[occipital cortex]].<ref name="B">{{cite web|url=http://emedicine.medscape.com/article/1144656-overview |title=Pathophysiology and Treatment of Migraine and Related Headache |date=|accessdate=2010-08-06}}</ref> People who are more susceptible to experience migraines without headache are those who have a family history of migraines, women, and women who are experiencing hormonal changes or are taking [[birth control pills]] or are prescribed [[Hormone replacement therapy (menopause)|hormone replacement therapy]].<ref name="C">{{cite web|url=http://www.migraineheadachetreatment.us/without.php|title=Migraine Without Headache |date=|accessdate=2010-08-06}}</ref>
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== Diagnosis approach ==
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{| style="float:right; width:40em; border:solid 1px #999999; margin:0 0 1em 1em;"
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|-
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! colspan="4" style="background-color: #CCEEEE;" | Differential diagnosis of headaches
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|-
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![[Tension headache]]
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![[New daily persistent headache]]
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![[Cluster headache]]
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![[Migraine]]
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|-
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|mild to moderate dull or aching pain<ref name="BBDtriptans">{{Cite document |author1 = Consumer Reports|author1-link = Consumer Reports |author2 = Drug Effectiveness Review Project |author2-link =Drug Effectiveness Review Project |date =March 2013 |title = Using the Triptans to Treat: Migraine Headaches Comparing Effectiveness, Safety, and Price |publisher = consumer Reports |work = Best Buy Drugs |page = 8 |url = http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/triptanFINAL.pdf |accessdate = 18 March 2013}}</ref>
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|
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|severe pain<ref name="BBDtriptans"/>
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|moderate to severe pain<ref name="BBDtriptans"/>
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|-
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|duration of 30 minutes to several hours<ref name="BBDtriptans"/>
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|duration of at least four hours daily<ref name="BBDtriptans"/>
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|duration of 30-minutes to 3 hours<ref name="BBDtriptans"/>
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|duration of 4 hours to 3 days<ref name="BBDtriptans"/>
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|-
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|
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|Occur in periods of 15 days a month for three months<ref name="BBDtriptans"/>
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|may happen multiple times in a day for months<ref name="BBDtriptans"/>
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|periodic occurrence; several per month to several per year<ref name="BBDtriptans"/>
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|-
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|located as tightness or pressure across head<ref name="BBDtriptans"/>
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|located on one or both sides of head<ref name="BBDtriptans"/>
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|located one side of head focused at eye or [[Temple (anatomy)|temple]]<ref name="BBDtriptans"/>
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|located on one or both sides of head<ref name="BBDtriptans"/>
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|-
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|
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|consistent pain<ref name="BBDtriptans"/>
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|pain describable as sharp or stabbing<ref name="BBDtriptans"/>
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|pulsating or throbbing pain<ref name="BBDtriptans"/>
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|-
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|no nausea or vomiting<ref name="BBDtriptans"/>
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|
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|
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|nausea, perhaps with vomiting <ref name="BBDtriptans"/>
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|-
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|no [[Aura (symptom)|aura]]<ref name="BBDtriptans"/>
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|no aura<ref name="BBDtriptans"/>
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|
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|auras<ref name="BBDtriptans"/>
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|-
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|uncommonly, [[Photosensitivity in humans|light sensitivity]] or noise sensitivity<ref name="BBDtriptans"/>
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|
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|may be accompanied by [[running nose]], [[tears]], and [[Ptosis (eyelid)|drooping eyelid]], often only on one side<ref name="BBDtriptans"/>
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|sensitivity to movement, light, and noise<ref name="BBDtriptans"/>
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|-
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|
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|exacerbated by regular use of [[acetaminophen]] or [[NSAIDS]]<ref name="BBDtriptans"/>
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|
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|may exist with tension headache<ref name="BBDtriptans"/>
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|-
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|}
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The [[American College of Emergency Physicians]] have guidelines on the evaluation and management of adult patients who have a nontraumatic headache of acute onset.<ref name=ACEP2008>{{cite journal |author=Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW |title=Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache |journal=Ann Emerg Med |volume=52 |issue=4 |pages=407–36 |year=2008 |month=October |pmid=18809105 |doi=10.1016/j.annemergmed.2008.07.001 |url=}}</ref>
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While, statistically, headaches are most likely to be primary (non serious and self-limiting), some specific secondary headache syndromes may demand specific treatment or may be warning signals of more serious disorders. Differentiating between primary and secondary headaches can be difficult.
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As it is often difficult for patients to recall the precise details regarding each headache, it is often useful for the sufferer to fill-out a "headache diary" detailing the characteristics of the headache. [[Electroencephalogram]]s have not been found to be useful in working up this symptom.<ref>{{cite journal|last=Gronseth|first=GS|coauthors=Greenberg, MK|title=The utility of the electroencephalogram in the evaluation of patients presenting with headache: a review of the literature|journal=Neurology|date=1995 Jul|volume=45|issue=7|pages=1263–7|pmid=7617180|doi=10.1212/WNL.45.7.1263}}</ref>
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===Imaging===
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When the headache does not clearly fit into one of the recognized primary headache syndromes or when atypical symptoms or signs are present then further investigations are justified.<ref>Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA 2006;296:1274–83</ref> Neuroimaging (noncontrast head CT) is recommended if there are new neurological problems such as decreased level of consciousness, one sided weakness, pupil size difference, etc. or if the pain is of sudden onset and severe, or if the person is known HIV positive.<ref name=ACEP2008/> People over the age of 50 years may also warrant a CT scan.<ref name=ACEP2008/>
   
