Headache : More Information
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Understanding Headache

  What You Should Know About Headache

     During the past year, nearly 90% of men and 95% of women have had
     at least one headache.

     * Most people with a headache use nonprescription pain relievers to
       treat their symptoms.
     * Store shelves hold a remarkable array of pain relievers, so you
       need more facts than ever to select one that best meets your
       needs.
     * In light of the growing trend towards self-care, you have more
       responsibility than ever in safeguarding your and your family's
       health and well-being.
     * There are two main types of headache: primary and secondary
         1. Primary headaches include tension-type, migraine, and cluster
            headaches and are not caused by other underlying medical
            conditions. More than 90% of headaches are primary.
         2. Secondary headaches result from other medical conditions,
            such as infection or increased pressure in the skull due to a
            tumor. These account for fewer than 10% of all headaches.
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  How Headaches Differ

    Tension-type headaches

     Tension type headaches are the most common, affecting upwards of
     75% of all headache sufferers.

     * As many as 90% of adults have had tension-type headache.
     * Tension-type headaches are typically a steady ache rather than a
       throbbing one and affect both sides of the head.
     * Some people get tension-type (and migraine) headaches in response
       to stressful events or a hectic day.
     * Tension-type headaches may also be chronic, occurring frequently
       or even every day.
     * Psychologic factors have been overemphasized as causes of
       headaches.

    Migraine Headaches

     Migraine headaches are less common than tension-type headaches.
     Nevertheless, migraines afflict 25 to 30 million people in the
     United States alone.

     * As many as 6% of all men and up to 18% of all women (about 12% of
       the population as a whole) experience a migraine headache at some
       time.
     * Roughly three out of four migraine sufferers are female.
     * Among the most distinguishing features is the potential disability
       accompanying the headache pain of a migraine.
     * Migraines are felt on one side of the head by about 60% of
       migraine sufferers, and the pain is typically throbbing in nature.
     * Nausea, with or without vomiting, as well as sensitivity to light
       and sound often accompany migraines.
     * An aura --a group of telltale neurologic symptoms--sometimes
       occurs before the head pain begins. Typically, an aura involves a
       disturbance in vision that may consist of brightly colored or
       blinking lights in a pattern that moves across the field of
       vision.
     * About one in five migraine sufferers experiences an aura.
     * Usually, migraine attacks are occasional, or sometimes as often as
       once or twice a week, but not daily.

    Cluster Headaches

     Cluster headaches are relatively rare, affecting about 1% of the
     population. They are distinct from migraine and tension-type
     headaches.

     * Most cluster headache sufferers are male-about 85%.
     * Cluster headaches come in groups or clusters lasting weeks or
       month.
     * The pain is extremely severe but the attack is brief, lasting no
       more than a hour or two
     * The pain centers around one eye, and this eye may be inflamed and
       watery. There may also be nasal congestion on the affected side of
       the face.
     * These "alarm clock" headaches may strike in the middle of the
       night, and often occur at about the same time each day during the
       course of a cluster.
     * A history of heavy smoking and drinking is common, and alcohol
       often triggers attacks.

    Rebound Headache

     Rebound headache may occur among people with tension-type headaches
     as well as in those with migraines.

     * It appears to be the result of taking prescription or
       nonprescription pain relievers daily or almost every day, contrary
       to directions on the package label.

  Headache Triggers

     No discussion of headache is complete without mention of headache
     triggers.

     * Stress may be a trigger, but certain foods, odors, menstrual
       periods, and changes in weather are among many factors that may
       also trigger headache.
     * Emotional factors such as depression, anxiety, frustration,
       letdown, and even pleasant excitement may be associated with
       developing a headache.
     * Keeping a headache diary will help you determine whether factors
       such as food, change in weather, and/or mood have any relationship
       to your headache pattern.

Some Questions:

What Causes Headache?

