Headaches / Migraines
Overview
Headache is a term used to describe aching or pain that occurs in one or more areas of the head, face, mouth, or neck. Headache can be chronic, recurrent, or occasional. The pain can be mild or severe enough to disrupt daily activities. Headache involves the network of nerve fibers in the tissues, muscles, and blood vessels located in the head and at the base of the skull.
Types
Primary headache accounts for about 90% of all headaches. There are three types of primary headache: tension headache, cluster headache, and migraine.
Tension headache is the most common type of primary headache. Episodes usually begin in middle age and are often associated with the stresses, anxiety, and depression that can develop during these years.
Cluster headaches occur daily over a period of weeks, sometimes months. They may disappear and then recur during the same season in the following year.
Secondary headache is associated with an underlying condition such as cerebrovascular disease, head trauma, infection, tumor, and metabolic disorder (e.g., diabetes, thyroid disease). Head pain also can result from syndromes involving the eyes, ears, neck, teeth, or sinuses. In these cases, the underlying condition must be diagnosed and treated. Also, certain types of medication produce headache as a side effect.
Severe, sudden, and debilitating secondary headache that develops after a blow to the head, that interferes with normal activity, or that accompanies other symptoms (e.g., convulsions, disorientation, dizziness, loss of consciousness, pain in the eye or ear, fever) should be evaluated by a physician as soon as possible.
Incidence and Prevalence
In the United States, over 45 million people-including more than the 33 million sufferers of asthma, diabetes, and heart disease-experience chronic, recurring headaches. Of these, 28 million suffer migraine every year.
Approximately 75% to 90% of all persons who complain of chronic or frequent headaches suffer from tension headache. Tension headache is more prevalent among women than men. Cluster headaches primarily affect men between the ages of 20 and 40.
Causes
Tension headaches are caused by stress, muscular tension, vascular dilation, postural changes, protracted coughing or sneezing, and fever. Physical and mental conditions that can lead to chronic muscular tension and headache include:
- Anxiety
- Arthritis in neck or spine
- Degenerative bone or disk disease in the neck or spine
- Depression
- Temporomandibular joint disorders
There are several well-known triggers associated with cluster headaches, including drugs that dilate or constrict blood vessels and alcohol. This suggests that changes in the walls of blood vessels in the head may be partly responsible.
Some researchers believe that a low level of endorphins may cause frequent, severe, or chronic headache pain. Endorphins are painkilling compounds found in the brain.
Tension Headaches
It is estimated that 75% to 90% of all persons who complain of chronic or frequent headaches suffer from tension headaches. They are the most common type of primary headache, and while they share some characteristics with the more serious migraine, they also display certain distinct differences that set them apart.
Some experts believe that tension headaches and migraines represent two ends of a common spectrum, and that migraines, which are severe but irregular in occurrence, sometimes progress or transform to the less severe, but more frequent, tension-variety headache.
Physical Findings
When a patient is examined by the physician, there are often findings of muscular tenderness. This is often present in the areas of the neck, at the base of the skull, shoulders, upper arms, and the jaw and face. Some people may show signs of clenching the teeth. The scalp and forhead may also be painful when palpated. The neurological examination is usually normal.
Causes
Like migraines, tension headaches seem to be more common in women than in men. Unlike migraines, which often make their initial appearance during adolescence, tension headaches usually begin in middle age. As such, their onset often is equated with the development of adult stresses, anxieties and depression that can characterize mid-life. The name "tension headache" therefore can be said to describe a response by the body to emotional strains and pressures, rather than to excessive muscular tightness and resultant constriction of the scalp arteries, as was once widely presumed. In many such cases, researchers have found that patients complaining of frequent headaches, which are generally not migraines, also exhibit varying degrees of depression, anxiety and worry.
