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HEADACHE
A headache or cephalalgia ispain anywhere in the region of thehead orneck.It can be
asymptom of a number of different conditions of the head and neck.[1]
Thebrain tissueitself is
not sensitive to pain because it lackspain 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 (theperiosteum of the
skull),muscles,nerves,arteries andveins,subcutaneous tissues,eyes,ears,sinusesandmucous
membranes.
There are a number of different classification systems for headaches. The most well-recognized
is that of theInternational Headache Society.Headache is anon-specific symptom,which means
that it has many possible causes. Treatment of a headache depends on the underlyingetiology or
cause, but commonly involvesanalgesics
Headaches are most thoroughly classified by theInternational Headache Society's InternationalClassification of Headache Disorders (ICHD), which published the second edition in
2004.[2]
This classification is accepted by theWHO.[3]
Other classification systems exist. One of the first published attempts was in
1951.[4]
TheNational Institutes of Health developed a classification system in 1962.[5]
ICHD-2[edit]
Main article:International Classification of Headache Disorders
TheInternational Classification of Headache Disorders (ICHD) is an in-
depthhierarchical classification of headaches published by theInternational Headache Society.It
contains explicit (operational)diagnostic criteria for headache disorders. The first version of theclassification, 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,cranialneuralgia,central and primary facial pain and other headaches for the last two
groups.[7]
The ICHD-2 classification definesmigraines,tension-types headaches, cluster headache and
othertrigeminal autonomic cephalalgias as the main types of primary headaches.[8]
Also,
according to the same classification, stabbing headaches and headaches due tocough,exertion
and sexual activity (coital cephalalgia)are classified as primary headaches. The daily-persistentheadaches 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
theirsymptoms.[8]
According to the ICHD-2 classification, the main types of secondary
headaches include those that are due to head or neck trauma such aswhiplash injury,intracranial
hematoma,post craniotomy or other head or neck injury. Headaches caused by cranial or
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/wiki/Arterieshttp://en.wikipedia.org/wiki/Nerveshttp://en.wikipedia.org/wiki/Muscleshttp://en.wikipedia.org/wiki/Pericraniumhttp://en.wikipedia.org/wiki/Pericraniumhttp://en.wikipedia.org/wiki/Nociceptorshttp://en.wikipedia.org/wiki/Brain_tissuehttp://en.wikipedia.org/wiki/Headache#cite_note-1http://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Neckhttp://en.wikipedia.org/wiki/Headhttp://en.wikipedia.org/wiki/Pain 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cervical vascular disorders such asischemic stroke andtransient ischemic attack,non-traumatic
intracranial hemorrhage,vascular malformations orarteritis are also defined as secondary
headaches. This type of headaches may also be caused bycerebral 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 ofdisorders or diseases that are intracranial but that are not associated with the vasculature of
thecentral 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,
intracranialinfections 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 bydialysis,high blood
pressure,hypothyroidism,and cephalalgia and evenfasting 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 includingteeth,jaws, ortemporomandibular joint.Headaches
caused by psychiatric disorders such assomatization orpsychotic disorders are also classified as
secondary headaches.
The ICHD-2 classification puts cranial neuralgias and other types ofneuralgia 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.
There are over 200 types of headaches, and the causes range from harmless to life-threatening.
The description of the headache, together with findings onneurological examination,determines
the need for any further investigations and the most appropriate treatment.[10]
Primary headaches[edit]
The most common types of headache are the "primary headache disorders", such astension-type
headache andmigraine.They have typical features; migraine, for example, tends to be pulsating
http://en.wikipedia.org/wiki/Stroke#Ischemic_strokehttp://en.wikipedia.org/wiki/Transient_ischemic_attackhttp://en.wikipedia.org/wiki/Cerebral_arteriovenous_malformationhttp://en.wikipedia.org/wiki/Arteritishttp://en.wikipedia.org/wiki/Cerebral_venous_thrombosishttp://en.wikipedia.org/wiki/Epileptic_seizurehttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/HIVhttp://en.wikipedia.org/wiki/AIDShttp://en.wikipedia.org/wiki/Infectionshttp://en.wikipedia.org/wiki/Dialysishttp://en.wikipedia.org/wiki/High_blood_pressurehttp://en.wikipedia.org/wiki/High_blood_pressurehttp://en.wikipedia.org/wiki/Hypothyroidismhttp://en.wikipedia.org/wiki/Fastinghttp://en.wikipedia.org/wiki/Teethhttp://en.wikipedia.org/wiki/Temporomandibular_jointhttp://en.wikipedia.org/wiki/Somatizationhttp://en.wikipedia.org/wiki/Psychotic_disordershttp://en.wikipedia.org/wiki/Neuralgiahttp://en.wikipedia.org/wiki/Headache