 
== Treatment ==
 
== Treatment ==
Not all headaches require medical attention, and many respond with simple [[analgesia]] (painkillers) such as [[paracetamol|paracetamol/acetaminophen]] or members of the [[Non-steroidal anti-inflammatory drug|NSAID]] class (such as [[aspirin]]/acetylsalicylic acid or [[ibuprofen]]).
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[[File:Image-Lottie Collins sings and dances to the tunes of Ta-Ra-Ra Boom-de-ay in a Bromo-Seltzer ad.jpg|thumb|An old advertisement for a headache medicine.]]
   
In recurrent unexplained headaches, healthcare professionals may recommend keeping a "headache [[diary]]" with entries on type of headache, associated symptoms, precipitating and aggravating factors. This may reveal specific patterns, such as an association with [[medication]], [[menstruation]] or [[absenteeism]] or with certain foods.
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===Chronic headaches===
It was reported in March 2007 by two separate teams of researchers that stimulating the brain with implanted electrodes appears to help ease the pain of cluster headaches.<ref>[http://newsmax.com/archives/articles/2007/3/8/155943.shtml Brain Stimulation May Ease Headaches]. [[Reuters]], [[March 9]], [[2007]].</ref>
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{{see also|Management of chronic headaches}}
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In recurrent unexplained headaches keeping a "headache [[diary]]" with entries on type of headache, associated symptoms, precipitating and aggravating factors may be helpful. This may reveal specific patterns, such as an association with [[medication]], [[menstruation]] or [[absenteeism]] or with certain foods.
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It was reported in March 2007 by two separate teams of researchers that stimulating the brain with implanted electrodes appears to help ease the pain of [[cluster headache]]s.<ref>[http://newsmax.com/archives/articles/2007/3/8/155943.shtml Brain Stimulation May Ease Headaches]. [[Reuters]], March 9, 2007.</ref>
   
=== Prevention ===
+
[[Acupuncture]] has been found to be beneficial in chronic headaches<ref>{{cite journal |author=Sun Y, Gan TJ |title=Acupuncture for the management of chronic headache: a systematic review |journal=Anesth. Analg. |volume=107 |issue=6 |pages=2038–47 |year=2008 |month=December |pmid=19020156 |doi=10.1213/ane.0b013e318187c76a |url=}}</ref> of both tension type<ref>{{Cite journal | last1 = Linde | first1 = K. | last2 = Allais | first2 = G. | last3 = Brinkhaus | first3 = B. | last4 = Manheimer | first4 = E. | last5 = Vickers | first5 = A. | last6 = White | first6 = AR. | title = Acupuncture for tension-type headache | journal = Cochrane Database Syst Rev | volume = | issue = 1 | pages = CD007587 | month = | year = 2009 | doi = 10.1002/14651858.CD007587 | pmid = 19160338 | last7 = Linde | first7 = Klaus | editor1-last = Linde | editor1-first = Klaus | pmc = 3099266 }}</ref> and migraine type.<ref name="ReferenceA">{{Cite journal | last1 = Linde | first1 = K. | last2 = Allais | first2 = G. | last3 = Brinkhaus | first3 = B. | last4 = Manheimer | first4 = E. | last5 = Vickers | first5 = A. | last6 = White | first6 = AR. | title = Acupuncture for migraine prophylaxis | journal = Cochrane Database Syst Rev | volume = | issue = 1 | pages = CD001218 | month = | year = 2009 | doi = 10.1002/14651858.CD001218.pub2 | pmid = 19160193 | last7 = Linde | first7 = Klaus | pmc=3099267 | editor1-last = Linde | editor1-first = Klaus}}</ref> Research comparing acupuncture to 'sham' acupuncture has shown that the results of acupuncture may be due to the [[placebo effect]].<ref name="ReferenceA"/>
Some forms of headache, such as [[migraine]], may be amenable to preventative treatment. On the whole, long-term use of painkillers is discouraged as this may lead to drug induced headaches and "rebound headaches" on withdrawal.<ref>{{cite journal |author= Fritsche G, Diener HC |title= Medication overuse headaches—what is new? |journal= Expert Opin Drug Saf |volume=1 |issue=4 |year=2002 |pages=331–8 |pmid=12904133 |doi=10.1517/14740338.1.4.331}}</ref> [[Caffeine]], a [[vasoconstrictor]], is sometimes prescribed or recommended as a remedy or supplement to pain killers in the case of extreme migraine. This has led to the development of [[paracetamol]]/[[caffeine]] [[analgesic]].
 
