Over 40 million Americans experience chronic headaches. For at least
half of these people, the problem is severe and sometimes disabling. It
can also be costly: headache sufferers make over 8 million visits a
year to doctor's offices. Migraine victims alone lose over 65 million
workdays because of headache pain.
Several areas of the head can hurt, including a network of nerves
which extends over the scalp and certain nerves in the face, mouth, and
throat. Also sensitive to pain, because they contain delicate nerve
fibers, are the muscles of the head and blood vessels found along the
surface and at the base of the brain.
The bones of the skull and tissues of the brain itself, however, never hurt, because they lack pain-sensitive nerve fibers.
The ends of these pain-sensitive nerves, called nociceptors, can be
stimulated by stress, muscular tension, dilated blood vessels, and
other triggers of headache. Once stimulated, a nociceptor sends a
message up the length of the nerve fiber to the nerve cells in the
brain, signaling that a part of the body hurts. The message is
determined by the location of the nociceptor.
A number of chemicals help transmit pain-related information to the
brain. Some of these chemicals are natural painkilling proteins called
endorphins, Greek for "the morphine within." One theory suggests that
people who suffer from severe headache and other types of chronic pain
have lower levels of endorphins than people who are generally pain free.
Not all headaches require medical attention. Some result from missed
meals or occasional muscle tension and are easily remedied. But some
types of headache are signals of more serious disorders such as head
injury and call for prompt medical care.
A test called an electroencephalogram (EEG) may be given to measure
brain activity. EEG's can indicate a malfunction in the brain, but they
cannot usually pinpoint a problem that might be causing a headache. A
physician may suggest that a patient with unusual headaches undergo a
computed tomographic (CT) scan. The CT scan produces images of the
brain that show variations in the density of different types of tissue.
The scan enables the physician to distinguish, for example, between a
bleeding blood vessel in the brain and a brain tumor. The CT scan is an
important diagnostic tool in cases of headache associated with brain
lesions or other serious disease. Experts generally agree, however,
that this sophisticated and expensive technology is not required to
diagnose simple or periodic headache.
An eye exam is usually performed to check for weakness in the eye
muscle or unequal pupil size. Both of these symptoms are evidence of an
aneurysm--an abnormal ballooning of a blood vessel. A physician who
suspects that a headache patient has an aneurysm may also order an
angiogram. In this test, a special fluid which can be seen on an X ray
is injected into the patient and carried in the bloodstream to the
brain to reveal any abnormalities in the blood vessels there.
Headaches are diagnosed as:
- Vascular
- Muscle contraction
- Traction
- Inflammatory
Vascular headaches are a group that includes the well-known migraine
- are so named because they are thought to involve abnormal function of
the brain's blood vessels or vascular system.
Muscle contraction headaches appear to involve the tightening or tensing of facial and neck muscles.
Traction and inflammatory headaches are symptoms of other disorders,
ranging from stroke to sinus infection. Some people have more than one
type of headache.
The most common type of vascular headache is migraine. Migraine
headaches are usually characterized by severe pain on one or both sides
of the head, an upset stomach, and at times disturbed vision.
Sensitivity to light is a standard symptom of the two most prevalent
types of migraine-caused headache: classic and common.
The major difference between the two types is the appearance of
neurological symptoms 10 to 30 minutes before a classic migraine
attack. These symptoms are called an aura. The person may see flashing
lights or zigzag lines, or may temporarily lose vision. Other classic
symptoms include speech difficulty, weakness of an arm or leg, tingling
of the face or hands, and confusion.
The pain of a classic migraine headache is described as intense,
throbbing, or pounding and is felt in the forehead, temple, ear, jaw,
or around the eye. Classic migraine starts on one side of the head but
may eventually spread to the other side. An attack lasts 1 to 2
pain-wracked days.
If you were about to experience a classic migraine headache, you
might find it difficult to read this article. You could lose part of
your vision temporarily and see zigzag lines and black dots. Such
visual problems--and other neurological symptoms--often precede classic
migraine.
The common migraine - a term that reflects the disorder's greater
occurrence in the general population--is not preceded by an aura. But
some people experience a variety of vague symptoms beforehand,
including mental fuzziness, mood changes, fatigue, and unusual
retention of fluids. During the headache phase of a common migraine, a
person may have diarrhea and increased urination, as well as nausea and
vomiting. Common migraine pain can last 3 or 4 days.
Both classic and common migraine can strike as often as several
times a week, or as rarely as once every few years, Both types can
occur at any time. Some people, however, experience migraines at
predictable times - near the days of menstruation or every Saturday
morning after a stressful week of work.
Research scientists are unclear about the precise cause of migraine
headaches. There seems to be general agreement, however, that a key
element is blood flow changes in the brain. People who get migraine
headaches appear to have blood vessels that overreact to various
triggers.
While a food-triggered migraine usually occurs soon after eating,
other triggers may not cause immediate pain. Scientists report that
people can develop migraine not only during a period of stress but also
afterwards when their vascular systems are still reacting. The
"Preacher Monday-Morning Headache" is named for those clergymen who get
migraines a day after the stress of delivering a Sunday sermon.
