The principle subject of this month’s issue is headaches, their categorization, descriptions, and treatment. We will focus on the chronic types: migraine, tension, and cluster headaches.
First off, as emphasized in the past, I am not a physician; therefore, the following information should be read with that in mind. It is information only. Secondly, the text that follows deals in some detail only with headaches and relevant medications; while recognizing that there are numerous other avenues of attack; including accupressure, accupuncture, herbal treatment, biofeedback, exercise (that’s right, our universal health improvement method; although it can also cause headaches for some people), various homeopathic measures, witchcraft, voodoo, and others.
As many of you know, in the past, it was commonly thought that many headaches were psychological – caused by stress. It now seems clear that stress may contribute to the intensity of a headache, but is not the cause. The causes are real, physical events. It is thought that the genetic X-Factor is a significant component of chronic headaches – brain chemistry and nerve paths. According to current thought, migraine and tension headaches, the most common types, are caused by an insufficiency of seratonin (a neurotransmitter, which is a significant component of communication between brain cells) during surges in its level, which are in response to certain triggers (see Note 1). Among other things, it plays a significant role in contracting and expanding blood vessels, and dilation of blood vessels is thought to be the cause of headache pain .
Note 1 – Headache “triggers” may be certain foods, environmental conditions (like heat, cold, noise, etc.), bright lights, head trauma, motion (as on a car or roller coaster ride, for example), fatigue; almost anything.
I once had a wife who had migraines, and I have to admit that I thought they were psychological phenomena. Now I understand more about the genetic reality of migraines, but, regardless of the cause, it has always been clear that the pain involved could be debilitating. My own experiences with headaches have been few and easily cured by aspirin, so it took me awhile to understand the enormity of chronic headaches, including migraines.
Headaches are a little like arthritis in the sense that there are many types, but we will focus mainly on three common chronic types: migraine, stress, and cluster headaches. Importantly enough as that being said also headaches like arthritis may be relieved with TENS devices such as Pain Gone pen device but we will get back to that later down the road. Migraine headaches are normally a product of one’s genetic inheritance, and occur more often in women than men. Symptoms are usually throbbing or aching pain, often on one side of the head, and often accompanied by nausea, maybe throwing up, and maybe visual abnormalities or dizziness. Some sufferers get an “aura.” An aura is a shimmering light, or colors; or some other visual oddities. With an aura, you have a “classic” migraine; without one, you just get credit for a “common” migraine. [Now everyone who gets a headache will see an aura. Who wants to be common?]
Tension headaches are the most common type. This type of headache results from contraction of the muscles in one’s head and neck, which causes the blood vessels in the head to expand, often resulting in a feeling of pain on each side of the head – like it’s being squeezed in a vice. If chronic, it is now thought that these headaches, like migraines, are genetically influenced. As with migraines, tension headaches can be intensified by overuse of over-the-counter (OTC) drugs.
Cluster headaches occur most often in men, and are characterized by excruciating pain in an eye or a temple, and last from 15 minutes to an hour or more. They occur in waves lasting weeks to months, and occurring once or twice a year.
Let’s be a bit more specific about how a headache happens. When a headache hits, it can be triggered (see footnote 1, page 1) by a number of factors. These triggers act upon people with a genetic disposition toward irregular serotonin control. It is thought that a trigger causes a wave of electrical activity to spread through the brain. Then the serotonin level surges (kind of a wave action). A result is that decreases in seratonin (at the ebb) cause blood vessels to become irritated, and maybe the trigeminal nerve (a major nerve in the brain/face) as well. The result is PAIN.
This leads us to the next step, which is how to ease or prevent the pain.
First, a word of warning. Many sufferers of chronic headaches increase their susceptibility by over-medicating, which can lead to rebound headaches. Rebound headaches are more frequent headaches which are the result of too much pain relief medication; where “too much” can be the amount of caffeine contained in three or four cups of coffee per day, or in more than twice-weekly doses of pain relievers or decongestants; or even two aspirins a day and some caffeine. The trick is to use medications sparingly (i.e., tolerate as much pain as you can). It is ironic that a person may find that something like Aleve, Advil, aspirin, or Tylenol may effectively reduce headache pain, which can lead to more frequent use, which may then cause more frequent headaches. And, for whatever reason, the medication of choice tends to become less effective, causing one to increase the frequency of its use – kind of an endless circle. This just isn’t fair!