   
[[Petasites]], [[magnesium]], [[feverfew]]. [[riboflavin]], [[CoQ10]], and [[melatonin]] are "natural" supplements that have shown some efficacy for migraine prevention; a 2006 review tentatively ranked [[petasites]] and [[magnesium]] with the best evidence, and melatonin with by far the least. Adverse events included sore mouth and tongue (including ulcers) and abdominal pain for feverfew.<ref>{{cite journal |author= Evans RW, Taylor FR |title= 'Natural' or alternative medications for migraine prevention |journal=Headache |volume=46 |issue=6 |pages=1012–8 |year=2006 |pmid=16732849 |doi=10.1111/j.1526-4610.2006.00473.x}}</ref>
+
One type of treatment, however, is usually not sufficient for chronic sufferers and they may have to find a variety of different ways of managing, living with, and seeking treatment of chronic daily headache pains.<ref>{{cite web|url=http://www.chronicheadache.us/treatment.html| title=Chronic Headache Treatments|date=|accessdate= June 21, 2010}}</ref>
   
=== Manual therapy ===
+
There are however two types of treatment for chronic headaches, i.e. acute abortive treatment and preventive treatment. Whereas the first is aimed to relieve the symptoms immediately, the latter is focused on controlling the headaches that are chronic. For this reason, the acute treatment is commonly and effectively used in treating migraines and the preventive treatment is the usual approach in managing chronic headaches. The primary goal of preventive treatment is to reduce the frequency, severity, and duration of headaches. This type of treatment involves taking medication on a daily basis for at least 3 months and in some cases, for over 6 months.<ref name="emedicine.medscape.com">{{cite web|url=http://emedicine.medscape.com/article/1144656-overview| title=Pathophysiology and Treatment of Migraine and Related Headache|date=|accessdate= June 21, 2010}}</ref> The medication used in preventive treatment is normally chosen based on the other conditions that the patient is suffering from. Generally, medication in preventive treatment starts at the minimum dosage which increases gradually until the pain is relieved and the goal achieved or until side effects appear.
Headache sufferers often use [[manual therapy]], such as [[spinal manipulation]], [[soft tissue therapy]], and [[Myofascial Release|myofascial trigger point treatment]]. A 2006 systematic review found no rigorous evidence supporting manual therapies for tension headache.<ref>{{cite journal |journal= Clin J Pain |year=2006 |volume=22 |issue=3 |pages=278–85 |title= Are manual therapies effective in reducing pain from tension-type headache?: a systematic review |author= Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA |doi=10.1097/01.ajp.0000173017.64741.86 |pmid=16514329}}</ref> A 2005 structured review found that the evidence was weak for effectiveness of [[chiropractic]] manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.<ref>{{cite journal |journal=Headache |year=2005 |volume=45 |issue=6 |pages=738–46 |title= Physical treatments for headache: a structured review |doi=10.1111/j.1526-4610.2005.05141.x |author= Biondi DM |pmid=15953306}}</ref> A 2004 [[Cochrane review]] found that spinal manipulation may be effective for migraine and tension headache, and that spinal manipulation and neck exercises may be effective for cervicogenic headache.<ref>{{cite journal |journal= Cochrane Database Syst Rev |year=2004 |issue=3 |pages=CD001878 |title= Non-invasive physical treatments for chronic/recurrent headache |author= Bronfort G, Nilsson N, Haas M ''et al.'' |doi=10.1002/14651858.CD001878.pub2 |pmid=15266458}}</ref> Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of spinal manipulation.<ref>{{cite journal |journal= J R Soc Med |year=2006 |volume=99 |issue=4 |pages=192–6 |title= A systematic review of systematic reviews of spinal manipulation |author= Ernst E, Canter PH |doi=10.1258/jrsm.99.4.192 |pmid=16574972 |url=http://www.jrsm.org/cgi/content/full/99/4/192}}</ref>
 
