Headaches

Headaches or cephalgia, which is pain in the head, is one of the most common neurological problems that are painful and debilitating. The pain can range anywhere from very mild to unbearable, and the frequency and severity of pain also differs. While some people may experience headaches just once or twice a year, others may suffer for more than 10-15 days every month. Some headaches may be accompanied by nausea, vomiting and other symptoms. The pain can also radiate from the head to the neck or from the neck, upper back and the eyes to the head.  Headaches are one of the leading causes of absence from school or work.

Types of Headaches

Headaches are classified by the National Headache Society, as primary and secondary.  Primary headaches are tension-type headaches, cluster headaches or migraine. Secondary headaches are caused by underlying disorders, such as by overuse of medication, giant cell arteritis, infection or increased intracranial pressure.

  • Primary Headaches

Primary headaches are recurrent in nature and the etiology of such headaches is not clear. The most common form of primary headaches is tension headaches, which affect about two-thirds of people at some point in their lives.

o   Tension headaches – are felt on both sides of the head as a dull and constant pain, and vary in intensity. They are best described as a “tight band” around the head and the pain may also radiate to the neck. It is described as slow onset pain that usually is exacerbated by noise, lights or any sort of stress.

o   Migraine or Neurovascular headaches – are usually felt on one side of the head and are seen more in women than men. They come with other symptoms like nausea, vomiting, light and/or sound sensitivity and cold hands.  Classic migraines are usually preceded by an “aura,” which may involve impaired speech, visual phenomena or numbness. These headaches may also occur during menstrual cycles.

o   Cluster headaches – are “groups” of headaches usually felt as a severe pain around or behind one eye. They usually occur at night and mostly affect men. These groups or clusters of headaches are seen to affect the same part of the head, occur daily at the same time, and continue for days or weeks, only to recur at the same time the next year. The pain which lasts anywhere between 20 minutes to 3 hours during each attack, is far more severe than pain associated with Migraines or Tension headaches.

  • Secondary Headaches

These headaches are caused due to an underlying condition, such as meningeal infections (bacterial, fungal, viral), malignant hypertension, intracranial hemorrhages or hematomas. Other pathologies are related to glaucoma, cataract, malignant tumors and several other diseases associated with headaches.

The Origin of Pain in Headaches

The trigeminal nerve is one of the 12 pairs of cranial nerves whose origin is at the base of the brain. This nerve sends all pain, temperature, vibration and touch information to the brain. The three branches from this nerve send the sensations from the blood vessels inside the brain and surrounding the brain.  A variety of triggers that affect the blood vessels and nerves both inside and surrounding the head cause pain signals to be sent through the trigeminal nerve, to the relay station in the brain and the thalamus that receives pain sensations from different parts of the body.

Scientists believe that migraine headaches originate within the brain itself. They are caused due to a combination of several neurotransmitters, nerve pathways and vasodilation (opening of the blood vessels) – all in the brain. When this happens, the Trigeminal nerve that supplies the sensory functions and some motor functions of the face, gets compressed and irritated, leading to pain in the head. A genetic link is also attributed to migraine headaches, with such people having a gene that makes them vulnerable to migraines.

Tension headaches are said to be caused due to chemical or neurotransmitter changes surrounding the brain, caused due to emotional reasons, including stress. Myofacial irritations may also cause tension headaches, and this irritation may be caused by activities such as jaw clenching and even a poor back or neck posture.

Secondary headaches are caused due to another health problem that causes the pain-sensitive nerve endings to get compressed, pressed, pushed or pulled.

Causes of Headaches

The different primary headaches such as migraine, tension and cluster headaches have different triggers.

Primary headaches – Triggers for Migraine:

  • Noise
  • Bright lights
  • Stress
  • Foods like chocolates, peanut butter, banana, citrus, pickled or fermented foods, etc.
  • Menstrual cycle
  • Activities of exertion
  • Mental health issues like depression

Primary headaches – Triggers for Tension headaches:

  • Stress
  • Depression
  • Anxiety
  • Intense work
  • Missed meals
  • Lack of sleep

Primary headaches – Triggers for cluster headaches:

  • Smoking
  • Alcohol
  • Previous head injury
  • Genetic

Secondary headaches are caused by:

  • Medication overuse
  • Fever
  • Infection
  • Stress or emotional problems
  • High blood pressure
  • Psychiatric disorders
  • Head injury
  • Trauma
  • Tumors
  • Nerve disorders
  • Stroke

Symptoms

All headaches don’t need medical attention. However, it is important to be aware that a seemingly simple headache may be signaling a more serious disorder in the body that needs emergent attention.

