For All Headaches, You Should Be More Concerned and Seek Care Immediately If:

• Your headache is different from or significantly worse than any headache you ever had before
• You feel confused or drowsy
• Your neck feels stiff
• Your temperature rises very high
• You have eye problems such as blurred or double vision
  

Primary vs. Secondary Headache

There are many ways of classifying headache. The major distinction is between primary headache (when there is no underlying illness or other cause) and secondary headache (when a specific cause is identifiable).

If a person has a stable pattern of headache, even if disabling, he or she most likely has a primary headache disorder. Atypical features or recent changes in headache pattern increase the possibility that a headache is secondary to some other medical condition.

Head injury, use of medicines, hormonal changes, or exposure to various harmful substances may be the cause of your headaches. This is the time that a thorough headache diary will come in handy. Knowing such things as the factors that trigger or relieve your headaches, when headaches happen most often, and what your moods are before a headache can assist the doctor greatly in arriving at the correct diagnosis.

 

Migraine

What Is Migraine?

Migraines are moderate-to-severe, throbbing headaches on both sides or on one side of the head. They are usually situated around the forehead and temples or around the eyes. Migraines occur in women more often than men—usually in patients who have a family history of migraine—and begin between the ages of 10 and 25. These headaches are often associated with nausea, vomiting, loss of appetite, sensitivity to noise, and sensitivity to light. They typically occur 1 to 4 times per month and last most of the day, usually improving with sleep. Some migraines involve an aura of visual changes or numb sensation that spreads in a typical fashion followed by a throbbing headache. Migraines occur in very predictable circumstances or are provoked by the following:

• Hormonal factors, such as menses, ovulation, oral contraceptives, pregnancy, or after birth
• Relaxation after stress, such as weekends or vacations
• Bright lights, such as headlights from cars while driving or fluorescent lights
• Weather changes, such as the Santa Ana winds in Southern California
• Caffeine withdrawal
• Alteration in sleep patterns, such as sleeping late or lack of sleep
• Alcohol consumption, especially red wine, champagne, and beer
• Ingestion of foods, such as aged cheeses, hot dogs, deli meats, citrus, yogurt, frozen foods, Chinese food containing MSG, artificially colored foods and beverages, yeast, and canned soups

 

What are Tension Headaches?

These are divided into episodic headache days (fewer than 15 per month) and chronic headaches (15 or more headache days per month). The typical episodic headache is the result of localized contraction of the head and neck muscles, associated with stress and fatigue. The chronic headaches are a symptom complex (symptoms that tend to occur together) due, in part, to psychological problems, especially depression.

The tension headache is a steady, nonpulsing, persistent ache, often described as a constricting pain (eg, “band-like,” “vise-like,” “weight,” “pressure,” and “tightness”). It may be on one side or both sides of the head, involve the temporal (sides of the head), occipital (back of the head), parietal (top of the head), or frontal (forehead) regions or a combination of these. It can be accompanied by tightness of the neck, upper back, and shoulders with localized areas that are tender to the touch. Blurred vision and sleep disturbance may occur. Vomiting and sensitivity to light and sound are usually absent. A simple tension headache usually lasts a few hours and has no other symptoms.

What You Should Do:

• Call your doctor for a 1st line treatment to relieve pain
• Try some of the following measures to relieve your headache
  1. Stretch and massage the muscles in your shoulders, neck, jaw, and scalp. Take a hot bath. Rest in a quiet, darkened room. Place a warm or cold wet cloth (whichever feels better) over the aching area.
  2. Don’t skip or delay meals. Drink plenty of liquids.
  3. Avoid alcoholic beverages and cigarettes; they often make a headache worse
  4. A good night’s sleep often is the best way to relieve a headache

 

Sinus

What Is a Sinus Headache?

Sinus headache is often diagnosed if a person has pain in the forehead or about the nose, often with congestion or clear nasal discharge. However, although acute sinusitis can be associated with pain, most people with “sinus headache” actually have migraine. As a result of misdiagnosis, people who are treated for “recurrent sinus headache” often do not receive the most effective therapies.

The confusion is common; a migraine can cause irritation of nerves that have branches in the forehead, cheeks, and jaw. This may produce pain in or near the sinus cavities. Pain in the sinus area does not automatically mean that you have a sinus disorder. However, sinus and nasal passages can become inflamed, leading to a headache.

There are many reasons headache sufferers have difficulty distinguishing between a sinus headache and the pain of a migraine attack.

Although many people associate migraine with strange visual aura symptoms, only 20% of migraineurs actually experience the aura phase of a migraine attack. Both sinus headaches and migraine attacks can be triggered by weather changes. Sinus headaches and migraine attacks can produce pain in the same areas. Both can cause drainage and other sinus symptoms such as teary eyes. Acute or chronic sinusitis may be associated with pain, but this typically worsens if you lie down and improves with breathing moist air and use of warm and cool compresses.

