A. Migraine headache :

Earlier migraine was classified into two major subgroups; classic and common migraine. Classic migraine characterized by an aura of neurologically significant preheadache phenomena, is now called migraine with aura. Common migraine with attacks of migraine without clear-cut preheadache neurologic symptoms is now referred to as migraine without aura. Focal neurologic disturbances without headache or vomiting have come to be known as migraine equivalents or accompaniments and appear to occur more commonly in patients between the ages of 40-70 years. The term complicated migraine has generally been used to describe migraine with dramatic focal neurologic features, thus overlapping with classical migraine.

Diagnostic criteria for migraine without aura

1. At least five attacks fulfilling criteria 2-4.
2. Headache lasts 4-72 hours, untreated or unsuccessfully treated.
3. Headache has atleast two of the following characteristics:
   Unilateral location
   Pulsating quality
   Moderate or severe intensity (inhibits or prohibits daily activities)
4. During headache at least one of the following:
   Nausea and/or vomiting
   Photophobia and phonophobia

Migraine is an inherited disorder, currently thought to represent an autosomal dominant trait with incomplete penetrance. Sex distribution is approximately equal in childhood, but by adulthood women are affected more than men in a ratio of approximately 2 to 3:1, a dominance thought to reflect the aggravating influence of estrogen on the central migraine mechanisms.

The headache is usually located over frontal or temporal, uni-or-bilateral. Onset of pain is usually after patient awakens and disappears once sleep sets in. It may be provoked by so many internal and external factors like food, odour, and menses etc., usually stops after second trimester of pregnancy. The headache can run in cycles of several months to years. It becomes less frequent and less severe with aging.

Treatment - Medical management

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B. Cluster Headache :

This condition is otherwise known as migrainous neuralgia or Horton's syndrome. The term derives from the fact that the attacks are clustered in time and space. This headache is characterized by periorbital or temporal headache coming in-group of episodes over 6-8 weeks and might disappear for 6 months to one year. The affected age group is between 16 to 50 years and men are more affected. Each attack is usually accompanied by lacrimation, nasal discharge, lid drooping, pupillary change and conjunctival injection. Sometimes the headache might get located over forehead and cheek region. The attack might last 1-2 hrs and in a day, if no obvious relief, might recur up to 6 to 10 times. Bouts of headaches often occur in early spring or early autumn. Clusters are interspersed by pain-free periods of months to years, but rarely more than 2 years. They can occur at any time of day but typically start soon after the onset of sleep. The pain is burning in character. Classically sufferers have deep nasolabial folds and peau d'orange skin changes. Precipitating factors include alcohol and altitude. Typically attacks may be triggered by alcohol, and during an attack the victim finds it impossible to keep still.

Diagnostic criteria

1. At least five attacks fulfilling criteria 2-4.
2. 2. Severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes untreated.
3. Headache is associated with at least one of the following signs, which have to be present on the same side as the pain:

- Conjunctival injection
- Lacrimation
- Nasal congestion
- Rhinorrhoea
- Forehead and facial sweating
- Miosis
- Ptosis
- Eyelid oedema

Frequency of attacks: from one every other day to eight per day

Treatment - Medical management

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C. Tension Headache :

Many people consider this chronic pain syndrome as a type of migraine variant form. This is characterized by bilateral tight band surrounding head, with neck muscles especially posterior ones being tight. This headache can be in intermittent or episodic form as well as a chronic form. The chronic form can last for more than 15 days per month. It is seen in all age groups with female preponderance. Other associated co morbid conditions include personality disorders, depression, epilepsy, and obsessive-compulsive disorder. Sometimes, tension type headache follows head injury.

Diagnostic criteria

1. At least 10 previous headache episodes, with frequency less than 180 headaches per year or less than 15 per month.
2. Headaches lasting 30 minutes to 7 days
3. At least two of the following:

- Pressing, tightening, non-pulsating.
- Mild or moderate
- Bilateral
- No aggravation by routine physical activity

4. Both of the following:

- No nausea or vomiting; anorexia may occur
- Never both photophobia and phonophobia

Treatment - Medical management

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D. Secondary Headache :

Secondary headaches are termed as nociceptive headache, wherein obvious pathology can be identified. Almost every disease is known to cause headache.
The location of headache can give clue about the pathology. The structures outside skull like paranasal sinuses, eyes, teeth, arteries, spine and the supporting muscles might be involved. The problems inside skull brain tumours, Bleeding , Blood clotting, infection might require specific investigations to confirm diagnosis. One should watch for neurological deficits and tender points.
Some of the common disorders of secondary headaches encountered by a pain specialist are as follows:
(i). Chronic sinusitis
(ii). Eye problems
(iii). Giant cell arteritis
The exact reason is not known. Most often seen in elderly age group people, with women preponderance. Patient complains of headache externally (outside the skull), dull in nature, and may be unilateral or bilateral. Other associated symptoms like fever, weight loss, fibromyalgia, jaw pain are noted. The headache will be worse at night. Blindness also has been reported.
(iv). Post-traumatic headache
It is of a different nature in that the neck pain and headache start immediately following the accident. These patients are often involved in legal matters and they are often labeled as psychosomatic in the absence of objective diagnostic findings.
(v). Cervicogenic headache

1. Treatment- Medical management
   - Interventions

Normally, some interventions are performed to localize the place of origin of secondary headache syndromes. They are as follows:

1. Atlanto-axial joint block
2. Upper cervical facet joint block
3. Sphenopalatine ganglion block
4. Trigeminal branches block
5. Stellate ganglion block.
6. Occipital nerve block

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