Headache

What is a headache? What causes headache?

A headache is pain felt in the head, either all over or in one specific area. Headache pain can be sharp, throbbing, or dull. Depending on the type of headache, the pain may be associated with other symptoms, such as nausea. Chronic headaches, including constant headaches and frequent headaches, can interfere with work, family, and personal life.

Headaches are one of the most common types of pain. Generally, even a severe headache does not indicate a serious medical problem. However, some headaches can signal a dangerous underlying medical condition, especially:

• Severe headaches that come on and worsen quickly,

• Headaches that occur days or weeks after an injury to the head, and

• Headaches that are accompanied by seizures or other neurological symptoms .

Experts have long divided headaches into two main categories: primary and secondary. In 2005, the International Headache Society revised its classification system to add a third category, which includes cranial neuralgias , facial pain , and other causes. Several types of headache fall under each category.

• Primary headaches occur when nerves that sense pain in the head or neck are stimulated and no other cause of the headache can be identified. Migraine, tension, and cluster headaches are included in this category.

• Secondary headaches are symptoms of an underlying medical condition. For instance, a secondary headache might occur in someone with a high fever. Secondary headache may also result from a brain tumor, bleeding in the brain, meningitis or encephalitis.

• Cranial neuralgias occur when nerves in the head and upper neck become inflamed, leading to headache. Facial pain can have many origins. Other causes of headache are those that do not fall under any of these other classifications.

(See further for more about Different Types of Headache

What Causes Headaches?

There are many causes for headaches. In many cases, experts cannot tell someone what causes headaches. Headache causes range from muscle tension to underlying disease. However, doctors do understand many of the physiological causes of headaches. Headaches occur when nerves that are sensitive to pain, called pain fibers, are disturbed. Pain fibers can be disturbed by inflammation, infection (such as sinusitis), injury, or other means. In turn, these fibers send pain signals to the brain, causing headache.

Headache pain does not originate in the brain. The brain has no nerve endings. But the brain is surrounded by several layers of tissues and blood vessels that do contain pain fibers. If these tissues or vessels become inflamed or compressed, pain results.

Headache pain can start in most structures of the head and neck, including:

• The large blood vessels of the head and neck—including those within the brain (though the number of pain fibers is reduced in the branches that lie deep within the brain itself)

• The sinuses (pain can affect the bone and/or the many veins)

• The first layer of bone (periosteum)

• The teeth

• The eyes

• The muscles of the face and the neck

• The tendons (which connect muscle to bone)

• The skin

• The joints between the vertebrae of the neck (cervical spine)

Headaches can also start outside the head

Sometimes the source of headache pain is obvious. For instance, the sinuses may become infected (sinusitis) and trigger pain at the site of the infection. But not all headaches start in your head. Pain that is perceived in the head can also come from elsewhere in the body, such as the neck.

Pain signals travel complex routes before they reach the brain, the brain processes it, and you say, “Ouch!”

The route that leads to head pain from nerve stimulation in the neck (and vice versa) is known as the cervical trigeminal relay. To understand this pathway, imagine that the spinal cord is a major river—such as the Mississippi—and the other nerves are connected to it like tributaries, all the way down to the tiniest mountain brook (nerve endings and pain fibers).

Any stimulus, such as touch, heat, or cold, acts like snowmelt. The stimulus touches the immediate nerve endings (the mountain brook), which release a signal that travels to the next larger nerve and the next, in the same way that a many mountain brooks flow into larger and larger streams until the water reaches the Mississippi.

As the signal passes along this pathway, receptors in various tissues may trigger activity in those tissues. For example, if the stimulus starts in an internal organ, it might trigger a sensory nerve in the abdominal wall so that the person feels pressure on the abdominal wall, regardless of the location or “message” (heat, pain) of that first stimulus.

Conversely, a sensory nerve can “fire” backward, causing the release of a noxious substance around the blood vessels that it supplies. This could lead to inflammation around the vessels, so the signal is translated from its original form to pain in the affected vessels.

Certain nerves of the head and face are so closely associated with the nerves of the neck (cervical spine) that signals can become “crossed”—for example, a pain stimulus that originates in the neck might be “felt” behind the eye. Recent studies have shown that this network of nerves may play a key role in causing headaches.

Are Severe Headaches Dangerous?

Most headaches, even severe ones, are not dangerous or life-threatening. But some warning signs do indicate that further testing and treatment may be required.

How can you tell the difference between “just another headache” and a headache that signals a potentially serious medical problem, such as a stroke or brain tumor, or a dangerous infection such as meningitis?

The following warning signs can help you to identify headaches caused by potentially dangerous conditions.

Does the headache:

• Start suddenly, remain constant and severe, and grow in intensity over 24 hours or less?

• Worsen rapidly and reach a crescendo within five minutes?

• Occur more frequently than in the past?

• Occur after a blow or a fall that causes injury to the head, especially if the person feels drowsy or nauseous or acts strangely?

• Occur after a change in medication, especially a blood-thinning medication such as warfarin (Coumadin) or aspirin?

• Prevent you from going about your normal activity more than any other headache has in the past?

• Are accompanied by unusual neurological symptoms such as seizures, temporary loss of or change in vision, memory loss, changes in speech, loss of strength in or numbness or tingling in one or both arms or legs, or other changes in sensation? Although these symptoms can occur with migraine headaches, they should be checked out if they have not occurred previously. They may indicate a stroke.

• Are accompanied by stiff neck, fever, night sweats, chills, loss of weight, loss of appetite, muscle pain, or other signs of illness?

• Grow worse when you cough or strain?

• Hardly hurt at all when you are lying down, but suddenly worsen when you sit or stand?

• Lead to personality changes, sudden changes in mood, seizures, weakness, excessive sleepiness, lethargy, or loss of consciousness?

Need to Know: Any significant change in headache pattern should be evaluated, even in people who regularly have severe headaches.

