Headache

Why Does it Hurt?

What hurts when you have a headache? The bones of the skull and tissues of the brain itself never hurt, because they lack pain-sensitive nerve fibers. Several areas of the head can hurt, including a network of nerves which extends over the scalp and certain nerves in the face, mouth, and throat. Also sensitive to pain, because they contain delicate nerve fibers, are the muscles of the head and blood vessels found along the surface and at the base of the brain. The ends of these pain-sensitive nerves can be stimulated by stress, muscular tension, dilated blood vessels, and other triggers of headache.

What Tests Are Used to Diagnose Headache?

Diagnosing a headache is like playing Twenty Questions. Experts agree that a detailed question-and-answer session with a patient can often produce enough information for a diagnosis. Many types of headaches have clear-cut symptoms which fall into an easily recognizable pattern.

Patients may be asked: How often do you have headaches? Where is the pain? How long do the headaches last? When did you first develop headaches? The patient's sleep habits and family and work situations may also be probed.

Most physicians will also obtain a full medical history from the patient, inquiring about past head trauma or surgery, eye strain, sinus problems, dental problems, difficulties with opening and closing of the jaw, and the use of medications. Many tests are available to help physicians diagnose the type of headache you experience.

Headaches are diagnosed as:

• Vascular

• Muscle contraction (tension)

• Traction

• Inflammatory

Vascular headaches - a group that includes the well-known migraine - are so named because they are thought to involve abnormal function of the brain's blood vessels. Muscle contraction headaches appear to involve the tightening or tensing of facial and neck muscles. Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection. Some people have more than one type of headache.

What Are Migraine Headaches?

The most common type of vascular headache is migraine. Migraine headaches are usually characterized by severe pain on one or both sides of the head, an upset stomach, and at times disturbed vision.

Symptoms of migraine.

Sensitivity to light is a standard symptom of both classic and common migraines.

Classic migraines are preceded by an “aura” 10 to 30 minutes before the headache. The person may see flashing lights or zigzag lines, or may temporarily lose vision. Other classic symptoms include speech difficulty, weakness of an arm or leg, tingling of the face or hands, and confusion.

The pain of a classic migraine headache may be described as intense, throbbing, or pounding and is felt in the forehead, temple, ear, jaw, or around the eye. Classic migraine starts on one side of the head but may eventually spread to the other side. An attack lasts 1 to 2 pain-wracked days.

Common migraine is not preceded by an aura. But some people experience a variety of vague symptoms beforehand, including mental fuzziness, mood changes, fatigue, and unusual retention of fluids. During the headache phase of a common migraine, a person may have diarrhea and increased urination, as well as nausea and vomiting. Common migraine pain can last 3 or 4 days.

Both classic and common migraine can strike as often as several times a week, or as rarely as once every few years. Both types can occur at any time.

Women and migraine.

The condition is more common in adult women. Both sexes may develop migraine in infancy, but most often the disorder begins between the ages of 5 and 35.

The relationship between female hormones and migraine is still unclear. Women may have "menstrual migraine" - headaches around the time of their menstrual period - which may disappear during pregnancy. Other women develop migraine for the first time when they are pregnant. Some are first affected after menopause.

Triggers of headache.

Although many sufferers have a family history of migraine, the exact hereditary nature of this condition is still unknown. People who get migraines are thought to have an inherited abnormality in the regulation of blood vessels.

These triggers include stress and other normal emotions, fatigue, glaring or flickering lights, changes in the weather, and certain foods. It may seem hard to believe that eating such seemingly harmless foods as yogurt, nuts, and lima beans can result in a painful migraine headache. However, some scientists believe that these foods and several others contain chemical substances which constrict arteries - the first step of the migraine process. Other scientists believe that foods cause headaches by setting off an allergic reaction in susceptible people.

While a food-triggered migraine usually occurs soon after eating, other triggers may not cause immediate pain. Scientists report that people can develop migraine not only during a period of stress but also afterwards when their vascular systems are still reacting. For example, migraines that wake people up in the middle of the night are believed to result from a delayed reaction to stress.

How is Migraine Headache Treated?

Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from the diet are the most common methods of preventing and controlling migraine and other vascular headaches.

Regular exercise, such as swimming or vigorous walking, can also reduce the frequency and severity of migraine headaches.

During a migraine headache, temporary relief can sometimes be obtained by applying cold packs to the head or by pressing on the bulging artery found in front of the ear on the painful side of the head.

Drug therapy.

Several drugs for the prevention of migraine have been developed in recent years, including drugs which mimic the action of serotonin in the brain. One of the most commonly used drugs for the relief of classic and common migraine symptoms is sumatriptan (Imitrex), which binds to serotonin receptors. For optimal benefit, the drug is taken during the early stages of an attack.

Biofeedback and relaxation training.

Drug therapy for migraine is often combined with biofeedback and relaxation training. Biofeedback refers to a technique that can give people better control over such body function indicators as blood pressure, heart rate, temperature, muscle tension, and brain waves.

In a type of biofeedback, the patient learns to control muscle tension in the face, neck, and shoulders. It may be combined with relaxation training, during which patients learn how to relax the mind and body.

The anti-migraine diet.

Scientists estimate that a small percentage of migraine sufferers will benefit from a treatment program focused solely on eliminating headache-provoking foods and beverages.

