406 ‒ Migraine, cluster headache, and tension headache: symptoms, causes, prevention, and treatment
In a Nutshell
Headache disorders lack biomarkers and rely on clinical criteria: tension-type headache is bilateral, non-throbbing, and mild; migraine requires 4-72 hour attacks with nausea or both photophobia/phonophobia plus two of unilateral, throbbing, movement-aggravated, moderate-severe pain; cluster headache is unilateral, periorbital, 15 min-3 hr, with autonomic features and marked restlessness. Only ~50 new headache specialists finish training yearly despite migraine affecting 12% of people; preventive therapy (CGRP mAbs, topiramate, propranolol, Botox for chronic migraine) is indicated once attacks become frequent or disabling, yet only 16-17% of eligible patients receive it. Acute treatment favors migraine-specific triptans or gepants over opioids/barbiturates, which risk medication-overuse headache; lifestyle regularity, headache diaries, and addressing comorbidities (sleep apnea, obesity, mood disorders) are essential to prevent chronification.
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Brian Grosberg is a neurologist specializing in headache medicine. Headache is one of the most common neurologic symptoms, with nearly every person experiencing a headache at some point. Medical education provides minimal headache training, with medical students and neurology residents receiving only a few hours of lectures across their entire training.
Grosberg entered the field by accident during his first month of neurology residency when caring for a litigator disabled for six weeks by a prolonged migraine. His future mentor recognized his detailed history-taking ability and offered additional training. Grosberg pursued headache medicine training on his own time during residency, working with his mentor after long hospital shifts, then completed formal fellowship training.
No biomarkers exist for headache diagnosis. Neither CT scans nor MRIs reveal the source of pain. The International Classification of Headache Disorders serves as the diagnostic reference and categorizes headaches as primary or secondary.
Primary headaches are syndromes in themselves, not attributable to another condition. The most common include migraine, tension-type headache, and cluster headache.
Secondary headaches are attributable to an underlying condition. Examples include medication overuse headache from frequent acute pain medication use, and caffeine withdrawal headache. These are not life-threatening but have pathophysiological mechanisms.
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