#cite_note-A-8http://en.wikipedia.org/wiki/Headache#cite_note-A-8http://en.wikipedia.org/wiki/Headache#cite_note-A-8http://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=3http://en.wikipedia.org/wiki/NIH_classification_of_headacheshttp://en.wikipedia.org/wiki/Headache#cite_note-Levine_et_al..2C_p_60-9http://en.wikipedia.org/wiki/Headache#cite_note-Levine_et_al..2C_p_60-9http://en.wikipedia.org/wiki/Headache#cite_note-Levine_et_al..2C_p_60-9http://en.wikipedia.org/wiki/Myogenichttp://en.wikipedia.org/wiki/Neurological_examinationhttp://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=5http://en.wikipedia.org/wiki/Tension_headachehttp://en.wikipedia.org/wiki/Tension_headachehttp://en.wikipedia.org/wiki/Migrainehttp://en.wikipedia.org/wiki/Migrainehttp://en.wikipedia.org/wiki/Tension_headachehttp://en.wikipedia.org/wiki/Tension_headachehttp://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=5http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Neurological_examinationhttp://en.wikipedia.org/wiki/Myogenichttp://en.wikipedia.org/wiki/Headache#cite_note-Levine_et_al..2C_p_60-9http://en.wikipedia.org/wiki/NIH_classification_of_headacheshttp://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=3http://en.wikipedia.org/wiki/Headache#cite_note-A-8http://en.wikipedia.org/wiki/Neuralgiahttp://en.wikipedia.org/wiki/Psychotic_disordershttp://en.wikipedia.org/wiki/Somatizationhttp://en.wikipedia.org/wiki/Temporomandibular_jointhttp://en.wikipedia.org/wiki/Teethhttp://en.wikipedia.org/wiki/Fastinghttp://en.wikipedia.org/wiki/Hypothyroidismhttp://en.wikipedia.org/wiki/High_blood_pressurehttp://en.wikipedia.org/wiki/High_blood_pressurehttp://en.wikipedia.org/wiki/Dialysishttp://en.wikipedia.org/wiki/Infectionshttp://en.wikipedia.org/wiki/AIDShttp://en.wikipedia.org/wiki/HIVhttp://en.wikipedia.org/wiki/Central_nervous_systemhttp://en.wikipedia.org/wiki/Epileptic_seizurehttp://en.wikipedia.org/wiki/Cerebral_venous_thrombosishttp://en.wikipedia.org/wiki/Arteritishttp://en.wikipedia.org/wiki/Cerebral_arteriovenous_malformationhttp://en.wikipedia.org/wiki/Transient_ischemic_attackhttp://en.wikipedia.org/wiki/Stroke#Ischemic_stroke -
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in character, affecting one side of the head, associated withnausea,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),
andhemicrania continua (a continuous headache on one side of the head).[10]
Secondary headaches[edit]
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 onneurological examination,mental confusion,being woken by headache,
headache that worsens with changing posture, headache worsened by exertion orValsalva
manoeuvre (coughing, straining),visual loss or visual abnormalities,jaw claudication (jaw pain
on chewing that resolves afterwards),neck stiffness,fever,and headaches in people
withHIV,cancer or risk factors forthrombosis.[10]
"Thunderclap headache" may be the only symptom ofsubarachnoid hemorrhage,a form
ofstroke in which blood accumulates around the brain, often from a rupturedbrain aneurysm.
Headache with fever may be caused bymeningitis,particularly if there is meningism (inability to
flex the neck forward due to stiffness), and confusion may be indicative
ofencephalitis (inflammation of the brain, usually due to particularviruses). Headache that is
worsened by straining or a change in position may be caused by increasedpressure in the skull;
this is often worse in the morning and associated with vomiting. Raised intracranial pressure may
be due tobrain tumors,idiopathic intracranial hypertension (IIH, more common in younger
overweight women) and occasionallycerebral venous sinus thrombosis.Headache together with
weakness in part of the body may indicate astroke (particularlyintracranial
hemorrhage orsubdural hematoma)or brain tumor. Headache in older people, particularly when
associated with visual symptoms or jaw claudication, may indicategiant cell arteritis (GCA), in
which theblood vessel wall is inflamed and obstructs blood flow.Carbon monoxide
poisoningmay lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and
blurred vision.Angle closure glaucoma (acute raisedpressure 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]
Thebrain itself is not sensitive topain,because it lackspain receptors.However, several areas of
thehead andneck do have nociceptors, and can thus sense pain. These include the extracranial
arteries, large veins, cranial and spinal nerves, head and neck muscles and themeninges.[11]
