2. Headache epidemiology
2.1 Headache classification and pathogenesis
|Primary headache classification||Headache type||Description and comments|
|Migraine||Migraine without aura||Headache has at least two of the following four characteristics:|
|Migraine with typical aura||Aura consisting of visual, sensory and/or speech/language symptoms, each fully reversible, but no motor, brainstem or retinal symptoms|
At least two of the following four characteristics:
|Migraine with brainstem aura||As with migraine with typical aura, but with at least two of the following brainstem symptoms:|
|Hemiplegic migraine||Similar to migraine with typical aura, but aura consisting of both of the following:|
|Chronic migraine||Headache occurring on 15 or more days per month for more than three months, which, on at least 8 days per month, has the features of migraine headache|
|Tension-type headache||Headache is typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea, but photophobia or phonophobia may be present.|
May be classified as infrequent episodic, frequent episodic, or chronic.
May be associated with pericranial tenderness.
|Trigeminal autonomic cephalalgias (TACs)||Hemicrania continua, cluster headache, paroxysmal hemicranias, and short-lasting neuralgiform headache attacks||The TACs exist along a spectrum (|
Newman, 2015) and are associated with symptoms of craniofacial autonomic alterations ipsilateral to the pain, such as lacrimation, ptosis, pupillary changes, tear production, conjunctival injection, rhinorrhea, or sweating.
Magnetic resonance imaging and pituitary testing should be performed to exclude pituitary tumors, which can rarely cause TAC-like pain.
Hemicrania continua and paroxysmal hemicrania are typically responsive to indomethacin
|Other||Primary stabbing headache||Transient and localized stabs of pain in the head that occur spontaneously in the absence of organic disease of underlying structures or of the cranial nerves. No accompanying cranial autonomic symptoms|
|Other migraine||Episodic and other syndromes that may be associated with migraine||Recurrent gastrointestinal disturbance (cyclical vomiting syndrome and abdominal migraine)|
Benign paroxysmal vertigo/chronic persistent perceptual dizziness
- Buse D.C.
- Loder E.W.
- Gorman J.A.
- Stewart W.F.
- Reed M.L.
- Fanning K.M.
- et al.
2.2 Approaches to the treatment of primary headache syndromes
2.2.1 Behavioral headache management
2.2.2 Pharmacologic management of migraine
- Holland S.
- Silberstein S.D.
- Freitag F.
- Dodick D.W.
- Argoff C.
- Ashman E.
2.2.3 Treatment of other primary headache disorders
2.2.4 Starting preventive headache therapies
2.3 Secondary headache syndromes in POTS
|Medication Class||Medication||Evidence level (|
|Typical daily dose||Comorbidities that may be worsened||Comorbidities that may be improved||Other considerations|
|Anti-seizure drugs||Divalproe × sodium, sodium valproate||A||500–2000 mg||Fatigue; dizziness; nausea; anorexia; abdominal pain; main worsen headache in some individuals||Mood disorders||Teratogenicity severely restricts use in women of childbearing potential|
Start at 250 to 500 mg daily
|Topiramate||A||50–200 mg||Anhidrosis/heat intolerance; cognition (“brain fog”); weight loss||May promote weight loss||Start 25 mg at bedtime, then increase 25 mg per week to 75–100 mg.|
|Beta-blockers||Metoprolol||A||100–200 mg daily||Fatigue, orthostatic intolerance, sexual||Palpitations/tachycardia|
|Propranolol||A||40–240 mg||The short-acting form dosed at 20 mg 2 or 3 times per day is often better tolerated.|
|Tricyclics||Amitriptyline||B||10–200 mg||Dry mouth, constipation, fatigue||Insomnia, chronic pain, depression||Start 10–25 mg at bedtime, increase weekly to 75–100 mg|
|Nortriptyline||Anecdotal||10–150 mg||Insomnia||Insomnia, chronic pain, depression||Start 10–25 mg at bedtime, increase weekly to 75–100 mg.|
If insomnia occurs, take in the morning.
|SNRI||Venlafaxine||B||75–225 mg||Tachycardia, insomnia||Chronic pain|
|Natural supplements||Feverfew||B||50–300 mg||Lack of long-term safety data; varied potency of commercially-available preparations|
|Riboflavin (vitamin B2)||B||400 mg||Maximal clinical effect starting at about two months|
|Magnesium citrate||B||400–600 mg||Constipation||Effectiveness of oral magnesium oxide (9 mg/kg/day) was equivocal, but magnesium oxide is often used at the same dose due to availability.|
May paradoxically worsen constipation in some individuals.
3. Pain epidemiology in POTS
3.1 Mechanisms of chronic pain
3.2 Approaches to treating chronic pain
|Medication or medication class||Comorbidities that may be worsened||Comorbidities that may be improved|
|Tricyclic antidepressants||Dry mouth, constipation, fatigue, orthostatic intolerance||Sleep disturbance; migraine; depression (may require higher doses); bladder pain|
|Serotonin reuptake inhibitors||Insomnia, headache, dizziness, fatigue, nausea, sexual dysfunction||Sleep disturbance|
|Cyclobenzaprine||Fatigue, dry mouth||Sleep disturbance|
|Alpha-2-delta calcium channel agonists (gabapentin, pregabalin)||Fatigue, weight gain||Sleep disturbance.|
May promote weight gain
|Serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, desvenlafaxine, milnacipran)||Headache; nausea; palpitations; dry mouth (in adults); abdominal pain (in children and adolescents); weight loss (in children and adolescents)||Depression|
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☆Dr. Cook is a military service member. This work was prepared as part of official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties.
☆The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
☆Financial support: Not applicable.