Headaches and Migraines


    Definition

    There are four types of headaches: vascular, muscle contraction (tension), traction, and inflammatory.

    • The most common type of vascular headache is a 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.

    • After migraine, the most common type of vascular headache is the toxic headache produced by fever.

    • Other kinds of vascular headaches include "cluster” headaches, which cause repeated episodes of intense pain, and headaches resulting from high blood pressure.

    • 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.

    Like other types of pain, headaches can serve as warning signals of more serious disorders. This is particularly true for headaches caused by inflammation, including those related to meningitis as well as those resulting from diseases of the sinuses, spine, neck, ears, and teeth.

    Causes

    Tension headaches are one of the most common forms of headaches. They may occur at any age, but are most common in adults and adolescents. If a headache occurs two or more times a week for several months or longer, the condition is considered chronic. Chronic daily headaches can result from the under- or over-treatment of a primary headache. For example, patients who take pain medication more than 3 days a week on a regular basis can develop rebound headaches.

    Tension headaches can occur when the patient also has a migraine. A migraine is caused by abnormal brain activity, which is triggered by stress, certain foods, environmental factors, or something else. However, the exact chain of events remains unclear. Today, most medical experts believe the attack begins in the brain, and involves various nerve pathways and chemicals. The changes affect blood flow in the brain and surrounding tissues.

    Any activity that causes the head to be held in one position for a long time without moving can cause a headache. Such activities include typing or other computer work, fine work with the hands, and using a microscope. Sleeping in a cold room or sleeping with the neck in an abnormal position may also trigger a tension headache.

    Other triggers of tension headaches include:
        •        Alcohol use
        •        Caffeine (too much or withdrawal)
        •        Colds and the flu
        •        Dental problems such as jaw clenching or teeth grinding
        •        Eye strain
        •        Excessive smoking
        •        Fatigue
        •        Nasal congestion
        •        Overexertion
        •        Sinus infection


    Symptoms

    The pain symptoms of a headaches and migraines are:
        •    The pain begins in the back of the head and upper neck and is described as a band-like tightness or pressure. 

        •    Often is described as pressure encircling the head with the most intense pressure over the eyebrows. 

        •    The pain usually is mild (not disabling) and bilateral (affecting both sides of the head). 

        •    The pain is not associated with an aura (see below), nausea, vomiting, or sensitivity to light and sound. 

        •    The pain occurs sporadically (infrequently and without a pattern) but can occur frequently and even daily in some people. 

        •    The pain allows most people to function normally, despite the headache.


    Exams and Tests

    A headache that is mild to moderate, not accompanied by other symptoms, and responds to home treatment within a few hours may not need further examination or testing, especially if it has occurred in the past. A tension headache reveals no abnormal findings on a neurological exam. However, tender points (trigger points) in the muscles are often seen in the neck and shoulder areas.

    The health care provider should be consulted — to rule out other disorders that can cause headache — if the headache is severe, persistent (does not go away), or if other symptoms are present with the headache.

    Headaches that disturb sleep, occur whenever you are active, or that are recurrent or chronic may require examination and treatment by a health care provider.


    Treatments

    Understanding your headache triggers can help you avoid situations that cause your headaches. A headache diary can help you identify your headache triggers. When you get a headache, write down the day and time the pain began. The diary should include notes about what you ate and drank in the last 24 hours, how much you slept and when, and what was going on in your life immediately before the pain started.

    Over-the-counter painkillers such as aspirin, ibuprofen, or acetaminophen may relieve pain if relaxation techniques do not work. If you are planning to take part in an activity that you know will trigger a headache, taking one of these painkillers beforehand may be helpful.
    Narcotic pain relievers are sometimes prescribed. Remember that pain medications only relieve headache symptoms for a short period of time. After a while, they do not work as well or the help they provide does not last as long. Regular, overuse of pain medications can lead to rebound headaches.

    Other prescription treatments may include:
        •    Muscle relaxants such as tizanidine
        •    Selective serotonin-reuptake inhibitors (SSRIs) such as paroxetine (Paxil) or citalopram (Celexa) taken daily to help prevent or decrease the number of headaches
        •    Tricyclic antidepressants such as amitriptyline, nortriptyline, or doxepin taken daily to help prevent or decrease the number of headaches

    Combining drug treatment with relaxation or stress-management training, biofeedback, cognitive behavioral therapy, or acupuncture may provide better relief for chronic headaches.

    Botox (botulinum toxin) is also becoming popular as a treatment for chronic daily headaches, including tension headaches. However, it is currently not approved for such use.

    Your doctor can diagnose this type of headache by asking questions about your symptoms and family history of migraines. A complete physical exam will be done to determine if your headaches are due to muscle tension, sinus problems, or a serious brain disorder.
    There is no specific test to prove that your headache is actually a migraine. However, your doctor may order a brain MRI or CT scan if you have never had one before or if you have unusual symptoms with your migraine, including weakness, memory problems, or loss of alertness.

    An EEG may be needed to rule out seizures. A lumbar puncture (spinal tap) might be done.


    Possible Complications

    Rebound headaches — headaches that keep coming back — may occur from overuse of painkillers.
    It’s important to see a doctor if you have chronic headaches. In some cases, the headache may be a symptom of a more serious disorder.

    When to Contact a Medical Professional

    Call 911 if:
        •    You are experiencing "the worst headache of your life"
        •    You have speech, vision, or movement problems or loss of balance, especially if you have not had these symptoms with a headache before
        •    Your headaches are more severe when lying down
        •    The headache starts very suddenly

    Also, call your doctor if:
        •    Your headache patterns or pain change
        •    Treatments that once worked are no longer helpful
        •    You have side effects from medication, including irregular heartbeat, pale or blue skin, extreme sleepiness, persistent cough, depression, fatigue, nausea, vomiting, diarrhea, constipation, stomach pain, cramps, dry mouth, or extreme thirst
        •    You are pregnant or could become pregnant — some medications should not be taken when pregnant


    Preventions

    Learn and practice stress management. Some people find relaxation exercises or meditation helpful. Biofeedback may improve relaxation exercises and may be helpful for chronic tension headache.

    Tips to prevent tension headaches:
        •    Keep warm if the headache is associated with cold.
        •    Use a different pillow or change sleeping positions.
        •    Practice good posture when reading, working, or doing other activities.
        •    Exercise the neck and shoulders frequently when typing, working on computers, or doing other close work.
        •    Get plenty of sleep and rest.

    Understanding your headache triggers can help you avoid foods and situations that cause your migraines. Keep a headache diary to help identify the source or trigger of your symptoms. Then modify your environment or habits to avoid future headaches.

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