Migraine (M) and Tension-type headache (TTH) are the most common forms of primary headaches.
They can be regarded as chronic neurological conditions with episodic exacerbations.
In M, attacks of head pain include associated autonomic symptoms, such as nausea, vomiting, hypersensitivity to sensory stimuli, pallor, and possible transitory neurological symptoms , such as visual or sensory disturbances (aura), or behavioral prodromes.
TTH is characterized by a mild to moderate headache, with a pressing character, that is not generally associated with the typical debilitating autonomic M symptoms, although some attacks may present phono-photophobia (no more than one of these, according to the most recent criteria)
Different clinical forms are described, both for M and TTH, on the basis of average frequency and other clinical features, and internationally accepted diagnostic criteria are available for each subform (the International Classification of Headache Disorders, ICHD, first edition delivered in 1988, 3rd edition published in 2018).
M and TTH are highly prevalent disorders, particularly in young adults and among women, and cause significant disability in daily activities, diminished quality of life – and relevant societal costs.
The mechanisms underlying primary headaches are not fully understood. A genetic predisposition is likely but it has been demonstrated only for rare conditions (FHM). Functional alterations at different levels have been postulated on the basis of clinical features and different areas of research (e.g. functional MRI), and they include complex alterations in those CNS areas involved in the elaboration of pain and emotions, peripheral and central sensitization, and neurovascular activation (in M).
The management of M and TTH is an important health care issue. It includes avoidance of trigger factors, lifestyle modifications, non-pharmacological therapies, and- mainly – medications. Pharmacological treatment is traditionally divided into acute or symptomatic treatment , intended to relieve attacks (NSAIDS, triptans, analgesics), and preventive treatment or prophylaxis , with the aim of reducing the frequency of attacks. As far as M prophylaxis, different drugs are recommended by international guidelines, belonging to several classes, such as beta-blockers, AED, antidepressants, etc. For TTH , evidence exists for preventive efficacy of amitriptyline and venlafaxine; also muscle relaxants, anxiolitics, mirtazapine, magnesium salts are often used.
Clinicians should be aware of the different treatment options, in order to choose the specific treatments in an individual patient, based on a comprehensive evaluation, which has to take into account also interference with comorbid conditions, personal and social aspects, problems of adherence to treatment schedules.
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