   
Spinal manipulation is associated with frequent, mild and temporary [[Adverse effect (medicine)|adverse effects]],<ref name=Ernst-adverse/> including new or worsening pain or stiffness in the affected region.<ref name=Thiel>{{cite journal |journal=Spine |year=2007 |volume=32 |issue=21 |pages=2375–8 |title= Safety of chiropractic manipulation of the cervical spine: a prospective national survey |author= Thiel HW, Bolton JE, Docherty S, Portlock JC |pmid=17906581}}</ref> They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours.<ref>{{cite journal |journal= J Can Chiropr Assoc |year=2005 |volume=49 |issue=3 |pages=158–209 |title= Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash |author= Anderson-Peacock E, Blouin JS, Bryans R ''et al.'' |url=http://www.jcca-online.org/Client/cca/jcca.nsf/objects/jcca-v49-3-158/$file/jcca-v49-3-158.pdf |format=PDF}} • {{cite journal |journal= J Can Chiropr Assoc |year=2008 |volume=52 |issue=1 |pages=7–8 |title= A clinical practice guideline update from The CCA•CFCREAB-CPG |author= Anderson-Peacock E, Bryans B, Descarreaux M ''et al.'' |url=http://www.jcca-online.org/Client/cca/JCCA.nsf/objects/JCCA_March_2008_52_1/$file/jcca-v52-1-007.pdf |format=PDF}}</ref> Spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death.<ref name=Ernst-adverse>{{cite journal |journal= [[J R Soc Med]] |year=2007 |volume=100 |issue=7 |pages=330–8 |title= Adverse effects of spinal manipulation: a systematic review |author= Ernst E |pmid=17606755 |url=http://www.jrsm.org/cgi/content/full/100/7/330 |doi=10.1258/jrsm.100.7.330}}</ref> The [[Incidence (epidemiology)|incidence]] of these complications is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, a particular concern.<ref name=Ernst-adverse/> Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and [[vertebrobasilar artery stroke]].<ref>{{cite journal |journal=[[The Neurologist|Neurologist]] |year=2008 |volume=14 |issue=1 |pages=66–73 |title= Does cervical manipulative therapy cause vertebral artery dissection and stroke? |author= Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM |doi=10.1097/NRL.0b013e318164e53d |pmid=18195663}}</ref>
+
To date, only [[amitriptyline]], [[fluoxetine]], [[gabapentin]], [[tizanidine]], [[topiramate]], and [[Botulinum toxin type a|botulinum toxin type A]] (BoNTA) have been evaluated as "prophylactic treatment of chronic daily headache in randomized, double-blind, placebo-controlled or active comparator-controlled trials. [[Antiepileptics]] can be used as preventative treatment of chronic daily headache and includes [[Valproate]].<ref name="emedicine.medscape.com"/>
  +
  +
Psychological treatments are usually considered in comorbid patients or in those who are unresponsive to the medication.
  +
  +
==Epidemiology==
  +
During a given year, 90% of people suffer from headaches. Of the ones seen in the [[Emergency department|ER]], about 1% have a serious underlying problem.<ref>{{cite book |author=Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey |title=Emergency medicine: avoiding the pitfalls and improving the outcomes |publisher=Blackwell Pub./BMJ Books |location=Malden, Mass |year=2007 |pages=39 |isbn=1-4051-4166-2 |oclc= |doi= |accessdate=}}</ref>
  +
  +
Primary headaches account for more than 90% of all headache complaints, and of these, episodic tension-type headache is the most common.<ref name="D">{{cite web|url=http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/headache-syndromes/ |title=Headache |date=|accessdate=2010-08-06}}</ref>
  +
  +
It is estimated that women are three times more prone than men to suffer from migraines. Also, the prevalence of this particular type of headache seems to vary depending on the specific area of the world where one lives. However, migraines appear to be experienced by 12% to 18% of the population.<ref name="D"/>
  +
  +
Cluster headaches are thought to affect less than 0.5% of the population, though their prevalence is hard to estimate because they are often mistaken for a sinusal problem. However, according to the existent data, cluster headaches are more likely to occur in [[men]] than [[women]], given that the condition tends to affect 5 to 8 times more men.
  +
  +
==History==
  +
[[File:Cruikshank - The Head Ache.png|thumb|An 1819 caricature by [[George Cruikshank]] depicting a headache.]]
  +
The first recorded classification system that resembles the modern ones was published by [[Thomas Willis]], in ''De Cephalalgia'' in 1672. In 1787 [[Christian Baur]] generally divided headaches into [[idiopathic]] (primary headaches) and [[symptomatic]] (secondary ones), and defined 84 categories.<ref name="Levine et al., p 60">Levine et al., p 60</ref>
  +
  +
==Children==
  +
  +
[[Child]]ren can suffer from the same types of headaches as adults do although their symptoms may vary. Some kinds of headaches include tension headaches, migraines, chronic daily headaches, cluster headache and sinus headaches.<ref>{{cite web|url=http://www.kidsmigraine.com/| title=Children Headaches Are Not Made Up|date=|accessdate= 2010-06-30}}</ref> [[Dental braces]] and [[orthodontic headgear]] (due to the constant pressure placed on the jaw area) are also known for causing occasional to frequent headaches in adolescents. It is actually common for headaches to start in childhood or [[adolescence]], for instance, 20% of adults who suffer headaches report that their headaches started before age 10 while 50% report they started before age 20. The incidence of headaches in children and adolescents is very common. One study reported that 56% of [[boy]]s and 74% of [[girls]] between 12 and 17 indicated having experienced a form of headache within the past month.<ref>{{cite web|url=http://www.webmd.com/migraines-headaches/guide/your-childs-headache| title=How Common Are Headaches in Children and Adolescents?|date=|accessdate= 2010-06-30}}</ref>
  +
  +
The causes of headaches in children include either one factor or a combination of factors. Some of the most common factors include [[genetic predisposition]], especially in the case of migraine; [[head trauma]], produced by accidental falls; illness and [[infection]], for example in the presence of [[Ear infection|ear]] or [[sinus infection]] as well as [[Common cold|colds]] and [[Influenza|flu]]; [[environmental factors]], which include [[weather]] changes; emotional factors, such as [[Stress (biology)|stress]], [[anxiety]], and [[Depression (mood)|depression]]; [[food]]s and [[beverages]], [[caffeine]] or [[food additives]]; change in [[sleep]] or routine pattern; loud noises. Also, excess [[physical activity]] or [[Sunburn|sun]] may be a trigger specifically of migraine.<ref>{{cite web|url=http://www.mayoclinic.com/health/headaches-in-children/DS01132/DSECTION=causes| title=Causes|date=|accessdate= 2010-06-30}}</ref>
  +
  +
Although most cases of headaches in children are considered to be [[benign]], when they are accompanied with other symptoms such as [[speech problems]], [[muscle weakness]], and [[loss of vision]], a more serious underlying cause may be suspected: [[hydrocephalus]], [[meningitis]], [[encephalitis]], [[abscess]], [[hemorrhage]], [[tumor]], [[blood clot]]s, or [[head trauma]]. In these cases, the headache evaluation may include CT scan or MRI in order to look for possible structural disorders of the [[central nervous system]].<ref>{{cite web|url=http://www.webmd.com/migraines-headaches/guide/your-childs-headache| title=What Causes Headaches in Children and Adolescents?|date=|accessdate= 2010-06-30}}</ref>
  +
  +
Some measures can help prevent headaches in children. Some of them are drinking plenty of [[water]] throughout the day; avoiding [[caffeine]]; getting enough and regular sleep; eating balanced [[meals]] at the proper times; and reducing stress and excess of activities.<ref>{{cite web|url=http://www.achenet.org/education/patients/headachesinchildren.asp| title=Headaches in Children|date=|accessdate= 2010-06-30}}</ref>
   
