Headache Facts : What Everyone Should Know

What is headache?

Headache is the result of pain signals caused by interactions between the brain, blood vessels, and surrounding nerves. During a headache, the pain does not come from the brain contrary to what many sufferers believe. Rather, the pain comes from activated nerves surrounding the skull, blood vessels, and head muscles. The reasons-why these nerves in the head are activated-are not understood. However, activation of specific nerves in the head sends pain signals to the brain that are interpreted as a "headache."

What are the different types of headache?

There are two different categories for headaches: primary and secondary. Primary headache is an actual clinical condition and not a symptom of or caused by another disorder. Primary headaches include migraine, tension-type headache, and cluster headache. Secondary headaches are caused by other medical conditions, such as sinus disease, allergies, dental disorders, head injury, or brain tumors.

Migraine

A migraine headache usually lasts one day and recurs once to several times per month. Typical migraine headaches are one-sided, pulsating, moderate or severe pain, worse with activity, and associated with nausea and sensitivity to light and/or noise. Some patients experience an aura (a neurological symptom that gradually develops over 5 to 20 minutes and usually lasts less than 60 minutes) before their headache.

• Tension Type
  A tension-type headache is a recurrent headache that can last minutes to days. The pain often is described as pressing or tightening, of mild or moderate intensity, felt on both sides of the head, and does NOT worsen with physical activity. Tension-type headache is usually not associated with nausea or sensitivity to light or noise.
• Chronic Daily
  Like the name implies, chronic daily headaches can occur every day or almost daily. Features of the headache could be those of migraine, tension type, cluster or a combination.
• Cluster
  Cluster headaches recur daily or almost daily for a period of usually 4 to 8 weeks. The headache increases in intensity within 10 to 15 minutes and lasts for 30 to 45 minutes. Attacks may occur one or more times per day and frequently awake the sufferer from sleep. Headache is almost always one sided, and the most common sites of pain are around the eye, temple, and side of the head. Cluster periods typically recur every 1 to 2 years. Rarely is it chronic with no periods of remission.
• Sinus
  Sinus headaches are caused by sinus infection or some other irritation inside the sinus cavities of the face and head.
• Rebound
  Increased use or overuse of painkillers and other analgesics can lead to dependency, causing headaches when drug levels taper.

Who suffers from headache?

Headache is among the most common pain complaint seen in primary care doctors' offices. As many as 45 million Americans suffer from headaches. Tension-type and migraine headaches are the most common, and cluster headache is the most rare. It is important to seek medical care for headaches because, if treated correctly, more than 85% of headaches will respond to treatment.

What causes headaches?

Headaches have a tendency to run in families. Specifically, inherited patterns are seen clearly with some types of migraine. Children of migraine sufferers also are more likely to experience migraine headaches. This is why family history is important when evaluating someone with headache.

Headaches can be triggered or made more severe when sufferers are exposed to specific environmental factors, such as strong odors like cigarette smoke or perfume. Specific aspects of one's diet (beverages, meals, snacks) also may trigger headache. For example, low blood sugar as seen with prolonged fasting or extensive dieting may lead to increased headaches.

Common Environmental Triggers

• Stress
• Pollution
• Noise
• Lighting
• Weather changes
• Odors

Common Dietary Triggers

• Nitrates and MSG
• Alcohol (red wine, champagne)
• Caffeine (coffee, tea, cola)
• Chocolate
• Medications

Changes in hormone levels in some women are associated with increased headaches.

• Some women experience migraine headaches immediately before, during, or a few days following menstruation.
• Similarly, hormone changes with ovulation may lead to headaches.
• Chemically induced changes in the body's hormones (for example while taking birth control pills) are thought to trigger headaches in susceptible women.

Why individualize treatment plans?

Although all headaches are associated with pain, they differ considerably in severity, frequency, and disability. Some sufferers may have severe pain only once each year, while others may have mild pain with severe nausea twice each month. Therefore, it is essential that the treatment strategy is tailored to meet the individual's needs. Another reason to individualize treatment is the risk of coexisting medical conditions, such as heart disease, depression, anxiety, and seizure disorder. For example, patients with asthma do not want to take a headache medication that might make their asthma worse or interact with their asthma medications.

What are the types of treatments?

Acute medications are used to treat an individual headache attack once it has begun. These medications may be used as soon as the headache begins or taken after the onset of pain. Some acute medications also are effective in reducing other symptoms of an attack, such as nausea, vomiting, and sensitivity to light or noise.

Preventive therapies are used daily to prevent an attack or reduce the frequency and severity of an attack. Medications and nonpharmacologic therapies, such as behavioral therapies and physical therapies, may help prevent headaches in some people.

Rescue medications generally are used after acute medication strategies have failed. Most rescue medications can be given at home, but more aggressive therapies, requiring intramuscular or intravenous injections, are given in the emergency department or in a physician's office. Many rescue medications cause drowsiness as a side effect. For some sufferers, this may induce sleep that can be helpful for seeking pain relief; for others, this may inhibit their ability to continue in their daily routine.

What are some available medications?

There are four different classes of agents used to treat an individual headache attack. These medications are often given at the onset of headache pain.

• Pain killers - (e.g., acetaminophen, aspirin, ibuprofen, naproxen sodium, opiates/opioids)
• Antiemetics - (e.g., metoclopramide, prochlorperazine, promethazine)
• Ergotamines - (e.g., dihydroergotamine, ergotamine)
• Triptans - (e.g., sumatriptan, naratriptan, zolmitriptan, rizatriptan)

Other medications include combinations of different agents, such as isometheptene or caffeine. Overuse of most acute medications can lead to increased incidence of headache also known as "rebound headache." Barbiturate hypnotics and opiates are effective in treating headache pain, but overuse of these agents may cause dependency.

