Migraine: diagnosis

As with other primary cephalalgia, the diagnosis of " migraine " is based entirely on complaints and data of anamnesis, and in most cases there is no need to conduct additional research methods. Careful inquiry is the basis of the correct diagnosis of migraine. When diagnosing, it is necessary to rely on the diagnostic criteria of MKGB-2 (the diagnostic criteria of the two most common forms are listed below: migraine without aura and migraine with aura).

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Diagnostic criteria of migraine

Pain: severe headache; the intensity of pain increases in minutes-hours; the pulsating (vibrating) nature of pain; one-sided localization (hemicranium) more often than bilateral; it is possible to move the localization of pain (migration); increased pain with physical activity; duration of headache from 4 to 72 hours; frequency of seizures.

Concomitant symptoms and signs: intolerance to noise (phonophobia); intolerance to light (photophobia); nausea, vomiting; pallor of the skin of the face, often their pasty; arterial hypotension; constipation; symptoms of aura that occur in 20% of patients: photopsy (flashing lights, flickering zigzag lines, lightning); loss of visual fields (hemianopsia, scotoma); numbness, paresthesia (face, hand, or other parts of the body); dysarthria; swaying while walking; dysphoria.

The following factors will provoke a migraine attack: emotional stress, stress (more often during the discharge phase), excessive sleep or lack of sleep, noise, bright light, flickering of the TV screen, unpleasant smells, strong stimuli of the vestibular apparatus (riding on a swing, riding a train, car, sea travel, flight in an airplane, etc.), the period of ovulation and menstruation, physical activity, weather changes, alcohol, long breaks between meals, constipation, some foods (chocolate, cocoa, milk, cheese, nuts, eggs, tomatoes, citrus fatty foods, celery, etc.), some medicines (oral contraceptives), and others.

Among all the variants of migraine, most often (in two thirds of cases) there is a migraine without an aura (simple migraine), which begins without any precursors, immediately with a headache. Often, a migraine attack consists of two phases.

The first is the phase of prodromal phenomena in the form of mood reduction (depression, fear, less often euphoria), irritability and anxiety, tearfulness, indifference to everything around, decrease in efficiency, drowsiness, yawning, changes in appetite, nausea, thirst, pastosity of tissues, local edema. This phase lasts for several hours.

The second phase - a headache occurs at any time of the day (often during sleep or on waking), pain increases over a period of 2-5 hours. A headache attack is accompanied by a decrease in the threshold of excitability of the sense organs (hearing, sight). A slight knock, a speech of ordinary loudness, a familiar electric light become completely unbearable. Touching the body can also become intolerable.

Patients are trying to seclude themselves during an attack, tightly bandaging their head, drinking warm tea, coffee, darkening the room, going to bed, closing the ears with a pillow and wrapping themselves in a blanket. Sometimes a swollen temporal artery is determined, its pulsation is visible to the eye. With severe compression of this artery, throbbing pain decreases. The conjunctival vessels on the side of the pain are dilated, the eyes are watery, the pupils and eyes are narrowed (Bernard-Horner's symptom), the swelling of the tissues around the orbit and temple, the face is pale.

During one attack, a headache can spread to the entire half of the head and grab the occipital region, neck. Pulsating pain passes into pain with a feeling of "splitting" the head, squeezing. The attack lasts several hours (8 -12 hours). At a part of patients at the end of an attack there is an abundant urination (polyuria). 

The frequency of migraine attacks without an aura is different, their frequency is individual. Characteristic of their development is not against the background of stress, physical stress, but against the background of the subsequent relaxation (migraine "weekend"). Migraine attacks are reduced or disappear during pregnancy and are resumed after cessation of lactation and recovery of menstruation.

[11], [12], [13], [14], [15], [16]

What kind of migraine?

Diagnostic criteria for migraine without aura and migraine with aura (MKGB-2, 2004)

1.1. Migraine without an aura.

• A. At least five seizures that meet the BD criteria.
• B. Duration of attacks 4-72 hours (without treatment or in case of ineffective treatment).
• C. Headache has at least two of the following characteristics:
  • one-sided localization;
  • pulsating character;
  • intensity of pain from moderate to significant;
  • the headache is aggravated from usual physical activity or requires its termination (for example, walking, climbing the stairs).
• D. Headache is accompanied by at least one of the following symptoms:
  • nausea and / or vomiting;
  • photophobia or phonophobia.
• E. Not related to other causes (abnormalities).