 
==See also==
 
==See also==
  +
* [[Coital cephalalgia]]
  +
* [[Headache attributed to a substance or its withdrawal]]
 
* [[Somatoform disorders]]
 
* [[Somatoform disorders]]
  +
   
   
 
== References ==
 
== References ==
{{reflist|colwidth=30em}}
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{{Reflist|colwidth=30em}}
   
== External links ==
+
==Further reading==
*[http://www.headaches.org/ National Headache Foundation]
+
*{{Cite document| author=Gorman, Christine|coauthor=Park, Alice | title= The New Science of Headaches| publisher= Time | date= 7 October 2002| url= http://www.time.com/time/covers/1101021007/story.html | accessdate= 22 February 2010| postscript=<!--None-->|archiveurl=http://web.archive.org/web/20030212204449/http://www.time.com/time/covers/1101021007/story.html|archivedate=12 February 2003}}
*[http://www.ihs-classification.org/en IHS - The International Headache Classification (ICHD-2)]
 
*[http://www.americanheadachesociety.org American Headache Society]
 
   
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==External links==
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* {{dmoz|Health/Conditions_and_Diseases/Neurological_Disorders/Headaches/}}
   
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Latest revision as of 05:24, August 28, 2014

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Name of Symptom/Sign:
Headache

Woman with a headache
ICD-10 G43-G44, R51
ICD-O: {{{ICDO}}}
ICD-9 339, 784.0
OMIM {{{OMIM}}}
MedlinePlus 003024
eMedicine neuro/517
DiseasesDB 19825

A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck.[1] The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Nine areas of the head and neck have these pain-sensitive structures, which are the cranium (the periosteum of the skull), muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes.

There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society. Headache is a non-specific symptom, which means that it has many possible causes. Treatment of a headache depends on the underlying etiology or cause, but commonly involves analgesics.

ClassificationEdit

Headaches are most thoroughly classified by the International Headache Society's International Classification of Headache Disorders (ICHD), which published the second edition in 2004.[2] This classification is accepted by the WHO.[3]

Other classification systems exist. One of the first published attempts was in 1951.[4] The National Institutes of Health developed a classification system in 1962.[5]

ICHD-2Edit

Main article: International Classification of Headache Disorders

The International Classification of Headache Disorders (ICHD) is an in-depth hierarchical classification of headaches published by the International Headache Society. It contains explicit (operational) diagnostic criteria for headache disorders. The first version of the classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in 2004.[6]

The classification uses numeric codes. The top, one-digit diagnostic level includes 13 headache groups. The first four of these are classified as primary headaches, groups 5-12 as secondary headaches, cranial neuralgia, central and primary facial pain and other headaches for the last two groups.[7]

The ICHD-2 classification defines migraines, tension-types headaches, cluster headache and other trigeminal autonomic cephalalgias as the main types of primary headaches.[8] Also, according to the same classification, stabbing headaches and headaches due to cough, exertion and sexual activity (coital cephalalgia) are classified as primary headaches. The daily-persistent headaches along with the hypnic headache and thunderclap headaches are considered primary headaches as well.

Secondary headaches are classified based on their etiology and not on their symptoms.[8] According to the ICHD-2 classification, the main types of secondary headaches include those that are due to head or neck trauma such as whiplash injury, intracranial hematoma, post craniotomy or other head or neck injury. Headaches caused by cranial or cervical vascular disorders such as ischemic stroke and transient ischemic attack, non-traumatic intracranial hemorrhage, vascular malformations or arteritis are also defined as secondary headaches. This type of headaches may also be caused by cerebral venous thrombosis or different intracranial vascular disorders. Other secondary headaches are those due to intracranial disorders that are not vascular such as low or high pressure of the cerebrospinal fluid pressure, non-infectious inflammatory disease, intracranial neoplasm, epileptic seizure or other types of disorders or diseases that are intracranial but that are not associated with the vasculature of the central nervous system. ICHD-2 classifies headaches that are caused by the ingestion of a certain substance or by its withdrawal as secondary headaches as well. This type of headache may result from the overuse of some medications or by exposure to some substances. HIV/AIDS, intracranial infections and systemic infections may also cause secondary headaches. The ICHD-2 system of classification includes the headaches associated with homeostasis disorders in the category of secondary headaches. This means that headaches caused by dialysis, high blood pressure, hypothyroidism, and cephalalgia and even fasting are considered secondary headaches. Secondary headaches, according to the same classification system, can also be due to the injury of any of the facial structures including teeth, jaws, or temporomandibular joint. Headaches caused by psychiatric disorders such as somatization or psychotic disorders are also classified as secondary headaches.