A reasonable beginning approach to fighting a headache is be to try one of the following (actually, maybe all of them):
- Try a relaxation technique, like deep breathing, or Yoga (you may have to consult Lilias for that);
- Try something with caffeine in it – coffee, soft drink, caffeine tablet, or ??
- Try aspirin, ibuprofen (like Advil, for instance), or acetaminophen – but not more than twice a week (avoid the rebound).
- Use ice packs wherever you are hurting; ice can be very effective.
- Try to rest or sleep in a dark, quiet room.
Note that exercise – aerobic exercise, done for thirty minutes, five times a week, may help prevent headaches (probably the endorphins released that tend to promote a sense of well-being).
More about caffeine. Sometimes taking a little caffeine will help fight off a migraine before it reaches full force. This strategy tends to work especially for someone who does not consume caffeine-containing products on days that are headache-free. Caffeine may help because it constricts dilated blood vessels, which might cause the pain. It is essential to heed the warning that excessive caffeine consumption can exacerbate a headache problem; a double-edged sword, as it were.
Now let’s address OTC pain relievers. If none of the previous strategies have worked, an OTC medication may help; again, it’s more likely to be effective if taken early in the development of pain. The list of the most effective OTC products includes:
- Excedrin Extra-Strength is an effective choice, but contains enough caffeine that it can cause rebound headaches.
- Aleve – previously discussed in the September 1995, issue of the MAF FITNESS NEWSLETTER, on page 12.
- Ibuprofen (e.g., Advil, Motrin, Nuprin, _ _ _), an inexpensive nonsteroidal, anti-inflammatory category of drugs known as NSAIDs. These drugs can be fairly effective against tension and migraine headaches, and are reasonably well tolerated, but gastrointestinal upset is not uncommon. This class of drugs may be more effective when caffeine is taken at the same time.
- Aspirin-Free Excedrin is less effective than Excedrin Extra-Strength, but it might be a good choice for those who don’t tolerate aspirin very well.
- Aspirin can be a good choice, but one has to be aware of the possible side-effects. It should be avoided for those who are pregnant, or have gastritis or ulcers. There are other side effects as well; like its blood thinning properties (which you may or may not want), it can cause liver damage, and, in high doses, kidney irritation.
- Anacin is less effective than Excedrin Extra-Strength, but it is less likely to cause sideeffects or rebound headaches (that is a side-effect, isn’t it?).
- Acetaminophen is less effective than aspirin-containing products, but may be useful for minor headaches, and without aspirin’s side-effects.
More on Migraines
So far, we have discussed mainly remedies for milder headaches. But, what if you are dealing with serious migraines? You may first try some of the options already discussed, but if they are ineffective, you will need to go to the next level, with a doctor’s help. There are two approaches to treating migraines: preventive, and eliminating one in progress. We will address in-progress treatment first.
Stopping a Migraine
In the event that one is getting a migraine, and non-drug therapy, as well as OTC medication, has failed to bring relief; a step up to the next level (prescription drugs) is in order. Ordinarily a physician will start by prescribing drugs that are only moderately stronger than OTC medications – this to avoid as many side-effects as possible. These include:
- Midrin is relatively safe and effective. So much so that it may be given to children as young as 5 years old. It can cause fatigue, and those with high blood pressure should avoid it.
- Norgesic Forte is a fairly potent non-addictive drug for stopping a migraine. But it has a high aspirin content, so it may cause stomach problems for some people.
- Butalbital compounds are all potentially addictive, but are considered safe when not overused.
If the above medications are ineffective, or are inappropriate for one’s use, the next group of medications from which a physician most likely will make a recommendation include:
- Sumatriptan (Imtrex), which is very effective, but also expensive ($34 a shot – literally, it must be taken by injection). But, at least the side effects seem pretty benign – sometimes nausea. The medication comes packaged for easy self-injection. This med also comes in pill form, which is less effective than the injection version (wouldn’t you know it?). In addition to being more effective, the injection version also works faster – as little as 10 minutes, as opposed to an hour for the pill form. Unfortunately, use of this drug can cause rebound headaches. Also, it is not a good choice for children; pregnant or nursing women; people with liver, kidney or heart disease; or those over age 60.