Other migraine patients may be helped by a diet to prevent low blood sugar. Low blood sugar, or hypoglycemia, can cause headache. This condition can occur after a period without food: overnight, for example, or when a meal is skipped. People who wake up in the morning with a headache may be reacting to the low blood sugar caused by the lack of food overnight.

Treatment for headaches caused by low blood sugar consists of scheduling smaller, more frequent meals for the patient. A special diet designed to stabilize the body's sugar-regulating system is sometimes recommended.

For the same reason, many specialists also recommend that migraine patients avoid oversleeping on weekends. Sleeping late can change the body's normal blood sugar level and lead to a headache.

Cluster headaches.

Cluster headaches are a rare form of headache notable for their extreme pain and their pattern of occurring in "clusters", usually at the same time(s) of the day for several weeks. A cluster headache usually begins suddenly with excruciating pain on one side of the head, often behind or around one eye. In some individuals, it may be preceded by a migraine-like "aura." The pain usually peaks over the next 5 to 10 minutes, and then continues at that intensity for up to an hour or two before going away.

People with cluster headaches describe the pain as piercing and unbearable. The nose and the eye on the affected side of the face may also get red, swollen, and runny, and some people will experience nausea, restlessness and agitation, or sensitivities to light, sound, or smell. Most affected individuals have one to three cluster headaches a day and two cluster periods a year, separated by periods of freedom from symptoms.

Cluster headaches generally begin between the ages of 20 and 50, although the syndrome can also start in childhood or late in life. Males are much more likely than females to develop cluster headaches. Alcohol (especially red wine) provokes attacks in more than half of those with cluster headaches, but has no effect once the cluster period ends. Cluster headaches are also strongly associated with cigarette smoking.

Scientists aren't sure what causes the disorder. The tendency of cluster headaches to occur during the same time(s) from day to day, and more often at night than during the daylight hours, suggests they could be caused by irregularities in the body’s circadian rhythms, which are controlled by the brain and a family of hormones that regulate the sleep-wake cycle.

What Are Muscle-Contraction Headaches?

Tension headache is named not only for the role of stress in triggering the pain, but also for the contraction of neck, face, and scalp muscles brought on by stressful events. Tension headache is a severe but temporary form of muscle-contraction headache. The pain is mild to moderate and feels like pressure is being applied to the head or neck. The headache usually disappears after the period of stress is over. Ninety percent of all headaches are classified as tension/muscle contraction headaches.

By contrast, chronic muscle-contraction headaches can last for weeks, months, and sometimes years. The pain of these headaches is often described as a tight band around the head or a feeling that the head and neck are in a cast. The pain is steady, and is usually felt on both sides of the head. Chronic muscle-contraction headaches can cause sore scalps - even combing one's hair can be painful.

In the past, many scientists believed that the primary cause of the pain of muscle-contraction headache was sustained muscle tension. However, a growing number of authorities now believe that a far more complex mechanism is responsible.

Occasionally, muscle-contraction headaches will be accompanied by nausea, vomiting, and blurred vision, but there is no preheadache syndrome as with migraine. Muscle-contraction headaches have not been linked to hormones or foods, as has migraine, nor is there a strong hereditary connection.

Emotional factors are not the only triggers of muscle-contraction headaches. Certain physical postures that tense head and neck muscles - such as holding one's chin down while reading - can lead to head and neck pain. So can prolonged writing under poor light, or holding a phone between the shoulder and ear, or even gum-chewing.

More serious problems that can cause muscle-contraction headaches include degenerative arthritis of the neck and temporomandibular joint dysfunction, or TMD. TMD is a disorder of the joint between the temporal bone (above the ear) and the mandible or lower jaw bone. The disorder results from poor bite and jaw clenching.

Treatment for muscle-contraction headache varies. The first consideration is to treat any specific disorder or disease that may be causing the headache. For example, arthritis of the neck is treated with anti-inflammatory medication and TMD may be helped by corrective devices for the mouth and jaw.

Acute tension headaches not associated with a disease are treated with analgesics like aspirin and acetaminophen.

Non-drug therapy

Non-drug therapy for chronic muscle-contraction headaches includes biofeedback, relaxation training, and counseling. A technique called cognitive restructuring teaches people to change their attitudes and responses to stress. In progressive relaxation, patients are taught to relax individual muscle groups. Many people imagine a peaceful scene - such as lying on the beach or by a beautiful lake.

People with chronic muscle-contraction headaches my also be helped by taking antidepressants or MAO inhibitors. Mixed muscle-contraction and migraine headaches are sometimes treated with barbiturate compounds, which slow down nerve function in the brain and spinal cord.

People who suffer infrequent muscle-contraction headaches may benefit from a hot shower or moist heat applied to the back of the neck. Cervical collars are sometimes recommended as an aid to good posture. Physical therapy, massage, and gentle exercise of the neck may also be helpful.

Conclusion

If you suffer from headaches and none of the standard treatments help, do not despair. Some people find that their headaches disappear once they deal with a troubled marriage, pass their certifying board exams, or resolve some other stressful problem. Others find that if they control their psychological reaction to stress, the headaches disappear. The important thing to do is to seek the help of a physician to guide you in the diagnosis and treatment of your headaches.

Courtesy NIH