The ICHD-2 classification puts cranial neuralgias and other types of neuralgia in a different category. According to this system, there are 19 types of neuralgias and headaches due to different central causes of facial pain. Moreover, the ICHD-2 includes a category that contains all the headaches that cannot be classified.

Although the ICHD-2 is the most complete headache classification there is and it includes frequency in the diagnostic criteria of some types of headaches (primarily primary headaches), it does not specifically code frequency or severity which are left at the discretion of the examiner.[8]

NIH Edit

Main article: NIH classification of headaches

The NIH classification consists of brief definitions of a limited number of headaches.[9]

The NIH system of classification is more succinct and only describes five categories of headaches. In this case, primary headaches are those that do not show organic or structural etiology. According to this classification, headaches can only be vascular, myogenic, cervicogenic, traction and inflammatory.

CauseEdit

There are over 200 types of headaches, and the causes range from harmless to life-threatening. The description of the headache, together with findings on neurological examination, determines the need for any further investigations and the most appropriate treatment.[10]

Primary headachesEdit

The most common types of headache are the "primary headache disorders", such as tension-type headache and migraine. They have typical features; migraine, for example, tends to be pulsating in character, affecting one side of the head, associated with nausea, disabling in severity, and usually lasts between 3 hours and 3 days. Rarer primary headache disorders are trigeminal neuralgia (a shooting face pain), cluster headache (severe pains that occur together in bouts), and hemicrania continua (a continuous headache on one side of the head).[10]

Secondary headachesEdit

Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication overuse headache may occur in those using excessive painkillers for headaches, paradoxically causing worsening headaches.[10]

A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes; some of these may be life-threatening or cause long-term damage. A number of "red flag" symptoms therefore means that a headache warrants further investigations, usually by a specialist. The red flag symptoms are a new or different headache in someone over 50 years old, headache that develops within minutes (thunderclap headache), inability to move a limb or abnormalities on neurological examination, mental confusion, being woken by headache, headache that worsens with changing posture, headache worsened by exertion or Valsalva manoeuvre (coughing, straining), visual loss or visual abnormalities, jaw claudication (jaw pain on chewing that resolves afterwards), neck stiffness, fever, and headaches in people with HIV, cancer or risk factors for thrombosis.[10]

"Thunderclap headache" may be the only symptom of subarachnoid hemorrhage, a form of stroke in which blood accumulates around the brain, often from a ruptured brain aneurysm. Headache with fever may be caused by meningitis, particularly if there is meningism (inability to flex the neck forward due to stiffness), and confusion may be indicative of encephalitis (inflammation of the brain, usually due to particular viruses). Headache that is worsened by straining or a change in position may be caused by increased pressure in the skull; this is often worse in the morning and associated with vomiting. Raised intracranial pressure may be due to brain tumors, idiopathic intracranial hypertension (IIH, more common in younger overweight women) and occasionally cerebral venous sinus thrombosis. Headache together with weakness in part of the body may indicate a stroke (particularly intracranial hemorrhage or subdural hematoma) or brain tumor. Headache in older people, particularly when associated with visual symptoms or jaw claudication, may indicate giant cell arteritis (GCA), in which the blood vessel wall is inflamed and obstructs blood flow. Carbon monoxide poisoning may lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and blurred vision. Angle closure glaucoma (acute raised pressure in the eyeball) may lead to headache, particularly around the eye, as well as visual abnormalities, nausea, vomiting and a red eye with a dilated pupil.[10]

Pathophysiology Edit

The brain itself is not sensitive to pain, because it lacks pain receptors. However, several areas of the head and neck do have nociceptors, and can thus sense pain. These include the extracranial arteries, large veins, cranial and spinal nerves, head and neck muscles and the meninges.[11]

Headache often results from traction to or irritation of the meninges and blood vessels. The nociceptors may also be stimulated by other factors than head trauma or tumors and cause headaches. Some of these include stress, dilated blood vessels and muscular tension. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts.[12]

It has been suggested that the level of endorphins in one's body may have a great impact on how people feel headaches[citation needed]. Thus, it is believed that people who suffer from chronic headaches or severe headaches have lower levels of endorphins compared to people who do not complain of headaches.

Primary headaches are even more difficult to understand than secondary headaches. Although the pathophysiology of migraines, cluster headaches and tension headaches is still not well understood, there have been different theories over time which attempt to provide an explanation of what exactly happens within the brain when individuals suffer from headaches. One of the oldest such theories is referred to as the vascular theory which was developed in the middle of the 20th century.[13] The vascular theory was proposed by Wolff and it described the intracranial vasoconstriction as being responsible for the aura of the migraine. The headache was believed to result from the subsequent rebound of the dilatation of the blood vessels which led to the activation of the perivascular nociceptive nerves. The developers of this theory took into consideration the changes that occur within the blood vessels outside the cranium when a migraine attack occurs and other data that was available at that time including the effect of vasodilators and vasoconstrictors on headaches.