1.2.1. A typical aura with a migraine headache.

• A. At least two seizures that meet the BD criteria.
• B. The aura includes at least one of the following symptoms and does not include motor weakness:
  • completely reversible visual symptoms, including positive (flickering spots or streaks) and / or negative (visual impairment);
  • completely reversible sensory symptoms, including positive (tingling sensation) and / or negative (numbness);
  • completely reversible speech disorders.
• C. At least two of the following:
  • homonymous visual disturbances and / or unilateral sensory symptoms;
  • at least one aura symptom gradually develops over a period of 5 min or more and / or various aura symptoms occur consistently over 5 min or more;
  • each symptom has a duration of at least 5 minutes, but not more than 60 minutes.
• D. Headache that meets the BD criteria for 1.1. (migraine without an aura), begins during an aura or within 60 minutes after its beginning.
• E. Not related to other causes (abnormalities).

In accordance with the international classification developed by the International Society for Headache, the following clinical forms of migraine are distinguished:

• I - a migraine without an aura (a synonym, used earlier, - a simple migraine) and
• II - migraine with aura (synonyms: classical, associated migraines).

The selection of these forms is based on the presence or absence of an aura, i.e., a complex of focal neurologic symptoms preceding the onset of pain or arising at the height of pain sensations. Depending on the type of aura in a group of migraines with aura, the following forms are distinguished:

• Migraine with a typical aura (previously - classical, ophthalmic form of migraine);
• with a prolonged aura;
• migraine familial hemiplegic;
• basilar;
• migraine aura without a headache;
• migraine with acute aura;
• ophthalmoplegic;
• migraine is retinal;
• periodic syndromes of childhood, which may be precursors of migraine or combined with it;
• benign paroxysmal dizziness in children;
• alternating hemiplegia in children;
• migraine complications:
  • migraine status;
  • migraine stroke;
• migraine, not falling under the listed criteria.

The classification also gives the main diagnostic criteria for migraine.

Migraine without aura

• A. At least 5 migraine attacks in an anamnesis that meet the following GH criteria.
• B. The duration of migraine attacks from 4 to 72 hours (without treatment or with unsuccessful treatment).
• B. Headache has at least two of the following signs:
  • one-sided localization of headache;
  • the pulsating nature of the headache;
  • moderate or significant pain intensity, which reduces the activity of the patient;
  • aggravation of the headache during monotonous physical work and walking.
• D. The presence of at least one of the following accompanying symptoms: nausea, vomiting, light and / or phobia. It is important to keep in mind that anamnestic data and objective research data exclude other forms of headache. It is very important the presence of indications in the anamnesis to replace the side of the headache, since the presence of only one-sided headache for a long time requires a search for a different cause of headaches.

Migraine with aura

• at least 2 attacks that meet the criteria of BB;
• Migraine attacks have the following characteristics:
  • complete reversibility of one or more symptoms of the aura;
  • none of the symptoms of the aura lasts more than 60 minutes;
  • the duration of the "light" gap between the aura and the onset of the headache is less than 60 min.

Depending on the nature of the aura and the clinical manifestations of a migraine attack with an aura, it is possible to determine the primary involvement of a certain basin in the pathological process. Symptoms of the aura indicate a violation of microcirculation in the cerebral artery intracerebral area.

The most frequent aura are visual disturbances with visual field defects in the form of a shimmering scotoma: glittering balls, dots, zigzags, lightning flashes starting at a strictly defined location. The intensity of photopsy increases within a few seconds or minutes. Then the photopsy is replaced by a scotoma or the visual field defect is widened to hemianopsia - right-sided, left-sided, upper or lower, sometimes quadrant. With repeated attacks of migraine, visual disorders are usually stereotyped. The provoking factors are bright light, its flickering, the transition from darkness to a well-lit room, flight - a loud sound, a sharp smell. 

Some patients have visual illusions before a headache attack: all surrounding objects and people seem to be elongated ("Alice's syndrome" - a similar phenomenon described in the book of L. Carroll "Apis in Wonderland") or reduced in size, sometimes with a change in the brightness of their color , as well as with difficulties in perception of one's body (agnosia, apraxia), a sense of "already seen" or "never seen," disturbances in perception of time, nightmares, trances, etc.