- DHE, or Dihydroergotamine, if you prefer. This is another of those injection meds, but you have to use a regular syringe, and load it yourself. It does not come in an easy applicator like Sumatriptan. It is, however, well-tolerated, and effective, but not as effective as Sumatriptan. But it lasts longer and does not cause rebound headaches. It should not be taken by those who are pregnant, have uncontrolled hypertension, poor circulation of the hands or feet, or are over age 60.
- Ergotamines can be effective, but they can cause several side-effects. Among them: nausea and anxiety. They can cause serious rebound headaches; and people over 40 probably shouldn’t use them – they can cause heart attacks.
- Pain gone pen can be really effective but you should find more details about it before deciding should you use it or not.
- Corticosteroids come in either pill or injection form, and is particularly effective with severe migraines and menstrual migraines, but must be taken only in small doses and for short periods of time. Extended use can cause several severe side-effects, like: liver failure, weight gain, adrenal gland suppression, and predisposition to fractures.
- Narcotics and sedatives are more-or-less a last resort if nothing else has worked. Doctors may wish to avoid prescribing drugs from this group because of the obvious possible addiction problem.
Antinausea medication may be needed, because nausea may result from the headache itself, or from an anti-pain medication. This category of drugs is available in pill form, as suppositories, or in injection form. Effectiveness increases as you go from pill, to suppository, to injection form. Without a prescription, one can try OTC antacids, vitamin B6, or Emetrol. Phenergan is an effective drug, which has what may be a good side-effect, which is that it may put you to sleep. There are many more drugs in this category, but rather than try to list them all, I will leave that to your doctor.
Preventing a Migraine
We have discussed “triggers” already, but it should be emphasized that emotions – stress, worry, depression, etc. can also act as triggers. It has been mentioned that emotions don’t cause migraines, but they can trigger them. One’s emotional state may be the biggest factor in whether migraines start or not. It is, therefore, essential to maintain good emotional balance, even if that means psychotherapy. Foods are often mentioned as significant triggers, but their importance pales in the face of stress and biochemical imbalances.
If all else has failed, one may decide to turn to a preventive medication, with a physician’s assistance, of course. That is almost a superfluous statement since the drugs can only be obtained through a prescription. Under the following circumstances, you may choose to follow this path:
- You get moderate to severe migraines more than three times per month, or:
- Migraine relief has so far failed, or:
- The frequency/intensity of your migraines is adversely affecting your quality of life, or:
- You are willing to play “human guinea pig” by taking daily doses of medications, suffer the possible side-effects, and change drugs often in a search for “the right stuff.”
The following medications probably won’t eliminate your migraines, but should improve the quality of your life:
- Antidepressants are used not for their psychological affect, but because they affect serotonin. Because many of them affect the heart, they may be inappropriate for the elderly.
- Beta Blockers are a group of medications which prevent blood vessel dilation. They can be a good choice for those with hypertension because, as well as fighting a headache, they help lower blood pressure. They may contribute to weight gain (some would consider that worse than the headache), depression, higher cholesterol levels, and other unpleasantries. Inderal may be the most commonly prescribed medication in this group. It is usually not prescribed for those with asthma or congestive heart failure.
- NSAIDs can be very effective at preventing migraines, but frequently cause gastrointestinal problems as well.
- Calcium Blockers are not among the most effective, but have few side-effects; therefore, are a reasonable choice for some.
For those who still haven’t found relief, a doctor might prescribe combinations of previously identified medications; or Depacote, which can be very helpful, but should not be used by those with liver problems.
As a last resort, there is a group of drugs called “MAO inhibitors” (like Nardil). These drugs are helpful for both migraines and simple daily headaches. While these drugs can be very helpful, along with the drugs comes a long list of foods and other drugs to avoid when taking them. It is too long to include here – your doctor will help you. Some of you may want to die before giving up some of the recommended list . This is as far as I am willing to go on migraine prevention. The next step may require hospitalization.
More on Tension Headaches
These headaches, usually milder than migraines may actually just be a mild migraine. Researchers aren’t sure yet. They can usually be successfully treated with an OTC. These headaches, like migraines, have a genetic connection.
Try these treatments first:
- Relaxation techniques, such as deep breathing, Yoga, etc.
