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Headache Pain

The head is one of the most common sites of pain in the body. A headache is often described as aching or pain that occurs in one or more areas of the head, face, mouth, or neck. Nearly everyone gets a headache at one time or another. Headaches may be chronic, recurrent or occasional. The range of pain often varies from mild to severe enough to disrupt daily activities. Headaches encompass the network of nerve fibers in the tissues, muscles, and blood vessels located in the head and at the base of the skull.

The most common types of headache are classified as primary, secondary and cranial neuralgias, facial pain, and other headaches. There are three types of primary headaches: tension headache, cluster headache, and migraine.

Studies show in the United States, more than 45 million people—including more than the 33 million sufferers of asthma, diabetes, and heart disease—suffer from chronic, recurring headaches. Of this number, 28 million suffer from migraines each year. The cost of these headaches in absenteeism and medical expenses may be estimated as high as $50 billion per year.

Secondary headaches are caused by an injury, other illness or condition, such as cerebrovascular disease, head trauma, infection, tumor and metabolic disorder. Head pain may be attributed to syndromes involving the eyes, ears, neck, teeth or sinuses. In cases of secondary headaches, the underlying condition must be diagnosed and treated. It also may be possible that certain types of medication may produce headache as a side effect.

A sudden or severe secondary headache that occurs following a blow to the head, that interferes with normal activity, or that accompanies other symptoms (i.e., disorientation, dizziness, loss of consciousness or pain in the eye or ear, fever) should be evaluated by a physician as soon as possible.

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Causes

Tension Headaches

The most common type of primary headache is the tension headache. Occurrences usually begin in middle age and may be associated with the stresses, anxiety, and depression that can develop over the years. Nearly 75% - 90% of all sufferers of chronic or frequent headaches suffer from tension headaches. Tension headaches occur more often with women than men.

Common causes of tension headaches include stress, muscular tension, vascular dilation, changes in posture, coughing or sneezing and fever. Certain physical and mental conditions can lead to chronic muscular tension and headache, including anxiety, arthritis in neck or spine, degenerative disc disease in the neck or spine, depression and temporomandibular joint disorders (TMJ).

Researchers have found that tension headaches and migraines represent two ends of a common spectrum. Migraines, which are severe but irregular in occurrence, may progress or evolve to the less severe, but more frequent, tension-variety headache.

Cluster Headaches

The exact cause of cluster headaches is unknown. Certain evidence indicates that changes in the blood vessels walls of the head may lead to cluster headaches. There are several well-known triggers associated with cluster headaches, these include drugs that dilate or constrict blood vessels and alcohol. Some studies show that a low level of endorphins may cause frequent, severe, or chronic headache pain. Endorphins are described as painkilling compounds found in the brain.

Changes in barometric pressure and altitude, inclement weather, such as heavy rain or snow, and high winds are environmental factors that may lead to cluster headaches in some people.

Secondary Headaches

Common causes of secondary headaches include brain tumors, cerebral aneurysm, temporal arteritis, infections, such as meningitis, sinusitis (sinus infection), ear infections, dental disease and infections of the eye.

Migraines

While there is much about headaches that is not understood, migraines may be caused by functional changes in the trigeminal nerve system, a major pain pathway in your nervous system, and by brain chemical imbalances, including serotonin, this regulates pain messages in the nervous system.

Serotonin levels drop during a headache. When this occurs, the trigeminal nerve releases substances called neuropeptides, which travel to your brain's outer covering. This causes blood vessels to become dilated and inflamed. The result is headache pain. It is also possible that low amounts of magnesium may cause nerve cells in the brain to misfire.

Common migraine headache triggers include hormonal changes, certain foods, such as alcohol, chocolate; fermented, pickled or marinated foods; aspartame; caffeine; and many canned and processed foods. Studies also indicate that skipping meals or fasting may also trigger migraines. Other migraine headache triggers include, stress, sensory stimulus, physical factors, such as intense physical exertion, environmental changes and certain medications.

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Symptoms

Tension Headaches

  • Usually begins gradually & increases steadily
  • Dull, steady, achy pain on both sides of the head
  • Possible pulsating quality in severe tension headaches

Cluster Headaches

  • Usually occurs daily over a period of weeks, sometimes months
  • Cluster headaches usually affect men between the ages of 20 and 40.
  • Sufferers of cluster headaches may have up to eight attacks per day, each attack could last 15 to 45 minutes or longer
  • Typically, attacks come in the early morning hours, and will waken the patient from sleep.
  • Cluster headaches are usually centered around one eye, and usually on one side of the head.
  • The pain experienced is often described as a knife or nail being driven into the head. Lying down can make the pain worse, unlike migraine pain.

