Doctor Leandro Valdemar

Specialist Neurology 
and Neurophisiology 
Out-Patients Consultation 
on Headaches 
Out-Patients Consultation 
on Botulinum Toxin 

Let's treat your headache in the consultation especially dedicated to headaches and migranes

HPA Magazine 12

It is estimated that about 15% of the Portuguese population may suffer from migraines and of this percentage, about 700 thousand people suffer from severe migraine. It is therefore a highly dysfunctional disease with high economic repercussions. In fact, it is considered the 3rd most prevalent disease in the world and the 7th most disabling. Reaching an accurate diagnosis of headaches and/or migraines is crucial to the success of the treatment. This is the reason why a specialized consultation was created, to provide proper diagnosis and new methods of treatment.

What is a headache?

Headache is a pain or discomfort in the region of the head including the face. Migraine is a specific type of headache. Headaches vary greatly in their different characteristics; location, type of pain, intensity, frequency, duration and associated symptoms. As a result of this variability, according to the International Headache Society, different categories and classifications of headaches have arisen, accounting for more than 300 different types of headaches.

Having a headache is very prequent in the general population?

According to the World Health Organization 2016, about half to ¾ of the world's population, aged between 18 and 65, suffered at least once from a headaches in the last year and about 30% of these were migraines. It is estimated that about 15% of the Portuguese population may suffer from migraines and about 700,000 from severe migraine, of which half will have missed work an average of 3.8 days per year as a consequence of this pathology. It is a highly dysfunctional disease with economic repercussions – 18 to 27 billion euros is the estimated cost of the disease in Europe and in the United States it is approximately 20 billion dollars. It is the 3rd most prevalent disease and the 7th most disabling in the world (Global Burden of Disease Survey 2010).
It is important to mention that frequently patients may have more than one type of associated headache, so it is not infrequently for the same patient to suffer from migraines and also from tension type headache, for example.

What causes a headache?

There are several structures in the head – nerves, muscles and blood vessels – that can cause pain during a headache; but the cerebral parenchyma itself does not hurt.
When a headache results from a structural alteration or occurs following a medical pathology, such a headache is said to be secondary, for example, headaches due to a head injury or sinusitis. Other examples of secondary causes are headaches associated with infections, High Blood Pressure (systolic BP> 160 mmHg and/or diastolic> 120 mmHg), giant cell arthritis, sleep apnea, and excessive symptomatic medication for headache (more than 10 to 15 days per month, depending on the medication), for more than 3 months.
The remaining headaches, where the cause is unknown, are called primary headaches and account for the vast majority, about 90% of all headaches. Tension headaches and migraines are the two most prevalent primary headaches.

How does one distinguish between a tension headache and a migraine?

Tension Headaches
These are the most common headaches. Stress and muscle tension are two factors that contribute to this type of headache. Although symptom may be varied, the following aspects are common to them all:

• Slow onset of the headache;
• The pain is usually on both sides of the head;
• It is a pressure type pain, such as when wearing a tight helmet;
• The pain may involve only the back of the head or neck;
• The intensity is mild to moderate, usually not described as severe;
• Usually not associated with nausea, vomiting or sensitivity to light (photophobia).

Migraines
This type of headache is accompanied by concomitant symptomatology: nausea and/or vomiting and/or photo/phonophobia and severe disabling intensity. It can last by definition up to 72hours. However, not all patients experience the same phases in the same sequence: prodrome, aura, migraine itself, and resolution phase.

• a) The prodromal phase may occur hours to days before the onset of a migraine and is defined as mood or behavior changes;
• b) The aura phase corresponds to a set of visual, sensory or language symptoms that may occur on their own or in various combinations, appearing immediately before the headache itself;
• c) The migraine itself is a period of intense incapacitating pain, usually throbbing, on one side of the head, but may also be bilateral and may be associated with nausea and/or vomiting, photo and/or phonophobia;
• d) In the resolution phase there is a decrease in the intensity of the pain and there can often be intense fatigue, irritability and difficulty concentrating.