- Apply ice to the point of pain
- Tolerate the pain as much as you can
The initial choices of a medication will come from the following list, which is very similar to that for migraines:
- Acetaminophen is less effective than aspirin, but easier to tolerate, but can cause rebound headaches.
- Aspirin – see previous description.
- Aleve is a very effective anti-inflammatory, but can cause stomach upset and nausea.
- Aleve is a very effective anti-inflammatory, but can cause stomach upset and nausea.
- Ibuprofen (e.g., Motrin, Advil, Nuprin) – maybe about the same effectiveness as aspirin, and stomach upset can be expected.
- Caffeine – same as for migraine
- Naproxin requires a prescription, but effective as an anti-inflammatory, and may be enhanced with caffeine. Nausea and stomach upset may be expected.
- Midrin (prescription only) is effective and safe, but fatigue and stomach upset are common.
- Norgesic Forte is a strong non-addicting abortive medication for tension and migraine headaches.
The next level of meds for aborting tension headaches includes:
- Butalbital Compounds like Esgic are effective, but are addictive – use sparingly.
- Narcotics, like codeine, These are last-resort meds, for obvious reasons.
- Sedatives, like Valium, are habit-forming and often cause sedation. You are in really bad shape if you are using narcotics or sedatives, and must be working closely with a doctor.
If you are at this level, you must realize that your goal must be to live with some level of pain, with minimal side effects. You will begin this phase of headache treatment by trying to find something acceptable from the following:
- Antidepressants are the primary choice for daily headaches, not so much for depression, as for impact on serotonin.
- NSAIDs are not as effective as antidepressants, but are without all of their side effects – especially sedation.
The next level of medications for preventing tension headaches includes:
- Beta Blockers – previously discussed.
- Muscle Relaxants
- Calcium Blockers
The final set of meds for preventing tension headaches, when all else fails, are:
- Take two preventive medications (e.g., a tricyclic antidepressant with an NSAID or a beta blocker; or amitriptyline with propranolol).
- MAO Inhibitors – previously described
- Tranquilizers, Amphetamines, and Narcotic Opioids are lumped together here as a group of dangerous choices that you and your doctor might want to discus as a real last act of desperation.
More on Cluster Headaches
Initial treatment for cluster headaches is almost exclusively limited to medications because of the intense pain associated with them, but some people find use of simple ice packs, or sometimes heat, to be of some help.
Typically, people who get cluster headaches will initially look into the following drugs (again, this is in conjunction with a physician):
- Oxygen is effective in roughly 80% of cases, the equipment (oxygen tank and mask) can be rented – hospitalization is not required.
- Imitrex – previously described on page 5.
- DHE is also described on page 5.
In the event that no relief is found from any of those, it is time to step up to:
- Pain Relievers, including OTC meds, and just about everything mentioned so far, including narcotics.
- Lidocaine Nasal Spray may be suggested, in combination with other options.
- Ketorolac Injections are about $10 apiece, but are an effective and a fast-acting anti-inflammatory. It is nonsedating and nonaddictive, and can be obtained in pill form, but which is less effective.
- Antinausea Medications – described on page 6.
Prevention may be taking a medication only during flareups (clusters of headaches), or it may be more expedient to take them everyday, all year.
Your initial choice of medication will likely be selected from the following:
- Cortisone is effective, but side effects are virtually assured. This med may be taken for only a short time during the peak of an episode.
- Verapamil is a calcium blocker with few side effects.
- Lithium can be effective for either episodic or chronic clusters, and is commonly combined with another med.
If you need to escalate your war on clusters, you will select from the following:
- Sansert is more effective for episodic, rather than chronic clusters. It does, however, have several side effects, like dizziness, leg cramps, and nausea. Not recommended for those over age 45, or those who are pregnant.
- Depakote may be useful, but it has a number of ugly side effects.
- Ergotamines may be effective, but should only be used in short term situations – as during an episode; otherwise rebound headaches and other side effects can develop.
- Ergonovine is less effective than Sansert, but with fewer side effects.
The last line of defense consists of the following:
- IV DHE can work quickly, and may be particularly good for mitigating cluster headaches while you are looking for an effective preventive med.
- Cocaine Solution is a last resort option.
