Headaches

Definition
Headache is the term used to describe any pain that occurs in the head area, including the scalp and facial structures. Because there are no nerve fibers in the bones of the skull or in the brain tissue itself, the nerves typically responsible for headaches are those in the scalp, face, mouth and throat, as well as in the muscles and blood vessels of the head.
Headaches are classified as primary or secondary. Primary headaches have no underlying causes. Most chronic headaches -- including tension-type, migraine and cluster headaches -- fall under this category. Secondary headaches, which do have an underlying cause, can be related to various conditions.


Diagnosis
Nearly everyone experiences headaches at some point. Although headaches can certainly be bothersome, most are not serious. To diagnose a headache disorder, the doctor will ask questions about your medical history and do a physical exam. You may need additional tests to rule out any serious causes.
If you have any of the following symptoms, some of which may indicate an emergency situation, it's important to seek medical attention.

a sudden headache
the worst headache you've ever had
a headache that begins during exertion, such as exercise or sex
a headache associated with fever, stiff neck, rash or other neurological symptoms
headaches that become progressively more severe
a significant change in a previous headache pattern
headaches that begin after age 50
new onset of headaches if you have a history of cancer or HIV (the virus that causes AIDS)
headaches that don't respond to treatment
In some cases, computed tomography (CT scan -- a computer-generated, cross-sectional picture of internal body parts) or magnetic resonance imaging (MRI, an imaging technique based on computer analysis of the body's response to a magnetic field) may be recommended. A lumbar puncture (placing a needle into the spinal cord to collect samples of spinal fluid) may be done if there are symptoms of brain irritation, such as fever, stiff neck or lethargy.


Primary headache disorders

Migraine headache
Causes/associated factors
Researchers believe that genetic factors play a role in predisposing certain people to developing migraines, which explains why migraines often run in families. Migraines tend to be more common in women, especially between ages 25 and 45, but they can even occur in children. Someone in nearly one of every four households in the United States is affected by this common type of headache.

Most migraines fall into two categories: those with auras (previously known as classic migraines) and, more commonly, those without auras (previously known as common migraines). An aura is a sensation that occurs before the headache starts, such as seeing flashing lights or developing a temporary blind spot. Certain symptoms may develop up to two days before either type of migraine begins, including food cravings, feelings of euphoria or depression, periods of hyperactivity, bloating or excessive yawning.

Migraines can have many triggers that vary from one person to the next, and even episode to episode. Typical triggers include bright light, strong odors, loud noises, hormonal changes, lack of sleep or change in sleeping patterns, missed meals, stress and changes in the weather. Migraines triggered by changes in barometric pressure are often misdiagnosed as sinus headaches. Hormonal changes trigger the menstrual migraines experienced by some women. One person may have several triggers.

The role of diet and migraines is not well supported by research, but certain people may be sensitive to particular foods, such as nitrates and nitrites (found in processed lunch meats and hot dogs), monosodium glutamate (often found in Chinese food), caffeine and phenylethylamines (found in aged cheeses, chocolates, certain nuts, beans, beer, red and blush wines).

Signs/symptoms
Migraine pain can be moderate to intense. It's often described as throbbing, and can occur on one or both sides of the head. Migraines typically last four to 72 hours. They're often associated with nausea, vomiting, and sensitivity to light or sound. Physical exertion often intensifies migraine symptoms.

Treatment
Various treatments are available for migraines. When developing a treatment plan, the doctor will consider your general health, the frequency and severity of your migraines, as well as any other contributing factors. Learning all you can about migraines and their treatment can help make your treatment more successful.

Acute treatment
When a migraine strikes, it may be comforting to lie down in a dark, quiet room and apply heat or cold to your head. A variety of medications taken as soon as the migraine begins may help stop the headache. For mild migraines, your doctor may recommend over-the-counter pain relievers such as nonsteroidal anti-inflammatory medications (NSAIDs, such as ibuprofen or naproxen) or combination analgesics containing caffeine.

If these medications don't help, your doctor may prescribe triptans. Sumatriptan (brand name Imitrex) may be taken orally, by injection or through a nasal spray. Several newer triptans are now available as well, all taken orally. These include almotriptan (Axert), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt) and zolmitriptan (Zomig). Triptans can cause constriction of the coronary arteries and should not be prescribed for anyone who has has certian medical conditions, such as a history of coronary artery disease or uncontrolled high blood pressure.

Ergot alkaloids are another class of medications used to treat migraines in people who can't take triptans. These include dihydroergotamine (D.H.E. 45 or Migranal, for example), ergotamine (Ergomar, for example) and ergotamine with caffeine (Cafergot, for example). Ergot alkaloids may be taken under the tongue, by mouth, or as a nasal spray or suppository. A note of caution: Overuse of ergot alkaloids or triptans can actually lead to more headaches, and like triptans, several conditions may restrict ergot alkaloid use.

