Health

By Lisa Davidson, MD

Almost everyone has had a headache at one time or another. Headache is one of the most common health ailments with over 45 million Americans currently suffering from chronic headaches. Headache accounts for more than three million visits to the emergency room and 80 million doctors’ office visits every year. Women account for nearly three out of four of those visits.

However, not every headache is a medical emergency. Headache may be frightening because many sufferers believe it may be the sign of something serious. Serious causes of headache are extremely rare. There are actually 150 different diagnostic categories but the majority fall into just a few categories. The first step in managing the condition is to determine what type of headache is causing the pain.

Headache Types

Headache is a symptom with many causes. It is important to distinguish between the two different types of headaches which are primary and secondary.

Primary Headache

Primary headache accounts for 90 percent of all headaches and is a medically-diagnosed condition that is not caused by another underlying cause. They exist independently of other medical conditions. The most common primary headaches are migraine, tension headache and cluster headache which all have different underlying characteristics and result in different types of pain.

Migraine Headache – Migraine headache is the most common type of headache that physicians see. Over 28 million people suffer from migraine headache. The exact cause of migraines is unknown. Symptoms of migraine headache are:

• Moderate or severe, one-sided pain commonly felt in the temple area

• Throbbing or pulsating pain lasting 8 to 72 hours, recurring multiple times a month

• Pain that worsens with physical activity

• Pain that interferes with daily routine

• Sensitivity to light, sound or smells

• Nausea with or without vomiting

• Dizziness

• Neck pain

• Any neurological deficit including visual and auditory disturbances

Not all migraines are the same. They may present with or without aura. Migraine with aura means the headache is preceded by certain warning signs like changes in vision, disturbances in sound or tingling in the hands or face. Most people do not experience aura with migraines.

Tension Headache – Tension headache is the most common type of headache but is the type least treated in the doctor’s office. Tension headache is also referred to as stress headache and can be a cause of chronic daily headache. The pain of tension headache is not disabling but more of a distraction. Signs of tension headache are:

• Dull, steady ache on both sides of the head

• Pain that increases over a few hours and becomes pulsating

• Persistent pain that may feel like pressure around the head or a band squeezing around the head

• Pain that does not worsen with activity

• Tight shoulders, neck and jaw and sore scalp, forehead and face

• Signs of clenching teeth

Cluster Headache – Cluster headache is the least common type of headache but is usually very severe. They affect 1 in 1,000 people and are more common in men than in women. Most cluster headache sufferers experience their first cluster before the age of 30. The term cluster refers to the headaches presenting in groups within a short period of time. They may occur up to eight times a day and last 15 to 45 minutes over a period of weeks.

Sufferers may experience headache-free periods for six months to a year later. Cluster headache tends to occur in the early morning hours and wake the person from sleep. Pain is excruciating and many sufferers pace the floor unable to get relief. Symptoms of cluster headache are:

• Pain that is burning or stabbing in nature

• Sharp, excruciating pain

• Pain that is one-sided and does not shift to the opposite side

• Red eye and runny nose

• Present in full force within 5-10 minutes of onset

• Headache with a similar pattern from episode to episode

Mixed Headache Syndrome – Mixed headache syndrome is when a headache sufferer actually shows signs and symptoms of having a combination of migraine and tension headache.

Additional Primary Headache - Other less common types of primary headache include hemicrania which is a migraine-like headache that involves a series of multiple short yet severe, stabbing headaches that affects one side of the cranium. Occipital neuralgia is also a common headache caused by a pinched nerve as a result of sleeping with the neck in a bad position, whiplash or other trauma.

Secondary Headache

Headache is secondary when it is caused by another underlying condition which may or may not be serious. Many medical conditions list headache as a symptom but patients generally present with clues that usually alert physicians that a headache is secondary in nature.

General medical conditions – There are many common medical conditions that may cause secondary headache. They include infections or disorders of the head and neck including sinusitis, meningitis and thyroid disorders. Head or neck trauma including concussion, whiplash or contusion are additional causes. The fluctuation in blood sugars with diabetes is also a culprit. Headaches are common when the body is imbalanced. Body imbalances include high blood pressure, dehydration, renal failure, thyroid problems, allergy problems and sleep disorders. TMJ, or temporomandibular joint disorder, is the swelling of the temporomandibular joint that can also cause headaches.

Perimenopause and menopause – Over 30 percent of women suffer from perimenopause headache. Because headache may be related to hormones, the abnormal flow of estrogen and progesterone that occurs during perimenopause and menopause may trigger headache. Migraine-like headache is a common symptom of these conditions. Hormone fluctuations and hot flashes may cause sleep disturbances. Sleep deprivation may then lead to headache. Women seem to be prone to headache at puberty and again at perimenopause when hormonal changes are at their peak. Headache generally subsides once menopause passes. Hormone replacement may help headache during this time.

