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Headache Tips

A headache is a condition of mild to severe pain in the head;sometimes upper back or neckpain may also be interpreted as a headache.

Headache is defined as pain in the head that is located above the eyesor theears, behind the head (occipital), or in the back of the upperneck. Headache, like chest pain or dizziness, has many causes.

Headaches are one of the most common health complaints. Most headachesthat occur without other symptoms will respond well to self-care. Mostheadaches are caused by tension and respond well to prevention and hometreatment.

Last Updated - 11th November 2005

Headaches have a wide variety of causes, ranging from eyestrain toinflammation of the sinus cavities to life-threatening conditions suchas encephalitis, brain cancer, meningitis, and cerebral aneurysms. Whenthe headache occurs in conjunction with a head injury the cause is usuallyquite evident; however, many causes of headaches are more elusive. Themost common type of headache is a tension headache. Some people experienceheadaches when they are hungry or dehydrated.

It is common to take over-the-counter painkillers such as aspirin oracetaminophen (sold as Tylenol or Panadol) to relieve headaches.

Types of Headache

• Tension headache
• Migraine
• Cluster headache
• Rebound headaches
• Ictal headache
• Ice cream / Brain Freeze headache
• Thunderclap headache
• Vascular headache

Tension Headache

• Tension headaches, which were recently renamed tension type headachesby the International Headache Society, are the most common type ofheadaches. The pain can radiate from the neck, back, eyes, or othermuscle groups in the body. Nearly everyone will have at least onetension headache in their lifetime.
• Frequency and duration - Tensionheadaches can be episodic or chronic. Episodic tension headaches aredefined as tension headaches occurring less than 15 days a month,whereas chronic tension headaches occur 15 days or more a month forat least 6 months. Tension headaches can last from minutes to daysor even months, though a typical tension headache lasts 4-6 hours.
• Pain - Tension headache painis often described as a constant pressure, as if the head were beingsqueezed in a vise. The pain is frequently bilateral which means itis present on both sides of the head at once. Tension headache painis typically mild to moderate, but may be severe. In contrast to migraine,the pain does not increase during exercise.
• Cause - The exact cause of tensionheadaches is still unknown. It has long been believed that they arecaused by muscle tension around the head and neck. However althoughmuscle tension may be involved, there are many forms of tension headachesand some scientists now believe there is not one single cause forthis type of headache. One of the theories is that the pain may becaused by a malfunctioning pain filter which is located in the brainstem. The view is that the brain misinterprets information, for examplefrom the temporal muscle or other muscles, and interprets this signalas pain. One of the main molecules which is probably involved is serotonin.Evidence for this theory comes from the fact that tension headachesmay be successfully treated with certain antidepressants. Anothertheory says that the main cause for tension type headaches and migraineis teeth clenching which causes a chronic contraction of the temporalismuscle.
• Treatment - Episodic tensionheadaches generally respond well to over-the-counter analgesics, suchas acetaminophen or aspirin. However, these medications should beavoided in cases of chronic tension headache, due to the risk of reboundheadaches. Chronic tension headaches are more difficult to treat.
• Suggested therapies include :
  • Swimming two to three times a week
  • Acupuncture
  • Biofeedback
  • Massage
  • Heat Pillow
• Tension headaches are exacerbated by states or activities that inducemuscle tension, such as stress. Avoiding such states can lessen thefrequency of tension headaches. Tension headaches can also be secondaryto other conditions, such as an upper respiratory infection or othervirus.
• Often the best treatment for a mild tension headache that does notimpair a person's ability to function is simple endurance. Many tensionheadache sufferers receive relief from sleep. However, it is alwaysbest to see your physician for a full work-up of the headaches.
• Prognosis - Tension headachesthat do not occur as a symptom of another condition are painful andannoying, but not harmful. It is usually possible to receive relieffrom treatment. Tension headaches that occur as a symptom of anothercondition are usually relieved when the underlying condition is treated.