"Alice's syndrome" is more likely to occur with migraine in childhood. The cause of visual auras are discirculation in the basin of the posterior cerebral arteries in the occipital lobe and ischemia in the adjacent territories of its blood supply (parietal and temporal lobes). The visual aura lasts 15-30 minutes, after which there is a throbbing pain in the fronto-temporal-gaaznichnoy area, increasing in its intensity from half an hour to an hour and a half and accompanied by nausea, vomiting, blanching of the skin. The average duration of an attack of such a "classic" migraine is about 6 hours. There are often a series of repeated attacks. This migraine is worse in the first and second trimesters of pregnancy. Less often, the aura manifests itself as a central or paracentral scotoma and transient blindness to one or both eyes. This is caused by a spasm in the central retinal artery (retinal migraine) system. Occasionally, before the paroxysm of migraine, transitory oculomotor disorders are observed on the one hand (ptosis, pupil dilatation, diplopia), which are associated with impaired microcirculation in the trunk of the oculomotor nerve or with the compression of this nerve in the wall of the cavernous sinus in vascular malformation. Such patients need a targeted angiographic study.

Relatively rare aura manifests itself in the transient paresis of the hand or hemiparesis in combination with hypoesthesia on the face, arm or entire body half. This hemiplegic migraine is associated with a violation of microcirculation in the basin of the middle cerebral artery (cortical or its deep branches). If the disturbance of microcirculation develops in the cortical branches of this basin in the dominant hemisphere (in the left in right-handed hemispheres), the aura manifests itself in partial or complete motor or sensory aphasia (aphthous migraine). Expressed speech disorders in the form of dysarthria are possible with dyscirculation in the basilar artery. This can be combined with transient dizziness, nystagmus, staggering when walking (vestibular migraine) or with severe cerebellar disorders (cerebellar migraine).

It is also rare for girls of 12-15 years to develop a more complex aura: it starts with visual disturbances (bright light in the eyes is replaced by bilateral blindness for several minutes), then dizziness, ataxia, dysarthria, tinnitus, short-term paresthesia around the mouth, in hands , feet. After a few minutes, there is an attack of a sharp, pulsating headache, mainly in the occipital region, vomiting, and even a loss of consciousness (syncopal condition). In the clinical picture of such a basilar migraine, there may be other signs of impaired brain stem function: diplopia, dysarthria, alternating hemiparesis, and so on.

Focal neurologic symptoms persist from a few minutes to 30 minutes. And not more than an hour. With unilateral symptoms of loss of brain function, an intense headache usually occurs in the opposite half of the skull.

In a number of cases, the aura manifests itself in pronounced autonomic hypothalamic disorders such as sympathetic adrenal, vagoinsular and mixed paroxysms, as well as in emotionally affective disorders with a sense of fear of death, anxiety, anxiety ("panic attacks"). These variants of the aura are associated with a violation of microcirculation in the hypothalamus and limbico-hypothalamic complex.

All variants of migraine proceed with different frequency - from 1-2 times a week, a month or a year. Occasionally there is a migraine status-a series of severe, successive seizures without a distinct clear interval.

In the study of the neurological status, migraine patients often display mild signs of asymmetry in the functions of the hemispheres of the brain (in two thirds - against the background of signs of latent levity): asymmetry of innervation of facial muscles (revealed with a smile), deviation of the tongue, tongue, anisoreflection of deep and superficial reflexes, type of vegetative status (arterial hypotension, pallor and pastosity of the skin, acrocyanosis, propensity to constipation, etc.). The majority of patients with migraine suffer from peculiarities of the psyche with accentuation of personality in the form of ambition, anger, pedantry, aggressiveness with constant internal tension, increased sensitivity and vulnerability to stress, irritability, suspicion, resentment, conscience, pettiness, a tendency to obsessive fears, intolerance to the mistakes of others, signs of depression. Characteristic of unmotivated dysphoria. 

In carrying out additional studies, craniograms are frequently found to show signs of hypertensive-hydrocephalic changes in the form of strengthening of the vascular pattern, finger-like impressions. One-third reveals an anomaly of Kimmerle. On EEG - desynchronous and disruptive manifestations. Computer and magnetic resonance tomograms often reveal an asymmetry in the structure of the ventricular system.

For rapid diagnosis of migraine, a special express questionnaire was developed.

• Have you ever had a headache in the last 3 months with the following symptoms:
  • nausea or vomiting? YES______ ; NO______ ;
  • intolerance to light and sounds? YES_____ ; NO______ ;
  • Has the headache affected your ability to work, study or daily activity for at least 1 day? YES_______ ; NO______ .