Frequently Asked Questions Q: I have had severe headaches for years, but my doctor says that nothing serious is wrong. I find that very hard to believe. A: Your doctor is most likely correct. The vast majority of headaches, although frightening if frequent and/or severe, do not signify any underlying problem. Headaches that accompany serious health problems tend to come on suddenly. Your history of headache would seem to argue in favor of your doctor’s reassuring diagnosis. Q: I’ve suffered from headaches for years and I asked my doctor for a CAT scan or an MRI. She says it isn’t necessary. Why not? A: Once liberally used on people who complained of headaches, CAT and MRI scans and are usually now reserved for people suspected of having brain abnormalities. This means they aren’t generally used for people with a history of headaches unless they have experienced a substantial change in their symptoms, such as seizures or abnormal neurological symptoms, or unless their headache developed following a blow or other trauma to the head. Q: My doctor says that my headache medication itself may be causing my headaches. How is this so? A: Overuse of over the counter or prescription medication can result in dependence (addiction). Chronic overuse of these substances may interfere with the brain’s ability to modulate pain. In addition, stopping the use of pain relievers, once the body becomes accustomed to a certain amount of the drug, can lead to withdrawal headaches. Q. I have frequent, severe headaches. Should I be taking medications to prevent my headaches? A: It depends. Some people with frequent, severe headaches can ward off future attacks simply by identifying and avoiding headache triggers such as smoking, eating certain foods, or changes in sleep and eating patterns. But if you meet the following criteria, you should talk to your doctor about using medications to prevent future attacks. You have frequent attacks (more than one per week). Pain-relief drugs don’t work well for you during the attack. You don’t do well or, because of other reasons, can’t use pain-relief drugs. You have used pain medications for a long time, frequently, or excessively in the past, making you less responsive to acute drug therapies. You prefer to take medications.

Facts about Headache

• Chronic, recurring headaches affect more than 45 million Americans (more than asthma, diabetes and coronary heart disease combined). (National Headache Foundation)

• More than 29.5 million Americans suffer from migraines each year (National Headache Foundation).

• About 20 percent of children and teens have significant headaches (National Headache Foundation)

• About 70 percent of migraine sufferers are women (National Headache Foundation)

• About 25 percent of women and 10 percent of men will experience migraine headaches sometime during their lives.

• Businesses lose an estimated industry 50 billion dollars per year due to absenteeism and medical expenses caused by headache.

• Migraine sufferers are absent from work more than 157 million days each year.

• More than four billion dollars are spent annually on over-the-counter (non-prescription) pain relievers for headache.

• The first clinic devoted to headache pain was founded in 1945 at Montefiore Hospital in Bronx, New York. Since then, hundreds of headache clinics have sprung up across the country.

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Types of Headache

The International Headache Society classifies 67 different types of headache into 13 categories. More broadly, headaches are classified in terms of primary and secondary causes, as well as cranial neuralgias, facial pain, and other causes.

Primary headaches are headaches that occur with no underlying medical cause. The most common are:

• Tension headache

• Migraine

• Cluster headache

• Medication overuse headache (formerly called rebound headache)

• Post-traumatic headache

• Chronic paroxysmal hemicrania

Secondary headaches are headaches caused by other factors. Some causes are trauma, stroke, brain tumors, and infection.

Cranial Neuralgias, facial pain, and other types of headache can be caused by a variety of things. Cranial neuralgias occur when nerves in the head and upper neck become inflamed, leading to headache. Facial pain can have many origins. Other causes of headache are those that do not fall under any other classifications, such as caffeine withdrawal headache, headache associated with exercising, and so-called “ice cream” headaches, which are caused by eating something very cold.

Types of Primary Headache

Tension Headache

Tension headaches are the most common form of headache. They may be episodic – meaning they occur occasionally and are generally relieved by over-the-counter (OTC) analgesics (pain relievers) such as acetaminophen (Tylenol), ibuprofen (Motrin or Advil), or naproxyn (Aleve). Or they may be chronic. Chronic tension headaches are tension-type headaches that occur almost every day, sometimes for months at a time, and are generally not relieved by OTC analgesics. These headaches vary in severity, from mild to moderate, and they can last for hours, days, or even longer.

Tension headaches are generally felt in the forehead, temples or the back of your head and neck. They are generally not associated with any significant changes on exertion. Often, only certain positions seem to provide relief.

Symptoms of tension-type headache include:

• Dull, continuous pain

• Soreness in the temples

• A tight “band-like” sensation around the head (some people describe this as a “vice-like” ache)

• Sensations of pressure

• Contracting head and neck muscles (some physicians refer to tension-type headaches as “muscle contraction” headaches).

• Tightness in the neck.

Nice To Know Sometimes, people who experience severe tension headaches have symptoms similar to migraine sufferers, such as: Aversion to light Aversion to sound Nausea These similarities have led some researchers to speculate that headache types may occur along a continuous spectrum, with tension headaches on one end and migraine headaches on the other. To compare symptoms of migraine and tension headaches, go to headache chart.

Tension headaches are thought to occur when muscles in the head and neck tighten, stimulating pain receptors in the blood vessels of the scalp. The underlying cause of tension headache—the reason for muscle tension—is often hard to pinpoint. However, tension headaches are often associated with one or more of the following:

• Physical stress. Standing or sitting with poor posture (or in an unnatural position) can cause tension in the muscles of the neck. Uncomfortable noise or light can also lead to muscle tension, as can abnormalities (such as misalignment) in the structures (muscles, bones, discs) of the face and neck.

• Emotional stress. Problems at work or lack of work, financial worries, noisy neighbors, and domestic unhappiness are just a few causes of stress that can result in tension headache.

• Depression Feelings of sadness, hopelessness, pessimism, and a general loss of interest in life are all parts of the emotional state known as depression. Depression is an important but often overlooked cause of headache.

Migraine

To read more about Migraine go to Migraine

Cluster Headache

Cluster headache is so named because attacks occur in groups. Characterized by severe, sharp, penetrating pain that begins with little or no warning, these headaches typically last for 30 to 45 minutes and recur up to 10 times per day. They are often accompanied by a stuffy or runny nose and tearing of the eye on the side of the head affected by the pain. Cluster headaches occur five times more commonly in men than women.

Cluster headaches most often strike in the morning or late at night, and can continue for months. The pain can disappear for weeks—or even months or years—at a time. In some sufferers, however, the attacks are not clustered and occur continuously. This debilitating headache type is not a symptom of any serious disease but does require expert medical treatment.