Sinusitis due to an infection will often produce a discolored nasal discharge, fever and fluid in the sinus, visible on an X-ray.

 

Cluster

What Is Cluster Headache?

Cluster headache is one of the most severe pain syndromes. Cluster headaches are strictly one-sided and seem to occur at the same time each day (following a person’s circadian rhythm) and may be caused by a problem in the region of the brain (pineal gland) that controls circadian rhythm.

Unlike migraine, which primarily affects women, cluster headache mainly affects men. Although the exact incidence is unknown, an estimated 500,000 to 2 million Americans experience cluster headaches.

These excruciatingly painful headaches occur in bursts every year, seemingly more often in the spring and fall than any other time. The cluster period usually lasts between 2 and 3 months. The penetrating and mostly non throbbing pain is often felt behind the eyes or in the temple.

Attacks can last up to 3 hours and tend to occur at night. The headaches are typically sudden and severe and may be accompanied by watery eyes or a runny nose on the side of the headache. You may feel sweaty, restless, or nauseated. The headaches often start at night and can wake you up.

Persons who smoke cigarettes or drink alcohol excessively are more likely to suffer cluster headaches. Many cluster headache sufferers also have peptic ulcers. Women who have cluster headaches may also have a history of migraine.

 

Rebound

What Is Rebound Or Medication Overdose Headache?

The daily use of simple and combination analgesics, barbiturates, sedatives, ergotamines, and caffeine (in medicines or beverages) contributes to the development of chronic and intractable (resistant to treatment) headaches and actually prolongs headaches and makes them worse. The term rebound refers to a worsening of the headache as the analgesic effects of the medications wear off, with an escalation of the pain secondary to withdrawal. Such headaches are often present on waking.

Patients will develop these headaches only if they are using these medications on a regular basis. How frequently patients take medication is more important than how much they use. Patients gradually develop an overuse cycle, often medicating 3 to 4 times a day. Patients who are withdrawn from these medications experience significant improvement and can become responsive once again to preventative medications. This improvement may occur 2 to 3 months after analgesic and caffeine withdrawal.

When you take pain relief medicines (painkillers) for headaches often or in large amounts, your body gets used to having these medicines and cannot manage to inhibit painful stimuli of any kind without them.

 

With Rebound Headaches You Will Notice the Following:

• The medicines do not work the way they used to
• The headache pain is harder to control
• You need larger and more frequent doses
• Your headaches get worse if you miss a dose
• Medications you may be taking to prevent headaches may become less effective

 

What Causes Rebound Headaches?

• Frequent use of painkillers or triptans (migraine medication)
• Taking pain medicines, including certain prescription medicines, as little as 3 times per week on a regular basis
• Regularly taking even 10 500-mg aspirin or acetaminophen tablets/caplets per week
• Taking analgesics (painkillers) including those containing caffeine (even coffee itself) daily or near daily

 

What Can You Do?

You should speak to your doctor. One way to begin is to keep a log of your headaches and the medicines you take. Remember that many medicines can contribute to rebound headaches, so be sure to include all the medicines you take, even those you use without a prescription.

 

Diet

Restrictive diets are frequently prescribed for headache sufferers. These diets generally limit exposure to foods rich in substances known to have effects on the blood vessels. Restricted foods include those containing tyramine (aged cheeses, alcohol, sour cream), phenylethylamine (chocolate), nitrates (hot dogs), and dopamine (broad beanpods).Studies evaluating single foods are few and offer mixed results. One study showed that taking excessive amounts of aspartame (NutraSweet®) for 4 weeks increased headache frequency in a group of migraine sufferers who had identified aspartame as one of their triggers. There was no change in headache severity. Study participants took 300 mg of aspartame 4 times a day: the equivalent of 12 cans of diet soda or 32 packets of sweetener every day for a month. More moderate use was not tested; this study showed only a small increase in headache after regularly consuming very large doses of aspartame. Chocolate is another commonly reported headache trigger food for 22% of chronic headache sufferers. In one study, more than 60 women with chronic headaches followed a restrictive diet and then were tested with 4 chocolate-flavored bars. Two of these bars were chocolate and 2 were carob. (Carob does not contain trigger chemicals.) Even women who believed that chocolate triggered their headaches did not have headaches when they didn’t know if they were eating chocolate or carob.

Why are there such strong myths about these foods as headache triggers? The mood and behavior changes that precede a migraine attack (called prodrome) often include food cravings. A false association can then be made between eating the food and getting a headache. The food doesn’t actually trigger the headache, but the craving is a sign that the headache process has already begun. In addition, sweet craving typically occurs in response to stress, fasting, and menstruation. Again, the true trigger may be the stress, fasting, or hormonal changes, with chocolate (or other craved foods) a reaction to the trigger rather than acting as a trigger itself.

If you believe that foods trigger your headache, expect to get a headache within 12 hours of eating the food item. Elimination of certain individual foods may be helpful for a minority of headache sufferers, but restricting a wide variety of foods on a long-term basis can be stressful and is rarely helpful.

