Northwest Health Winter 2012

Oh, My Aching Head!

Almost everyone experiences the pain of a headache. Learn what triggers yours, what might prevent it, and what can help it go away.

Go to: Northwest Health Index

Group Health member Jennifer Merrill, now in her 30s, suffered her first migraine headache when she was around 11 years old. "All the women in my family get them," she says. But knowing that migraines tend to run in families hasn't helped her much when a headache sets in, which happens as often as seven or eight times a month. "It disrupts my life," says Merrill, who sometimes misses a day of work or an important party or event due to the excruciating pain.

Merrill isn't alone in coping with this problem. According to one population study, 95 percent of women and 90 percent of men will develop some type of headache each year. While many of those will pass quickly, others will require treatment, a prevention plan, and occasionally testing for underlying conditions. Group Health neurologist Tim Scearce, MD, who has a particular interest in headaches, says it's not always easy to sort out the causes and treatments for troublesome headaches. "The thing that really matters is time in the room, talking to the patient," he says. "If we listen, our patients are often telling us the diagnosis."

The Four Big Headache Categories

Sinus Headaches
Pain level: Moderate
Duration: Several days

Traditionally, patients and their doctors have used the diagnosis "sinusitis" to explain achy pressure felt behind the cheekbones, the bridge of the nose, forehead, and even in teeth around the sinuses, and the headaches that can go with it. Patients are often prescribed antibiotics because a bacterial infection is suspected. But recent research has shown that when patients report a sinus headache to their doctor, a medicine used to treat migraines will provide relief 80 percent of the time. Researchers believe that these sinus symptoms are actually migraine symptoms. "You feel the pain in the sinuses, but the problem is farther back in the migraine center of the brain," says Dr. Scearce.

Signs that a headache is probably caused by a bacterial sinus infection include several days of symptoms such as yellow-green or blood-tinged nasal discharge; pain, pressure, and fullness in the cheeks, brow, or forehead; sinus tenderness on one side of the jaw; fever; sore throat; cough; fatigue; or achy feeling in the upper teeth.

Many sinus infections are caused by viruses, which don't respond to antibiotics. Using antibiotics when they are not needed can result in bacteria that are resistant to any antibiotic.

Cluster Headaches
Cluster headachesPain level: Severe
Duration: 15 minutes to 3 hours

These severe, stabbing headaches, which also run in families, occur on one side of the head, usually in or around the eye, and cause a watery eye and runny nose on the affected side. They occur in groups, or clusters, over weeks or months, and may happen multiple times in a day.

The cause of these headaches is unknown, but triggers include seasonal allergies, and nitrates found in wine, some cured meats, and aged cheeses. Inhaling smoke and consuming alcohol can make them worse. They come on suddenly and may last only a short time, sometimes not even long enough for an over-the-counter pain reliever to take effect.

As soon as a cycle starts, there are prescription medications that can reduce the frequency and duration of cluster headaches, so it's worth consulting your physician if you get them. Administering oxygen is sometimes an effective treatment for cluster headaches, but should be done the first time under supervision of a doctor. If this proves effective for the patient, oxygen may be prescribed for home use.

Most people prone to these headaches experience one or two cluster periods per year, though sometimes many years may pass between clusters.

Tension Headaches
Tension headachesPain level: Mild to moderate
Duration: 30 minutes to 7 days

This most common type of headache usually feels like mild to moderate squeezing on both sides of the head and sometimes the upper back or neck. Triggers can include stress, poor sleep, depression, and poor posture, such as slumping for hours at an office desk. Often these headaches are relieved by proper workstation ergonomics, rest, applying heat or cold to the area that hurts, or taking over-the-counter pain medicine such as ibuprofen (Advil) or acetaminophen (Tylenol).

Some tension headaches are severe and recurring. Chronic neck-muscle tension caused by stress or a traumatic event such as a car accident can be one source of these. A visit to a chiropractor or massage therapist may give temporary relief for this condition, but following self-care exercises for the neck is the best solution. "The patients of mine who do best take what they learn from therapists and apply it to themselves. The healing comes from within," says Dr. Scearce. He recommends the exercises in the book "Treat Your Own Neck" by Robin McKenzie.

Migraine Headaches
Migraine headachesPain level: Severe
Duration: Several hours to several days

Pain from migraines is often felt on one side of the head, though it can also alternate sides, or occur on both sides at once. Those suffering from migraines usually experience sensitivity to noise and light, and nausea at least some of the time. Vision changes — including blurred vision, flashes of light and color, or loss of peripheral vision — are sometimes part of a migraine, or can signal the onset of one. Vision changes usually last 10 to 30 minutes. Dr. Scearce says these changes are related to a temporary reduction in blood flow to the brain where vision is processed.

