Cephalea (headache) is one of the most common disorders of the nervous systems.
There are several types of cephalea. The term primary headache refers to migraine, cluster headache, and tension-type headache. Secondary headache is caused by brain, cranial, internal or psychiatric conditions or substance abuse (e.g. addiction to painkillers). Another type of headache is cranial neuralgia, which includes trigeminal neuralgia.
The most common types are tension-type headache, migraine, cluster headache and chronic headache.
Migraine, in particular, is among the most common disorders in the world. It is a disorder of the familial type which affects 12% of the population on average, with peaks of almost 25% in women of childbearing age. It is in all likelihood the most frequent disorder in a person’s productive years and has heavy economical implications.
Migraine often presents as recurrent episodes alternated with periods of absence of symptoms. A migraine attack occurs with moderate or severe pain, generally pulsating in nature and unilateral (affecting one half of the head). It is made worse by physical activity and is associated with nausea/vomiting and/or sensitivity to light or sound.
A migraine attack may last from four hours to three days.
Migraine can be considered as a complex neurobiological phenomenon due to temporary alteration of the normal functioning of nerve cells, without structural alterations of the nervous system. The neurophysiological bases of migraine are still little known.
Some factors are known to trigger a migraine attack: stress, sleep deprivation, changes in hormones, climate, fasting, intense smells. The role played by foods is often not so central and has recently been scaled down.
Migraine symptoms are very characteristic; a diagnosis can be based only on their presence. They may be preceded by prodromic symptoms such as mood shifts (euphoria, hyperactivity, irritability), increased appetite –especially for sweet foods- or thirst. Approximately 10% of patients experience aura, which includes visual disturbances (experienced as blind spots or bright lights) or tingling; more significant neurological symptoms occur more rarely and include speech impairment, weakness, dizziness and coordination problems (focal neurological signs are particularly associated with basilar migraine and are caused by an affection of the brain stem area, which is reached by the basilar artery).
The pain is often pulsating and often affecting one side of the head (‘migraine’ comes from the Greek words “hemi” –half- and “kranion” – skull). It is made worse by physical activity and is associated with weakness, hypersensitivity to light and sound, nausea and vomiting. The pain is frequently located in the cervical area (most neck headaches are actually acute migraine attacks in which pain concentrates in the cervical area).
Episodes may last from a few hours to several days and can be extremely disabling. They generally lead to interrupting normal daily activities.
Repeated headaches and the constant fear of the next attack damage family, social and work life. Cephalea brings not only pain, but also severe affliction, because it causes social and economical problems for those who suffer from it.
Symptoms, however, are completely reversible.
A precise diagnosis of the type of headache is key to establishing the best treatment. The diagnosis must be carried out by a physician.
There are several drugs that can treat acute attacks, but it is impossible to foresee what type of medication is most effective in every single patient. That is why it is vital to collect all available information on the efficacy of drugs that the patient has already taken in the past, and systematically test efficacy starting from traditional painkillers, which can be very effective if administered in the right dosage.
Adding antiemetics strengthens the effect of medications and counters nausea and vomiting which are often associated with migraine.
Chronic use of the drugs mentioned above may trigger cephalea, which is why their use should be limited to acute attacks.
Besides treatment, an important aspect is prevention.
First of all, one should eliminate all triggers, including especially smoking. The patient should also become aware of particularly stressing situations and avoid them. Relaxation techniques can be very helpful.
If these measures do not lead to a significant decrease in attacks, or if there are more than 4 severe episodes per month, prophylactic drugs are recommended.
There are several drugs with tested prophylactic activity, the efficacy of which needs to be tested with proper dosage and for sufficiently long periods of time.
Prophylaxis should be followed for at least some months, during which all possible side effects should be assessed in every single patient. Besides, since it is impossible to pre-determine what drug and what dosage is most efficacious for every patient, the therapy must be adapted to individual needs.
The goal of a good prophylaxis is to reduce or eliminate migraine attacks with low dosage of a single, well-tolerated medication.
Prognosis of migraine is positive: after 50 years of age it tends to spontaneous remission.
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