  Q. How common are headaches?

     While almost everybody has occasional headaches, the best estimates
     indicate that between 40 and 50 million Americans suffer from
     chronic or repeated headache. Headache may be the most common
     reason for missing work or school in this country, and many more
     sufferers drag themselves to work to endure a day of decreased
     productivity.

  Q. Can headaches be a symptom of some serious disease?

     Headache can occasionally be caused by bleeding, tumor, or
     infection inside the skull, or else by diseases involving teeth,
     eyes, or sinuses. Flu or any sickness that causes fever can also
     cause headache. Such headache is known as secondary headache
     because it is due to--or secondary to--other problems. That is, the
     headache is only a symptom of some other disorder.

     The vast majority of the patients who visit physicians each year for ]
     headache, however, suffer from what is known as primary headache,
     including migraine, "tension-type headache," and cluster headache.
     For these individuals, the headache itself is the primary problem and
     not just a symptom of some other disease.

     Chronic headache is serious because it can interfere with the
     quality of daily life and reduce human productivity. It is a valid
     biological disorder, as real as diabetes, arthritis, or heart
     disease, and deserves the careful attention of the medical
     profession. Fortunately, research breakthroughs in the last several
     years have helped physicians understand much better what actually
     happens in the body during a headache attack. This knowledge has
     led to new and highly effective treatments that make control
     possible for most headache sufferers.

     A few headache types should be cause for alarm and reason enough
     for you to seek prompt medical attention. If you have the sudden
     onset of a headache that is very severe and different from any
     other headache you've had in the past, or if a headache seems to be
     steadily worsening instead of getting better with the passage of
     time, you should see your doctor right away. If you have a headache
     with fever and stiff neck, you should seek immediate medical
     attention since this could mean meningitis or other serious
     infection. Headache that lasts for more than a week following a
     head injury should also be checked.

     If you have headache accompanied by any neurological symptoms such
     as disturbed vision or speech, numbness or weakness in one part of
     the body, blackouts, or difficulty thinking and remembering, this
     must be investigated.

     None of these things is a sure sign of life-threatening illness,
     but you'll feel relieved having them checked out. If you do have
     something seriously wrong, you're more likely to have a good
     outcome if you get early treatment.

  Q. If tests and examinations don't show any underlying disease, what is
  causing the headaches?

     Considerable medical evidence suggests that migraine,
     "tension-type," and cluster headache are caused by an electrical
     and chemical instability of certain key brain centers that regulate
     blood vessels around the head and the neck, as well as the flow of
     pain messages into the brain. This instability, similar to that
     which causes seizure disorders, seems to be inherited and appears
     to involve chemical messengers known as neurotransmitters. The
     neurotransmitter serotonin, in particular, plays a key role. Like
     seizure disorders, these headaches can be treated by using drugs
     that stabilize brain chemistry.

  Q. What kinds of headache can this instability in the brain cause?

     Brain instability may actually cause several different kinds of
     headaches. In the past, primary headache thought to be due to
     painful swelling of the blood vessels of the head has been called
     migraine  or vascular headache. Other attacks that were thought to
     involve tightness and spasm of muscles around the head, neck and
     jaw have been called "tension-type" or muscular headache.

     Although the exact mechanism of these headaches hasn't been
     completely worked out, recent research has shown that many
     headaches may involve a mixture of painfully inflamed blood vessels
     and tight, aching muscles as well as other profound body changes.
     Most headache specialists now believe that the majority of headache
     attacks originate within the brain itself. Since the brain is the
     body's "control center," it's not hard for the attack to then
     spread to involve other structures. Cluster headache is a
     relatively rare but very distinctive type of headache that mainly
     affects males.

     Physicians have often noticed that many people who begin with
     occasional attacks of typical migraine eventually go on to
     experience milder but more frequent headaches that occur daily.
     This condition, which in some cases appears to be a natural
     progression of the disorder, is now called transformed or
     "progressed" migraine and probably accounts for many headaches that
     were previously called "chronic tension-type headaches." If overuse
     of painkiller medications is involved, then the term "rebound
     headache" may be used.

