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Classification of Primary Headache Disorders (neurovascular and tension-type disorders)
(International Headache Society, 1987)

1) Tension-type headaches
2) Migraine headaches
3) Cluster headaches and chronic paroxysmal hemicrania

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1) Tension-type headache

It is the most common headache disorder. 78% of adults go through at least one tension-type cephalalgic episode in their life span.

It occurs more frequently in young women.

For tension headache to be diagnosed, at least two of the following criteria must be present:
- both sides of the head are involved
- pressing / tightening quality of pain
- intensity ranging from mild to moderate
- no worsening with physical activity
- absence of nausea, vomiting, photophobia or phonophobia (aura)

It is referred to as chronic tension-type headache if occurs more than 15 days per month for a period of at least six months. Conversely, if it occurs for fewer than 15 days per month, it is referred to as episodic

Tension headache classification
(International Headache Society, 1987)

1) Episodic tension-type headaches
1.1 Episodic tension-type headaches associated with pericranial muscle disorders
1.2 Episodic tension-type headaches unassociated with pericranial muscle disorders

2) Chronic tension-type headaches
2.1 Chronic tension-type headaches associated with pericranial muscle disorders
2.2 Chronic tension-type headaches unassociated with pericranial muscle disorders

3) Tension-type headaches not fulfilling above criteria

2) Migraine headache

It affects 15-17 % of all women and 5-6% of all men.

It is characterized by severe attacks having at least one of the following symptoms:
- nausea, combined photo / phonophobia
- hyperesthesia (smell)
- recurring

The painful attacks can be partially or totally localized in:
- the face
- the teeth
- the upper jaw

It is of similar character to the essential trigeminal neuralgia and the pulpal pain so that the patient may sometimes experience unjustified avulsions.
Criteria for the diagnosis of migraine must include at least two of the following characteristics:
- unilateral
- throbbing
- moderate or severe intensity
- aggravated by physical activity

and at least one of the following two symptoms:
- nausea and vomiting
- photo and/or phonophobia

Migraine classification
(International Headache Society, 1987)

1 Migraine without aura
2 Migraine with aura
- Migraine with typical aura
- Migraine with prolonged aura
- Familial hemiplegic migraine
- Basilar migraine
- Migraine aura without headache
- Migraine with acute onset aura

3 Ophthalmoplegic migraine

4 Retinal migraine

5 Childhood periodic syndromes that may be precursors to or associated with migraine
- Benign paroxysmal vertigo of childhood
- Alternating hemiplegia of childhood

6 Complications of migraine
- Status migrainosis
- Migrainous infarction

7 Migrainous disorders not fulfilling above criteria

(biblio 22, 23)

Migraines can be divided into:

a) migraine unaccompanied by neurologic symptoms (without aura) (it is the most common)

b) migraine associated with ‘focal’ neurologic symptoms of premonition (with aura)

Such phenomena, termed “aura”, generally precede the headache (this warning signs appear up to 60 minutes before the headache begins) and can last up to an hour. If they last more than an hour, a neurologic visit is necessary. If they last more than 4 hours, an ischemic lesion should be suspected.

Types of aura:

1) visual symptoms
- dazzling zigzag lines in your field of vision
- scintillating scotoma
- hemianopsia

2) sensorial symptoms
- paresis
- aphasia

3) hypo/ hyperactivity

4) depression / euphoria

5) a craving for certain foods

6) impaired ability to comprehend

c) basilar migraine (migraine with aura symptoms originating from the brain stem or from both occipital lobes)

The aura manifestations of basilar migraine are:

1) visual symptoms and hemianopsia
2) dysarthria
3) vertigo
4) tinnitus
5) hypoacusis (decreased hearing)
6) diplopia
7) ataxia
8) paresthesia and / or bilateral paresis
9) obnubilation (decreased level of consciousness)

d) ophthalmoplegic migraine – It is manifested by paresis of the eye muscles; a neurologic exam is
necessary. If the migraine becomes chronic, the underlying medications may trigger new headaches (a serious complication known as rebound headaches).

Tension-type headaches and above all migraines can even extend only to the face and teeth and be therefore confused with neuralgia or pulpal pain (biblio 24).

3)Cluster headache and chronic paroxysmal hemicrania

It is characterized by:
- almost yearly cycles
- one or more attacks within 48 hours (an attack last 15 to 180 minutes)
- attacks grouped in a ‘cluster’ for periods lasting weeks to months
- regular frequency with intervals of months or years
- periorbital unilateral pain
- homolateral phenomena of the autonomic nervous system such as:
conjunctival injection
tearing
eyelid swelling
nasal congestion
rhinorrhea
Horner’s syndrome

Chronic paroxysmal hemicrania
It is characterized by:
- periorbital unilateral pain
- up to 5 short attacks per day (5 to 45 minutes of duration)
- same autonomic phenomena as cluster headache
- attacks respond well when pharmacologically treated with indomethacin (biblio 24)

A systematic neurologic examination of the cranial nerves is a procedure of the utmost semeiologic (diagnostic) value that, if correctly carried out, can highlight several hidden pathologic conditions of odontostomatologic, neurologic and otorhinolaryngologic significance.
We suggest to keep a medical record for a thorough assessment of the cranial nerves (sensory and motor components) potentially involved in a neuroalgologic problem.
Understanding the cranial nerves semiology cannot be separated from a summary knowledge of some elementary concepts of functional anatomy hereafter briefly illustrated.

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