Isometheptene (a vasoconstrictor, which constricts blood vessels) or isometheptene combination agents (Midrin, for example) and some prescription NSAIDs, such as diclofenac (Voltaren, for example), can also be used to treat mild to moderate headaches. Combinations of a barbituate (such as butalbital) are usually limited and need to be carefully monitored due to potential overuse and withdrawal concerns.

For severe migraine attacks, an intravenous or injected form of dihydroergotamine (D.H.E 45, for example) may be given in an emergency room setting. An opioid narcotic such as meperidine (Demerol) may be another treatment choice in the hospital. These drugs may be taken with an antinausea medication if nausea and vomiting are present.

Preventive treatment
Preventive therapy to decrease the frequency and severity of migraine headaches, as well as make the acute medications more effective, may be recommended if you have migraines more than twice a week or don't respond to acute medications. Beta-blockers (such as atenolol or metoprolol), NSAIDs, antidepressants, calcium channel blockers (such as verapamil) and anticonvulsants are most often prescribed for preventive therapy, although some are not approved by the U.S. Food and Drug Administration (FDA) to treat migraines.

Preventive therapy often begins with a low dose of the medication, which is gradually increased. It often takes six to eight weeks to determine if a particular dosage is effective. Preventive treatment is often recommended for at least six months, although the optimal length of therapy may be debated. In some cases, preventive treatment fails due to an ineffective dose of the medication, an inadequate length of time, or an overuse of acute migraine medications.

Discuss any side effects of migraine medications with your doctor. It's also important to take any migraine medications exactly as prescribed. Do not stop taking preventive medications without consulting your doctor.

Other types of treatment
Treatments such as biofeedback (a technique that trains a person to voluntarily control bodily functions, such as blood pressure), cognitive-behavioral therapy (psychotherapy to help deal with stress and headache triggers), hypnotherapy, meditation and relaxation therapy may also be offered to treat migraines. However, keep in mind that only biofeedback, cognitive-behavioral therapy and relaxation therapy have scientific evidence of effectiveness.

Complications
Status migrainosis is a rare condition in which a migraine lasts more than 72 hours despite treatment. A migrainous stroke is another rare complication characterized by symptoms of nervous system dysfunction that persist or become permanent. With a migrainous stroke, changes may be noted on brain scans.

Prevention
Prevention can play an important role in migraine treatment. For example, certain lifestyle changes may reduce the frequency and severity of your migraines, such as identifying and avoiding triggers, eating regular meals, maintaining good sleep habits, and exercising regularly. It's also a good idea to keep a headache diary that includes the date and time of each headache, how long it lasts, any other symptoms you experience, potential triggers, and the most effective treatments. Sharing this information with your doctor can help you identify patterns and develop the best treatment plan.


Tension-type headache
Causes/associated factors
Tension-type headaches are thought to be triggered by stress, eyestrain and poor posture. Tense muscles in the neck and shoulders may also lead to a tension headache. They're more common among females, and most often start in adolescence. The frequency of tension-type headaches tends to decrease with age.

Signs/symptoms
The pain of tension-type headaches is often described as a tight, band-like, steady pressure of mild to moderate intensity that occurs on both sides of the head. Occasional tension-type headaches last from minutes to days. Chronic tension-type headaches are present at least 15 days of the month, and may occur with migraines.

Treatment
Your doctor may recommend rest and over-the-counter pain relievers such as NSAIDs or analgesics. Triptans may also be an option. A note of caution: Using any analgesic medication more than two or three days a week may lead to more headaches, known as rebound headaches, as well as reduce the effectiveness of medications used for preventive therapy.

In some cases, preventive therapy to help decrease the frequency and severity of tension-type headaches may be recommended. Therapy may include tricyclic antidepressants such as amitriptyline (Elavil, for example) or the anticonvulsants valproate (Depakene) or divalproex (Depakote).

Prevention
Aerobic exercise and biofeedback may be recommended by your doctor to help prevent tension-type headaches.


Cluster headache
Causes/associated factors
Cluster headaches are a rare type of headache most common among men in their 20s to 50s. Genetic factors may be involved in their development. Cluster headaches are often misdiagnosed as sinus or dental problems or migraines. Sometimes they're mistaken for a serious neurological problem.

Cluster headaches occur in episodes or clusters (hence, their name). They may occur at exactly the same time of day, up to eight times in the same day. They may occur every day for weeks or months, and then not return for months or even years. Cluster headaches may also occur at certain times of the year. For example, about one-third of patients experience episodes within two weeks of the summer and winter solstices (about June 22 and December 22). Alcohol, nitrates and certain stages of sleep can trigger a headache during a cluster episode.

Signs/symptoms
The pain of a cluster headache is intense and steady. It often occurs behind one eye, although it may be present above the eye or in the temple area. The headache may also be accompanied by symptoms such as tearing, reddening of the eye, drooping or swelling of the eyelid, constriction of the pupil, nasal stuffiness, runny nose and facial sweating. These symptoms appear on the same side as the headache. Restlessness is also common during a cluster headache, typically lasting from 15 minutes to three hours.