Migraine Headache

• Migraine is a form of headache, usually very intense and disabling.It is a neurologic disease of neuronal origin. The word "migraine"comes from the Greek construction hemikranion (pain affecting oneside of the head)
• Symptoms - Migraine is characterized by attacks of moderateor severe pain and must include one of the following:
  • pain on only one side of the head, nausea, vomiting, photophobiaand phonophobia,
  • or pain worst with movement.
• The symptoms and their timing vary considerably among migraine sufferers,and to a lesser extent from one migraine attack to the next. Migrainehad been thought to be caused by vasodilation in the head and neck,however newer research suggests the cause of the pain itself is fromactivation of the trigeminal nerve. The trigger of the migraine maybe overactivity of nerve cells in certain areas of the brain (forexample, the raphe nucleus). Dilation of the blood vessels is nowknown to be caused from chemicals released from nerve terminals andinflammatory cells.
• Classical migraine or migraine with aura is preceded by a groupof specific symptoms called aura, most commonly experienced as a visualdisturbance. Common migraine or migraine without aura, in contrast,lacks this specific warning. Many migraine patients will experiencea prodrome, a vague sensation that things are just not right thatmay precede the headache by several hours. Some experience aura withoutmigraine, a condition formerly called amigrainous migraine and usuallycalled acephalic migraine. Although sometimes comparable in severity,the symptoms of migraine differ from those of cluster headache.
• The most common aura preceding a migraine attack is a multicoloredzig-zag pattern which grows from a small dot until it covers a largepart of the left or right visual field of both eyes. The aura mustlast less than 60 minutes and the headache must begin sometime afterthe start of the aura until 60 minutes from the end of the aura. Aurascan be any specific neurological symptom complex and some experiencetingling sensations called paresthesias or disturbances of other regionsof the brain (such as language ability or smell) instead of a visualaura, either as an occasional alternate or their normal aura.
• Migraine can accompany, in many cases, another type of headachecalled tension headache. Studies have demonstrated in those patientsthat get both migraine and tension type headaches, that their tensionheadaches will respond to their usual migraine treatment. This isin contrast to patients who only get tension type headaches. Migrainescan be associated with seizures. Stroke symptoms are seen in somepatients and are known as complicated migraine. These symptoms shouldnot be permanent.
• Migraine often runs in families and starts in adolescence, althoughsome research indicates that it can start in early childhood or evenin utero. Migraine occurs more frequently in women than men, and ismost common between ages 15-45, with the frequency of attacks decliningwith age in most cases.
• Because their symptoms vary, an intense headache may be misdiagnosedas a migraine by a layperson. Where possible, see a doctor to determineif the headaches are a symptom of something else.