Despite these findings, many physicians and researchers still believe strongly that stress-induced muscular tension in the head, neck and shoulders can bring on tension headaches. This is supported by evidence of muscular tenderness in areas of the neck, the base of the skull, scalp, forehead, face, jaw, shoulders or upper arms in many tension-type headache sufferers. Others show signs of pronounced clenching of the teeth, suggesting that problems related to the temporomandibular joint (TMJ) are causative factors, along with cervical disorders, such as arthritis or degenerative disease of the neck and/or spine, leading to chronic muscular contraction.
Signs and Symptoms
The typical tension headache is one that produces a dull, steady, achy pain on both sides of the head. This contrasts which the classic symptom of migraine, which is severe, throbbing or pulsating pain, usually on one side of the head.
However, a small proportion of tension-headache patients report that their pain, when at its worst, does at times develop a pulsating quality, a phenomena which physicians sometimes call a tension-vascular headache. This represents one more area where the distinction between tension headaches and migraines becomes somewhat blurred, and tends to support the theory that the two headache types are not actually separate conditions, but opposite ends of common spectrum of primary headache activity.
Many tension headache sufferers describe their pain as producing a sensation of pressure or tightness around the head, as though a band were pulled tightly around it; others compare the feeling to having their head clamped in an ever-tightening vise. The pain usually begins gradually and increases steadily over a period of hours, but while severe and distracting, it rarely becomes overwhelming and physically debilitating, as in a migraine.
Diagnosis
Physicians typically diagnose tension-type headache on the basis of observed differences between its symptoms and those that characterize migraines, cluster headaches and other kinds of chronic craniofacial pain. With all patients who complain of abnormally frequent head pain, however, the physician usually will perform a thorough physical examination, including a medical history and one or more diagnostic procedures, to rule out any underlying serious medical problems that may be producing the headaches as a secondary symptom.
Treatment
Many patients with tension headaches do not seek medical attention or advice, instead choosing to treat themselves with nonprescription analgesics and over-the-counter pain medications.
While this works for some people, others, whose tension headaches are severe enough or sufficiently frequent to compel them to seek professional treatment, obtain relief through a course of doctor-prescribed antidepressant or anxiety-reducing medications, such as amitriptyline, nortriptyline or desipramine.
When headaches are severe, symptomatic treatment with aspirin, acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be helpful. In such cases, care must be taken to avoid medication overuse, as this can lead to "rebound headaches." Due to potentially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed.
Some patients report beneficial results from secondary treatments that help reduce the effects of stress and tension on the body, such as massage, meditation and the use of biofeedback techniques. In some cases, patients also may benefit from the effects of psychotherapy as a means of learning how to cope with stress and tension.
Cluster Headache
Cluster headaches are unique in several ways. They occur in an episode-or cluster-that may occur daily over a period of weeks, sometimes even months. They may then disappear, only to recur seasonally the following year. In contrast with migraine, which is more common in women, cluster headaches occur mainly in men between the ages of 20 and 40. A person experiencing cluster headaches may have up to eight attacks per day, each lasting about 15 to 45 minutes or longer. Attacks often come in the early morning hours, and will waken the patient from sleep.
The pain of cluster headaches usually is centered around one eye, and is almost always on one side of the head. There can be nasal stuffiness and tearing with the headache. The pain is excruciating for most people, often described as a knife or nail being driven into the head. Unlike migraine headache, lying down often makes cluster headaches worse. Some people pace the floor and move about, unable to find any relief.
Causes
Precisely what causes cluster headaches is unknown, but the condition has several well-recognized triggers, including alcohol, particularly if a person is going through a cluster period, and nitroglycerine or similar drugs. The fact that some of these triggers also cause blood vessels to dilate or open up to increase blood flow, or involve medications which make blood vessels constrict or narrow to reduce blood flow, suggests that changes in the vascular structure of the head may be partly responsible. There are other causes of headache as well.
Brain Tumors
Many people with brain tumors have headaches. Their pain may be worse in the morning as a result of pressure buildup in the brain after lying flat all night. It usually increases with coughing or straining, and is often accompanied by nausea and vomiting. CT (computer tomography) scans or MRI (magnetic resonance imaging) scans can help differentiate between cluster headaches and those caused by brain tumors.