The neurovascular approach towards primary headaches is currently accepted by most specialists. According to this newer theory, migraines are triggered by a complex series of neural and vascular events. Different studies concluded that individuals who suffer from migraines but not from headache have a state of neuronal hyperexcitability in the cerebral cortex, especially in the occipital cortex.[14] People who are more susceptible to experience migraines without headache are those who have a family history of migraines, women, and women who are experiencing hormonal changes or are taking birth control pills or are prescribed hormone replacement therapy.[15]

Diagnosis approach Edit

Differential diagnosis of headaches
Tension headache New daily persistent headache Cluster headache Migraine
mild to moderate dull or aching pain[16] severe pain[16] moderate to severe pain[16]
duration of 30 minutes to several hours[16] duration of at least four hours daily[16] duration of 30-minutes to 3 hours[16] duration of 4 hours to 3 days[16]
Occur in periods of 15 days a month for three months[16] may happen multiple times in a day for months[16] periodic occurrence; several per month to several per year[16]
located as tightness or pressure across head[16] located on one or both sides of head[16] located one side of head focused at eye or temple[16] located on one or both sides of head[16]
consistent pain[16] pain describable as sharp or stabbing[16] pulsating or throbbing pain[16]
no nausea or vomiting[16] nausea, perhaps with vomiting [16]
no aura[16] no aura[16] auras[16]
uncommonly, light sensitivity or noise sensitivity[16] may be accompanied by running nose, tears, and drooping eyelid, often only on one side[16] sensitivity to movement, light, and noise[16]
exacerbated by regular use of acetaminophen or NSAIDS[16] may exist with tension headache[16]

The American College of Emergency Physicians have guidelines on the evaluation and management of adult patients who have a nontraumatic headache of acute onset.[11]

While, statistically, headaches are most likely to be primary (non serious and self-limiting), some specific secondary headache syndromes may demand specific treatment or may be warning signals of more serious disorders. Differentiating between primary and secondary headaches can be difficult.

As it is often difficult for patients to recall the precise details regarding each headache, it is often useful for the sufferer to fill-out a "headache diary" detailing the characteristics of the headache. Electroencephalograms have not been found to be useful in working up this symptom.[17]

ImagingEdit

When the headache does not clearly fit into one of the recognized primary headache syndromes or when atypical symptoms or signs are present then further investigations are justified.[18] Neuroimaging (noncontrast head CT) is recommended if there are new neurological problems such as decreased level of consciousness, one sided weakness, pupil size difference, etc. or if the pain is of sudden onset and severe, or if the person is known HIV positive.[11] People over the age of 50 years may also warrant a CT scan.[11]

Treatment Edit

File:Image-Lottie Collins sings and dances to the tunes of Ta-Ra-Ra Boom-de-ay in a Bromo-Seltzer ad.jpg

Chronic headachesEdit

In recurrent unexplained headaches keeping a "headache diary" with entries on type of headache, associated symptoms, precipitating and aggravating factors may be helpful. This may reveal specific patterns, such as an association with medication, menstruation or absenteeism or with certain foods. It was reported in March 2007 by two separate teams of researchers that stimulating the brain with implanted electrodes appears to help ease the pain of cluster headaches.[19]

Acupuncture has been found to be beneficial in chronic headaches[20] of both tension type[21] and migraine type.[22] Research comparing acupuncture to 'sham' acupuncture has shown that the results of acupuncture may be due to the placebo effect.[22]

One type of treatment, however, is usually not sufficient for chronic sufferers and they may have to find a variety of different ways of managing, living with, and seeking treatment of chronic daily headache pains.[23]

There are however two types of treatment for chronic headaches, i.e. acute abortive treatment and preventive treatment. Whereas the first is aimed to relieve the symptoms immediately, the latter is focused on controlling the headaches that are chronic. For this reason, the acute treatment is commonly and effectively used in treating migraines and the preventive treatment is the usual approach in managing chronic headaches. The primary goal of preventive treatment is to reduce the frequency, severity, and duration of headaches. This type of treatment involves taking medication on a daily basis for at least 3 months and in some cases, for over 6 months.[24] The medication used in preventive treatment is normally chosen based on the other conditions that the patient is suffering from. Generally, medication in preventive treatment starts at the minimum dosage which increases gradually until the pain is relieved and the goal achieved or until side effects appear.

To date, only amitriptyline, fluoxetine, gabapentin, tizanidine, topiramate, and botulinum toxin type A (BoNTA) have been evaluated as "prophylactic treatment of chronic daily headache in randomized, double-blind, placebo-controlled or active comparator-controlled trials. Antiepileptics can be used as preventative treatment of chronic daily headache and includes Valproate.[24]

Psychological treatments are usually considered in comorbid patients or in those who are unresponsive to the medication.

EpidemiologyEdit

During a given year, 90% of people suffer from headaches. Of the ones seen in the ER, about 1% have a serious underlying problem.[25]

Primary headaches account for more than 90% of all headache complaints, and of these, episodic tension-type headache is the most common.[26]

It is estimated that women are three times more prone than men to suffer from migraines. Also, the prevalence of this particular type of headache seems to vary depending on the specific area of the world where one lives. However, migraines appear to be experienced by 12% to 18% of the population.[26]

Cluster headaches are thought to affect less than 0.5% of the population, though their prevalence is hard to estimate because they are often mistaken for a sinusal problem. However, according to the existent data, cluster headaches are more likely to occur in men than women, given that the condition tends to affect 5 to 8 times more men.