     Although cluster headache appears to be distinct, it's difficult to
     draw a dividing line between migraine and "tension-type" headache.
     Some headache experts think they may represent different ends of a
     spectrum of primary headache activity, as illustrated in this
     diagram.

  Q. What actually happens during a migraine attack?

     People have different experiences during a migraine attack, but
     there are some common themes. Early in a migraine attack some
     people may experience warning symptoms called the aura, from the
     Greek word for "wind." Just as a strong wind may warn of a coming
     storm, the aura may come just a few minutes before the "storm" of a
     severe migraine attack. The warning symptoms seem to involve both
     electrical and chemical changes in the brain as well as a reduction
     in the flow of blood to parts of the brain. This type of headache
     is called migraine with aura. Occasionally an aura is not followed
     by head pain. Such a condition--the warning without the head
     pain--is known as a migraine equivalent attack.

     These changes can affect vision temporarily, causing flashing
     lights, zigzag lines, or just a vague awareness that something is
     wrong. Occasionally people may experience numbness or difficulty
     forming words or thoughts, which can be frightening. Most patients,
     however have no aura or warning at all; this is called migraine
     without aura. Even if there's no clear-cut warning, some people
     with migraine may notice irritability or mood swings just before
     the attack begins. Some migraine attacks may even begin just as a
     person wakes up in the morning.

     There may be nausea or vomiting with attacks. In addition to severe
     pulsating or throbbing pain, there is usually sensitivity to light
     and noise. Dizziness and lightheadedness are common. Sometimes the
     pain is located on just one side of the head. In fact, the word
     migraine comes from the Greek word "hemikrania," meaning "half the
     head."

     Recently the International Headache Society (IHS) published
     criteria for diagnosis of migraine that are now widely accepted and
     used by physicians all over the world. If your headaches have any
     two features from Group A below, plus any one feature from Group B,
     chances are you have migraine.

    Group A:

    1. Pain is one-sided
    2. Pain is throbbing
    3. Pain is bad enough to interfere with or prevent normal activity
    4. Pain is worsened by activity

    Group B:

    1. Nausea or vomiting comes with the pain
    2. Sensitivity to light and noise comes with the pain

  Q. How widespread is migraine headache?

     A recent large study showed that at least 6% of males and 18% of
     females suffer from migraine. Surveys have demonstrated that
     proneness or susceptibility to migraine is largely hereditary.
     Between 70% and 90% of migraine sufferers have other family members
     who are or have been affected. This may take a little detective
     work to uncover, since many of these migraine attacks may have been
     wrongly blamed on "sinuses," "stress," or other factors. In fact,
     it is estimated that over half of people who have migraine have
     never been diagnosed.

     Until puberty, migraine is about equally common among boys and
     girls. After puberty, migraine becomes 2 to 3 times more common
     among females. This is thought to be due to the effects of the
     female sex hormone estrogen on brain chemistry.

  Q. How does estrogen affect migraine?

     The mechanism is not completely understood, but fluctuations in
     estrogen levels seem to bring on attacks. Females are likely to
     have changes in their headache patterns during pregnancy,
     menopause, or when they use birth control pills. Many women have
     their most severe attacks during or just before their menstrual
     period. The use of estrogen replacement therapy at menopause may
     also have an effect on migraine.
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Rebound Headaches

  Q. I've heard that taking too much pain medicine can make headache worse. Is
  that true?

     Some people complain to their doctors that their head hurts all the
     time. Sometimes people with this complaint may have had daily
     headache for months or even years. In the past, the problem has
     often been blamed on "tension" or "stress." Clinical research in
     the past decade suggests, though, that many such people who may
     have started out with migraine years earlier are now having daily
     headache due to overuse of medication. This condition is now called
     "drug rebound headache."

     The offending drugs include both prescription and over-the-counter
     painkillers, sedative/tranquilizer drugs, and ergotamine tartrate.
     Fortunately, the headache often improves dramatically after these
     medications are stopped. Daily medications used to prevent headache
     then become more effective.