Unfortunately, cluster headache can be extremely difficult to treat. The pain is both unexpected and short-lived, so it typically resolves by the time medication has been absorbed. It is sometimes treated with a variety of combination painkillers, steroids, ergotamine compounds and, more recently, sumatriptan, a medication developed for migraine relief. Medications are often administered through the nose or injected, so they work more quickly. Oxygen, used at home with a portable cylinder and mask, may also be used to treat cluster headache. If all other treatments fail in relieving cluster headache, surgical procedures such as the destruction of the active nerve endings may be effective.

Need To Know Cluster headaches are sometimes confused with another—quite different—condition that causes agonizing pain in the face: trigeminal neuralgia. Trigeminal neuralgia is a type of cranial neuralgia that causes painful spasms, usually starting in the cheek or chin. In contrast to cluster headache, trigeminal neuralgia attacks last for seconds only. It is important to distinguish these two causes for pain, as the treatments are quite different.

Medication Overuse Headache (Previously Called Rebound Headache)

Medication overuse headache, previously called rebound headache, is another common—though often unrecognized—type of headache. Medication overuse headache occurs with long-term use of prescription and/or over-the-counter.

People who experience frequent headaches or other chronic pain may take more than the recommended dose of a medication or take it more frequently than directed. They may even take these medications preemptively, to “ward off” a potential headache.

When medications are overused in this way, the body develops a tolerance to these drugs. Eventually, the person may become dependent on them. At the point of drug dependence, not only is more of the drug required to achieve the desired effect (pain relief), but the body actually “asks” for the drug by signaling “pain.” Eventually, the drug is no longer effective in controlling pain, but the body still requires it.

Need to Know Caffeine withdrawal headache is one of the most common types of medication overuse headache. Caffeine withdrawal headache can occur when regular coffee or tea drinkers skip their morning cup. The pain may be localized or generalized and may be accompanied by fatigue and irritability.

Symptoms of medication overuse headache include pain that:

• Occurs in headache sufferers who take pain relievers very frequently (more than two days per week), often in excessive amounts

• Occurs daily or nearly daily.

• Varies in severity, type and location

• Is accompanied by fatigue, nausea, stomach distress, restlessness, anxiety, irritability, memory problems, difficulty in intellectual concentration, and/or depression

• Tends to occur in the early morning hours, between 2 and 5 a.m.

• Worsens over time, so larger and more frequent doses of drugs are needed

• Occurs when medication is discontinued abruptly

This tolerance and dependency can develop with any pain reliever, and caffeine can make it worse. Treatment consists of discontinuing use of the medication. However, that may be difficult to do.

Those dependent on over-the-counter drugs may be able to gradually stop using the drugs by themselves, but withdrawal symptoms may interfere. A physician can design a program to help the patient through this period.

Need to Know A patient who has overused prescription medications should always work with a doctor to overcome the dependency.

Post-Traumatic Headache

This chronic headache condition is caused by an injury to the head or neck that affects the nerves. The description of the pain varies, but it is often felt at the back of the head and can be present daily. In some cases, these headaches may take on the characteristics of migraine.

Chronic Paroxysmal Hemicrania

Chronic paroxysmal hemicrania is a rare type of headache that bears similarities to cluster headaches. Once reported mainly in women (at a ratio of 7:1), more recent studies show that men and women may be affected about equally. Pain occurs in one side of the head, on or around the eye and is often severe and debilitating. Some patients have described the pain as throbbing or claw-like.

Individual attacks may last from 2 minutes to an hour. People with chronic paroxysmal hemicrania typically experience 10 to 20 attacks per day, although some people have reported experiencing as many as 45 attacks in one day.

Like cluster headaches, the attacks of chronic paroxysmal hemicrania are associated with red and tearing eyes and nasal congestion or runny nose, which is generally more severe on the affected side. The pain always occurs on the same side.

This type of headache responds to the prescription pain reliever indomethacin (Indocin) and occasionally to calcium channel blockers, a type of drug that causes a widening of the blood vessels. Oxygen is ineffective.

Secondary Headaches

Secondary headaches are symptoms of some other medical condition. The most common causes of secondary headaches are:

• Stroke Stroke occurs when blood flow to the brain is suddenly interrupted, causing massive damage or death of cells in a particular area of the brain. During a stroke, a sudden, severe headache may occur.

Need To Know People who experience a sudden, severe, unexplained headache and who have no previous headache history should seek immediate medical care. The warning signs of stroke are: Sudden weakness or numbness of the face, arm, and leg on one side of the body. Sudden loss of vision or dimmed vision, particularly in one eye. Loss of speech, or trouble talking or understanding speech. Sudden, severe headaches with no apparent cause. Unexplained dizziness, unsteadiness, or sudden falls, especially if accompanied by any of the previous symptoms. There are two types of stroke: Ischemic stroke, which refers to a condition caused by a decreased supply of oxygenated blood to a body part. Hemorrhagic stroke, which is caused by bleeding within the brain (called subarachnoid or intracerebral hemorrhage) Stroke can be a life-threatening medical emergency. If you suspect a stroke, call emergency medical services immediately. In most of the United States and many other areas, that means dial 9-1-1.

• Subarachnoid Hemorrhage: A subarachnoid hemorrhage occurs when an artery ruptures and blood leaks into the fluid surrounding the brain, called the subarachnoid space .

Subarachnoid hemorrhages usually occur when a distended and weakened segment of artery, known as an aneurysm, gives way. Trauma, such hitting the head during a fall from a bicycle, can also cause subarachnoid hemorrhage. Although this type of bleeding can lead to stroke (i.e. brain cell death), the two are not the same.

The sudden rupture of the artery causes intense, severe pain. People who have experienced it have likened it to having been hit across the back of the head with a hammer. The bleeding often leads to changes in consciousness ranging from confusion, disorientation, or belligerence to coma. Weakness on one side of the body is also common.

Subarachnoid hemorrhage is a life-threatening medical emergency. Anyone who experiences a sudden onset of intense, severe head pain should seek emergency medical care immediately. Call 9-1-1 in the United States.

Need to Know About half of the patients who have a full-blown subarachnoid hemorrhage may have had a “warning leak” during the weeks or months preceding the attack. This bleeding can cause a less severe headache of similar nature. People who experience a sudden, severe headache and who have no previous history of headaches should have a full neurological examination.