Potential migraine trigger factors:

• Emotional Stress
• Fatigue
• Diet: skipping meals, alcohol (especially red wine), chocolate, cured cheese, increased or decrease in the consumption of caffeine, nitrates present in cured meat and fish, monosodium glutamate present in some Asian food (used as a flavor enhancer in Chinese food).
• Sensory Stimuli: bright or intermittent lights, noises, intense smells.

How is a headache diagnosed?

The diagnosis of a headache is essentially reached by the patient’s medical history and a physical/neurological examination including complementary diagnostic tests, when pertinent. When the medical history and a normal neurological exam are compatible with migraine or tension headache, additional complementary diagnostic tests are not needed. 
However, whenever a secondary causality is suspected, various tests should be requested; blood tests, CT Scan of the perineal sinuses, cranial CT Scan or MRI, among others.
Medical history plays a crucial role in the diagnosis of the type headache. During the consultation with a specialist the patient must therefore be as specific as possible when describing the various characteristics of the headache. The information provided will help to define and differentiate the type of headache. Aspects such as, at what time of the day does the headache normally occur? On which part of the head is the pain felt most? type of pain? duration? associated symptoms? triggering factors? history of past head trauma? are the symptoms always the same or does the type of headache vary? 

What is the treatment for a headache?

Treatment involves establishing the correct diagnosis of the type of headache in question, identifying and altering possible exacerbation factors (including medication), developing a plan for treating the headache during the acute phase, and determining whether there is a need for preventive treatment and what it should be. 
Specific headache treatment is based on the patient's age, medical history, type of headache, frequency and severity of the headache, patient tolerance to specific medication, procedures to be adopted and therapies.

More general measures can be recommended to prevent headaches:

• Avoid triggers: certain foods, sleep deprivation, fasting;
• Altering eating habits;
• Regular physical exercise.

During the acute phase of the headache the patient should have his/her "SOS Kit" already well defined, with medication previously determined in the consultation and prescribed by his physician which he knows will be effective, sometimes not before trial error until the ideal drug is reached. In addition to medication, it is also possible that rest in a quiet and dark room is recommend in the acute phase (in the case of migraines), learning to deal with stress (eg yoga practice).
If your doctor chooses to start prophylactic treatment this means that for a few months you will take medication daily, reducing the frequency and severity of each headache crises, ideally until there are no headaches. The efficacy and necessity of subsequent alterations to the medication are evaluated during the Headache Consultation. A crisis calendar is recommended to facilitate a more global approach to the type and profile of the headache in question.
There are other, specific and targeted treatments for more particular headaches, such as occipital nerve block, application of botulinum toxin, or the latest treatment for migraine prophylaxis monthly injection of monoclonal antibody of the CGRP receptor. All these treatments are available in the Headache Consultation of the HPA. 

What are the alarm signals of a headache?

• New onset of headaches after the age of 40;
• “The worst headache ever” with the intensity reaching a peak in seconds or in a few minutes;
• A headache that starts or worsens significantly with exertion, Valsalva maneuvers, coughing or sneezing;
• When associated with mood changes or consciousness;
• When associated with vomiting without nausea;
• When associated with visual alterations ;
• Associated with systemic signs or symptoms, e.g. fever, cold shivers, stiff neck, weight loss;
• When associated with neurological symptoms, e.g. loss of strength in the hand or leg, or neurological alteration detected in an examination;
• Alterations in the characteristics of a pre-existing headache
• Headaches associated with posture changes e.g., significant increase of pain when moving from a lying down position to a standing up position or vice versa;
• Headache that is resistant to medication and becomes increasingly severe and continuous, especially if it persists on the same spot;
• A headache that starts early in the morning or wakes the patient up during the night.

The Hospital Particular do Algarve has, since the 1st of April 2019 been providing a specific headache consultation by the Neurologist Dr. Leandro Valdemar on the 2nd Floor of the Gambelas Hospital. It is possible to book an appointment for Monday mornings. It should be pointed out that this is the first consultation of its kind in the whole region of the Algarve. Its purpose is specifically to treat patients with this neurological pathology in a targeted and personalized way, which is considered to be the most frequent pathology of all, providing a new differentiated treatment to these patients.