http://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Trigeminal_neuralgiahttp://en.wikipedia.org/wiki/Trigeminal_neuralgiahttp://en.wikipedia.org/wiki/Cluster_headachehttp://en.wikipedia.org/wiki/Hemicrania_continuahttp://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=6http://en.wikipedia.org/wiki/Medication_overuse_headachehttp://en.wikipedia.org/wiki/Medication_overuse_headachehttp://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Thunderclap_headachehttp://en.wikipedia.org/wiki/Paresishttp://en.wikipedia.org/wiki/Neurological_examinationhttp://en.wikipedia.org/wiki/Mental_confusionhttp://en.wikipedia.org/wiki/Valsalva_manoeuvrehttp://en.wikipedia.org/wiki/Valsalva_manoeuvrehttp://en.wikipedia.org/wiki/Visual_losshttp://en.wikipedia.org/wiki/Claudication#Jawhttp://en.wikipedia.org/wiki/Meningismhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/HIVhttp://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Intracranial_berry_aneurysmhttp://en.wikipedia.org/wiki/Meningitishttp://en.wikipedia.org/wiki/Encephalitishttp://en.wikipedia.org/wiki/Virushttp://en.wikipedia.org/wiki/Intracranial_pressurehttp://en.wikipedia.org/wiki/Brain_tumorhttp://en.wikipedia.org/wiki/Idiopathic_intracranial_hypertensionhttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Subdural_hematomahttp://en.wikipedia.org/wiki/Giant_cell_arteritishttp://en.wikipedia.org/wiki/Vasculitishttp://en.wikipedia.org/wiki/Carbon_monoxide_poisoninghttp://en.wikipedia.org/wiki/Carbon_monoxide_poisoninghttp://en.wikipedia.org/wiki/Glaucomahttp://en.wikipedia.org/wiki/Intraocular_pressurehttp://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=7http://en.wikipedia.org/wiki/Human_brainhttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Nociceptorhttp://en.wikipedia.org/wiki/Headhttp://en.wikipedia.org/wiki/Neckhttp://en.wikipedia.org/wiki/Meningeshttp://en.wikipedia.org/wiki/Headache#cite_note-ACEP2008-11http://en.wikipedia.org/wiki/Headache#cite_note-ACEP2008-11http://en.wikipedia.org/wiki/Headache#cite_note-ACEP2008-11http://en.wikipedia.org/wiki/Headache#cite_note-ACEP2008-11http://en.wikipedia.org/wiki/Meningeshttp://en.wikipedia.org/wiki/Neckhttp://en.wikipedia.org/wiki/Headhttp://en.wikipedia.org/wiki/Nociceptorhttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Human_brainhttp://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=7http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Intraocular_pressurehttp://en.wikipedia.org/wiki/Glaucomahttp://en.wikipedia.org/wiki/Carbon_monoxide_poisoninghttp://en.wikipedia.org/wiki/Carbon_monoxide_poisoninghttp://en.wikipedia.org/wiki/Vasculitishttp://en.wikipedia.org/wiki/Giant_cell_arteritishttp://en.wikipedia.org/wiki/Subdural_hematomahttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Intracranial_hemorrhagehttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Idiopathic_intracranial_hypertensionhttp://en.wikipedia.org/wiki/Brain_tumorhttp://en.wikipedia.org/wiki/Intracranial_pressurehttp://en.wikipedia.org/wiki/Virushttp://en.wikipedia.org/wiki/Encephalitishttp://en.wikipedia.org/wiki/Meningitishttp://en.wikipedia.org/wiki/Intracranial_berry_aneurysmhttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Cancerhttp://en.wikipedia.org/wiki/HIVhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Meningismhttp://en.wikipedia.org/wiki/Claudication#Jawhttp://en.wikipedia.org/wiki/Visual_losshttp://en.wikipedia.org/wiki/Valsalva_manoeuvrehttp://en.wikipedia.org/wiki/Valsalva_manoeuvrehttp://en.wikipedia.org/wiki/Mental_confusionhttp://en.wikipedia.org/wiki/Neurological_examinationhttp://en.wikipedia.org/wiki/Paresishttp://en.wikipedia.org/wiki/Thunderclap_headachehttp://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Medication_overuse_headachehttp://en.wikipedia.org/wiki/Medication_overuse_headachehttp://en.wikipedia.org/w/index.php?title=Headache&action=edit§ion=6http://en.wikipedia.org/wiki/Headache#cite_note-SIGN-10http://en.wikipedia.org/wiki/Hemicrania_continuahttp://en.wikipedia.org/wiki/Cluster_headachehttp://en.wikipedia.org/wiki/Trigeminal_neuralgiahttp://en.wikipedia.org/wiki/Trigeminal_neuralgiahttp://en.wikipedia.org/wiki/Nausea 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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 includestress,dilatedblood 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 ofendorphins 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 theaura of the migraine. The headache was believed toresult 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 thecerebral cortex,especially in
theoccipital cortex.[14]
People who are more susceptible to experience migraines withoutheadache are those who have a family history of migraines, women, and women who are
experiencing hormonal changes or are takingbirth control pills or are prescribedhormone
replacement therapy
TheAmerican 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 canbe 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]
Imaging[edit]
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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.[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
In recurrent unexplained headaches keeping a "headachediary" with entries on type of headache,
associated symptoms, precipitating and aggravating factors may be helpful. This may reveal
specific patterns, such as an association withmedication,menstruation orabsenteeism 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 ofcluster
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 theresults of acupuncture may be due to theplacebo 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 involvestaking 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, onlyamitriptyline,fluoxetine,gabapentin,tizanidine,topiramate,andbotulinum 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
includesValproate.[24]
Psychological treatments are usually considered in comorbid patients or in those who are
unresponsive to the medication.
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