Preventive medications are taken on a daily basis. The kinds of medications used for headache prevention include:

• Beta-blockers
• Anticonvulsants
• Antidepressants
• Calcium antagonists
• Serotonergic agents
• Ergotamines
• Methysergide
• NSAIDs
• Alpha2-agonists

It is important for the doctor to screen for coexisting medical conditions before initiating treatment for headache. Rescue medications are used when acute medications have failed or provided insufficient relief. It is important to know that some rescue medications may be habit-forming, and others may cause drowsiness which may impede driving and work abilities. Medications frequently used as rescue therapy include:

• Opiates
• Barbiturate hypnotics (e.g., butalbital)
• Steroids
• Phenothiazines

Headache medications can be taken:

• orally
• intranasally
• rectally
• subcutaneously (under the skin)
• intramuscularly
• intravenously

It is important to discuss these different delivery systems with the doctor. Using the optimal delivery technique will increase the success of the treatment plan.

New research advances are being made constantly to improve medications for treatment of headache. Within the last decade, a new drug class-commonly referred to as the "triptans"-was developed. Continued clinical research is being done to test the efficacy of new acute therapies. The focus of this new research is to develop a drug that works effectively on those parts of the body specifically involved in headache, while other parts of the body remain unaffected.

What are other types of treatments?

Throughout the world, there are a number of nondrug treatments that are used successfully in some people to help keep headaches under control. Many of these methods can be used to prevent the onset of headaches, while others are used to treat an actual attack.

Biofeedback therapy electronically monitors the body's senses, such as temperature and muscle tension. This electronic information is signaled back to the patient. The patient tries to improve control of muscle tension and/or body temperature. The goal is to reduce symptoms associated with headache, such as muscle tension, and ultimately reduce the frequency and severity of headache attacks. A trained clinical psychologist or biofeedback technician administers biofeedback.

Cognitive therapy is the process where people learn to control their thoughts. Psychologists and other health-care professionals who practice cognitive therapy help people reduce negative thought processes. Specifically, cognitive behavioral training may help sufferers gain stress-management skills, self-coping skills, and other tools that will help control their responses to situations which might trigger a headache.

For many, the frequency and severity of headaches may actually be a signal of how hectic and stressful life may be for them. Lifestyle changes can help reduce the frequency and severity of headaches. Here are some examples of lifestyle changes that may improve headache management:

• Diet: Eat a healthy, balanced diet at regular times. Long periods of fasting, and dramatic swings in blood sugar levels, may cause an increase in headaches. Limit caffeine and smoking.
• Exercise: Regular exercise is an important part of reducing headaches and maintaining a healthy lifestyle.
• Sleep: Fatigue and sleep deprivation may lead to an increase in headaches. Excessive sleep may trigger headaches.
• Calendars: Track the frequency and severity of headaches by keeping a calendar. This will help monitor lifestyle factors that contribute to headaches.

When to talk to the doctor?

There are three easy steps headache sufferers can take before they talk to their doctor.

1. Make a specific appointment. Headache history, family history, and a review of other coexisting health conditions are an important part of a proper headache evaluation. Reviewing these factors appropriately will require a full office visit.

2. Personal headache history. Complete a "headache calendar (diary)". This will help review headache symptoms, headache frequency, associated disability, and related lifestyle factors that can make headaches worse. For example, certain foods, menstruation, travel, and other factors can trigger headaches.

3. List medications or treatments. A complete understanding of current health conditions and medications will help the physician select appropriate treatment options. A list of medications that have NOT proven useful also will help in this decision-making process.

What to discuss with the doctor?

• Discuss impact of headache. Make sure to discuss the impact of headaches on work, home life, and social function.
• Discuss treatment options. As there are many different types of medications and delivery techniques, find the one that is most likely to be successful.
• Agree on a treatment plan. Create a treatment plan that will work. Here are some common questions to ask when agreeing to a treatment plan:
• How do I take each medication?
• How often will I need to take each medication?
• What are the possible side effects?
• How quickly will the medication work?
• What should I do if I do not get headache relief?
• Is this medication covered by my health insurance?
• What are the signs that show my headaches are not under optimal control, e.g., frequency of headaches, amount of
• medication needed, frequency of medication needed?
• Make a follow-up appointment. Regular office visits are important because medications or dosages may need to be adjusted.

What can the sufferer do?

Taking control of headaches is an important part of self-care. Several important, easy steps will maximize the chance for success of the agreed-upon treatment plan:

Take medications as directed by the doctor. Remember-more is not necessarily better and may actually lead to more frequent headaches.

Plan ahead. Headache sufferers should carry medications with them.

Keep a headache calendar/diary. This will help the doctor tailor medications as needed and provide valuable information regarding what is helpful or harmful.

Monitor lifestyle factors. Diet, exercise, rest, and stress control are important to maximize the success of the agreed-upon treatment plan.

Headache sufferers need to call their doctor when there is ANY change in their health status. For example:

• Change in headache frequency or severity
• Change in type of pain
• Reaction to any medications
• New or recurring health conditions such as asthma, arthritis, depression, anxiety
• Pregnancy
• Other health status changes

Source: American Council for Headache Education, 2000