  Q. How is drug rebound headache diagnosed?

     The features of drug rebound headaches are as follows:

     * Daily or almost-daily headache
     * Daily or almost-daily use of relief medicines
     * Frequent depression and sleep disturbances
     * Occasional occurrence of more severe migraine-type attacks
     * Frequent family history of headache

  Q. What really causes drug rebound headache? How can painkillers make pain
  worse?

     One theory is that the daily or almost-daily use of painkillers and
     other relief medications over a period of time interferes with the
     body's own pain-fighting systems in the brain. Eventually, the
     person becomes more vulnerable to headache whenever the medicine
     starts to wear off.

  Q. How is drug rebound headache treated?

     Headache specialists agree that the first step in dealing with drug
     rebound headache is to stop the daily or almost-daily use of
     painkillers and/or ergotamine tartrate. Unfortunately, there's a
     natural reluctance to give up medications that may have helped in
     the past, even if they haven't been helping recently. Attempts to
     give up the medications gradually usually result in headaches
     "rebounding" or flaring up, so that the effort is soon abandoned.

     Milder over-the-counter painkillers can usually be withdrawn
     abruptly fairly comfortably with the help of self-administered or
     office injections of specific antimigraine medications, nerve
     blocks (similar to those given by the dentists before doing a
     filling), and/or nonsteroidal anti-inflammatory drugs.

     Abrupt withdrawal from painkillers containing barbiturates, or from
     medicines containing codeine, other narcotics, or ergotamine
     tartrate generally requires a brief stay in the hospital. Some
     sedative-tranquilizers may have to be withdrawn gradually over a
     somewhat longer period to reduce the risk of agitation or even
     seizures. People who go into a hospital receive specific
     antimigraine medications by way of an IV drip for several days to
     suppress rebound headache long enough to allow the body's own
     pain-fighting mechanisms to recover. Once the relief medications
     are withdrawn, daily preventive drugs often become much more
     effective, even if they have failed in the past.
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Cluster Headache

  Q. How are cluster headaches different from migraine?

     Unlike migraine, which mainly affects women, cluster headache is a
     male problem by a ratio of about six to one. Many men who suffer
     from cluster headaches smoke heavily; some are heavy drinkers.
     Cluster headaches come in groups or clusters lasting weeks or
     months; then the victim may go for months or years without pain.
     The pain is extremely severe, but fortunately each attack is
     relatively short. Generally, attacks last no more than an hour or
     two, although this may seem like forever to the cluster headache
     sufferer. Along with the severe pain, which is usually centered
     around one eye, there are other characteristic symptoms. The
     affected eye may water or become red, and the nose may run; but,
     vomiting is rare. One interesting feature is that the headache may
     occur at about the same time each day. Attacks will often awaken
     the sufferer 1 to 2 hours after he falls asleep. Alcohol often
     triggers attacks.
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Headache After Injury

  Q. What kinds of injuries cause headaches?

     Headache is a common symptom following auto accidents or falls. In
     the case of auto accidents, being thrown or jerked around in the
     car may be enough to cause injury, whether or not there is loss of
     consciousness or a blow to the head. This is called an
     "acceleration-deceleration" type of injury. In about one third of
     head injury patients, or approximately one million people each
     year, headache will last more than two months after the injury.
     Along with the chronic headaches a number of other symptoms
     sometimes occur. The headache and accompanying symptoms make up
     what has been called the post-traumatic or post-concussion
     syndrome. There may be little or no correlation between the
     severity of the head injury and the severity of the headaches or
     other post-traumatic symptoms.

     In addition to headache, other symptoms commonly include faintness,
     poor memory, inability to concentrate, short attention span,
     anxiety, insomnia, and irritability. After head injury, some people
     become depressed and lose interest in their usual activities and
     pleasures. Less common symptoms include ringing in the ears,
     spinning sensations or vertigo, fatigue, intolerance of alcohol or
     medications, fainting, and sexual difficulties. Adults may not
     perform as well at work, or children may start to fail in school.