Symptoms that require immediate medical attention:

  • Sudden onset of severe headache with still neck
  • Sudden onset of headache with nausea, vomiting or fever, in cases where there is no other existing illness
  • Acute headache with vision loss, double vision, weakness, confusion or loss of consciousness
  • Headaches that worsen with each passing day
  • Recurring headaches in children or adults
  • Head injury and headaches
  • Headaches with weakness or loss of sensation in any part of the body. This could indicate a stroke
  • Headaches with convulsions
  • Headaches with shortness of breath
  • Sudden headaches in people who have no history of headaches, especially if they are mature individuals around 50-years of age.
  • New headaches in people with HIV/AIDS history

Diagnosis

Patients with headaches are advised to maintain a headache journal, to help the doctor administer appropriate treatment. The journal should have information like the time of occurrence, duration, intensity, any known triggers, medicines used, how the patient slept the previous night, details of stress, weather influences, daily activity, food and drinks consumed, and anything else that can help the doctor diagnose the problem. Women should also include details of their menstrual cycles, as some headaches have their onset during menstruation. The doctor will also want to know if there is any family history of headaches.

Once a thorough medical and headache history has been done, the doctor will then decide on the next step. There may or may not be need for further tests.

Tests Performed

  • Neurological exam
  • Lab screening
  • Blood tests and urinalysis to can help diagnose infection of the spinal cord or brain and any damaged blood vessels
  • Cerebrospinal fluid analysis is done to detect any conditions that affect the brain or spine. Everything from infections to brain hemorrhages can be detected
  • Diagnostic imaging: CT scan and MRI can detect any problems in the bones and blood vessels
  • Neuroimaging is used to find out what is happening in the brain during a headache attack
  • EEG or electroencephalogram is done to measure brain wave activity, which reveals information about head injuries, brain tumors, inflammation and seizures, all of which may lead to headaches.

Treatment of Headaches

The treatment for primary headaches is classified as “preventive” or “abortive.”

Preventive therapy

As the name suggests, preventive therapy is aimed at preventing the headaches, or at least reducing the severity of the pain and frequency. However, because acute headaches are usually not prevented by the medications used for preventive therapy, this form of treatment is used in combination with abortive therapies.

Medications used in preventive therapy:

  • Antidepressants
  • Antihistamines
  • Cardiovascular drugs, such as calcium channel blockers and beta blockers.
  • Antiseizure medications

Abortive therapy

Abortive treatment involves stopping the pain as soon as it starts.  This does provide pain relief in headaches, but the medications used are not effective in decreasing the intensity or frequency of the headaches, and they also do not prevent the attacks.  Over-the-counter medicines do not work for aborting the headaches.

The efficacy of the medications used varies between people and the type of headaches. If the patient’s headaches are caused due to “overuse of medication,” then it is possible that this treatment will not only NOT work, but also have the opposite effect, aggravating the headache.

Medications used in abortive therapy:

  • Non-steroidal anti-inflammatory medication (NSAIDs)
  • Opiates
  • Anti-emetics
  • Triptans
  • Butalbital in combination with acetaminophen or aspirin
  • Ergots
  • Oxygen, which is most commonly used for cluster headaches that are acute

Injections administered for headaches:

  • Botox injections – have been found to be very effective for migraines. They not only help with the intensity of pain but many patients have experience a reduction in frequency of migraine headaches
  • Occipital Nerve Stimulation
  • Cervical Epidural Steroid injections
  • Occipital Nerve Blocks
  • Cervical Facet injections
  • Sphenopalatine Nerve Blocks
  • Supratrochlear Nerve Blocks

Conservative Treatments

  • For Migraine

Migraine is one of the most common headaches that people suffer from.  Treatment for migraine is aimed at relieving the symptoms and preventing further attacks.

o   Resting with eyes closed in a quiet and dark room

o   Placing an ice pack or cool cloth on the forehead

o   Drinking plenty of fluid, especially if there is vomiting

o   Caffeine consumed in small quantities may help some people when the migraine attack has just begun

  • For Tension-type and Clusters

o   Relaxation training

o   Biofeedback

o   Meditation

o   Breathing techniques

o   Cognitive-Behavioral therapy (CBT) for stress reduction

o   Hot shower or heat pads applied to the neck and back

o   Massage

o   Physical therapy

o   Gentle neck exercises

  • For Clusters

o   Oxygen therapy is administered where pure oxygen is breathed using an oxygen mask to reduce blood flow

Care for Headaches

Most of the treatments are interlinked with each other. Rest, good diet and exercise still stand the test of time for all types of headaches.  Group therapies, prayer and nutrition counseling along with vitamin supplements will improve the overall health and mood, leading to reduction in headaches. Relax whenever possible and try to get a good night’s sleep, as this keeps stress and unwanted emotions at bay. Look for triggers and avoid them.  Following a disciplined lifestyle helps cope with the headaches better.