It is estimated that 96 percent of humans will suffer from one or more headaches during their lifetime. References to headaches can be found in ancient writings like the Ebers Papyrus (dating to circa 1550 B.C.). Visual symptoms from headaches were described by Hippocrates in 400 B.C. Interest in headaches extends back as far as recorded history, and it is one of the most common complaints of patients who present for medical care. The direct and indirect socioeconomic costs of headaches to society are estimated at $14 billion per year. For reasons that are unknown, headaches are more common in women. Overall, tension-type headaches account for 40 percent of the total amount of headaches, and migraines account for 10 percent. Headaches may be primary (migraine, tension, trigeminal neuralgia) or secondary (due to something else like trauma, infection, and other diseases). Fortunately, only one percent of patients with a brain tumor will have headache as the only complaint.
Migraines are the seventh highest cause of disability worldwide. Migraines may occur with or without an aura. The aura is a fully-reversible set of neurologic symptoms, most often visual or sensory, that appear gradually and then recede. The headache begins about 60 minutes after the aura recedes. Most migraine headaches occur on one side of the head and are accompanied by nausea, vomiting, photophobia (avoidance of light), and phonophobia (avoidance of noise). Hemiplegic migraines are rare – the aura of this type of migraine includes one-sided limb weakness. While the exact cause of migraines is unknown, it is thought that the brain is ultrasensitive to changes that can trigger a headache. These changes then cause the nervous system to release substances that cause the nervous system and brain to become inflamed. Medications are available and can be used to both treat the headache and, if taken regularly, prevent headaches from occurring. Lifestyle modifications like avoidance of red wine and chocolate and smoking cessation also help prevent migraine headaches.
When evaluating a person for headaches, brain imaging with MRI or CT scan is rarely indicated unless there are red flags. In the U.S., it is estimated that $1 billion dollars a year is wasted on unnecessary brain imaging in patients with primary headache disorder. These red flags include new headaches in an older person, abnormal neurologic examination, a change in headache pattern or progressively worsening headaches, new headache in the setting of HIV risk factors, cancer, a compromised immune system, signs of systemic illness (fever, rash, stiff neck), headache that is triggered by coughing, exertion, or Valsalva maneuver (i.e. straining during a bowel movement), headache in pregnancy or postpartum period, and first or worst headache. While not a red flag in and of itself, brain imaging is indicated for thunderclap headaches. This type of secondary headache is a very sudden onset, severe headache that reaches maximal intensity within one minute of onset and is often caused by an emergent brain condition like cerebral hemorrhage.
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