This Issue

Headaches: A universal pain in the neck

Chronic condition may need stronger relief

Relax, take a deep breath …
stop that headache

Help your doctor help you … and keep a headache diary

Q & A

A closer look


Triggers

Although it is not always possible to prevent a headache, it may be possible to reduce its frequency by determining and avoiding what cause it. Triggers are factors that spark a headache. Most triggers arerelated to migraines but may be related to cluster and tension-type headaches as well.

  • Change in the weather, particularly heat and moisture

  • Fatigue

  • Emotional stress

  • Lack of sleep or too much sleep

  • Bright or blinking lights

  • Loud noises

  • Strong smells, such as perfumes

  • Alcohol, particularly red wine

  • Smoking

  • Certain foods — Chocolate, caffeine, aged cheeses, processed meats

Surprising headache triggers

Triggers

Not just any headache!


Most headaches are annoying inconveniences, but some may signal a serious condition — such as meningitis or stroke — that require prompt medical attention. People may complain of the “worst headache ever.”

  • A severe headache with sudden onset

  • Headaches that first develop after the age of 50

  • Headaches that increase with coughing or abrupt movement

  • Persistent headache after a blow to the head

  • Headache pain that feels like an explosion or thunderclap

  • Headache pain that gets worse and won’t go away

  • Headache accompanied by any of these symptoms

    • stiff neck and fever

    • severe pain when bending over

    • decreased alertness or mental confusion

    • persistent, severe vomiting

  • Headaches accompanied by neurological symptoms

    • visual disturbances

    • slurred speech

    • weakness or numbness on one side

    • seizures

Which one is it?

Not just any headache!

Help your doctor help you …
… and keep a headache diary

In order to pinpoint your type of headache, which will help to diagnose and treat it correctly, pay close attention when it surfaces.

Keep track of:

  • the date of each headache
  • the time it started and the time it ended
  • type of pain and intensity on a scale of 1 to 10
  • where the pain is centered
  • foods and beverages you had during the last day
  • amount of sleep and caffeine
  • stress level
  • any sensitivity to light, sound or odors
  • the date of your menstrual cycle if you are female
  • weather conditions
  • type of treatment and its effect
  • your thoughts and actions shortly before the pain began

Discuss any frequent headaches with your doctor, who can recommend appropriate treatment.

Call your doctor immediately if you experience a very severe, sudden, or explosive headache (especially after a head injury or if your headache is accompanied by stiff neck and fever, weakness, or difficulty speaking or seeing, which could signal more serious problems, such as meningitis or stroke).

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A closer look


A contradiction in terms

Do pain relievers treat a headache,
or cause a headache?

Yes

Regular use of pain relievers — including nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen — can actually cause headaches. “Rebound” or medication-overuse headaches can occur when the medication is taken more than two to three days a week or more than the recommended dosage. For reasons not fully understood, a drop in the level of drugs in the blood precipitates another headache, which in turn precipitates another dose. The cycle continues resulting in chronic daily headaches with more severe and frequent pain. Rebound headaches can occur with prescription drugs as well.

Chronic condition may need stronger relief


Hazel Reese decided it was better to write about her headaches rather than complain about them. She published “I Will Not Complain” in 2004 and is working on a follow-up book. Smith suffers from mixed (tension-migraine) as well as chronic daily headaches. (Photo courtesy of Hazel Reese)
Hazel Reese, 66, knows a lot about headaches. She should. She has suffered them for the last 50 years. Her migraine was hormone-related and returned like clockwork every month. Her father gently massaged her temples before she went to sleep. “When I woke up, they’d [her headache] be gone,” she said.

At the time she didn’t know she had migraines, a particularly painful type of headache. What’s worse, nor did her doctors.

They insisted she had sinus headaches. It wasn’t until 1982, when Reese was almost 40 years old, that she learned the nature of her headaches.

By now, she knows exactly which type of headache she has. “Migraine with aura,” she proclaimed.

Unfortunately for Reese, it’s not only migraines that attack. She also suffers from “mixed headaches,” or tension-migraine headaches.

“It starts with pain on the left side of my head and a stabbing pain behind my left eye,” she said.

All this is preceded by an aura. “I see flashing colored lights,” she said. The tension-type pain is then added to the mix. “That one begins in the back of the neck and moves to the shoulder,” she said.