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• Treatment - Conventional treatmentfocuses on three areas: trigger avoidance, symptomatic control, andpreventive drugs.
• Elimination of triggers - Ina minority of patients the incidence of migraine can be reduced throughdietary changes to avoid certain chemicals present in such foods ascheddar cheese, chocolate, nuts and most alcoholic beverages. Sometriggers (for example, hunger or stress) may be situational and canbe avoided through lifestyle changes. However, other triggers suchas particular points in the menstrual cycle or certain weather patternsare impossible or impractical to avoid.
• Avoid bright flashing lights if you notice these trigger attacks;most migraineurs are sensitive and avoid bright or flickering lights.Relaxation after stress, notably weekends and holidays, is a potenttrigger; wind down gradually if possible.
• Symptomatic control to abort attacks- For patients who have been diagnosed with recurring migraines,doctors recommend taking painkillers to treat the attack as soon aspossible. Many patients avoid taking their medications when an attackis beginning, hoping that "it will go away". However inmany cases once an attack is underway, it can become intensely painful,last for a long time, and become somewhat resistant to medical treatment.In contrast, treating the attack at the onset can often abort it beforeit becomes serious, and can reduce the frequency of subsequent attacksin the near-term.
• The first line of treatment is over-the-counter medications. Doctorsstart patients off with simple analgesics, such as paracetamol (acetaminophen),aspirin and caffeine. They may provide some relief, although theyare not effective for most sufferers.
• Narcotic pain killers (for example, codeine, morphine or other opiates)provide variable relief, but their side effects and high risk of addictioncontraindicates their general use.
• If over-the-counter medications do not work, the next step for manydoctors is to prescribe fioricet or fiorinal, which is a combinationof butalbital (a barbituate), acetaminophen (in fioricet) or acetylsalicylicacid (in fiorinal), and caffeine. While the risk of addiction is low,butalbital can be habit-forming if used daily, and it can also leadto rebound headaches.
• Anti-emetics by suppository or injection may be needed in caseswhere vomiting dominates the symptoms. The earlier these drugs aretaken in the attack, the better their effect.
• Until the introduction of sumatriptan (Imitrex®/Imigran®)around 1985, ergot derivatives were the primary oral drugs availableto abort a migraine once it is underway. However, ergotamine tablets(usually with caffeine), though sometimes effective, have fallen outof favour. Absorption is erratic unless taken by suppository or injection.Dihydroergotamine (DHE), which must be injected or inhaled, can alsobe effective. These drugs can be used either as a preventive or abortivetherapy.
• Sumatriptan and related serotonin agonists are now the therapy ofchoice for severe migraine attacks that cannot be controlled by othermeans. They are highly effective, reducing the symptoms or abortingthe attack within 30 to 90 minutes in 70-80% of patients. Some patientshave a rebound migraine later in the day, and only one such reboundin a day can be treated with a second dose of a triptan. They havefew side effects if used in correct dosage and frequency. Some membersof this family of drugs are:
  • sumatriptan (Imitrex®, Imigran®)
  • zolmitriptan (Zomig®)
  • naratriptan (Amerge®, Naramig®)
  • rizatriptan (Maxalt®)
  • eletriptan (Relpax®)
  • frovatriptan (Frova®)
  • almotriptan (Almogran®)
• Evidence is accumulating that these drugs are effective becausethey act on serotonin receptors on the nerve endings as well as theblood vessels. This leads to a decrease in the release of a severalpeptides including CGRP, Substance P, among others.
• These drugs are available only by prescription (US and UK). Manymigraine sufferers do not use them only because they have not soughttreatment from a physician.
• Preventive drugs - It is criticallyimportant that patients who have more than 2 headaches days per weekbe placed on preventatives and avoid overuse of acute pain medications.
• Preventive medication has to be taken on a daily basis, usuallyfor a few weeks, before the effectiveness can be determined. It isused only if attacks occur more often than every two weeks. Supervisionby a neurologist is advisable. A large number of medications withvarying modes of action can be used. Selection of a suitable medicationfor any particular patient is a matter of trial and error, since theeffectiveness of individual medications varies widely from one patientto the next.
• The most effective prescription medications include several classesof medications including Beta blockers such as propranolol and atenolol,Antidepressants such as amitriptyline, and anticonvulsants such asvalproic acid and topiramate.
• Migraine sufferers usually develop their own coping mechanisms forintractable pain. A cold or hot shower directed at the head, lessoften a warm bath, or resting in a dark and silent room may be ashelpful as medication for many patients, but both should be used whenneeded.
• Alternative approaches - Somemigraine sufferers find relief through acupuncture which is usuallyused to help prevent headaches from developing. Sometimes acupunctureis used to relieve the pain of an active migraine headache. In theonly controlled trial of acupuncture with a sham control in migraine,the acupuncture was not more effective than the sham acupuncture butwas more effective than delayed acupuncture.
• Biofeedback has been used successfully by some to control migrainesymptoms through training and practice.
• Supplementation of coenzyme Q10 has been found to have a beneficialeffect on the condition of some sufferers of migraines.
• The plant feverfew (Tanacetum parthenium) is a traditional herbalremedy believed to reduce the frequency of migraine attacks. Clinicaltrials have been carried out, and appear to confirm that the effectis genuine (though it does not completely prevent attacks).
• Kudzu root (Pueraria lobata) has been demonstrated to help withmenstrual migraine headaches and cluster headaches. While the studieson menstrual migraine assumed that kudzu acted by imitating estrogen,it has since been shown that kudzu has significant effects on theserotonin receptors.
• Diet, visualization, and self-hypnosis are also important alternativetreatment and prevention approaches.

