Headache is one of the most common maladies. There is scarcely anyone who has not had a headache at some point in their lives. For many, a headache is an occasional painful inconvenience easily controllable with an over-the-counter medication. But for others, the headache is frequent and can disable them and cause missed work or damage social and family aspects of life. There are about three hundred causes of headaches but only the most common ones will be discussed here.
The International Headache Society (IHS) broadly divides headache into two categories: primary and secondary headaches. Primary headaches are a constellation of clinical symptoms and not a result of another disorder.
Primary headaches include:
- Migraine headache and its variants
- Cluster headache
- Tension type headache
Secondary headaches are headaches caused by an underlying medical condition such as sinus disease, brain tumor, or stroke. There are numerous causes that could be listed for secondary headaches. A thorough evaluation by a trained professional is aimed at investigating causes for the headache.
Getting help - What to Expect
Getting help for frequent and severe headache starts with an expert who is experienced in the evaluation and treatment of headaches, especially if a clear diagnosis and/or effective treatment is not forthcoming.
A headache expert takes a thorough medical and dental history. Common questions include asking about diet, depression, anxiety, work, and family, as well as past evaluations and treatments. Of primary importance will be the nature, frequency and location of your headaches and any other symptoms that accompany them.
After taking the history, the doctor performs a thorough examination including examination of the cranial nerves in the head and neck, examination of the ears and eyes, and palpation of head, neck and jaw muscles.
Diagnostic tests may include magnetic resonance imaging (MRI) and computer assisted tomography (CT). Other tests, such as blood tests and urinalysis, may help to diagnose diseases that secondarily cause headaches.
After assembling all information, a diagnosis is made and treatment is planned. Simple treatment, such as identifying and eliminating causes of headache (such as eating certain foods), is tried first. Trials of one or more medications may be indicated. Other treatments, such as those performed by psychologists, physical therapists, chiropractors, and acupuncturists, may help as part of overall medical/dental treatment. Before initiating any of these treatments, the doctor explains the diagnosis and treatment plan as well as risks or side effects.
Common Forms of Headache and Their Treatment
Migraine Headache and its Variants
Migraine headache affects over 23 million Americans. Women are affected three times as often as men and there is a hereditary component in many migraine sufferers. Research has shown that migraine and other forms of headache result from neurochemical changes in the brain and are not the result of psychological problems. We know that anxiety and depression often accompany headache and comprehensive treatment should address these conditions. Understanding these scientific advances led researchers to discover better treatments than in the past.
Migraine with Aura
Migraine with aura is the "classical" migraine headache. This kind of migraine has four phases - the prodrome, the aura, the headache, and postdrome or after effect of the headache.
The prodrome occurs anywhere from 2 to 24 hours before the start of the headache and can include such symptoms as lightheadedness, funny smell, upset stomach, dizziness, and sometimes a general feeling of something not being quite right. The aura occurs several minutes to an hour before the headache starts and can include disturbances in vision, numbness, muscle weakness, speech disturbance, lightheadedness, and nausea. If the aura lasts more than one hour, the patient may be referred to a neurologist to rule out possibly dangerous problems that seem like migraine with aura, but aren't. During the headache phase, patients experience moderate to severe head, neck, facial or oral pain, often, but not always, accompanied by nausea and vomiting. The headache is usually one sided and may or may not have a pulsating quality that lasts from four hours to three days, sometimes longer. Most migraine sufferers complain that light and sound bothers them during the headache and they prefer to lie down in a dark, quiet, cool room.
Doctors sometimes divide migraine into categories related to the cause of the headache; for example, migraine occuring monthly in a woman relating to the menstrual cycle is referred to as "menstrual migraine", or a migraine that started after head injury might be called "traumatic migraine".
Subtypes of Migraine Headache
Many, if not most, migraine sufferers have headache without a prodrome and/or aura but still suffer with debilitating headaches associated with light and sound sensitivity and nausea and vomiting.
Migraine can occur anywhere in the head, neck, face, or mouth. Often, it is one sided and concentrates around one of the eyes.
In some patients, the migraine is started by specific stimuli. These stimuli may be poor sleep, increased stress, or diet. Specific foods that can trigger a migraine headache include those containing monosodium glutamate, citrus fruits and drinks, red wines, aged cheeses, and chocolate.
The treatment of migraine often falls into three categories - behavior modification, physical therapy and exercise, and medications. Commonly, several treatments are used in combination.
Behavior modification can include dietary avoidance, stress reduction techniques, and avoidance of headache triggers. Patients can learn to avoid stressful situations when possible and also learn simple relaxation exercises to "turn off" their anxiety. Erratic sleep schedules, smoking, altitude changes, and hormonal changes are other examples of triggers that can be changed.
Often times, the patient will note radiating pain into the muscles of the face and more often the neck. While this may represent a pain referral pattern from the area of the brain that causes the migraine, many patients experience at least partial relief from doctor prescribed stretching and other exercises aimed at alleviating muscle soreness in the head and neck. Patients can be taught to apply heat and cold and to massage these areas, giving them a tool to obtain some relief.
The most common way to control migraine headache is through the use of medication. The two most common approaches are those medications aimed at preventing the headache and those that stop or "abort" the headache once it has begun. These two approaches are often used in combination. New medications are being developed constantly and have vastly improved over the last several years.
Preventive medications are prescribed when the headaches are frequent, long lasting, and/or severe enough to change activities of daily living, family and social interactions, and ability to work. These preventive medications lower the frequency and intensity of headaches and, in some patients, may prevent them all together. Often a medication originally intended for another purpose, for example, lowering blood pressure, will be chosen to prevent headache. Other medications commonly used to prevent headache are anti-seizure and anti-depressant medication. Use of these medications does not indicate that your doctor believes you are depressed, but that research and experience have shown these are effective drugs.
Abortive medications include various forms of over-the-counter and prescription medications. The newest groups of abortive medications are taken orally, by nasal spray, or injected.
Whether using preventive or abortive medications, or a combination of both, the doctor tailors the doses and kinds of medication, taking into consideration the particular headache pattern, the patient's past experiences with medication, other medications being taken at the time, and other medical problems.
Pain anywhere in the trigeminal nerve's distribution, which includes the jaw joints (TMJ's), jaw muscles, neck muscles, teeth and other oral structures, can trigger headache. A thorough headache treatment regimen should include evaluation and treatment of any active or latent sources of stimulation within the trigeminal system to reduce the potential they will trigger a headache.
Cluster Headache
Cluster headache is extremely painful, most often affecting middle-age men. Patients may describe pain in or behind one eye and describe the feeling of the headache as an "ice pick" kind of pain. The headache may be accompanied by a runny nose and tearing of the eye. Cluster headache patients may be in so much pain that they need to pace around the room and are restless and agitated.
The headaches occur in clusters of one to seven days, last from 20 to 60 minutes and often awake the patient from sleep. While the medications used for cluster headache are similar to those used for migraine, the cluster sufferer will often get quick relief from inhaling 100% oxygen. A variant of cluster headache affecting mostly women is known by the complicated name "Chronic Paroxysmal Hemicrania" or CPH for short. These headaches are short, between 5 and 20 minutes, but can occur as many as 15 times in a single day. Fortunately, these headaches frequently respond to an anti-inflammatory drug called Indomethacin.
Tension Type Headache
Tension Type Headache (TTH) is the most common kind of headache. They usually affect both sides of the head and can range in location from the base of the neck to the temples, top of the head and to the eyes. The causes of TTH vary and are not always readily identifiable and may or may not be associated with stress. The cause of the headache may be as common as a stressful work environment or a difficult personal relationship. What are often described as "sinus headache" or "eye strain" can actually be TTH.
Tension Type Headache can be chronic, occurring over long periods of time, or they can be episodic. They may or may not be accompanied by muscle pain in the head and neck.
Orofacial pain specialists often see patients that clench or grind their teeth at night or during the day. Many of these patients complain of daily headache, sometimes accompanied by other symptoms such as tooth pain, ear pain, facial pain, jaw clicking or popping, pain around the eyes and even pain in the neck and shoulders. This is thought to be tension type headache.
The treatment for TTH can very but often includes anti-inflammatory medications, muscle relaxants, anti-depressants and pain medication to control the headache. A great deal of attention has to be paid to stress management and physical conditions that may bring on and/or maintain the headache and, therefore, relaxation training, counseling, and physical therapy are important treatments. It is necessary to stress that while the name of this headache contains that word "tension", it is not certain that psychological factors play a role in causing these headaches.
Chronic Migraine
Migraine patients who take prescription or over-the-counter medications for a long period of time may experience an increase in frequency and a change in the quality of their pain. What started as episodes of migraine can then change to a chronic daily headache. This phenomenon, although very common, often goes unrecognized and undiagnosed. Once diagnosed, there are treatments that can break the chain of daily medication-induced headache and make the residual headache amenable to treatment.