HistoryEdit

File:Cruikshank - The Head Ache.png

The first recorded classification system that resembles the modern ones was published by Thomas Willis, in De Cephalalgia in 1672. In 1787 Christian Baur generally divided headaches into idiopathic (primary headaches) and symptomatic (secondary ones), and defined 84 categories.[9]

ChildrenEdit

Children can suffer from the same types of headaches as adults do although their symptoms may vary. Some kinds of headaches include tension headaches, migraines, chronic daily headaches, cluster headache and sinus headaches.[27] Dental braces and orthodontic headgear (due to the constant pressure placed on the jaw area) are also known for causing occasional to frequent headaches in adolescents. It is actually common for headaches to start in childhood or adolescence, for instance, 20% of adults who suffer headaches report that their headaches started before age 10 while 50% report they started before age 20. The incidence of headaches in children and adolescents is very common. One study reported that 56% of boys and 74% of girls between 12 and 17 indicated having experienced a form of headache within the past month.[28]

The causes of headaches in children include either one factor or a combination of factors. Some of the most common factors include genetic predisposition, especially in the case of migraine; head trauma, produced by accidental falls; illness and infection, for example in the presence of ear or sinus infection as well as colds and flu; environmental factors, which include weather changes; emotional factors, such as stress, anxiety, and depression; foods and beverages, caffeine or food additives; change in sleep or routine pattern; loud noises. Also, excess physical activity or sun may be a trigger specifically of migraine.[29]

Although most cases of headaches in children are considered to be benign, when they are accompanied with other symptoms such as speech problems, muscle weakness, and loss of vision, a more serious underlying cause may be suspected: hydrocephalus, meningitis, encephalitis, abscess, hemorrhage, tumor, blood clots, or head trauma. In these cases, the headache evaluation may include CT scan or MRI in order to look for possible structural disorders of the central nervous system.[30]

Some measures can help prevent headaches in children. Some of them are drinking plenty of water throughout the day; avoiding caffeine; getting enough and regular sleep; eating balanced meals at the proper times; and reducing stress and excess of activities.[31]

See alsoEdit


References Edit

  1. Template:DorlandsDict
  2. 216.25.100.131. (PDF) the Headache Classification Subcommittee of the International Headache Society.
  3. Olesen et al., p. 9–11
  4. BROWN MR (September 1951). The classification and treatment of headache. Med. Clin. North Am. 35 (5): 1485–93.
  5. Ad Hoc Committee on Classification of Headache (1962). Classification of Headache. JAMA 179 (9): 717–8.
  6. Jes Olesen, Peter J. Goadsby, Nabih M. Ramadan, Peer Tfelt-Hansen, K. Michael A. Welch (2005). The Headaches, 3, Lippincott Williams & Wilkins.
  7. Morris Levin, Steven M. Baskin, Marcelo E. Bigal (2008). Comprehensive Review of Headache Medicine, Oxford University Press US.
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  9. 9.0 9.1 Levine et al., p 60
  10. 10.0 10.1 10.2 10.3 10.4 Scottish Intercollegiate Guideline Network (November 2008). Diagnosis and management of headache in adults.
  11. 11.0 11.1 11.2 11.3 Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW (October 2008). Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 52 (4): 407–36.
  12. Headache - Pathophysiology. URL accessed on June 21, 2010.
  13. Goadsby PJ (January 2009). The vascular theory of migraine--a great story wrecked by the facts. Brain 132 (Pt 1): 6–7.
  14. Pathophysiology and Treatment of Migraine and Related Headache. URL accessed on 2010-08-06.
  15. Migraine Without Headache. URL accessed on 2010-08-06.
  16. 16.00 16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08 16.09 16.10 16.11 16.12 16.13 16.14 16.15 16.16 16.17 16.18 16.19 16.20 16.21 16.22 16.23 16.24 16.25 16.26 (March 2013)Using the Triptans to Treat: Migraine Headaches Comparing Effectiveness, Safety, and Price.
  17. Gronseth, GS, Greenberg, MK (1995 Jul). The utility of the electroencephalogram in the evaluation of patients presenting with headache: a review of the literature. Neurology 45 (7): 1263–7.
  18. Detsky ME, McDonald DR, Baerlocher MO, Tomlinson GA, McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA 2006;296:1274–83
  19. Brain Stimulation May Ease Headaches. Reuters, March 9, 2007.
  20. Sun Y, Gan TJ (December 2008). Acupuncture for the management of chronic headache: a systematic review. Anesth. Analg. 107 (6): 2038–47.
  21. (2009). Acupuncture for tension-type headache. Cochrane Database Syst Rev (1): CD007587.
  22. 22.0 22.1 (2009). Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev (1): CD001218.
  23. Chronic Headache Treatments. URL accessed on June 21, 2010.
  24. 24.0 24.1 Pathophysiology and Treatment of Migraine and Related Headache. URL accessed on June 21, 2010.
  25. Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes, 39, Malden, Mass: Blackwell Pub./BMJ Books.
  26. 26.0 26.1 Headache. URL accessed on 2010-08-06.
  27. Children Headaches Are Not Made Up. URL accessed on 2010-06-30.
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  29. Causes. URL accessed on 2010-06-30.
  30. What Causes Headaches in Children and Adolescents?. URL accessed on 2010-06-30.
  31. Headaches in Children. URL accessed on 2010-06-30.

Further readingEdit

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