Migraines that wake people up in the middle of the night are also
believed to result from a delayed reaction to stress.
In addition to classic and common, migraine headache can take
several other forms: Patients with hemiplegic migraine have temporary
paralysis on one side of the body, a condition known as hemiplegia.
Some people may experience vision problems and vertigo--a feeling that
the world is spinning. These symptoms begin 10 to 90 minutes before the
onset of headache pain.
In ophthalmoplegic migraine, the pain is around the eye and is
associated with a droopy eyelid, double vision, and other sight
problems.
Basilar artery migraine involves a disturbance of a major brain
artery. Preheadache symptoms include vertigo, double vision, and poor
muscular coordination. This type of migraine occurs primarily in
adolescent and young adult women and is often associated with the
menstrual cycle.
Benign exertional headache is brought on by running, lifting,
coughing, sneezing, or bending. The headache begins at the onset of
activity, and pain rarely lasts more than several minutes.
Status migrainosus is a rare and severe type of migraine that can
last 72 hours or longer. The pain and nausea are so intense that people
who have this type of headache must be hospitalized. The use of certain
drugs can trigger status migrainosus. Neurologists report that many of
their status migrainosus patients were depressed and anxious before
they experienced headache attacks.
Headache-free migraine is characterized by such migraine symptoms as
visual problems, nausea, vomiting, constipation, or diarrhea. Patients,
however, do not experience head pain. Headache specialists have
suggested that unexplained pain in a particular part of the body,
fever, and dizziness could also be possible types of headache-free
migraine.
During the Stone Age, pieces of a headache sufferer's skull were cut
away with flint instruments to relieve pain. Another unpleasant remedy
used in the British Isles around the ninth Century involved drinking
"the juice of elderseed, cow's brain, and goat's dung dissolved in
vinegar." Fortunately, today's headache patients are spared such
drastic measures.
Drug therapy, biofeedback training, stress reduction, and
elimination of certain foods from the diet are the most common methods
of preventing and controlling migraine and other vascular headaches.
Regular exercise, such as swimming or vigorous walking, can also reduce
the frequency and severity of migraine headaches. During a migraine
headache, temporary relief can sometimes be obtained by using cold
packs or by pressing on the bulging artery found in front of the ear on
the painful side of the head.
There are two ways to approach the treatment of migraine headache
with drugs: prevent the attacks, or relieve symptoms after the headache
occurs.
For infrequent migraine, drugs can be taken at the first sign of a
headache in order to stop it or to at least ease the pain. People who
get occasional mild migraine may benefit by taking aspirin or
acetaminophen at the start of an attack. Aspirin raises a person's
tolerance to pain and also discourages clumping of blood platelets.
Small amounts of caffeine may be useful if taken in the early stages of
migraine. But for most migraine sufferers who get moderate to severe
headaches, and for all cluster patients, stronger drugs may be
necessary to control the pain.
One of the most commonly used drugs for the relief of classic and
common migraine symptoms is ergotamine tartrate, a vasoconstrictor
which helps counteract the painful dilation stage of the headache. For
optimal benefit, the drug is taken during the early stages of an
attack. If a migraine has been in progress for about an hour and has
passed into the final throbbing stage, ergotamine tartrate will
probably not help.
For headaches that occur three or more times a month, preventive
treatment is usually recommended. Drugs used to prevent classic and
common migraine include methysergide maleate, which counteracts blood
vessel constriction, propranolol, which stops blood vessel dilation,
and amitriptyline, an antidepressant.
Antidepressants called MAO inhibitors also prevent migraine. These
drugs block an enzyme called monoamine oxidase which normally helps
nerve cells absorb the artery-constricting chemical, serotonin.
MAO inhibitors can have potentially serious side effects -
particularly if taken while ingesting foods or beverages that contain
tyramine, a substance that closes down arteries.
Drug therapy for migraine is often combined with biofeedback and
relaxation training. Biofeedback is a space-age word for a technique
that can give people better control over such body function indicators
as blood pressure, heart rate, temperature, muscle tension, and brain
waves. Thermal biofeedback allows a patient to consciously raise hand
temperature. Some patients who are able to increase hand temperature
can reduce the number and intensity of migraines. The mechanism of this
hand-warming effect is being studied by research scientists.
Scientists estimate that a small percentage of migraine sufferers
will benefit from a treatment program focused solely on eliminating
headache-provoking foods and beverages.
Other migraine patients may be helped by a diet to prevent low blood
sugar. Low blood sugar, or hypoglycemia, can cause dilation of the
blood vessels in the head. This condition can occur after a period
without food: overnight, for example, or when a meal is skipped. People
who wake up in the morning with a headache may be reacting to the low
blood sugar caused by the lack of food overnight.
Treatment for headaches caused by low blood sugar consists of
scheduling smaller, more frequent meals for the patient. A special diet
designed to stabilize the body's sugar-regulating system is sometimes
recommended.