93% of patients who answered "YES" for at least two questions, suffer from migraine.

In most cases, objective examination does not reveal organic neurologic symptoms (note no more than 3% of patients). At the same time, in almost all patients with migraine, stress and soreness in one or several pericranial muscles (the so-called myofascial syndrome) are revealed during examination. In the face area, these are the temporal and chewing muscles, in the nape of the neck - the muscles attached to the skull, the muscles of the back surface of the neck and the shoulder pads (syndrome "coat hangers"). Stress and painful muscle tightens become a constant source of discomfort and pain in the neck and neck, they can create the prerequisites for the development of the accompanying tension headache. Often, with an objective examination of a patient with migraine, signs of autonomic dysfunction can be noted: palmar hyperhidrosis, a change in the color of the fingers of the hands (Raynaud's syndrome), signs of increased neuromuscular excitability (the Khvostek symptom). As already mentioned, additional tests for migraines are not informative and are shown only with atypical flow and a suspicion of the symptomatic nature of migraine.

Characteristics of the objective status of patients in the period of attack and in the interstitial state

Objective data during the period of cephalic crisis in the study of neurological status, as already indicated, depend on the form of migraine. Some additional studies during the cephalgic attack are of interest: computed tomography (CT), rheoencephalography (REG), thermography, cerebral blood flow, etc. According to the thermogram, foci of hypothermia on the face that coincide with the projection of pain (more than 70% of cases ); On the REG, during the attack, all its phases are practically reflected: vasoconstriction-vasodilation, atony of the walls of the vessels (arteries and veins), more or less severe arterial and venous blood flow obstruction. The changes are usually bilateral, but more severe on the side of the pain, although the degree of expression of these changes does not always coincide with the degree of pain.

According to CT, when frequent severe attacks, areas of reduced density may appear, indicating the presence of edema of the brain tissue, transient ischemia. On the M-echo in rare cases there is an indication of the expansion of the ventricular system and, as a rule, the displacement of the M-echo is not determined. The results of ultrasound examination of blood flow during an attack are contradictory, especially when studying it in different pools. During the attack of pain on the affected side, the blood flow velocity in the common carotid, inner and outer carotid arteries increased in 33% of cases and decreased in the ocular artery, while in 6% of the patients the opposite changes were observed. A number of authors note an increase in the rate of cerebral blood flow mainly in the basin of extracranial branches of the external carotid artery during the period of pain.

In somatic status, the pathology of the gastrointestinal tract was most often (11-14%): gastritis, peptic ulcer, colitis, cholecystitis. The latter served as an excuse to distinguish the syndrome of "three twins": cholecystitis, headache, arterial hypotension.

In the overwhelming majority of patients in the interictal period, the syndrome of vegetative-vascular dystonia was found to differ in intensity: bright red persistent dermographism (more pronounced on the side of pain), hyperhidrosis, vascular necklace, tachycardia, fluctuations in arterial pressure more often toward lowering it, or persistent arterial hypotension; propensity to allergic reactions, vestibulopathy, increased neuromuscular excitability, manifested by symptoms of Khvostek, Trusso-Bansdorf, paresthesia.

In some patients, microchurch neurological symptoms were revealed in the form of a difference in tendon reflexes, hemiipalgesia, in 10-14% of cases, neuroendocrine manifestations of hypothalamic genesis (cerebral obesity combined with menstrual irregularity, hirsutism) were observed. In the study of the psychic sphere, there were bright emotional disorders, as well as some personality traits: increased anxiety, a tendency to subdepressive and even depressive tendencies, a high level of ambition, ambition, some aggressiveness, demonstrative traits in behavior, the desire to focus on the recognition of others from childhood cases of hypochondriacal manifestations.

The overwhelming number of patients in the anamnesis had indications of childhood psychogeny (single parent family, conflict relations between parents) and psychotraumatic situations preceding the onset or worsening of the disease. An additional study in 11-22% of cases revealed moderately expressed hypertensive-hydrocephalic changes on the craniogram (strengthening of the vascular pattern, the back of the Turkish saddle, etc.). The composition of the cerebrospinal fluid is usually within normal limits.