• Brain Tumors. Commonly, people who suffer with severe headaches fear that they have a brain tumor. In most cases, their fears are unfounded. Less than five percent of headaches are caused by brain tumors. It is true, however, that headache is one of the most common symptoms of a brain tumor.

Need To Know Warning signs of a brain tumor: A short history of headaches before the tumor begins to become evident. Persistent headache that is most painful in the morning. Headache that worsens when the person bends forward, sneezes or coughs. Headache accompanied by loss of balance, changes in vision, weakness, or numbness in a particular area of the body. Seizure in a person who does not have a history of seizures. Changes in hearing, speech or vision. Neurological symptoms, such as weakness in an arm or leg.

• Infection Headache often accompanies the flu or other causes of fever. The pain does not indicate that the brain is infected; infection in any part of the body can cause a fever and headache.

• Meningitis is an infection of the meninges (tissues that cover the brain and spinal cord). This potentially fatal infection can be caused by a number of common bacteria. Viral meningitis is much less dangerous and can resolve without treatment. Meningitis is most common in children, but it can occur in adults as well.

Need To Know A condition known as meningism, which is an irritation of the meninges, can occur without actual infection of these tissues. It is very difficult to distinguish meningism from early stage meningitis. The physician usually must perform a spinal tap (lumbar puncture) to make a diagnosis. Meningism is also more common in children than adults, and often accompanies infection or inflammation of the upper respiratory tract. Encephalitis is an inflammation of the brain itself (usually caused by a virus) that causes symptoms that may be confused with meningitis. The inflammation may irritate of the coverings of the brain (meninges) or compress blood vessels, causing headache.

• Temporal Arteritis. Temporal Arteritis is an inflammation of the temporal arteries, the medium-size arteries located above and in front of the ears on both sides of the head. One of the most common symptoms of temporal arteritis is headache. Changes in vision are also commonly reported. Temporal arteritis affects one to five out of 10,000 people over 50 in the United States and occurs four to six times more frequently in women than men.

Symptoms of temporal arteritis include:

• A headache with pain centered on one temple, though it can be more diffuse

• Swelling and warmth in the temporal artery

• Tenderness of the scalp over the artery

• Double vision, blurred vision, large blind spots, blindness of one eye or other changes in vision

• Pain upon chewing as the vessels that supply blood to the muscles of the jaw become compressed by the inflammation

• In extreme cases, the temporal artery may be visible as a knobby, hard structure running over the surface of the skull

Temporal arteritis is typically treated with corticosteroids.

Cranial Neuralgias, Facial Pain, and other Types of Headaches

The International Headache Society established a third category of headache in 2005, cranial neuralgias, facial pain, and other types of headache.

Cranial neuralgia or facial pain occur when nerves in the head and neck become irritated or inflamed. Twelve nerves, called cranial nerves, supply the brain with information about the face, upper neck, and head. These nerves also control motion of the face, allowing us to smile, frown, chew, talk, and more.

Underlying causes of cranial neuralgia and facial pain vary widely and include physical and emotional stress, tumors, meningitis, Herpes zoster infections,

Treatment of cranial neuralgia may involve removing the source of the pressure or treating underlying illness. Most of the time, however, treatment is focused on relieving symptoms.

• People who experience spastic pain resembling tic douloureux may benefit from anti-seizure medications.

• People for whom the pain is resembles facial pain may find relief from tricyclic antidepressants and a phenothiazine.

• The physician may perform a procedure called a nerve block, in which she injects a pain-numbing medication into a specific cranial nerve. This helps the doctor determine which nerve is affected and may provide pain relief even after the medication wears off.

Common cranial neuralgias and facial pain include:

• Trigeminal neuralgia. This type of headache is characterized by brief episodes of stabbing pain, often starting in the chin or cheek. It occurs when the fifth cranial nerve, called the trigeminal nerve, becomes irritated or inflamed. The trigeminal nerve controls muscles involved in chewing and conducts sensory impulses to the face, mouth, and sinuses.

• Occipital neuralgia. Pain behind the eye occurs when the second cranial nerve, the occipital nerve, becomes irritated or inflamed. This headache is characterized by a continuous throbbing ache, with occasional shock-like jabs of pain. Pressure can make the pain worse. Physical and emotional tension can trigger an attack.

• Glossopharyngeal neuralgia. Short, sharp spasms of pain in the back of the nose, throat, tongue, or behind the jaw or lower ear suggest glossopharyngeal neuralgia. This type of headache occurs when the ninth cranial nerve, the glossopharyngeal nerve, becomes irritated or inflamed. , Chewing, swallowing, talking, coughing, or yawning can trigger a pain spasm.

• Exertional headache. Also known as a “sports headache,” exertional headache occurs in some people when they exercise. It is most likely caused by dilation of vessels as the blood pressure increases. In most people, the headache is harmless and can often be prevented by taking an over-the-counter pain reliever about an hour or so before exercising.

• Idiopathic stabbing headache. This type of headache occurs more commonly in people who get migraines. These headaches begin without warning and consist of brief, sharp, stabbing, ice-pick like pains in various parts of the head. They are believed to be due to discharges in the sensitive occipital nerve. Although these headaches can be frightening, they are benign.

• “Ice cream” headache. This type of headache occurs briefly in the forehead or temples and is caused by eating ice cream or other cold food too quickly. The headache is caused by a sudden stimulus of cold going over the gullet, which in turn stimulates the glossopharyngeal nerve.

To read more about determining the cause of a headache, go to Finding the cause of your headache.

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Medication for Headaches: What Works?

Medication for headaches can be an important part of a headache treatment plan. Medications for headaches include various nonprescription and prescription drugs. In general, medications for headaches fall into two types: drugs used to treat acute headache, and drugs used to prevent attacks in people with chronic headache syndromes. For people who experience chronic or severe headache, medications are an essential part of headache treatment.