But Reese’s headaches fall under an even broader category — chronic daily headaches. Most people have headaches from time to time, but if a headache occurs 15 days or more a month for at least three months, it is considered a chronic daily headache.

Reese says she is never completely without headache pain. “They never really go away completely,” Reese said. “On a scale of 1 to 10, if I have a 5 or 6 headache, that’s like no headache at all.”

Fortunately, most headaches can be treated at home. Over-the-counter (OTC) drugs, such as aspirin and ibuprofen and other NSAIDS (nonsteroidal anti-inflammatory drugs), are the first line of treatment. But overuse can be just as bad — in some cases worse — than the original headache.

Internal bleeding or perforation of the lining of the intestines can result, according to the American College of Gastorenterology. Rebound headaches often occur when pain killers are taken more than three days a week or in a higher than recommended dose. Over-use is no trivial matter. Thousands — many of whom are elderly — die each year as a result.

The good news is that with the advent of a class of drugs called triptans, many people suffering from migraines are living more comfortably with their condition.

Often referred to as a “miracle drug” triptans do not prevent migraines, but instead are used to abort the symptoms of an attack. They are taken as needed. For those with more disabling chronic attacks, prescription drugs are taken daily as a preventive measure.

“Many people take it for granted that a headache is something you can’t avoid,” said Dr. Eduard Vaynberg, an anesthesiologist who specializes in pain management at Boston Medical Center. “They view them as benign ailments.”


Eduard Vaynberg, M.D.
Anesthesiologist
Boston Medical Center
Vaynberg understands that sort of fatalism. “Going to the doctor can be a hassle,” he admitted. “But when you can’t drive because you can’t move your head, that poses a problem.”

Diagnosing headaches correctly is a challenge. “People can suffer from headaches for 10 years and no one has been able to diagnose it correctly,” he said.

Headaches are divided into two categories — primary and secondary. Primary headaches are not caused by a disease or condition — the headache itself is the problem. Migraine, tension and cluster headaches fall into the primary category. Secondary headaches, on the other hand, are symptoms of an underlying disorder, such as infections, tumors and neurological aberrations.

Cervicogenic, or neck-based headache, is a secondary headache. Although not as common as tension-type, they make up 20 percent of the patients with chronic pain treated in pain management clinics, according to a recent study published in the Journal of the American Osteopathic Association.

The pain from neck-related headaches is distinctive and is sometimes confused with migraine pain. It is characterized by moderate to severe pain on one or both sides of the head often triggered by neck movement. Some may experience nausea, vomiting and sensitivity to sound and light.

Some experts attribute this problem to overload — just two or three small bones in the neck bear the brunt of most of the movements of the head and neck, let alone the weight of the head itself. The head is roughly 12 percent of a person’s total body weight.

That’s an awful lot of repetitive stress and strain for two or three small bones. And it can come with a price. Eventually the bones show signs of wear and tear, the links between the bones become impaired and the pathway for the intricate system of nerves can narrow.

When conventional treatments fail, various interventions are offered, according to Vaynberg, who specializes in the treatment of cervicogenic headaches. Anesthesiologists can perform an anesthetic block to the nerve or muscle trigger points. Local anesthetics and steroids mixtures are commonly used. Botulinum toxin is sometimes used when local anesthetics give short term relief and in some cases has been successful. However, its use is considered experimental and it is not covered by insurance.

Radiofrequency is another technique, which cauterizes the nerve endings in the neck, thus providing a long-term relief of pain.

“Headaches are very challenging,” Vaynberg admits. “We often know what works, but don’t always know why they work.”

Either way, Reese is not complaining. Although the migraines precipitated her retirement 22 years ago — earlier than she had anticipated — she says she’s doing all right.

She knows her triggers. Perfume and loud noises can set it off. “The biggest trigger is the weather,” she offered. “Rain and warm temperatures in particular.” There are also foods she steers clear of — especially chocolates, hot spices or beans. “If I eat something I’m not supposed to, within the first 15 minutes, I can feel it,” she said.

Because of other serious medical problems, she is now on a “restrictive” medication for her headaches.

“Over the years you learn to live with it,” she said. “[But] I’m in control now.”

Is it migraine or cervicogenic?