There were no changes in the EEG (although sometimes there are "flat" EEG, or the presence of dysrhythmic manifestations); Echoencephalography, as a rule, is within the norm. On the REG in the interictal period, a decrease or increase in vascular tone, mainly of the carotid arteries, an increase or decrease in the pulse blood filling of them and a dysfunction (more often difficulty) of the venous outflow are noted; these changes are more pronounced on the side of the headache, although they may not be present at all. There were no clear changes in cerebral blood flow during the inter-attack period, although the data are inconsistent in this regard (some describe the decrease, others increase), which is apparently due to the phase of the study - soon or in the long-term after the attack. Most authors believe that angiospasm causes a decrease in regional cerebral blood flow for a sufficiently long period of time (a day or more).

In addition to these routine studies, patients with migraine are studying the state of afferent systems, which are known to be systems that perceive and conduct painful sensations. For this purpose, the evoked potentials (VP) of different modalities are explored: visual (VEP), auditory potentials of the brain stem (MSIC), somatosensory (SSVP), VP of the trigeminal nerve system (due to the important role of the trigemino-vascular system in the pathogenesis of migraine). Analyzing provoking factors, it can be assumed that in cases of the priority role of emotional stress - it is the changes in the brain that cause a migraine attack. Indication of the role of the cold factor (cold, ice cream) gives reason to believe about the primary role of the trigeminal system in initiating a migraine attack. Tyramine-dependent forms of migraine are known - where, apparently, biochemical factors play a special role. Menstrual forms of migraine testify to the role of endocrine factors. Naturally, all these and other factors are realized against the background of genetic predisposition.

[17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29]

Differential diagnosis of migraine

There are a number of diseases that can mimic migraine attacks.

I. In cases of severe migraines with intolerable headache, nausea, vomiting, dizziness, night attacks, first of all it is necessary to exclude the organic pathology of the brain:

1. tumor,
2. abscesses;
3. acute inflammatory diseases, especially accompanied by edema of the brain, etc.

In all these cases, attention is drawn to the different nature of the headache and its course, as a rule, the absence of the above-mentioned migraine-specific factors and the positive results of the corresponding additional studies.

II. The most important are the headaches, which are based on the vascular pathology of the brain. Firstly, these are aneurysms of cerebral vessels, the rupture of which (ie, the onset of subarachnoid hemorrhage) is almost always accompanied by an acute headache. This is especially important to keep in mind when migraine with an aura. The most significant in this respect is the ophthalmoplegic form of migraine, which is often caused by an aneurysm of the vessels of the bases of the brain. The development of the clinical picture in the future: a severe general condition, meningeal symptoms, neurological symptoms, the composition of the cerebrospinal fluid and data from additional paraclinical studies help correct diagnosis.

III. It is important to conduct a differential diagnosis also with the following diseases:

1. Temporal arteritis (Horton's disease). Common features with migraine: a local pain in the temple, sometimes radiating to the entire half of the head, often aching, breaking, but permanent in nature, but it may become paroxysmally worse (especially with tension, cough, movements in the jaw). In contrast to migraine, palpation is accompanied by densification and increased pulsation of the temporal artery, tenderness, dilated pupil on the side of the pain; decreased vision; is more common in a more mature age than a migraine. Observed subfebrile temperature, increased ESR, leukocytosis, there are signs of damage to other arteries, especially the arteries of the eye. It is regarded as local suffering of connective tissue, local collagenosis; specific histological signs - giant-blood-exact arteritis.
2. The syndrome of Tolosa - Hanta (or painful ophthalmoplegia) resembling a migraine in character and localization of pain. Sharp pain burning, vomiting, localized in the frontal-orbital region and inside the orbit, holds for several days or weeks with periodic enhancement, accompanied by oculomotor nerve damage (which is important to consider when compared with the ophthalmoplegic associated form of migraine). The process also includes nerves passing through the upper orbital fissure: the leading, block, orbital branch of the trigeminal nerve. Pupillary disorders due to denervation hypersensitivity of the capillary muscle are revealed, which is confirmed by the adrenaline-cocaine test. There is no other pathology in additional studies. Until now, the cause is not clearly established: there is an opinion that this syndrome arises from the compression of the siphon area by an aneurysm on the basis of the brain. However, most authors believe that the cause is a carotid intracavernous periarteritis in the area of the cavernous sinus - the upper globular gap or a combination of them. In favor of a regional periarteritis is indicated by subfebrile condition, mild leukocytosis and an increase in ESR, as well as the effectiveness of steroid therapy.

