side. Sometimes the pain presents on both sides in people who do not experience an aura. Characterized as moderate to severe pulsating pain that increases in intensity with any form of physical activity, a migraine is accompanied by nausea or vomiting and possible sensitivity to lights or sounds. Other symptoms include swelling or tenderness of the scalp (Chawla, 2017; International Headache Society, 2016; Wikipedia, 2017b). Once the headache pain has peaked, the postdrome, or resolution phase, begins (Wikipedia, 2017b). As the pain subsides, it is replaced with soreness and in some cases a headache “fog.” During these final moments, the patient is likely to be overcome with fatigue, weakness, and mood changes. This concludes the migraine episode, but it can differ with each subsequent attack (Chawla, 2017; International Headache Society, 2016; Wikipedia, 2017b). It is most common for people to experience a migraine without aura, previously known as common migraine . A migraine with aura, which has several subtypes and is generally known as classic migraine , can be experienced at any time even if the patient usually suffers common migraine (International Headache Society, 2016). This may be because of triggers, or the cause for an attack. The validity of triggers as a singular cause for an attack is uncertain; however, enough sufferers have noted similar precipitants that health care providers must take note. Some of the most prominent triggers are hormonal changes, stress, weather, strong odors, or artificial sweeteners like aspartame (Chawla, 2017; Wikipedia, 2017b). Research is still being conducted to understand the role these play in sparking an attack, so patients are encouraged to maintain a headache diary to help pinpoint the relevancy of triggers in migraine episodes. Numerous theories are being explored to explain the phenomenon that is a migraine, especially one with aura. These range from genetics to magnesium deficiency and include Cluster headaches The last of the primary headaches is rather uncommon although may affect more sufferers than reported because it is often misdiagnosed as sinusitis or migraine long before being recognized as a cluster headache. This happens largely because of the severity of pain coupled with nasal congestion and redness of the eye on the affected side (International Headache Society, 2016; Wikipedia, 2017d). Also, cluster headaches are recurrent, like migraines, but last only a maximum of three hours, as opposed to migraines, which have a maximum of four hours (International Headache Society, 2016). Another differentiation from a migraine attack is that a cluster headache has been described as a stabbing hot poker behind the eye with such intensity the sufferer is unable to rest and rather fervently paces the room until the attack subsides (Lowth, 2015; Wikipedia, 2017d). During this time, suicidal thoughts may appear. The peak pain persists anywhere from 30 minutes to 2 hours, consequently earning the alternative name of suicide headaches (DeLaune, 2008). Following are the official criteria for diagnosis of cluster headaches in the ICHD-3 beta: 1. Must have at least five attacks consisting of the following criteria: 2. Excruciating pain behind the eye, above the eye, or in the temple region lasting 15 minutes up to 3 hours. 3. Either or both of the following: ○ At least one of the following signs: ■ Red eye with or without tearing. ■ Runny nose with or without congestion. ■ Swollen or drooping eyelid. ■ Sweating. ■ Flushing skin.
dopamine and serotonin imbalances (Chawla, 2017). The currently held belief is cortical spreading depression (CSD). This is a domino effect that begins with a lack of difference in the charge inside the cell located in the brain compared to the charge outside of the cell, altering its permeability, which then triggers the aura phase of a migraine. From there, the trigeminal nerve is irritated, resulting in headache pain commencing the pain phase. The initial depolarization also results in a release of neurotransmitters from nearby tissues that continue the spreading cascade of effects (Chawla, 2017). Another theory labels trigger points as the culprit for migraine. Upon analyzing muscles of the head and neck for trigger points (as noted under the tension-type headaches section), an overwhelming majority of people showed positive results for referred pain patterns that replicated their migraine pain, as well as light-headedness and visual or auditory sensitivity (DeLaune, 2008). Because this theory does not explain the phenomenon of auras, it is only important to note as a reminder for the massage therapist to practice caution in trigger point therapy on a migraine sufferer. Knowing precipitants and premonitory signs will help refrain triggering an immediate attack. There are far too many theories regarding the cause for migraines that most scientists have agreed to simply classify it as a neurological disorder with various possible origins (Fritz, 2015). Regardless of the cause, a massage can be beneficial in preventing migraines or in reducing the frequency of episodes by carefully addressing trigger points (DeLaune, 2008), relieving stress, and having a positive influence on numerous neuroendocrine chemicals, such as dopamine, serotonin, and cortisol. These chemicals affect mood, sleep, motor control, pain sensation, and various structures of the body. The only contraindication for massage is an acute migraine attack (Fritz, 2015). 4. Half of attacks recurring anywhere between once every other day and eight in a single day when not in remission. (International Headache Society, 2016) A unique feature of cluster headaches is the alarm-like frequency of recurrence. During an episode, or cluster, each individual attack occurs at the same time of day for the entire duration of that cluster period, which could last several weeks, months, or years. The pain is severe enough to awaken the sufferer from sleep. Typical onset is seen around 20 years of age but may occur as late as 40 years of age, with males being stricken significantly more than females by this disorder (Wikipedia, 2017d). The true cause of cluster headaches is unknown. Inhaling pure oxygen at the onset of an attack has proven extremely helpful in relieving symptoms. However, this does not affect the recurrence of another attack (Wedro, 2017). Considering the clock-like timing plus imaging taken during an attack showing increased activity in this area, it is speculated that the hypothalamus plays a major role in this disorder (Wikipedia, 2017d). While researchers continue to seek the cause of cluster headaches, it is imperative for health care providers to be able to identify this headache type, and, at the same time, for the patient to maintain a headache diary. It has been reported that a cluster headache sufferer may seek help from several different disciplines of medicine for an average of seven years before receiving a correct diagnosis (Wikipedia, 2017d). Although treatment does not eradicate the condition, considering the excruciating pain that is characteristic of cluster headaches, having the means to diminish them will help immensely. Summary In summation, the three main headache types classified as primary headaches are tension-type, migraine, and cluster headaches. Each shares a direct biological cause although differing in origin.
■ Clogged feeling in the ear. ■ Contraction of the pupil.
○ Restlessness.
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