Medications Used to Treat Acute Headache

When a person feels the pain of a headache, no matter how severe, the headache is considered acute. Most people can find headache relief in over the counter headache medications. However, during an acute headache, people with severe, chronic headache may need to turn to their “headache meds.” People with severe headaches should consult their doctors about using one of the many prescription drugs used for headache treatment.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs), which are available in both prescription and OTC forms, are the first line of defense against headache pain. Many patients will initially self-medicate with one of the following OTC formulations:

• Aspirin (the most common)
• Ibuprofen (Advil, Motrin)
• Naproxen sodium (Aleve)

Prescription formulations such as the following should only be used under the supervision of a doctor:

• Indomethacin (Indocin)
• Piroxicam (Feldene)
• Sulindac (Clinoril)
• Tolmetin sodium (Tolectin)
• Meclofenamate sodium (Meclomen)
• Ketorolac (Acular, Toradol)
• Naproxen (Naprosyn) in higher doses; Naproxen sodium (Naprelan, Anaprox)
• Ibuprofen in higher doses

Need to Know Although over-the counter medications can be purchased without a prescription, they are still potent drugs. They should be used according to the package directions, and patients need to be alert to side effects. In addition, prolonged or frequent use can lead to dependency (which can, in turn, lead to medication overuse headaches). People who take painkillers of any sort more often than two days per week should consult a doctor for further advice about preventing headaches.

NSAIDs, as a group, share certain common side effects. They may cause stomach upset, nausea, and vomiting. These effects may be avoided by taking the drugs with food or milk. Long-term and high-dose use can damage the kidneys or stomach lining and may contribute to the development of ulcers.

NSAIDs also have a “blood thinning” effect, so they should not be combined with other anticoagulants (such as warfarin [Coumadin] or other NSAIDs). If you have asthma or heart disease, consult your doctor or pharmacist before taking any NSAIDs, whether OTC or prescription. Individual formulations may have additional, specific side effects; read labels and follow directions carefully.

Acetaminophen (Tylenol, Anacin-3, Panadal, Tempra), a non-narcotic analgesic, is a reasonable alternative to the OTC drugs noted above when existing stomach distress, ulcers, or allergic reactions prohibit the use of NSAIDs. Pregnant women may be able to take acetaminophen, but they should consult their physicians first. Side effects are rare when the drug is used according to instructions, but overuse or prolonged use can lead to liver damage and other toxic effects.

Triptans

Triptan drugs are prescription drugs used to treat moderate to severe migraine pain. Among migraine medications, triptans are preferred for moderate to severe pain. Injectable and inhaled forms of triptan drugs are also accepted medications for cluster headaches. Because these forms of the drug are absorbed quickly and begin to act almost immediately, they are sometimes used to treat cluster headaches.

Triptans act by increasing levels of the neurotransmitter serotonin in the brain. Serotonin lowers the pain threshold, making it easier for you to handle pain, and causes blood vessels to constrict, lessening the pain signals in the head.

Seven triptans are available for treatment of acute migraine. These are:

• Sumatription (Imitrex, Imigran)
• Zolmitriptan (Zomig, Zomig-ZMT)
• Naratripton (Amerge, Naramig)
• Rizatriptan (Maxalt, Maxalt-MLT)
• Almotriptan (Axert)
• Frovatriptan (Frova
• Eletriptan (Relpax)

Ergot Derivatives

Ergot derivative drugs are sometimes used to help control migraine and cluster headache pain when triptans fail. They work by binding to serotonin receptors on nerve cells, thus lessening the transmission of pain signals along nerve fibers. They also act on some other receptors, most likely on those for dopamine and noradrenalin. Ergo derivatives include:

• Ergotamine tartrate (Cafergot)
• Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)
• Acetaminophen-isometheptene-dichloralphenazone (Midrin)

Narcotic and Combination Analgesics (Pain Relievers)

Individuals with more severe headaches may need to use narcotic pain medications, which require a doctor’s prescription. Narcotic pain medications work by interfering with pain receptors on nerves, thus interrupting the pain signal.

To make them more effective, narcotic pain medications are often combined with other drugs. Many combination analgesic “cocktails” consist of an analgesic, caffeine, and a narcotic. Caffeine acts as an adjuvant, helping the pain-killing drugs to work more effectively, and it helps to constrict blood vessels. These combination analgesics help lessen any kind of pain.

Examples of these combination drugs include

• Acetaminophen with codeine (Tylenol with Codeine)
• Butalbital-acetaminophen-caffeine (Fioricet)
• Butalbital-aspirin-caffeine (Fiorinal),

As with NSAIDs, overuse of narcotic analgesics for chronic headaches can lead to dependency and medication overuse (previously called “rebound”) headaches. Other side effects that may occur with narcotic analgesics include light-headedness, sedation, dizziness, shortness of breath, nausea, and vomiting. Abdominal pain, constipation, depression, and itchy skin are less common side effects.

Need To Know Caffeine is a drug familiar to headache sufferers for two reasons: It can be a cause of pain, and it can help to relieve it. In small amounts, caffeine acts to constrict blood vessels. It is often added to analgesic drugs to make them more effective. A small amount of caffeine can actually reduce the dose of a pain medication needed to relieve pain. When caffeine is a regular component of the diet, however, such as for habitual coffee- or soda-drinkers, tolerance and dependence on this stimulant drug can lead to medication overuse and/or withdrawal headache.

What Medications are Used to Prevent Headaches?

Medications may be used to help prevent headaches in people with chronic headache syndromes such as migraine or cluster. Indeed, many of the medications used to prevent migraines are also used to prevent cluster headaches. Preventing migraines or cluster headaches requires a comprehensive approach, and medications can be an important part of managing chronic headaches of any type.

Medications commonly used to prevent migraines and cluster headache include oral steroids, antidepressants, Botox, anticonvulsants, beta blockers, calcium channel blockers, and lithium. Less commonly, Methysergide maleate (Sansert) may be prescribed.

Oral Steroids

Oral steroids (corticosteroids) are generally a form of prednisolone. These compounds can be effective in relieving pain caused by inflammation. Steroids should only be used under a doctor’s supervision; the appropriate dose is often highly individual.

Common side effects associated with oral steroids include diarrhea or constipation; headache; increased or decreased appetite; increased sweating; nervousness, restlessness, or difficulty sleeping; upset stomach; and unusual or increased growth of hair on the face or body.

Antidepressants

Antidepressants effectively help prevent several types of severe headaches. Mild tranquilizers are also prescribed occasionally, but they tend to be highly addictive and should only be used on a short-term basis.