Women are more likely than men to suffer from this type of headache, and there is a genetic disposition to them. While some people are lucky enough to get only one or two migraines in their lifetime, recurring migraines are common. Those who have them frequently get to know their patterns well.

"For me it's always in exactly the same place — a piercing pain like a lance stuck through the inner corner of my left eyebrow," says Group Health member Jill Sheldon. She has connected the migraines she experiences to eating certain foods and traveling across time zones. Specific foods, lack of sleep, dehydration, and scents from perfume are all common migraine triggers. For some women, migraines are linked to monthly hormone shifts.

For patients with recurring migraines, doctors recommend keeping a headache diary noting dates of headaches, severity, and possible triggers. Sheldon, who kept such a notebook for a year and a half, learned that some of her migraines were hormonal, occurring at the same time each month. Doctors can often help prevent those headaches by prescribing a medication to take for a few days before and around the likely date of migraine onset. Starting or stopping birth control pills may also work to reduce the migraines of some patients with hormone-related headaches. Many women find relief from migraines after menopause.

Preventing Headaches

There are steps that headache sufferers can take to prevent some headaches, or shorten their duration. For example, sometimes taking prescription medications to prevent the onset of migraines or cluster headaches will help.

But the best way to manage most recurring headaches is with simple lifestyle changes. Michelle Seelig, MD, a primary care physician who sees patients at our Capitol Hill Campus in Seattle, begins by asking patients if they are eating well, sleeping enough, and getting exercise. "People agree that when they are doing these three things, their symptoms are much better controlled," she says. She also recommends stress-reduction techniques, which could include such activities as meditation, yoga, or prayer.

Dr. Scearce, who often sees patients with a long history of migraines, also believes that self-care is important to reduce the severity and number of migraine headaches. "In my view, we should first think about how we can have fewer headaches without pills," he says.

One reason to seek drug-free solutions is that nearly all prescription headache medicines have side effects. Sheldon says she stopped taking one drug because it made her depressed. Her current medication leaves her drowsy and dry-mouthed. Merrill, who would like to have children, is searching for a way to lessen her migraines without medications because those drugs can't be taken during pregnancy.

Sometimes painful and difficult-to-treat headaches are actually caused by the overuse of prescription or over-the-counter pain medications, whether the drugs were used for headaches or for pain in another part of the body. These so-called "rebound" headaches can even come from medication that was taken several days earlier. According to Dr. Scearce, it can take 6 to 12 weeks to get rid of the rebound effects of medication.

Identifying headache triggers is also a way to prevent them. "Raw onions trigger migraines for me, and red wine," says Merrill. Sheldon has eliminated a much longer list of foods including hot dogs and anything else with nitrites, bananas, citrus fruits, broad beans, and avocados.

Some migraine sufferers have found that taking regular supplements such as vitamin B2, riboflavin, and butterbur reduce the frequency of their headaches. Others, such as Sheldon, have found they experience fewer headaches when they get regular acupuncture.

Sheldon also believes that finding other headache sufferers — in her case, those who get migraines — and creating community is a good way to feel less alone with the problem. Also important, says Sheldon, is to take care of yourself on headache days. "I take it really easy instead of fighting it," she says.

A Guide to Headaches

Type & Pain Level Duration Symptoms Treatment When to See a Doctor
Moderate pain
Several daysAching pressure behind cheekbones, nose, forehead, and teeth; green or blood-tinged nasal discharge; feverOver-the-counter medication to treat pain; prescription migraine medications; antibiotics if bacterial infection is foundLack of response to treatment
Severe pain
15 minutes to 3 hoursStabbing pain on one side of head, often in or around one eye, sometimes causing redness and tearing; nausea and vomiting; runny noseOxygen, done the first time under supervision of a doctorWorsening despite treatment
Mild to moderate pain
30 minutes to 7 daysSqueezing pain felt on both sides of the headOver-the-counter pain relievers; hot or cold washcloth on foreheadIf these are chronic and interfere with your life
Severe pain
Several hours to several daysPulsing headache affecting one side of head; often nausea, vomiting, light and sound sensitivity, aurasRest in a dark room; sleep; regular habits for eating, sleeping, and exercise for prevention; prescription medication for pain and preventionLack of response to treatment
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