Infections
Meningitis, an infection of the coverings of the brain, or brain abscess, a collection of infected tissue in the brain, also can lead to headaches. Such patients may have a stiff neck, fever, abnormal laboratory test or neurological examination results. CT scans, MRIs or a spinal tap, a procedure in which cerebrospinal spinal fluid is drawn for examination, may be necessary for a differential diagnosis.
Other infections that can cause headaches are sinusitis (sinus infection), ear infections, dental disease and infections of the eye.
Cerebral Aneurysm
An aneurysm is a widening of a blood vessel wall that can rupture, leading to bleeding in the brain, known as subarachnoid hemorrhage. The pain this causes has often been described as the worst headache of one's life. CT scans and MRI scans are used to make a differential diagnosis. Other tests include angiography (procedure in which a catheter is threaded upward through successive arteries to the neck and brain, where a contrast dye is injected into the blood to facilitate x-ray images) and spinal tap, which can disclose the presence of blood in the cerebrospinal spinal fluid.
Temporal Arteritis
An inflammation of an artery, this disorder usually occurs in older persons, and is associated with headache, muscular and joint aches, weight loss, malaise, fever and sometimes jaw pain. Its most worrisome symptom is transient visual loss, which may lead to permanent blindness if the disorder goes undiagnosed.
Patients typically complain of tenderness when the scalp or sides of the head are touched. Laboratory studies may show an elevation of the patient's ESR (erythrocyte sedimentation or "sed" rate), indicating inflammation. Some patients with temporal arteritis also have low blood iron levels (anemia). Most patients with suspected temporal arteritis are sent for a biopsy, in which a surgeon removes a small piece of the inflamed artery for microscopic examination to ensure correct diagnosis. Treatment involves steroids, mainly prednisone, often for an extended period to control the inflammation and prevent blindness.
Trigeminal Neuralgia
This pain, also known as tic douloureux, involves the nerves of the face and usually occurs on one side of the face only. Its pain is intermittent and severe, often describes as electric shock-like or stabbing. Talking, eating, or even by something as seemingly innocuous as wind blowing against the cheeks may trigger pain. Where many attacks occur in a short period, the face may be sore constantly. People often lose weight and sleep from frequent attacks.
Trigeminal neuralgia is most common in people over 40. The disorder may have many causes. Multiple sclerosis, tumors and blood vessel abnormalities may be responsible for a few cases, but in most instances the cause remains obscure.
One of the more commonly prescribed drugs used to treat trigeminal neuralgia is carbamazepine (Tegretol, Carbatrol). Three-quarters of all patients respond favorably to its use. Other medications that may be beneficial include gabapentin (Neurontin), tramadol (Ultram) and phenytoin (Dilantin). Pain medications also may be necessary during prolonged attacks.
Treatment
Treating cluster headache involves addressing the severe, sometimes unbearable, pain during the headache, and disrupting or shortening the cluster episode. Acute treatment medications are similar to those used for migraine and include:
- Sumatriptan, which can be given in injectable or nasal form for rapid onset. The other oral triptans may also be effective.
- DHE(Migranal)-Delivered as a nasal spray, can have a rapid onset. DHE is also available in an injectable form. It is also useful in migraine. Side effects include nausea and dizziness.
- Narcotics may be helpful, although the onset of most oral agents may not be rapid enough, given the severity and brief duration of the headache.
- Breathing 100% oxygen during the acute headache can be helpful for some people. When the diagnosis of cluster is made, and other medications do not work well, a tank of oxygen can be kept for home use.
Prevention
Prednisilone(Prednisone)
This is a steroid medication that is taken initially in high doses, then tapered over days to weeks, depending on the response. This medication is best if used for short periods of time, as long term steroid use is associated with many complications.
Lithium carbonate
This medication is taken orally, usually twice a day in order to interrupt the cluster. Laboratory testing including lithium levels should be followed closely. Side effects include tremor, increased thirst and gastrointestinal symptoms.
Verapamil
This is a medication that can also be effective in migraine. It can be taken twice daily in a sustained oral preparation. Side effects include dizziness and constipation.