Treatment
An injection of the medication sumatriptan is the most common way to stop a cluster headache. Ten to 15 minutes of oxygen therapy may also stop a cluster headache. Ergotamine given under the tongue may be another treatment option, but caution should be used if you're at risk for coronary artery disease due to the drug's constriction of the blood vessels.

Preventive treatment with ergot alkaloids or calcium channel blockers may be recommended during a cluster episode. Other choices may include lithium or steroids. Often, effective preventive therapy takes less than two or three months. During this time, the dosage of medication is eventually decreased and then stopped. If you smoke, avoiding smoking during a cluster episode may also reduce the headache pain.

Prevention
Avoid alcohol during a cluster episode -- it may trigger a headache.


Chronic daily headache
Chronic daily headache is a term typically used for a headache that's present more than 15 days a month for more than one month. These headaches may have characteristics of more than one type of headache and can often be difficult to treat. Associated symptoms may include fatigue, dizziness, sleeping problems or depression. The overuse of pain relievers may contribute to the development of chronic daily headaches.

Secondary headache disorders
Secondary headaches can occur because of an underlying medical condition, but often improve or resolve once the condition is treated. These headaches can also occur during withdrawal or as a side effect from substances such as medication, caffeine, tobacco and alcohol. For example, more than 1,000 medications list headaches as a possible side effect. Some medication headaches are harmless and resolve once your body adjusts to the medication. Others are more serious and may even require you to stop taking the medication after talking with your doctor.
A secondary headache may also result from a condition that may involve a possible medical emergency for which you need immediate medical attention, such as:

central nervous system infections, such as meningitis (inflammation of the membranes surrounding the brain or spinal cord) or encephalitis (inflammation of the brain)
bleeding within the brain, possibly associated with a head injury, rupture of abnormal blood vessels in the brain or other conditions, such as stroke
temporal arteritis (inflammation of the arteries near the temples)
acute angle-closure glaucoma (an eye disease in which the optic nerve is damaged, typically due to elevated fluid pressure inside the eye)
exposure to a toxic substance, such as a medication overdose or exposure to a poisonous gas (such as carbon monoxide) or chemical (such as methanol, lead or mercury), or ingestion of certain plants (such as eucalyptus, daffodils or morning glories)
Other conditions that may cause a secondary headache include:

inflammation of the cranial nerves (the nerves that stem from the brain)
sinusitis (inflammation of a passage or cavity)
an abrupt elevation in blood pressure
lupus (a chronic, unpredictable disease that causes the body to make antibodies that break down its own tissues)
Hashimoto's disease (an autoimmune disorder in which the body's immune system produces antibodies that attack the thyroid gland)
illnesses involving infection with HIV (the virus that causes AIDS)
inflammatory bowel disease (a chronic disorder in which the intestine becomes inflamed; inflammatory bowel disease often causes abdominal cramps and diarrhea)
viral infections such as the flu or mononucleosis)
Recurring headaches may result from conditions such as temporomandibular joint syndrome (TMJ, a group of musculoskeletal conditions that limit jaw movement and cause pain in the jaw joint and surrounding muscles), dental pain or neck problems. People who have brain tumors may also complain of headaches. Contrary to popular belief, however, these headaches are not usually severe.


Complications
It's possible to abuse headache medications and become addicted to narcotics or barbituates used to treat headaches. In addition, side effects from long-term use of NSAIDs or other pain relievers can be harmful. It's essential to follow your doctor's instructions for medication use and seek follow-up care on a regular basis to monitor the treatment's effectiveness.

Pregnancy-specific information
Headaches are common during early pregnancy, often due to muscle tension. Other possible causes may include fatigue, stress, eyestrain, sinus congestion or caffeine withdrawal. By midpregnancy, headaches tend to decrease. Even women who have frequent migraine headaches often find their headaches are less frequent and less severe during pregnancy.
If you develop headaches during pregnancy for the first time, conditions other than migraines need to be considered. Headaches after 20 weeks of pregnancy can be a symptom of preeclampsia, a serious complication of pregnancy. Other symptoms of preeclampsia may include excessive weight gain, shortness of breath, abdominal pain, nausea, vomiting, and swelling in the feet, ankles, hands and face. If you have any of these symptoms, contact your doctor immediately.

During pregnancy, treating migraines with medication is limited by the potential side effects. Ergot alkaloids are not safe for pregnant women, and many other drugs are not approved by the FDA for use during pregnancy. Other treatments such as behavior modification, biofeedback, hypnotherapy, relaxation therapy and meditation may be better options during pregnancy. Work with your doctor to develop a treatment plan that poses the least possible risk to the baby yet helps relieve your migraines.


Senior-specific information
Primary headache disorders are more common among younger people. Tension-type headaches don't usually begin after age 50, and, although migraines may persist among seniors, they tend to decrease in frequency and severity with age. If you develop a new headache after age 50, consult your doctor. He or she will weigh any other health concerns you have and any medications you take before prescribing a treatment plan for your headache.