 

Common Food Triggers

• Alcohol (less than what would cause you a hangover), most commonly red wine, as well as brandy, whiskey, champagne, white wine, beer, and other drinks
• Chocolate and chocolate milk, cocoa
• Ripened cheese, such as cheddar, blue, brick, colby, roquefort, brie, gruyère, mozzarella, parmesan, boursault, and romano, and processed. American, cottage and cream cheese are much less likely to trigger a headache than the aged cheeses
• Citrus fruit, including grapefruit and orange
• Pineapple
• Grapes
• Caffeine in coffee, soda, cocoa, and other drinks. Usually caffeine helps headaches; too much caffeine, however, can cause increased rebound headaches. Heavy caffeine users need to reduce their intake gradually. Some migraine sufferers are extremely sensitive to small amounts of caffeine
• Monosodium glutamate (MSG) may also be labeled “autolyzed yeast extract, “hydrolyzed vegetable protein,” or “natural flavoring.” Possible sources of MSG include Chinese restaurant food; broth or stock; canned or instant soup; whey protein; soy extract; malt extract; caseinate; barley extract; textured soy protein; chicken, pork, or beef flavoring; processed meat; smoke flavor; spices and seasonings including seasoned salt, carrageenan, meat tenderizer; TV dinners; instant gravy; and some potato chips and dry-roasted nuts
• Hot dogs, pepperoni, bologna, salami, sausage, canned or aged meat, cured meat (bacon, ham), or marinated meat
• Fresh, hot homemade yeast bread (once cool is OK)
• Buttermilk
• Yeast extract
• Acidophilus milk
• Pizza, freshly baked and still hot (less likely to trigger headache if cooled and reheated)

 

Less Common Migraine Food Triggers

• Onions
• Beans, such as lima, navy, fava, lentil, garbanzo, pinto, and Italian
• Snow peas
• Sauerkraut
• Pickles and pickled food
• Marinades
• Chili peppers
• Licorice or carob candy
• Figs, raisins, avocados, bananas, passion fruit, papayas
• Fried food
• Peanuts, peanut butter
• Popcorn
• Nuts or seeds, all types
• Sugar in excess
• Salt in excess
• Seafood
• Sour cream or yogurt
• Chicken livers

 

Chronic Migraine

Chronic migraine (CM) is defined as: Headache on 15 days per month for at least 3 months, and 8 of the 15 days meet the criteria for migraine.
Incidence of CM: 2.5% of those with Episodic migraine (EM), i.e.: less than 15 days per month of headache, progress yearly to CM.

• The headaches are not always associated with migraine features, and may resemble a mixture of migraine and tension-type headaches with intermittent severe migraine type headaches.
• Depression is present in 80% of CM patients.
• Risk factors for conversion from EM to CM include: medication overuse (especially opiates and barbiturate combinations), high caffeine use, female gender, stressful life events, anxiety, baseline high attack frequency, lower educational and socioeconomic levels, white race, those previously married, lifetime injuries to the head or neck, obesity, snoring, arthritis, and diabetes.
• Only 20% of patients with CM are diagnosed correctly.
• Only 33% of patients with CM are using preventative medications.
  Medication overuse is a common cause of chronic migraine. When the medications listed below are used at the frequency stated the diagnosis is CM and possible medication overuse headache.

 

Treatment options for CM:

Transitional therapy options will be discussed and planned with your doctor. Options include:

• Withdrawal of the overused medication and initiation of preventative medication (the overused medications must be tapered gradually to avoid complications).
• Caffeine use limited to 200 mg per day. Some patients are even more sensitive and require further restriction
• Anti-inflammatory medications including steroids may be helpful during the transition.
• Long acting triptans such as Amerge (Naratriptan) or Frova (Frovatriptan) may be used.
• Occipital and trigeminal nerve blocks with local anesthetic may be helpful
• IV DHE (dihydroergotamine) regimen which requires hospitalization for 2-5 days may be necessary in some cases.

On a botulinum toxin A (Botox) is the only approved treatment for CM, approved in 2010 based upon the PREEMPT trials. Studies have shown that some patients who do not respond after the first treatment may respond after the second or third treatment given at 12 week intervals. Expense of treatment is offset by less triptan use and a reduction in migraine-related ED/hospital/urgent care visits.

Other medication options that have been studied with randomized-controlled-trials and shown beneficial in CM include Topamax (topiramate), Elavil (amitriptyline), Neurontin (gabapentin), and tizanidine (Zanaflex). Open-label trials of Lyrica (pregabalin), Zonegren (zonismide), and Namenda (memantine) indicate these may also provide some benefit.

Alternative complementary treatments have not been demonstrated in studies to be effective for CM.

However, the following options could be considered:

• Behavioral sleep modification, relaxation therapy, physical exercise.
• Weight loss even with Bariatric surgery might provide some benefit.
• Occipital and Trigeminal nerve stimulation for CM still being assessed.