Signs and Symptoms
Tension Headache
Tension headache usually produces a dull, steady ache on both sides of the head. The pain usually increases over a period of hours. A small number of tension-headache patients report that, when at its worst, the pain develops a pulsating quality.
Tension headache pain has been described as pressure or tightness around the head, as though a band were pulled tightly around it or as if it were clamped in a vise.
Muscular tenderness in areas of the neck, the base of the skull, scalp, forehead, face, jaw, shoulders, or upper arms may be present in tension-headache sufferers. The scalp and forehead may be painful to the touch. Some people may show signs of clenching their teeth.
Cluster Headache
A person experiencing cluster headache may have up to 8 attacks per day, each lasting about 15 to 45 minutes or longer. Attacks often come in the early morning hours and waken the patient from sleep.
The pain of cluster headaches usually is located around one eye and is almost always on one side of the head (unilateral). There can be nasal stuffiness and tearing with the headache.
The pain is excruciating for most people and lying down often makes cluster headaches worse. Some people pace the floor and move about, unable to find relief.
Diagnosis
Diagnosis of tension or cluster headache is based on symptoms and a thorough medical examination, including the following:
- Blood tests including thyroid, liver, and kidney function tests
- Eye examination
- Family history
- Medical history (including medications and characteristics of the headache)
- Neurological examination
- Sleep habits
Imaging studies of the brain may be necessary to rule out any serious underlying medical problem, such as brain tumor, stroke, infection, and vascular malformation (e.g., aneurysm).
Imaging studies that may be performed include:
- Computed tomography (CT scan) or magnetic resonance imaging (MRI scan) to examine the tissues and structures around, on, and in the brain
- Electroencephalogram (EEG) to measure brain activity
- X-rays or magnetic resonance angiography (MRA) to evaluate the brain's blood vessels
Laboratory and imaging tests can help rule out secondary causes of headache, such as the following:
- Brain tumor
- Cerebral aneurysm
- High blood pressure (hypertension)
- Infection (e.g., meningitis, sinusitis, ear infection)
- Temporal arteritis
- Trigeminal neuralgia
Treatment
Headache treatment often depends on the type, the severity, and the frequency of occurrence. In many cases, tension headache can be effectively treated using conservative measures, such as lifestyle modifications (e.g., improvements in diet and sleep patterns) and over-the-counter pain relievers (e.g., acetaminophen, ibuprofen).
Cluster headache and migraine headache may require prescription medications and preventative (prophylactic) treatment.
Tension Headache Occasional tension headache usually can be treated successfully with lifestyle adjustments and over-the-counter analgesics (e.g., aspirin, ibuprofen, acetaminophen). When headaches are severe or frequent, care must be taken to avoid analgesic overuse, which can lead to rebound headaches.
In rebound headache, high levels of the drug in the body actually cause daily headache. In most cases, rebound headaches improve when the medication is stopped.
Tension headaches that resist treatment with over-the-counter agents may be treated with antidepressant or anxiety-reducing medications, such as amitriptyline, nortriptyline or desipramine.
Some tension-headache patients report beneficial results from secondary treatments that help reduce the effects of stress and tension on the body, such as massage, meditation, and biofeedback. When appropriate, psychotherapy may help some patients learn to cope better with stresses that can lead to headache.
Cluster Headache Treating cluster headache involves relieving the severe, sometimes unbearable pain during the headache, and disrupting or shortening the cluster episode. Acute treatment medications are similar to those used for migraine and include:
- Sumatriptan (Imitrex®)-injectable or nasal spray (Other oral triptans may also be effective.)
- DHE (Migranal®)-injectable or nasal spray (May cause nausea and dizziness.)
- 100% oxygen-inhaled from oxygen tank (Oxygen tank can be kept for home use.)
- Narcotics (e.g., codeine)-oral form (May not act quickly enough.)
Prednisone is a corticosteroid, a potent chemical that occurs naturally in the body. It is taken initially in high doses and then tapered over days or weeks, depending on the response. This medication is best if used for short periods of time.