Migraine

A typical migraine headache attack produces some or all of these signs and symptoms:

  • Severe, throbbing or pulsating pain, usually on one side of the head
  • Pulsating or throbbing quality
  • Physical activity increases pain
  • Regular daily activities are hindered
  • Nausea with or without vomiting
  • Light and sound sensitivity
  • Typically lasts from four to 72 hours
  • Frequency varies from person to person

While it is less common, some people experience migraines with auras, meaning they experience sparkling flashes of light, zigzag lines or blind spots in the field of vision, tingling, pins and needles sensations in one arm or leg and even weakness or language and speech problems.

Some sufferers may have one or more sensations of premonition before the onset of a headache, including:

  • Intense energy or feelings of elation
  • Cravings for sweets
  • Thirst
  • Drowsiness, irritability or depression

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Diagnosis

Diagnosis of tension or cluster headache is based on symptoms and a thorough medical examination, including the following:

  • Observation
  • Physical examination
  • Blood tests including thyroid, liver, and kidney function tests
  • Eye examination
  • Family history
  • Medical history (including medications and characteristics of the headache)
  • Neurological examination
  • Sleep habits

Migraines are a chronic disorder, but oftentimes they may go undiagnosed and untreated. Individuals that experience signs and symptoms of migraine, should track and record their attacks along with treatments used. The next step is to make an appointment with a doctor to discuss the migraines and decide on a treatment plan.

Warning Signals:

Even those with a history of headaches should see a doctor if the pattern changes or if headaches suddenly feel different. Seek immediate medical attention if you have any of the following signs or symptoms, as they may indicate another, more serious medical problem, such as a concussion, blood clot or brain tumor:

  • A sudden, severe headache like a thunderclap
  • A new severe headache that is felt on both sides of the head
  • Headache along with fever, stiff neck, rash, mental confusion, seizures, double vision, weakness, numbness or difficulty speaking
  • Headache following a recent sore throat or respiratory infection
  • Headache following a head injury, especially if the headache worsens
  • A chronic headache that worsens after coughing, exertion, straining or a sudden movement
  • New headache pain if you're older than 55

Imaging studies of the brain, such as CT scans or MRI, may be necessary to rule out any serious underlying medical problem, such as brain tumor, stroke, high blood pressure or infection. A spinal tap, a procedure in which cerebrospinal spinal fluid is drawn for examination, may be necessary for a differential diagnosis. X-rays or magnetic resonance angiography (MRA) may be performed to evaluate the brain's blood vessels.

In cases where the patient has typical migraine headaches or a family history of migraines, diagnose of the condition may be made based on medical history and a physical exam. However, if headaches are unusual, severe or sudden, certain tests are often performed to rule out other possible causes for the pain.

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Treatment

Tension Headaches

Headache treatment will depends on the type, severity and frequency of occurrence.
Many tension headache sufferers do not seek medical attention or advice, instead they use self treatment techniques such as nonprescription analgesics and over-the-counter pain medications. In cases where tension headaches are severe or frequent enough to seek professional treatment, relief may be found through a course of doctor-prescribed antidepressant or anxiety-reducing medications, such as amitriptyline, nortriptyline or desipramine.

It is important to avoid medication overuse, as this can lead to "rebound headaches." A “rebound headache” occurs when high levels of the drug in the body actually cause daily headaches. In most cases, rebound headaches improve when the medication is stopped.
Due to potentially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed.

Some secondary treatments that may help reduce the effects of stress and tension on the body include massage, meditation and the use of biofeedback techniques. Some patients may benefit from the effects of psychotherapy in order to learn how to deal with stress and tension.

Cluster Headaches

The goal of treatment of cluster headaches is to lessen the severe, sometimes unbearable, pain during the headache, as well as to shorten the cluster episode. Acute treatment medications are similar to those used for migraine and include:

  • Sumatriptan, this medication is injectable or may be taken in nasal form for rapid onset. Other oral triptans may also be effective.
  • DHE (Migranal), this may be delivered as a nasal spray in order to experience a rapid onset. DHE is also available in an injectable form. Side effects may include nausea and dizziness.
  • In some cases, narcotics may be helpful, while the onset of most oral agents may not be rapid enough, due to the severity and brief duration of the headache.
  • Some people may find relief through breathing 100% oxygen during an acute headache. A tank of oxygen can be kept for home use if other medications do not work well.
  • Prednisone is a corticosteroid, a potent chemical that occurs naturally in the body. It is taken initially in high doses and then tapered over days or weeks, depending on the response. This medication is best if used for short periods of time.
  • Long-term corticosteroid use can cause many serious adverse side effects because it is involved in several different functions in the body. Potential side effects include an increase in intraocular pressure, osteoporosis, behavioral changes, ulcer, and diabetes.
  • Lithium carbonate may increase the levels of dopamine and norepinephrine in the brain. It is taken orally, usually twice a day, to interrupt a cluster headache. Concentration of lithium in the blood is closely monitored with periodic blood tests. Side effects include tremor, increased thirst, nausea, and frequent urination. Lithium carbonate typically is used to treat manic episodes in manic-depressive patients.
  • Verapamil dilates blood vessels. It can be taken twice daily in a sustained oral preparation. Side effects include nausea, dizziness, and constipation. Verapamil typically is used to treat angina, hypertension, and arrhythmias.