  Q. What causes all these symptoms? Are they psychological?

     The majority of these symptoms have a physical or neurological
     cause. The human brain contains billions of nerve cells. We now
     know that tiny breaks in this fantastically complex web of
     connections can occur even with relatively minor injuries. Although
     this type of injury doesn't show up on a brain scan, it can be seen
     under a microscope.

     Sophisticated computer-averaging techniques have made it possible
     to measure tiny electrical signals from the scalp overlying the
     brain. The speed with which these signals travel through the brain
     is considerably slowed in up to half of those who have suffered a
     concussion. This is probably why head-injured persons sometimes
     can't process information at a normal rate and have slowed reaction
     times. Disturbances of inner-ear function can be proven, and in
     some cases there is evidence of decreased blood circulation to the
     brain for months or years following head injury.

  Q. What is headache due to injury like? Can anything be done about it?

     Post-concussion headache is generally constant, dull, and aching
     rather than episodic. Head injury may occasionally trigger typical
     migraine attacks, especially where there is a positive family
     history. Just as with any other chronic headache disorder,
     management of post-concussion headache consists of avoiding the
     overuse of potentially habit-forming medications.

     People who have had brain injuries and who suffer from pain as a
     consequence often are very upset about what has happened to them.
     Many benefit from psychological counseling. Psychological testing
     can be helpful to determine the degree of memory and concentration
     difficulty, and in making decisions about work and rehabilitation.
     Finally, the injured person's family and employer may need to be
     educated so that they can be helpful rather than adding to the
     problem.

  Q. What's the outlook for headaches due to injury?

     With patient, supportive care, at least 85% of those who suffer
     with chronic post-traumatic headache and other symptoms of
     post-traumatic syndrome will recover completely. However, recovery
     may take many months or even several years.
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Other Types of Headache

  Q. Are the sinuses a common cause of headache?

     Although infection of the sinuses can certainly cause headache,
     this is not a common cause for chronic headache. Usually it's not
     too difficult to diagnose this type of headache as there is
     generally low-grade fever, a thick, colored drainage from the nose
     or in the back of the throat, and tenderness over the sinus area
     around the eyes and cheeks. Antibiotics and decongestants typically
     relieve headache due to sinus infection within a few days.

     Q. What is "TMJ Syndrome"? Is this a common cause for chronic
     headache?

     The temporo-mandibular joint, or "TMJ," is the hinge-like joint
     just in front of the ear canal where the lower jaw attaches to the
     skull. When this joint is diseased, there may be pain and
     discomfort chewing. Like pain arising from other structures in and
     around the head, such as the eyes and ears, this pain can sometimes
     spread and be experienced as headache. Usually the headache is on
     just one side and continuous rather than coming and going. The clue
     to the correct diagnosis is tenderness and pain centered over the
     temporo-mandibular joint itself or nearby chewing muscles, and
     worsening of the pain during chewing or yawning.

     Aging can cause some other symptoms of wear and tear on the joint
     such as popping or clicking when the mouth is widely opened.
     However, if there is no actual pain on joint movement, such as with
     chewing or yawning, then a disorder of the temporo-mandibular joint
     is not likely to be the cause of chronic headache. Some tense
     individuals clench their teeth unconsciously during the day or
     grind them together during sleep. While these fairly common habits
     may sometimes aggravate headache, they generally do not cause
     headaches by themselves. In any case, TMJ Syndrome is a much less
     frequent cause of chronic headache than, for example, migraine.
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OTCs and Occasional Headache

     Headaches can be managed with proper medication, diet, exercise,
     and lifestyle modification. When headaches occur occasionally (one
     time a week), over-the-counter medications, a "time out" for
     relaxation, or a short nap will likely provide pain relief. In
     fact, most people with occasional headaches will select a
     nonprescription "over-the-counter" (OTC) pain reliever from their
     pharmacy or supermarket shelves.