Long-term corticosteroid use can cause many serious adverse side effects because it is involved in several different functions in the body. Potential side effects include an increase in intraocular pressure, osteoporosis, behavioral changes, ulcer, and diabetes.
Lithium carbonate Lithium may increase the levels of dopamine and norepinephrine in the brain. It is taken orally, usually twice a day, to interrupt a cluster headache. Concentration of lithium in the blood is closely monitored with periodic blood tests. Side effects include tremor, increased thirst, nausea, and frequent urination. Lithium carbonate typically is used to treat manic episodes in manic-depressive patients.
Verapamil dilates blood vessels. It can be taken twice daily in a sustained oral preparation. Side effects include nausea, dizziness, and constipation. Verapamil typically is used to treat angina, hypertension, and arrhythmias.
Natural Medicine
What causes headaches? The most common cause of regular headaches is muscle tension caused by spinal misalignment. A simple chiropractic evaluation and adjustment is often all it takes to relieve recurrent headaches.
Paradoxical as it may seem, a surprising percentage of headaches may be caused by headache medication. The "rebound effect" of analgesic and ergotomine compounds has been implicated as a contributing factor for sufferers of daily headaches. Discuss this phenomenon with your prescribing doctor if you are taking more than 30 analgesic tablets a month or if you regularly use ergotamine derivatives. Withdrawal from these products can temporarily make headaches worse, but eliminating these products altogether may ultimately mean far fewer headaches.
How what you eat can give you headaches When exploring the causes of headaches, the easiest place to start is diet. Food reactions are a significant contributor to headaches and some improvement, if not complete remission, can usually be achieved by eliminating problematic dietary items. The elimination/challenge trial described below is a good way to identify food reactions that may be causing headaches.
The elimination/challenge trial This traditional naturopathic procedure has been accurately diagnosing food-related symptoms for many years and continues to be the standard for identifying food sensitivities.
There are 2 ways to approach an elimination/challenge. The first and more difficult but more effective route is outlined as option #1 below. It involves eliminating all the major suspects that usually cause problems and then slowly, over time, adding them back into the diet one-by-one. It provides clear insight into the impact of foods.
The second option is reserved for those who already have a good idea about what foods are problematic for them. The suspected food group is eliminated until symptoms clear and then added back into the diet to determine if symptoms return.
Symptoms associated with food challenges may not be the same as those experienced before the elimination process. For example, patients who experienced chronic sinus pain prior to embarking on the elimination/challenge may find that upon challenging the suspect food causes stomach pain. This doesn't mean the food group being challenged does not cause sinus pain, rather that the body may react a bit differently when re-introduced to the offending agent.
Symptoms that can occur on a food challenge include: headache (may be brief or prolonged), nausea, sleepiness, irritability, depression, anxiety, excitability, stomach ache, sharp abdominal pain, sore throat, stuffy nose, runny nose, itchy nose or eyes, tightness in the chest, skin rash or itching, facial flushing, red ears, muscle twitching, insomnia, and fatigue. There are as many ways of manifesting sensitivities as there are people who suffer from them.
Elimination/challenge is the most effective way to determine food intolerance. It also provides an excellent opportunity to explore and understand your relationship with food.
Option #1
Option #1 involves an elimination that lasts from 2 to 6 weeks, followed by a challenge. The elimination involves managing your diet based on the following criteria.
Eliminate all suspect foods:
- wheat products (e.g., pasta, bread, processed foods)
- dairy products (e.g., milk, cheese, yogurt, cream)
- corn products (e.g., tortillas, chips, polenta, cornstarch)
- peanuts (peanut butter, peanut oil)
- soy products (e.g., tofu, tempeh, soy milk, soy protein powder, soy oil)
- glutinous grains (e.g., rye, barley, oats, spelt, kamut, seitan, hops)
- beef
- chocolate
- sugar
- nutrasweet/aspartame (artificial sweeteners)
- food colorings/dyes
- pesticides and chemical spoilage retardants (especially sulfites)
Maintain a diet based on:
- Fresh fruits and vegetables
- potatoes
- yams
- animal protein (fish, poultry, lamb)
- non-glutinous grains (millet, buckwheat, rice, amaranth)
If you have a choice, always choose organic foods. Otherwise, you could be ingesting pesticides, herbicides, fungicides, and/or formaldehydes.