Side effects vary widely according to individual drugs, but some of the more common effects related to antidepressant medications include: changes in sleep patterns; dry mouth; changes in vision; constipation; anxiety; nausea; and worsening of existing heart disease. Patients should be alert to any and all changes that may result from a new or changed antidepressant treatment.

Botox

Botox (onabotulinumtoxinA), known widely for its use in cosmetic procedures, is sometimes used as a treatment for chronic migraine and other severe headache types. Botox is a formulation that contains botulinum toxin, a neuro-muscular poison that causes temporary paralysis. It has been tested and approved for a number of neuro-muscular conditions, and is considered to be safe in the small doses required for therapy.

Botox was approved by the FDA in October 2010 to help people with chronic migraine prevent future attacks. To effectively avoid or dull future attacks, Botox should be given approximately every 12 weeks as multiple injections around the head and neck. However, the drug has not been shown to work for the treatment of episodic migraine headaches that occur 14 days or fewer per month, or for other forms of headache.

The most common adverse reactions reported by patients being treated with Botox for chronic migraine were neck pain and headache. The most common side effect of Botox treatments in other contexts is muscle weakness in the treated area, but this is generally temporary. Rarely, flu-like symptoms have been reported.

Other preventive medications

Other medications may be prescribed to help prevent repeated attacks for specific types of headaches. These include:

• Anticonvulsants. These drugs, originally developed to treat people with seizure disorders, may help to lessen pain and increase levels of certain neurotransmitters in the brain. Specific anticonvulsants used to prevent migraine and cluster headaches are valproic acid, gabapentin, phenobarbital, and topiramate.

• Beta blockers. Generally used to treat high blood pressure and irregular heart rhythms, beta blockers are also helpful for some people in controlling migraines. Propanolol, in particular, is approved by the FDA for prevention of migraine. Migraine frequency usually decreases within four to six weeks of starting treatment. Doctors do not know exactly how these drugs help prevent migraines. Some experts speculate that beta blockers help to stabilize blood vessels and prevent them from widening too much. Beta blockers may also help prevent migraine by reducing anxiety and excitability of the nervous system, as well as balancing levels of the neurotransmitter serotonin , People with asthma or other respiratory diseases should not use beta blockers. Alert your doctor if you receive allergy shots. Slow heart rate and low blood pressure are common side effects. Beta blockers should not be stopped abruptly, as this can lead to a dangerous rise in heart rate.

• Calcium channel blockers. These medications are used to treat heart and blood vessel problems such as high blood pressure. They help to control blood pressure by altering the movement of calcium ions into the muscle cells that control blood vessels. By controlling the narrowing and widening of blood vessels, these drugs can help to prevent migraine and cluster headaches. Calcium channel blockers have not been approved by the FDA for prevention of migraine. However, some research suggests that the calcium channel blocker Verapimil may help prevent both migraine and cluster headache. High doses of Verapimil may be needed to treat cluster headache cycles. People with asthma and other respiratory diseases can use calcium channel blockers. Side effects of these drugs include low blood pressure and constipation.
• Lithium. Lithium is very helpful in prevention of chronic cluster headaches and sometimes episodic cluster. It is given in small doses, one to three 300 mg. tablets per day, for cluster headache. Although lithium is usually well tolerated in low doses, side effects may include drowsinesss, mood swings, nausea, tremor, and diarrhea may occur. People taking lithium need to have blood tests done regularly.
• Methysergide maleate (Sansert) may be prescribed for people with severe migraine or cluster headache. The drug acts by counteracting blood vessel constriction. Methysergide maleate has several side effects, including nausea, leg cramps, dizziness, and a feeling of heat in the head; it can lead to fibrosis when used for extended periods. Pregnant women and people with stomach ulcers, heart and blood vessel disease, or kidney disease should not use methysergide maleate. However, used judiciously, the drug can be effective in preventing both migraine and episodic cluster headaches.

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Finding the cause of your headache

Determining what is the cause of a headache involves several steps, including a physical exam, blood tests, and imaging tests of the head and neck. Diagnosis of headache is an essential step to help determine the type and cause of your headache – and how to treat it.

Physical Examination

A physical examination includes checking vital signs to look for high blood pressure and fever. The doctor will also evaluate range of motion (how far you can move) in the neck.

Blood Chemistry Test and Urinalysis

Laboratory tests including blood chemistry and urinalysis can highlight many possible causes of headaches, including infection, kidney disease, and thyroid disease. If these tests indicate that there is no serious underlying cause for the headache, many doctors will halt testing at this point.

Electroencephalography (EEG)

In Electroencephalography (EEG), a number of small electrodes are attached to the scalp and connected to an instrument that measures and records the electrical impulses produced the brain. This test is used to evaluate neurological activity.

Computed Axial Tomography (CT or CAT scan)

Computed Axial Tomography, also called a CT of CAT scan, is a sophisticated imaging test that uses x-rays to produce cross-sectional views. Doctors use CT scans to help diagnose fractures, sinus problems, brain tumors or blood clots (indicative of stroke).

For more detailed information about CT scans, go to CT Scans.

Magnetic Resonance Imaging (MRI)

MRI is another sophisticated imaging tool. It uses a strong magnetic field, rather than x-rays, to produce a highly detailed image of soft tissues. Magnetic resonance images can demonstrate even slight differences between normal and abnormal tissues.

Like CT scans, MRI was once liberally used on headache patients. These exams are now usually reserved for cases in which abnormalities are suspected.

For more detailed information about the MRI procedure, go to MRI.

Lumbar Puncture

Also known also as a “spinal tap,” a lumbar puncture is used only when meningitis or encephalitis are suspected. In this test, a needle is inserted between two vertebrae, into the spinal canal to obtain a sample of the cerebrospinal fluid. The fluid is normally clear and colorless, so changes (such as cloudiness) may indicate infection. The test can cause a headache that may last for several hours.

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Alternative Remedies for Headaches

What are Alternative Remedies for Headaches?

A variety of natural and home remedies for headaches are available. However, alternative therapies for headache, such as herbal remedies, are not regulated in the same way that drug therapies are. Their efficacy may not have been proven with scientific studies. Some people suggest, therefore, that any relief found through alternative therapies is due to “placebo effect” —that is, the patient believes the treatment will bring relief, so the patient experiences relief, even though the treatment itself accomplished nothing.