  Medication

     Available without prescription, OTC pain relievers contain
     powerful, effective ingredients. There are several different groups
     of OTC pain relievers including combination products:

     * Aspirin products
     * Acetaminophen products
     * NSAIDs such as ibuprofen and naproxen sodium products
     * Combination products such as those that contain OTC pain relievers
       and caffeine

     Each group has specific advantages and side effects. The most
     appropriate way to select a medication or combination of
     medications is to weigh the desired effect against potential side
     effects. Most OTC pain relievers are available in tablets, caplets
     and geltabs. While all forms of a medication are equally effective,
     some may be easier to swallow than others.

     Note: If you take medications for any other medical condition (such
     as high blood pressure, arthritis, diabetes, ulcer or even acne),
     be sure to check with your physician or pharmacist before taking an
     OTC pain reliever.

     Make certain that adding a pain reliever to the medicines you
     already take will not result in undesirable drug interactions.

  What You Need to Know About Combination Products

     Pain relief products with a combination of aspirin, acetaminophen,
     and caffeine have been shown to provide greater pain relief than
     single ingredient aspirin or acetaminophen products.
     In fact, to get the same relief found with a single dose of the
     aspirin-acetaminophen-caffeine combination you would have to
     increase the equivalent dose of aspirin or acetaminophen by almost
     40%. If you are sensitive to caffeine, however, you should check
     with your doctor.
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  Guidelines for Use of Nonprescription Pain Relievers

     Nonprescription pain relievers have been demonstrated to be safe
     when used as directed on the package. The following precautions,
     however, are important:

     * Know the active ingredients in each product. Be sure to read the
       entire label.
     * Do not exceed recommended dosage on the package.
     * Carefully consider how you use pain relievers and all medications;
       it is easy to escalate from appropriate use to overuse.
     * Check with your doctor before taking products that contain
       aspirin, ibuprofen, or naproxen sodium if:
          + You have a bleeding disorder or hemophilia
          + You have asthma
          + You have recently had surgery or dental surgery, or are about
            to have surgery
          + You are pregnant, especially during the last three months of
            pregnancy
          + You have ulcers, kidney or liver damage
          + You take any arthritis drugs or nonsteroidal
            anti-inflammatory medications such as ibuprofen, naproxen
            sodium, piroxicam, etc.
     * Check with your doctor before taking acetaminophen-containing
       products if you suffer from kidney or liver damage.
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  The Risk of OTC Overuse: Rebound Headache

     Rebound headache may result from taking prescription or
     nonprescription pain relievers daily or almost every day, contrary
     to directions on the package label.

     If prescription or nonprescription pain relievers are overused,
     headache may "rebound" as the last dose wears off, leading one to
     take more and more medication.

  Exercise

     Regular aerobic exercise, including brisk walking, swimming, and
     bicycling, helps many people handle stress and may help avoid
     headaches.

     * Exercise may help get rid of a headache. So if your headache is
       mild and is not the kind that requires medical attention, go ahead
       and exercise! You may be glad you did.
     * Migraine sufferers, too, remark that the frequency of their
       headaches decreases when they exercise regularly.

  Diet

     Some people with headaches find that certain foods, alcohol, and
     preservatives trigger headaches.

     * Keep a diary that lists what you eat and when your headaches
       occur. Symptoms can develop between 1 and 24 hours after eating.
     * A review of these notes will help you determine whether foods are
       likely headache triggers.
     * A generally healthful diet may help, too. Eating regularly
       scheduled meals three times a day is especially important. Most
       people find what works by experimentation.
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  Guidelines for Managing Your Headaches

    1. Know when to consult your doctor.
    2. Don't hesitate to ask your pharmacist about headache pain
       relievers.
    3. Choose an appropriate pain reliever. All OTC pain relievers can be
       effective. When selecting a pain reliever, you should consider any
       existing medical problems that could be adversely affected by any
       of the ingredients. Follow all package directions carefully.
    4. To reduce risk of rebound headache, do not take pain relievers
       daily and be sure to follow package directions when you do take
       them.
    5. Eat a healthful diet, and get enough exercise.