Cluster Headache

• Cluster headaches are rare headaches that occur in groups or clusters.Cluster headache sufferers typically experience very severe headachesof a piercing quality near one eye or temple that last for between15 minutes and three hours. Cluster headaches are frequently associatedwith drooping eyelids, red, watery eyes, and nasal congestion on theaffected side of the face. The headaches are unilateral and occasionallychange sides. The neck is often stiff or tender in association withcluster headaches, and jaw and teeth pain is sometimes reported.
• In episodic cluster headache, these headaches occur once or moredaily, often at the same times each day, for a period of several weeks,followed by a headache-free period lasting weeks, months, or evenyears. Approximately 10-15% of cluster headache sufferers are chronic;they can experience multiple headaches every day for years. Clusterheadaches are occasionally referred to as "alarm clock headaches",as they can occur at night and wake a person from sleep. Other synonymsfor cluster headache include Horton's syndrome and "suicide headaches"(a reference to the excruciating pain and resulting desperation).
• The location and type of pain has been compared to a 'brain-freeze'headache from rapidly eating ice cream; this analogy is limited, butmay offer some insight into the cluster headache experience. Personswho have experienced both cluster headaches and other painful conditions(childbirth, migraines) report that the pain of cluster headachesis far worse. During a cluster headache attack, a person often alternatesbetween pacing and laying still. Sensitivity to light is more typicalof a migraine, as is vomiting, but they can be present in some sufferersof cluster headache.
• Whereas other headaches, such as migraines occur more often in women,cluster headaches occur in men at a rate 2.5 to 3 times greater thanin women. Between 1 and 4 people per thousand experience cluster headachesin the U.S. and Western Europe; statistics for other parts of theworld are fragmentary. Latitude plays a role in the occurrence ofcluster headaches, which are more common as one moves away from theequator towards the poles. It is believed that greater changes inday length are responsible for the increase.
• While the immediate cause of pain is in the trigeminal nerve, thetrue cause(s) of cluster headache is complex and not fully understood.Among the most widely accepted theories is that cluster headachesare due to an abnormality in the hypothalamus. This can explain whycluster headaches frequently strike around the same time each day,and during a particular season, as one of the functions the hypothalamusperforms is regulation of the biological clock. Certain immune dysfunctionsand metabolic abnormalities have also been reported in patients. Thereis a genetic component to cluster headaches, although no single genehas been identified as the cause. As a group, cluster headache patientsare more likely to have suffered brain trauma than the general population.Sinus problems, damage to the jaw, and sleep apnea are also more commonin cluster headache patients, but these factors do not adequatelyexplain the disease.
• Treatment - Many doctors areunfamiliar with this disease, and cluster headaches often go undiagnosedfor many years. Paroxysmal Hemicrania (PH) is a condition similarto cluster headache, but PH responds well to treatment with the anti-inflammatorydrug indomethacin and the attacks are very much shorter, often lastingseconds only.
• Medically, cluster headaches are considered benign, but becauseof the extreme and often debilitating pain associated with them, asevere attack is nevertheless treated as a medical emergency by doctorswho are familiar with the condition. Doctors who are less familiarwith the disease may neglect sufferers in emergency rooms and forcethem to endure inordinate spans of time before receiving treatment,if any treatment at all is granted. Sometimes, sufferers of the diseasemay even be accused of drug seeking behavior.
• Even narcotics are mostly ineffective due to the intensity of thepain involved in cluster attacks. Anecdotal evidence indicates thatcluster headaches, on occasion, can be so excruciating that even morphinedoes little to ease the pain. Usually, however, demerol is sufficientif used at the onset of pain.
• Over the counter pain medications (such as aspirin, acetaminophen,and ibuprofen) have no effect on the pain from a cluster headache.Some have reported partial relief from narcotic pain killers, butthe frequency of their use in a cluster cycle (1-3 times a day) oftendisqualifies them from use. However, some newer medications like fentanylhave shown great promise in early studies and use.
• Medications to treat cluster headaches are classified as eitherabortives or prophylactics (preventatives). The most successful abortivesinclude breathing pure oxygen (12-15 liters per minute in a non-rebreathingapparatus) and triptan drugs like sumatriptan and zolmitriptan. Awide variety of prophylactic medicines are in use, and patient responseto these is highly variable. Preventitives include muscle relaxants,lithium, calcium channel blockers such as Verapimil, ergot compounds,anti-seizure medicines, and atypical anti-psychotics.
• Magnesium supplements have been shown to be of some benefit in about40% of patients. Melatonin has also been reported to help some. Hotshowers have helped about 15% of people who try it. Feverfew, a herbused to treat migraine, is not clearly beneficial according to anecdotesfrom web forums.
• There is substantial anecdotal evidence that psilocybin (mushrooms)and LSD may be able to abort cluster cycles. A clinical study underthe auspices of MAPS is being developed at Harvard University.
• Nitroglycerin (glyceryl trinitrate) can sometimes induce clusterheadache similar to spontaneous attacks. Alcohol is recognized asa common trigger of cluster headaches when a person is in cycle orsusceptible. Hydrocarbons (petroleum solvents, perfume) are also recognizedas a trigger for cluster headaches. Many patients have a decreasedtolerance to heat, and this may act as a trigger in some. The roleof diet and specific foods in triggering cluster headaches is controversialand not well understood.
• Some people with extreme headaches of this nature (especially ifthey are not unilateral) may actually have something else: an ictalheadache. Anti-convulsant medications can significantly improve thiscondition, so make sure you talk with your doctor about this possibilityif you think you might be affected.
  