Rare but more serious medical conditions - It is common for many to worry about more serious causes of headache like brain tumor at the first sign of headache. These conditions are rare and the odds of a patient presenting with these are low. Other more serious causes of secondary headache are possible but are very rare. They are stroke, aneurysm and brain tumor. Only a small percentage of strokes produce headache. However the sudden onset of severe headache may lead a physician to check for bleeding on the brain. When a cerebral aneurysm begins to leak blood, a patient may present with a sudden onset of the worst headache of one’s life or a thunderclap. Brain tumors rarely present with headache as a first symptom but rather with neurological deficiencies.

Primary or Secondary Headache?

The key to distinguishing between primary and secondary headache lies in the characteristics of the headache, other symptoms that are occurring simultaneously and physical examination. Certain warning signs may suggest to a physician that a headache may be a secondary headache and not a primary condition. These include:

• Neurological symptoms during or between headaches

• Abnormal neurological examination

• New or unusual type of headache

• Sudden or worst headache of your life

• Fever

Most headaches can be diagnosed by a patient’s history and physical examination but in the presence of any of the signs noted, a doctor may order blood tests, vision tests, x-rays, CT scans, MRIs, lumbar puncture or EEGs to rule out any potentially serious secondary headache causes.

Headache Prevention

Sometimes headache prevention is the best medicine. Not every headache can be stopped but making simple lifestyle changes will help ward them off. Keeping a headache diary will help determine which triggers are unique to each individual and is the first step to developing an effective treatment plan.

Common Triggers - While some headache triggers can be controlled others are not, including changes in the weather, family history and fluctuations in hormones. Not all headaches can be prevented but recognizing these triggers and modifying lifestyles can help minimize the frequency, duration and degree of headache:

• Stress: manage stress levels

• Caffeine consumption: limit caffeine to less than three forms a day

• Drinking alcohol: limit alcohol consumption

• Dehydration: stay hydrated by drinking plenty of water throughout the day

• Lack of exercise: stick to an exercise regimen to increase endorphins, which help relieve pain

• Smoking: do not smoke

• Food additives like MSG, processed cheese and aspartame: recognize and avoid food sensitivities

• Skipping meals: do not skip meals and eat smaller more frequent meals

• Change in caffeine intake: even one morning of missed coffee can trigger headache

• Change in sleep patterns: form good, consistent sleep habits

Treatments for Headache

Not every headache is the same, therefore not every treatment works for every person. Headache tends to vary in frequency, severity and disability, that’s why it is important to tailor treatment plans to each individual situation. However, relaxation techniques, stress management and exercise are proven forms of therapy.

Most over-the-counter analgesics such as aspirin, ibuprofen, acetaminophen and muscle relaxants help relieve tension headaches and if taken at the first sign of attack, may help migraine headache. Decongestants may help migraine and tension headache. However, the overuse of over-the-counter pain pills may often lead to increased headache frequency or rebound headaches. Botox may also be used for treating migraine headache but only after other forms of treatment have failed.

When making changes in lifestyle habits, using relaxation techniques and taking over-the-counter painkillers do not work, sometimes other forms of treatment are necessary.

If migraine headache occurs four or more times a month, a physician may prescribe other prophylactic or preventative medications to help relieve headache symptoms. They include blood pressure drugs, muscle relaxants, antidepressants and anti-seizure medications. To stop a migraine, the physician may prescribe triptans, which come in the form of pills, injection or nasal sprays.

Cluster headaches do not respond to over-the-counter analgesics because they do not act quickly enough. Many abortive treatments are used to relieve cluster headache including Imitrex injections, anesthetics and high flow oxygen. Preventive medications for recurrent cluster headaches include calcium channel blockers, beta blockers and steroids.

When to Consult a Physician

Seek medical attention immediately for any of the following signs or symptoms which may be indicative of a more serious health problem:

• Headache that is the worst headache of one’s life (a good indicator is if a person has to think about if it is the worst of their life, it probably is not)

• Abrupt onset of headache without warning signs

• Headache after injury or trauma especially if headaches worsen

• Change in pattern of recurrent headaches or if recurrent headache is life-altering

• Onset of headache at unusual age (before age five or after age 50)

• Onset of headache with seizure or syncope

• Experiencing any neurological deficits including seeing or hearing

• Headache that is worse after coughing, straining or any exertion.