Headaches

The Facts

Headaches are extremely common – most people have a headache at some time in their life. Most headaches disappear on their own (with a little time) or with the help of mild pain relievers. Although most headaches are mild and temporary annoyances, some people have headaches that are so severe they need to consult a doctor for pain relief.

Children can also have headaches, some well before they reach the age of 10. Research shows that before puberty, headaches are more common in boys, but that trend is reversed after puberty. Adult women experience more headaches than adult men, and they’re often linked to a woman’s menstrual cycle. With advancing age, both women and men tend to have fewer, less severe headaches.

Headaches come in various forms: tension, migraine, sinus, and cluster headaches. In a small number of cases, headaches may signal a more serious condition that requires immediate medical attention.

Causes

Headaches can be triggered by a variety of factors. The most common cause of headaches is prolonged tension or stress. These are called tension headaches or muscle-contraction headaches. Virtually everyone suffers from this at some time. Muscles in your scalp, neck, and face tighten and contract, causing spasms and pain. Psychological factors such as anxiety, fatigue (e.g., eyestrain), and stress (e.g., long periods of concentration) as well as mechanical factors such as neck strain (e.g., working on a computer for prolonged periods) are often the culprits behind a typical tension headache.

Migraines are generally more severe and can be debilitating. The cause of migraine is not known but many trigger factors are recognized. These include hormonal changes (during a woman’s menstrual cycle), certain foods (e.g., chocolate, aged cheeses), beverages (e.g., red wine), strong odours, lack of sleep, and even stress. It is not uncommon to experience mixed tension-migraine headaches.

Sinus headaches are less common than people think. Many people with sinus headaches actually have migraine headaches. They can occur after a bout of upper respiratory infection, such as a cold. Along with the headache, people often have a runny or stuffy nose. Sinus headaches are caused when bacteria invade and infect the nasal sinuses.

Cluster headaches are a relatively uncommon type of headache. They more often affect men, run in families, are strongly associated with cigarette smoking, and tend to occur in clusters over a few days, weeks, or months with long headache-free periods lasting from months to years. In some cases, they are triggered by alcohol. The cause is not known.

So-called “ice pick” or primary stabbing headaches are severe headaches that occur suddenly, causing a few seconds of intense pain at a small, localized spot. The exact cause of these headaches is unknown, but they are usually not due to a serious problem.

Symptoms and Complications

Tension headaches generally cause a constant pressure or a dull ache that affects the entire head. In most cases it begins slowly, with the ache usually focused above the eyes. There’s a feeling of tightness across the forehead or at the back of the neck. The ache can last for hours or days at a time, with mild-to-moderate pain that is not worsened by activity and that typically improves when the source of tension is removed.

Cluster headaches occur in “clusters” or groups, with pain lasting about 20 to 90 minutes at a time. The ache and pain is limited to one side of the head and can be extremely severe. They are often accompanied by other symptoms on the side of the headache such as redness and tearing of the eye, drooping eyelid, and nasal stuffiness and dripping.

Migraines range from mild to severe. They often occur as one-sided head pain but can sometimes affect both sides. The location, duration, and intensity of pain vary widely from person to person as well as from one episode to another. Migraine is usually a pulsating pain, often with other symptoms such as nausea, vomiting, visual disturbances, and hypersensitivity to light, noise, and smells. A migraine attack can last from hours to days, averaging 12 to 18 hours per episode. They’re often so severe and incapacitating that many migraine sufferers are unable to carry out normal daily activities.

Migraine headaches are divided into two categories: migraine with aura and migraine without aura. Some people experience a pre-headache stage known as an aura, which can last about 10 to 30 minutes. A typical aura includes visual disturbances such as blind spots, zigzag flashes, and light sparks. The aura normally clears as the headache starts, but there can be some overlap. Sometimes the aura will occur without a headache but more often no aura occurs before the headache.

Although headaches can be painful and debilitating, they are usually not due to dangerous conditions. However, headaches can occasionally be a sign of something more serious. Very severe high blood pressure (above 180/110 mm Hg), stroke, brain tumour, or an aneurysm (a dilated weakened blood vessel) in the brain may cause headaches. Meningitis (an infection of the brain’s lining) may also cause a headache. Warning signs are a sudden onset of headache accompanied by fever, stiff neck, and visual problems (double vision).

It’s critical that you seek emergency medical care if you experience a headache that:

• gets worse over days or weeks
• is accompanied by impaired neurological function (e.g., loss of balance, weakness, numbness, or speech disturbance) and double vision (could signal a stroke)
• is accompanied by persistent nausea and vomiting
• is accompanied by seizures, mental disturbances, and loss of consciousness
• is associated with a fever or stiff neck (could signal meningitis)
• is different than the usual pattern of headaches you have experienced
• strikes suddenly with great intensity
• wakes you from sleep or is worse when you lie down

Making the Diagnosis

If you tend to have headaches that are frequent and severe, your doctor will examine you for any serious, life-threatening conditions (e.g., stroke, meningitis) and start emergency care if needed. As well, if you regularly have headaches and experience a change in the pattern of your usual headaches, you should see your doctor.

Typically, a thorough medical history and physical examination is enough for a good diagnosis. Since tension headaches are very common, your doctor will ask questions about your current stress level and other personal factors (e.g., work) that may be triggering your headaches. Depending on the location, duration, and any accompanying symptoms, the type of headache can be determined.

In some cases, a brain scan called a CAT (computer assisted tomography) scan or MRI (magnetic resonance imaging) may be used to check for serious causes of headache.

Treatment and Prevention

Since tension headaches are caused by factors such as neck strain, stress, and anxiety, treatment involves eliminating the stressful situation, if possible. Taking an over-the-counter pain reliever such as acetaminophen* or ibuprofen, and finding ways to relax, rest, correct poor posture, and exercise can all help to relieve and prevent headache pain.

Cluster headaches respond poorly to over-the-counter medications. Oxygen therapy and prescription medications such as lithium, calcium channel blockers (used also to treat high blood pressure), steroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and some antimigraine medications, among others, can help in many cases. If you suspect that you have cluster headaches, you should check with your doctor.

Sinus headaches usually require antibiotics or other treatments to clear up the infection. Once the infection is gone, the headache will go away, too. Until the infection gets better, taking an over-the-counter pain reliever can help ease the pain.

Migraines can be treated with over-the-counter pain relievers, such as acetylsalicylic acid (ASA), acetaminophen, or ibuprofen, if the headaches are mild.

Stronger medications may need to be prescribed if the headaches are more severe. These can be divided into two groups:

1) Acute treatments:

• pain relievers containing codeine or meperidine
• NSAIDs
• ergot derivatives (e.g., ergotamine)
• serotonin agonists called “triptans” (e.g., sumatriptan, zolmitriptan)
• dopamine antagonists (e.g., metoclopramide, prochlorperazine)

2) Preventive treatments:

• antiseizure medications such as valproic acid, divalproex sodium, gabapentin, and topiramate
• blood pressure medications such as beta-blockers (e.g., propranolol or metoprolol), candesartan, lisinopril, and calcium channel blockers (e.g., flunarizine and verapamil)
• riboflavin (vitamin B2), coenzyme Q10, butterbur, or magnesium supplements
• serotonin blockers such as pizotifen
• tricyclic antidepressants such as amitriptyline and nortriptyline
• avoiding headache triggers

There is some evidence suggesting that chiropractic care, such as spinal manipulation, can help alleviate headaches originating from the neck.

---