Whatever the underlying reason, the natural remedies for headache described below have helped some people find headache relief and successfully manage headaches. Not all patients respond to these treatments in the same way. However, they are all considered valid headache treatment options.

Relaxation Therapy and Headaches

Relaxation therapy can be used before and during a headache to relieve stress and anxiety. In some cases, relaxation techniques may prevent a headache. In others, it simply helps to make the pain more bearable by giving the patient a sense of control.

Some of the more common (and easy to learn) relaxation techniques include:

• Abdominal breathing, which simulates the breathing of deep sleep;

• Visualization, in which the patient imagines him/herself in a calm, pleasant, relaxed setting;

• Regular aerobic exercise, which helps to release both physical and psychological stress and tension;

• Body scanning, which consists of mentally scanning the body to find areas of tension; and

• Progressive muscle relaxation (PMR), which involves alternatively tensing, then relaxing, all of the major muscle groups in the body.

Hypnosis and Headaches

The word hypnosis is derived from the Greek word hypnos, which means “sleep.” Hypnosis is a state of focused concentration that mimics deep relaxation. It can be self-applied or induced by a hypnotherapist. During states of hypnosis, physical changes occur that are similar to those observed during states of deep relaxation. Typically, blood pressure drops, nervous system activity slows, and oxygen consumption decreases. Changes in brain wave activity are also evident. These physiological changes may provide headache relief.

Biofeedback for Headaches

Biofeedback is a method used to teach people how to consciously control bodily functions that are generally considered to be involuntary. People can learn to regulate muscle contraction, heart rate, blood pressure, brain activity, and even skin temperature. Biofeedback training requires a professional trainer and specialized monitoring equipment in the beginning, but the goal of training is to develop techniques that can be used anywhere at any time.

During the training process, biofeedback sensors are applied to the skin. The sensors collect physical response data, such as muscle tension, and convert it to information that can be displayed on a screen. The patient uses the information provided to regulate his/her responses. Half of all migraine sufferers who learn biofeedback techniques and use them report a 50 percent improvement.

Acupuncture / Acupressure for Headaches

Acupuncture involves the insertion of thin needles into specific points of the body in order to prevent or treat illness. Long a staple of Eastern medicine, acupuncture is winning converts here in the treatment of many types of chronic pain, including headache and migraine.

According to traditional Chinese medicine, acupuncture works by correcting the balance of energy, or ch’i, in the body. For good health, this energy must flow freely through the body. Disruptions in ch’i can cause illness and pain. The insertion of acupuncture needles at specific points is meant to correct disruptions. Acupressure is a similar technique that doesn’t involve needles. Instead, the therapist applies concentrated pressure at specific points using his/her fingers.

Some researchers theorize that acupuncture and acupressure can be effective in relieving pain because these techniques stimulate the release of endorphins. Endorphins are natural hormones that block pain signals.

Chiropractic Treatment and Headaches

Many chiropractors claim they can treat headaches by traction of the neck, and this method is sometimes effective. Chiropractic treatment for headaches involves spinal manipulation, which can release pressure on the cervical nerve roots as they exit the cervical spine.

Food and Headaches

Many food-related headache triggers exist, including caffeine, alcohol, and overly-processed foods. You may be able to discover links between certain foods or additives and headache by keeping a headache diary. Write down information about what and when food and drink you consume, and note the onset of any headache symptoms. If you find any food-related headache triggers, you may be able to prevent or reduce headache pain by avoiding them.

 

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Headache Clinics

What Is A Headache Clinic?

A headache clinic is a facility staffed by specialists dedicated to the treatment of severe headache and migraine. The staff at a headache clinic typically includes psychologists, nutritionists, relaxation specialists, physicians, and support personnel. Headache clinics typically provide a range of services, including physical evaluation, diagnostic tests, and the development of a headache management plan.

Headache sufferers may turn to a specialized headache clinic for a number of reasons:

• His regular doctor cannot diagnose the headache type.
• She may be unable to tolerate conventional medications for headaches and is seeking alternative remedies for her headaches.
• He may have developed a tolerance of or dependency on a particular drug, and may suffer from medication overuse headache (formerly called rebound headache). This situation requires rehabilitation from the addiction as well as treatment for headache pain.
• The debilitating effects of frequent headaches or severe headaches have led to psychological or psychiatric problems.

Most headache clinics are operated on an outpatient basis. There are a few inpatient headache clinics. But inpatient care is costly and is generally reserved for patients who are seriously addicted to pain medication, suffer unrelenting, prolonged pain that has been impossible to relieve by other means, or have other unusually severe headaches or associated problems. Such treatment is generally a last resort, but staff at headache clinics are able to offer significant help to this tiny minority group.

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Headache: Summary. What you need to know.

• Almost everyone experiences a headache at one time or another. Headache is one of the most common forms of pain, affecting 7 out of 10 people at least once a year.
• There are many types of headaches, and people experience them in different ways.
• Although headaches can be excruciatingly painful, they rarely indicate a serious or life-threatening medical condition.
• Severe, sudden headaches (in a person without a significant history of such headaches) warrant medical attention.
• Headache pain does not start in the brain, because the brain has no nerve endings. However, many of the structures and layers of cells surrounding the brain do have nerve endings and pain fibers. If these layers are inflamed, compressed, or otherwise stimulated, pain results.
• Headache pain can be difficult to diagnose and treat because the source of the pain is not always obvious.
• Tension-type headaches are the most common form of headache. They may be constant or occasional. Although tension headaches are usually not severely painful, they can be debilitating.
• Twenty-eight million Americans suffer from migraines, and 70 percent of migraine sufferers are women.
• Although it’s not often recognized, medication overuse headache is a common type of headache. Medication overuse headache is caused by overuse of the medications used to relieve headache pain.
• Methods of diagnosis for headache vary depending on the type and severity of pain. It can be difficult to verify a headache type or the exact cause of the pain.
• Headaches can be treated using both conventional and alternative remedies including over-the-counter and prescription medications, relaxation therapy. Hospitalization may sometimes be necessary.
• Medications for headache include drugs that help control the pain during the headache and those that help prevent headache from happening.
• Effective treatment does not necessarily depend on an exact diagnosis of headache type.

 

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Glossary: Headache

Acupuncture: An alternative therapy based on the insertion of thin needles into specific points of the body to prevent or treat certain health conditions.