Rebound Headache

• Rebound headaches occur when medication is taken too frequentlyto relieve headache pain. Rebound headaches frequently occur dailyand can be very painful. A diagnosis of rebound headaches can be easyor difficult, as the cause is very easy to identify but very difficultto diagnose. Overuse of painkillers can be confirmed simply by askingthe patient if his or her headaches assumed a new pattern or becamemore severe after taking painkillers excessively (generally classifiedas more than 3 times per week). However, the only way to make a certaindiagnosis of rebound headache is to withdraw the patient from medicationfor anywhere up to 6 months. It should be noted that withdrawal frommedication will actually intensify the headaches for the first fewweeks. After this period, the headaches will gradually recede.
• Following treatment, many patients revert to their prior headachepattern. A physician should be consulted before re-use of medications.

Ictal headache

• Ictal headaches are headaches associated with seizure activity.They may occur either before (pre-ictal), after (post-ictal), or mostrarely during a seizure. Many cases of ictal headache may be misdiagnosedas migraine with aura, or even cluster headache. However, whereasthese conditions usually involve just one side of the head (are unilateral),an ictal headache may be centrally situated or cover the entiretyof the head.
• Severity of ictal headaches can vary from a slight pressure or "cloud"to an intensity far beyond migraine. Some have called it a "suicideheadache" in the worst instances. Temporary blindness may alsooccur in some cases.
• Ictal headaches can be controlled with anti-convulsant medications,in many cases.
• Note that other symptoms besides headache may be either presentor absent, and may include unusual thoughts or experiences. In thesecases it is especially important to obtain a correct diagnosis. Manypeople with these experiences are accidentally diagnosed with conditionssuch as psychosis or even schizophrenia and given anti-psychotic medicationswhich ironically may increase seizure activity. An EEG is recommendedto detect other signs of epilepsy in all cases, however even whenthis does not prove determinative, anti-convulsants may be a firstline of treatment if these symptoms are present with headache.

Ice Cream / Brain freeze Headache

• Brain Freeze or ice cream headache are term used to describe a formof cranial pain or headache which human beings are known to sometimesexperience after consuming cold beverages or foods such as ice cream,often as a result of consuming at a high rate of speed.
• In rare instances, neuro-cranial blood vessels can constrict socompletely that a temporary blackout can occur.
• Mechanism/Cause - The reaction is triggered by the cold fromthe substance consumed coming into contact with the roof of the mouthwhile the individual eats it. It triggers nerves that give the brainthe impression of a very cold environment. To return warmth to thebrain, blood vessels start to swell, which causes the pain for, typically,around 30 seconds.
• It is reported that pain can be relieved by moving the tongue tothe roof of the mouth, which will cause greater warmth in the region.

Thunderclap Headache

• A thunderclap headache is a sudden and severe headache, diagnosedvia a process of exclusion with accompanying negative CT and lumbarpuncture results.
• Thunderclap headaches can be indicative of life threatening medicalproblems. If one occurs in yourself or someone else then they mustbe taken to a hospital immediately. If no transportation is availableor the condition is rapidly deteriorating then a call for help mustbe made.

Vascular headache

• A vascular headache is a headache where blood vessel swelling ordisturbance is causing the pain.
• Vascular headaches include:
  • Migraine
  • Cluster headache

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