IV. The next group - diseases caused by the defeat of organs located in the head, face.

1. Headaches in ocular pathology, mainly glaucoma: a sharp acute pain in the eyeball, periorbital, sometimes in the field of the temple, photophobia, photopsy (i.e., the same character and localization of pain). However, there are no other signs of migraine pain, and, most importantly, increased intraocular pressure.
2. The following forms also matter:
   1. bilateral pulsating headache may accompany vasomotor rhinitis, but without the typical attacks: there is a clear connection with the occurrence of rhinitis, nasal congestion due to certain allergic factors;
   2. with sinusitis (frontal sinusitis, maxillary sinusitis), pain, as a rule, has a local character, although it can spread to the "whole head", does not have a paroxysmal course, occurs daily, increases from day to day, intensifies, especially during the day, and lasts about an hour , does not have a pulsating character. Typical rinological and roentgenological features are revealed;
   3. with otitis also may be hemicrania, but a blunt or shooting character, accompanied by symptoms characteristic of this pathology;
   4. In the Kosten syndrome, severe intense pain in the temporomandibular joint may occur, sometimes engaging the entire half of the face; pain does not have a pulsating, paroxysmal character, provoked by chewing, talking. There is a clear soreness in palpation in the joint area, the cause of which is joint disease, an incorrect bite, and a poor prosthesis.

A number of authors distinguish vascular pain syndrome of the face, or, as it is more often called, carotidinia. It is caused by the defeat of the periarterial plexuses of the external carotid artery, the carotid node, and can manifest itself in two forms:

1. Acute onset in young or middle age; there is a pulsating burning pain in the region of the cheek, submandibular or temporal-zygomatic area, painfulness is noted during palpation of the carotid artery, especially near its bifurcation, which can intensify the pain in the face. The pain lasts 2-3 weeks. And, as a rule, does not resume (this is a very important feature that distinguishes it from the facial form of migraine).
2. Another form of carotidinia is described, more often in elderly women: attacks of pulsating, burning pain in the lower half of the face, lower jaw, lasting from several hours to 2-3 days, repeated with a certain frequency - 1-2 times a week, a month, six months . At the same time, the external carotid artery is sharply tense, painful on palpation, and its pulsation is intensified. Age, the nature of pain, the lack of heredity, the presence of objective vascular changes in external examination and palpation can distinguish this form from a true migraine. There is an opinion that the nature of this suffering is infectious-allergic, although there is no fever and blood changes, and there is no significant effect from hormone therapy (it is stopped by analgesics). The genesis of this syndrome is not entirely clear. It is possible that any harmfulness - chronic irrigation, local inflammatory processes, intoxication - can underlie carotidinia. We should not forget about the group of craniofacial neuralgia, which primarily include neuralgia of the trigeminal nerve, as well as a number of other more rare neuralgia: occipital neuralgia (neuralgia of the great occipital nerve, suboccipital neuralgia, neuralgia of the arnold nerve), small occipital, glossopharyngeal nerves (Weisenburg-Sikar syndrome), etc. It must be remembered that, in contrast to migraines, all these pains are characterized by acuity, "lightning fastness", the presence of trigger points or "trigger" zones, defined by iruyuschie factors and no typical symptoms of migraine pain (referred to above).

It is also necessary to differentiate migraine without aura from the tension headache, which is one of the most common forms of headache (more than 60% according to world statistics), especially from its episodic form lasting from several hours to 7 days (whereas chronic headaches daily) for 15 days or more, in a year - up to 180 days). When conducting a differential diagnosis, the following diagnostic criteria for a tension headache are considered:

1. localization of pain - bilateral, diffuse with predominance in the occipitoneal or parietal-frontal areas;
2. character of pain: monotonous, squeezing, like "helmet", "helmet", "hoop", almost does not happen pulsating;
3. intensity - moderate, sharp intensive, usually not intensified during physical exertion;
4. accompanying symptoms: rarely nausea, but more often a decrease in appetite until anorexia, rarely photo or phonophobia;
5. combination of tension headache with other algic syndromes (cardialgia, abdominalgia, dorsalgia, etc.) and psycho-vegetative syndrome, with emotional disorders of depressive or anxious-depressive nature prevailing; soreness of the pericranial muscles and muscles of the collar zone, neck, and shoulder pads. 

[30], [31], [32], [33], [34], [35], [36], [37], [38], [39]