Primary headache disorders are defined as
headaches that are unrelated to an underlying medical condition and are categorized into 4 groups:
migraine,
tension-type headache,
trigeminal autonomic cephalalgias, and other
primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that
tension-type headache affected 38% of the population, while
migraine affected 12% and was the most disabling.
Secondary headache disorders are defined as
headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with
headache should be evaluated to determine whether their
headache is most likely a primary or a
secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset,
neurologic signs, age 50 years and older, presence of
cancer or immunosuppression, and provocation by physical activities or postural changes. Acute
migraine treatment includes
acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include
caffeine. Patients not responsive to these treatments may require
migraine-specific treatments including
triptans (5-HT1B/D agonists), which eliminate
pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient
flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for
cardiovascular disease should avoid
triptans because of vasoconstrictive properties. Acute treatments with
gepants, antagonists to receptors for the inflammatory
neuropeptide calcitonin gene-related peptide, such as
rimegepant or
ubrogepant, can eliminate
headache symptoms for 2 hours in 20% of patients but have adverse effects of
nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist,
lasmiditan, is also available for acute
migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include
antihypertensives,
antiepileptics,
antidepressants,
calcitonin gene-related peptide monoclonal antibodies, and
onabotulinumtoxinA, which reduce
migraine by 1 to 3 days per month relative to placebo.
CONCLUSIONS AND RELEVANCE: