Headaches

HEADACHES DEFINITION AND GENERAL INFORMATION Headache simply means pain in the head. It is estimated that 45 million Americans experience headaches on a chronic basis. For many of these people, the headache can be disabling and costly. Headache sufferers make over 8 million visits to doctor’s offices, urgent care centers and emergency departments every year and lose over 160 million workdays every year secondary to headache symptoms. Headache pain is not brain pain! The brain itself is insensitive to pain. Headache pain occurs in the tissue covering the brain (the meninges), the tissue around and supporting the head and brain and the blood vessels and muscles of the face, scalp and neck. HEADACHE SYMPTOMS Headache symptoms vary greatly from person to person and from one type of headache to another. Many headache sufferers have other associated symptoms as well head pain, these include photophobia (inability to tolerate bright light), nausea and vomiting, facial tingling and numbness, pain in the base of neck or back of head. COMMON TYPES OF HEADACHES The International Headache Society has established a detailed system to categorize different types or causes of headache. The initial categories focus on the three primary causes of headaches: tension type headache, migraine and cluster headache. Other forms of headache that are different and have an identifiable cause are those headaches associated with cerebrovascular disease, head trauma, tumors, infections, and metabolic abnormalities. Tension Type Headache Are the most frequent cause of headache. It is estimated that 80% of people who have headaches suffer from tension headaches. Some experts believe that migraine and tension headaches are from opposite ends of a common spectrum and that migraine headaches can transform into tension headaches and visa versa. The headache is characterized by pain in the back of the head and neck and is usually on both sides. The pain can last weeks to months with only occasional periods of relief. The pain of often described as a tight band-like pain or pressure. “My head feels like it is in a vise!” is a common description of the pain. The physical exam usually displays muscular tenderness at the base of the skull and along the neck. The scalp and forehead may also be tender to palpation. The neurological exam is usually normal. The diagnosis is usually made on the history and on the physical findings of muscular tenderness. Many patients with tension headaches do not seek medical help but use nonsteroidal anti-inflammatory medications to control their symptoms. Other patients find relief through techniques that help relieve stress and tension on the body such as biofeedback, massage and meditation.

Migraine Headache The term migraine dates back to Roman times. Studies have shown that it is relatively common, affecting 18% of woman and 6% of men. Typically migraines occur first during the teen years. It is rare to have the first migraine attack after age forty. Attacks are usually recurrent and tend to decrease in severity and frequency with age. Many migraine sufferers have specific triggers that can precipitate their symptoms. Some of these triggers are; alcohol, sleep deprivation, MSG, stress, medication, and menstruation. Pregnancy can also cause migraine headaches to increase but for a few, it can result in an improvement for the duration of the pregnancy. Migraine pain is thought to be caused by the dilatation of cerebral blood vessels. An important substance in this pain pathway is the neurochemical serotonin. Many of the newer anti-migraine medications are related to the serotonin molecule and mimic some of its functions. Migraine pain is described as usually unilateral (one-sided), throbbing and severe. Patients may also be sensitive to light and experience nauseous and vomiting. Many migraine sufferers have an aura, a period of symptoms or feeling before the actual painful attack. This aura is thought to be caused by an initial vasoconstriction (narrowing) of the blood vessels. Other types of migraines include opthalmoplegic migraines which began with eye pain and are often accompanied by vomiting. As the pain progresses, the patient’s eyelid droops and the eye is unable to move. This symptom may persist for days to weeks. Basilar artery migraines and retinal migraines are two other types of less common migraines. Cluster Headache While migraine headaches are more common in woman, cluster headaches are more common in men. Cluster headaches tend to occur in cycles, often during warmer months. Many times it is triggered by alcohol. They typically last between one and three months and occur at least one time per day. The pain is intense, usually peaks in 15-20 minutes and resolves in about an hour. Patients complain about severe stabbing pain centered in one eye, above the eye, or in the temple. Associated symptoms may include runny or stuffy nose, pupillary changes and a drooping eyelid. OTHER CAUSES OF HEADACHES Sinus Headaches usually occur across the forehead, around the eyes or across the cheeks. They usually get worse throughout the day and are accompanied by fever, congestion and runny nose. In rare instances, it can cause double vision and even loss of vision. When these symptoms occur it is a sign of a serious infection and needs to be treated immediately. Temporal Arteritis is a condition characterized by arterial inflammation of the medium and large sized arteries. The disease has a tendency to affect the temporal artery usually occurring in patients over 50. The pain is typically described as throbbing and can be aggravated by chewing. Patients often complain of scalp sensitivity. Another hallmark of the condition is visual field disturbance and even visual loss. Temporal-Mandibular Joint Dysfunction is caused by clenching the teeth at night during sleep. Most people wake up with headaches caused by this mechanism. The diagnosis is easily made if

chewing produces pain or if jaw palpation or movement mimics the headache pain. Brain Tumors can cause headaches that are frequently worse with coughing or straining and are often worse in the morning after lying flat all night. A tumor can cause a build up of pressure from constricting the outflow of cerebral spinal fluid. CT (Computer Tomography) or MRI (Magnetic Resonance Imaging) studies can help diagnose this condition. Cerebral Aneurysm is a dilatation or widening of a blood vessel wall that can lead to bleeding or rupture. The pain is usually described as the “worst headache in my life.” The headache is often accompanied by neck stiffness and neurological deficits. A CT scan is useful to diagnose this condition although more sophisticated tests like MRI, angiogram and lumbar puncture may also be needed. Trigeminal Neuralgia or tic douloureux involves the nerves of the face and usually occurs only on one side. The associated pain is severe, stabbing and described as “electric shocks.” Trigeminal Neuralgia is more common in people over 40. Treatment consists of pain relief and medications like carbamazepine (Tegretol), gabapentin ( Neurontin) and phenytoin (Dilantin). MEDICATIONS USED TO TREAT HEADACHES Treatment for acute migraine pain in those patients not requiring preventative therapy, centers around analgesic pain medications, antiemetics, and serotonin receptor medications. Analgesic preparations are over the counter medications like Tylenol, Ibuprofen and Midrin. Other prescription pain medications include Ultram, opiate containing medications and compound medications like Fiorinal. Antiemetic medication can be used to prevent the nausea and vomiting that often accompany a migraine. They are also used to treat the migraine itself. One example Compazine, comes in a pill, suppository and an injectable form. Serotonin receptor medications (Triptans and Ergots) act on the blood vessels and can be taken at any point during the acute headache. Examples of these Triptans are Imitrex, Zomig and Maxalt. They are not used to prevent headaches. Ergots have been used for many years and act like the Triptans in that they block dilatation of the cerebral blood vessels. Cafergot and DHE are both examples of Ergots. Both the Ergots and the Triptans should be prescribed very cautiously in patients with heart or vascular disease, high blood pressure, diabetes, men over 40 and postmenopausal woman. These medications may cause flushing, numbness and chest tightness when administered. WHEN TO SEEK MEDICAL ADVISE • Headache after head trauma. • Headache accompanied or followed by loss of consciousness or confusion. • Headache associated with a convulsion. • Sudden and severe headache. • Headache with neck stiffness. • Headache in a person who typically does not have headaches. • Persistent or recurring headaches in a child. • Headache which interferes with normal activities.

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Headache with fever. Headache with blurred vision, eye or ear pain.

WHAT TO EXPECT AT THE DOCTOR’S OFFICE The diagnosis of the cause of the headache is most often made from the history so expect the doctor to ask about quality of the pain, factors that make the headache worse or better, timing, triggers, past medical history and family history.