Migraine Headaches

According to the American Academy of Neurology, more than 28 million Americans, three times more women than men, suffer from migraine headaches, a severe type of headache that is often disabling. The pain can be excruciating and may incapacitate you for hours or even days.

The good news is that in the last decade, migraine headache pain relief has improved dramatically. Patients who have seen a doctor in the past with little success, it's time to make another appointment. While there's still no cure, medications may help reduce the frequency of migraine headaches and stop the pain once it has started. Home remedies and changes in lifestyle partnered with the right medications may make a tremendous difference for migraine sufferers.

There are several drugs commonly used to treat other conditions that also may help relieve migraines in some people. Some medications aren't recommended if you're pregnant or breast-feeding. Some aren't used for children. Your doctor can help find the right medication for you.

All of these medications fall into two classes:

  • Pain-relieving medications - these stop pain after it has started.
  • Preventive medications - these reduce or prevent a migraine headache. The best candidates for preventive therapy have two or more debilitating attacks a month, use pain-relieving medications more than twice a week, pain-relieving medications aren't helping or if migraines are uncommon.

Types of Pain-relieving medications

It is generally most effective to take pain-relieving drugs as soon as you experience signs or symptoms of a migraine headache. Additional relief may be found by resting or sleeping in a dark room after taking medication.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), may also ease moderate migraines, but aren't effective alone for severe migraines. In cases where over-the-counter medications do not offer relief, your doctor may suggest a stronger, prescription-only version of the same drug. NSAIDs may lead to ulcers, gastrointestinal bleeding and rebound headaches if taken too frequently or over a long period of time.
  • Triptans. The first drug specifically developed to treat migraines was Sumatriptan (Imitrex). This drug mimics the action of serotonin by binding to serotonin receptors and causing blood vessels to constrict. This drug is available in oral, nasal and injection form. Injected sumatriptan works faster and is more effective than any other migraine-specific medication. The relief can be felt in as little as 15 minutes.
  • Medications for nausea. While these medications do not relieve the migraine pain itself, medications like metoclopramide (Reglan), chlorpromazine (Thorazine) and others can be useful for relieving the nausea and vomiting associated with migraines. Some drugs may also improve gastric emptying, which can lead to better absorption and more rapid action of many oral drugs. It's best to take these medications early in the course of the migraine.

Preventive medications

The goal of preventive medications include reduced frequency, severity and length of migraines. These medications may also increase the effectiveness of pain-relieving medicines used during migraine attacks. It is important to note that preventive medications do not eliminate headaches completely, and some may cause serious side effects.

  • Cardiovascular drugs. Beta blockers may decrease the frequency and severity of migraines. They are considered among first-line treatment agents. The drugs are commonly used to treat high blood pressure and coronary artery disease. Calcium channel blockers, another class of cardiovascular drugs, especially verapamil (Calan, Isoptin), also may be helpful. It is not precisely known why all of these cardiovascular drugs prevent migraines. Side effects can include dizziness, drowsiness or lightheadedness.
  • Antidepressants. Certain antidepressants are good at helping prevent all types of headaches, including migraines. Most effective are tricyclic antidepressants, such as amitriptyline and protriptyline (Vivactil). These medications are often the first-line treatment drugs and may reduce migraines by affecting the level of serotonin and other brain chemicals.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen or aspirin, may help relieve mild migraines. Drugs marketed specifically for migraine, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), may also ease moderate migraines, but aren't effective alone for severe migraines. In cases where over-the-counter medications do not offer relief, your doctor may suggest a stronger, prescription-only version of the same drug. NSAIDs may lead to ulcers, gastrointestinal bleeding and rebound headaches if taken too frequently or over a long period of time.
  • Anti-seizure drugs. While it is largely unclear why, some anti-seizure drugs, such as divalproex sodium (Depakote) and topiramate (Topamax), which are used to treat epilepsy and bipolar disease, help to prevent migraines. However, these drugs may cause side effects such as nausea and vomiting, diarrhea, cramps, hair loss and dizziness when taken in high doses.
  • Cyproheptadine. This antihistamine drug helps to affect serotonin activity. This is sometimes given to children as a preventive measure.
  • Botulinum toxin type A (Botox). It has been found that some people who receiving Botox injections for facial wrinkles have noted improvement of their headaches. It is possible that changes in your nervous system modify your tendency to develop migraines.

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