Treating Headaches And Migraines

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

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