 

Aneurysm: An abnormal thinning or balloon-like bulging of the wall of an artery. The bursting of an aneurysm in a brain artery or blood vessel causes a subarachnoid hemorrhage and may lead to stroke.

 

Biofeedback: A method by which a person learns to control bodily functions usually considered to be involuntary, including skin temperature, muscle contraction, heart rate, blood pressure and brain waves.

 

Brain tumor: An abnormal growth on or in the brain. Although not always cancerous, brain tumors are always serious because they create pressure on the brain and other structures as they grow.

 

Computed Axial Tomography (CT or CAT scan): A sophisticated imaging test that uses x-rays to create cross-sectional images.

 

Cervical trigeminal relay: A concept that explains how pain signals are transferred along the various nerves of the head and neck, and why pain that originates in one location may actually be “felt” in a different location.

 

Chronic daily headache: The name given to a syndrome characterized by frequent (generally daily) headaches of one type, including tension headache, post-traumatic headache, and rebound headache.

 

Chronic paroxysmal hemicrania: A rare form of severe headache similar to Cluster Headache, but occurring slightly more often in women. It responds to treatment very differently from cluster headache.

 

Cluster headache: A rare form of severe headache, occurring most often in men, characterized by sharp, penetrating pain that can disappear for months, then reoccur in daily series of excruciating pain punctuated by periods of relief.

 

Electroencephalography (EEG): A test in which a number of small electrodes are attached to the scalp and connected to an instrument that measures and records the electrical impulses produced by the brain.

 

Lumbar puncture: Also known also as a spinal tap, this test involves inserting a needle into the spinal canal to obtain a sample of cerebrospinal fluid.

 

Magnetic Resonance Imaging (MRI): A sophisticated imaging method that uses a strong magnetic field to produce a highly detailed images of soft tissues. Magnetic resonance images can demonstrate even slight differences between normal and abnormal tissues.

 

Meninges: The three layers of tissues that cover and protect the brain and spinal cord.

 

Meningitis: An infection of the meninges caused by bacteria or a virus. Bacterial meningitis is potentially fatal, while viral meningitis is generally less serious.

 

Migraine: A severe headache, lasting from a few hours to a few days, which may be accompanied by disturbances of vision, nausea, vomiting, and neurological symptoms.

 

Placebo effect: The apparent treatment effect of a chemically inert substance given in place of a drug; the effect is generally thought to be caused by the recipient’s belief that he/she is receiving the drug and that it will have some effect.

 

Post-traumatic headache: The name given to a chronic headache condition caused by injury to the head or neck.

 

Rebound headache: A type of headache caused by withdrawal from headache pain relievers.

 

Sinusitis: Inflammation of the membrane lining of the facial sinuses, the air-filled cavities in the bones surrounding the nose.

 

Soft tissue: Tissues of the body other than bone, including muscles, ligaments, tendons, and nerve cells.

 

Stroke: Massive cell damage or death caused by the sudden interruption of blood flow to a part of the brain.

 

Subarachnoid hemorrhage: Bleeding caused by a ruptured blood vessel that leaks into the subarachnoid space between the brain and the skull. This space between the web-like arachnoid membrane and the surface of the brain is filled with cerebrospinal fluid. It acts as a cushion to protect the brain from blows.

 

Temporal arteritis: An inflammation of the arteries of the brain and head which causes headaches and changes in vision; occurs most often in those over 50 years old.

 

Tension headache: The most common type of headache; it is most often described as feeling like a tight band encircling the head.

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Sources Of Information For Headache

American Headache Society Committee for Headache Education (ACHE)

19 Mantua Road

Mt. Royal, NJ 08061

achehq@talley.com
http://www.achenet.org

Tel: 1-856-423-0043 or 1-856-423-0043

Fax: 1-856-423-0082
American Pain Foundation
201 North Charles Street
Suite 710
Baltimore, MD   21201-4111
info@painfoundation.org
http://www.painfoundation.org
Tel: 888-615-7246

Fax: 410-385-1832
Migraine Awareness Group: A National Understanding For Migraineurs (MAGNUM)

Tel: (703) 349-1929

http://www.migraines.org

Migraine Research Foundation
300 East 75th Street
Suite 3K
New York, NY   10021
contactmrf@migraineresearchfoundation.org
http://www.migraineresearchfoundation.org
Tel: 212-249-5402

Fax: 212-249-5405
National Institute of Neurological Disorders and Stroke (NINDS), NIH, HHS

Tel: (800) 352-9424

http://www.ninds.nih.gov

 

National Headache Foundation
820 N. Orleans
Suite 217
Chicago, IL   60610-3132
info@headaches.org
http://www.headaches.org
Tel: 1-312-274-2650 or 1-888-NHF-5552 (643-5552)
Fax: 312-640-9049

 

National Menstrual Migraine Coalition

http://www.headachesinwomen.org

 

References

Epocrates. Drug Database. “Aspirin – contradictions/cautions.” Available at https://online.epocrates.com/u/103144/aspirin/Contraindications+Cautions

International Headache Society. IHS Classification ICHD-II. Available at http://ihs-classification.org/en/

Jeffrey, Susan. (Oct 16, 2010). “Botox Approved for Headache Prophylaxis in Chronic Migraine.” Retrieved March 21, 2011 from http://www.medscape.com/viewarticle/730682

National Headache Society. (2011). Clinical Update: Caffeine and Headache. Available at http://www.headaches.org/educational_modules/caffeine_module/executive.htm

National Institute of Neurological Disorders and Stroke. “Headache: Hope through Research.” Last update Feb 18, 2011. Available at http://www.ninds.nih.gov/disorders/headache/detail_headache.htm#156653138

Robbins, LR. (1999, August). “Cluster Headache – Preventive Medications.” Available at http://www.headachedrugs.com/archives/preventivemeds.html

Silberstein, SD. (2001). “Preventative Treatment: Anticonvulsants.” Available at http://www.medscape.com/viewarticle/429680_12

Singh, MK, Campbell, GH, Lutsep, HL, & Gautam, S. (2009, August 21). “Trigeminal Neuralgia: Treatment and Medication.” Available at http://emedicine.medscape.com/article/1145144-treatment

 

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