For the same reason, many specialists also recommend that migraine
patients avoid oversleeping on weekends. Sleeping late can change the
body's normal blood sugar level and lead to a headache.
After migraine, the most common type of vascular headache is the
toxic headache produced by fever. Pneumonia, measles, mumps, and
tonsillitis are among the diseases that can cause severe toxic vascular
headaches. Toxic headaches can also result from the presence of foreign
chemicals in the body. Other kinds of vascular headaches include
"clusters," which cause repeated episodes of intense pain, and
headaches resulting from a rise in blood pressure.
Repeated exposure to nitrite compounds can result in a dull,
pounding headache that may be accompanied by a flushed face. Nitrite,
which dilates blood vessels, is found in such products as heart
medicine and dynamite. Hot dogs and other meats containing sodium
nitrite can also cause headaches.
"Chinese restaurant headache" can occur when a susceptible
individual eats foods prepared with monosodium glutamate (MSG)--a
staple in many Oriental kitchens. Soy sauce, meat tenderizer, and a
variety of packaged foods contain this chemical which is touted as a
flavor enhancer.
Jokes are often made about alcohol hangovers but the headache
associated with "the morning after" is no laughing matter. Fortunately,
there are several suggested remedies for the pain, including ergotamine
tartrate. The hangover headache may also be reduced by taking honey,
which speeds alcohol metabolism, or caffeine, a constrictor of dilated
arteries. Caffeine, however, can cause headaches as well as cure them.
Heavy coffee drinkers often get headaches when they try to break the
caffeine habit.
Cluster headaches, named for their repeated occurrence in groups or
clusters, begin as a minor pain around one eye, eventually spreading to
that side of the face. The pain quickly intensifies, compelling the
victim to pace the floor or rock in a chair. "You can't lie down,
you're fidgety," explains a cluster patient. "The pain is unbearable."
Other symptoms include a stuffed and runny nose and a droopy eyelid
over a red and tearing eye.
Cluster attacks can strike at any age but usually start between the
ages of 20 and 40. Unlike migraine, cluster headaches are more common
in men and do not run in families. Research scientists have observed
certain physical similarities among people who experience cluster
headache. The typical cluster patient is a tall, muscular man with a
ragged facial appearance and a square, jutting or dimpled chin. The
texture of his coarse skin resembles an orange peel. Women who get
clusters may also have this type of skin.
Studies of cluster patients show that they are likely to have hazel
eyes and that they tend to be heavy smokers and drinkers.
Paradoxically, both nicotine, which constricts arteries, and alcohol,
which dilates them, trigger duster headaches. The exact connection
between these substances and cluster attacks is not known.
The sudden start and brief duration of cluster headaches can make
them difficult to treat. By the time medicine is absorbed into the
body, the attack is often over. However, research scientists have
identified several effective drugs for these headaches. The
antimigraine drug ergotamine tartrate can subdue a cluster, if taken at
the first sign of an attack. Injections of dihydroergotamine, a form of
ergotamine tartrate, are sometimes used to treat clusters.
Chronic high blood pressure can cause headache, as can rapid rises
in blood pressure like those experienced during anger, vigorous
exercise, or sexual excitement.
The severe "orgasmic headache" occurs right before orgasm and is
believed to be a vascular type. Since sudden rapture of a cerebral
blood vessel can also occur during orgasm, this type of headache should
be promptly evaluated by a doctor.
Tension headache is named not only for the role of stress in
triggering the pain, but also for the contraction of neck, face, and
scalp muscles brought on by stressful events. Tension headache is a
severe but temporary form of muscle-contraction headache. The pain is
mild to moderate and feels like pressure is being applied to the head
or neck. The headache usually disappears after the period of stress is
over.
Acute tension headaches not associated with a disease are treated
with muscle relaxants and analgesics like aspirin and acetaminophen.
Stronger analgesics, such as propoxyphene and codeine, are sometimes
prescribed. As prolonged use of these drugs can lead to dependence,
patients taking them should have periodic medical checkups and follow
their physicians' instructions carefully.
Nondrug therapy for chronic muscle-contraction headaches includes
biofeedback, relaxation training, and counseling. A technique called
cognitive restructuring teaches people to change their attitudes and
responses to stress. Patients might be encouraged, for example, to
imagine that they are coping successfully with a stressful situation.
In progressive relaxation therapy, patients are taught to first tense
and then relax individual muscle groups. Finally, the patient tries to
relax his or her whole body. Many people imagine a peaceful scene--such
as lying on the beach or by a beautiful lake. Passive relaxation does
not involve tensing of muscles. Instead, patients are encouraged to
focus on different muscles,suggesting that they relax. Some people
might think to themselves, Relax or My muscles feel warm.
If you suffer from headaches and none of the standard treatments
help, do not despair. Some people find that their headaches disappear
once they deal with a troubled marriage, pass their law board exams, or
resolve some other stressful problem. Others find that if they control
their psychological reaction to stress, the headaches disappear.
Headache - Hope Through Research. U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES. NIH Publication No. 84-158