Avoid sulfite-containing foods, which most include canned vegetables and fruits, wine, and canned tuna (albacore).
Read labels. Know that "vegetable protein" is either wheat or soy; thickening agents and stabilizers are either wheat or corn; and food starch is usually wheat or corn. It is much easier to avoid processed food while on the diet than to figure out all the additives in prepared foods.
After 2 to 6 weeks of maintaining a strict elimination diet, you should experience a relief from symptoms.
Challenge Begin your challenge with the food group you feel is the least likely culprit. Eat several servings from that food group throughout the day. For example, if you are challenging dairy, have milk with breakfast; include cheese, cream and yogurt in your lunch and dinner menus; drink milk at meals; and snack on dairy items. Then wait. DO NOT continue to add that food group to your diet. You only challenge for one day, then wait for at least 48 hours. Return to eating ONLY your elimination diet foods. If you do not experience a return of symptoms after 48 hours, go on to the next suspected food group.
Continue this process until you find the problematic food group. In most cases you will experience a return of symptoms within 48 hours. Rarely do symptoms appear several days or weeks later. If, however, you want to wait more than 48 hours, feel free to do so as this will only increase the accuracy of this test. A week between food group challenges is optimal. Only challenge one food group at a time.
Option #2
Maintain your regular diet, eliminating only the food group that you believe to be causing your symptoms. Eliminate ALL items in that food group for at least 1 month. If your symptoms disappear during this time, continue to abstain from that food group for 1 more week after symptom relief. If, for example, you find yourself symptom-free after just a few days of avoidance, you must still continue to avoid that food group for another week before you can effectively challenge. When you challenge, follow the guidelines stated above: eat several servings of the suspect food group during a 24-hour period, then return to the elimination diet and wait. More often than not you will get immediate information about how your body is interacting with a problem food group.
Physical medicine Submerge the feet in a bucket of very hot water while at the same time applying an ice compress to the back of the neck. This actually draws the blood down to the feet away from the head. Reduction of pain coincides with the duration of application.
Acupressure type massage can be helpful. See a trained acupressure therapist for instructions on procedures to do at home.
Chiropractic adjustments and maintaining correct spinal alignment can be very supportive in the prevention of headaches that are triggered by muscle stress and spasm.
Acupuncture
Acupuncture is a very useful treatment. It can balance underlying hormonal deficiencies, tonify the gastrointestinal system, and calm reactive blood vessels. It can support the balancing required in any healing process.
A word of caution: when selecting an acupuncturist, be very careful to research the training and qualifications of your practitioner. Medical doctors can take weekend courses in acupuncture and call themselves certified acupuncturists. A weekend course is NOT enough study to understand the complex philosophy or practice of Chinese Medicine.
Choose a practitioner who holds a full doctorate degree in Chinese medicine: an O.M.D. (Oriental Medicine Doctor) or Lic.Ac (licensed acupuncturist). These practitioners are required to complete several years of training. The letters TCM (Traditional Chinese Medicine) after the name means that the doctor has additional training in the prescribing of Chinese herbs. The more knowledge a practitioner has about Chinese Medicine, the better they will be able to diagnose and treat your symptoms. Also, as with all health care practitioners, check the practice reputation in the community.
Your environment and your headaches Headaches can be agonizing and debilitating. The inclination to "make the pain go away now," however, can be an obstacle to curing the cause of the pain. It is easy to become trapped in a cycle medication and side effects. Headaches do not just happen; they are not a random occurrence. They are your body interacting with the environment. Explore the environment as well as the your body's relationship to it to determine the factors that are upsetting your internal balance and you can control your headaches and know how to prevent them from re-occurring.