Headaches and Adolescents Over Age 11
Kids at this age should be encouraged to use relaxation techniques in preference to medications, but, admittedly, they are unlikely to stick with this method, or biofeedback, another preferred headache strategy – albeit one that can be expensive because of the need for this to be done in a doctor’s office.
Most adolescents can get by without preventive meds, but abortive meds may be useful. However, to avoid the now famous “rebound” headache, preventive meds may occasionally be justified.
Adolescents who get migraine headaches may need antinausea medication, just like adults. And both adolescents and adults should always take any medications with food.
Tension Headache Prevention
- Anti-inflammatories – Naproxen or Ibuprofen may be effective and are well tolerated.
- Antidepressants are ordinarilly safe for long-term use, but only in low doses.
- Beta Blockers can be useful, but their are nasty side effects.
- Anti-inflammatories are the first choice.
- Tricyclic antidepressants
- Beta Blockers
- Combinations from groups one and two.
- Nardil an MAO inhibitor
- IV DHE
Following is a list of a few “other” types of headaches, accompanied by their most common medications:
- Post-trauma headaches are treated initially by anti-inflammatories like aspirin or ibuprofen.
- Exercise headaches – yes, it can happen – are likely to respond to NSAIDs.
- Spinal Tap headaches respond, for most people, to analgesics, like aspirin.
- Sinus headaches may actually be some other kind, but; if you have one, ant-biotics are probably in order, or OTC sinus meds may work.
- Allergy headaches may require prescription nasal sprays or antihistamines.
- Eyestrain headaches can be attacked with the same meds used for tension headaches, and you might want to get an eye test as well.
Note that many of the prescription medications mentioned above can be prepared by your pharmacist in lozenge, suppository, or nasal spray form, on request. This is, of course, instead of its normal form – usually a pill.
Twelve million Americans suffer from migraine headaches, or “hemicrania.” Migraines are caused by the inability of the blood vessels in the membrane covering the brain to expand and contract at uniform rates. When the velocity of blood increases through the larger vessels, the pressure on the smaller ones causes painful stretching as they unsuccessfully attempt to accommodate the heavier flow. As the arterial system undergoes this general spasmatic stretching and constricting, the nerve cells register an incessant throbbing, sometimes pounding pain, often accompanied by nausea, distortions of speech, hearing, and vision, and clamminess of the skin.
Common triggers of migraine include stress, menstruation, use of oral contraceptives, and certain allergenic foods. Pain-killers (such as aspirin) are the most widely prescribed drugs, though anti-inflammatory drugs, narcotics, and various “channel-blocking” agents can also be useful. These drugs reduce both the frequency and severity of attacks in many people, but none actually prevents the attacks. Migraine is known to run in families, though the genetic origins have not yet been successfully isolated.
A number of research projects involving experimental preventive measures have been reported in the current medical literature. Some of these experiments may prove to be helpful either in reducing the risk of migraine, or perhaps preventing it altogether: (1) a strict regimen of vitamin B therapy; (2) eating a good breakfast (including yogurt, but excluding citrus fruits); (3) taking an aspirin tablet every other day; (4) avoiding carbohydrates (milk and peas in particular), and such allergenic foods as chocolate, red wine, and aged cheeses; (5) discontinued use of oral contraceptives; (6) application of acupuncture and acupressure; and (7) effects of biofeedback training.
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Buring and others, 1995. Migraine and subsequent risk of stroke in the Physicians’ Health Study. Archives of Neurology (February 1995), volume 52(2), pages 129-134.
Edmeads, 1989. Four steps in managing migraine. Postgraduate Medicine (May 1, 1989), volume 85(6), pages 121-4, 127-8, 131-4.
Grazzi and Bussone, 1993. Effect of biofeedback treatment on sympathetic function in common migraine and tension-type headache. Cephalalgia (June 1993), volume 13(3), pages 197-200.
Hesse, Mogelvang, and Simonsen, 1994. Acupuncture versus metoprolol in migraine prophylaxis: a randomized trial of trigger point inactivation. Journal of Internal Medicine (May 1994), volume 235(5), pages 451-456.
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Montastruc and Senard, 1992. Calcium channel blockers and prevention of migraine. Pathologie Biologie (April 1992), volume 40(4), pages 381-8.
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Sheftell, Weeks, Rapoport, Siegel, Baskin, and Arrowsmith, 1994. Subcutaneous sumatriptan in a clinical setting: the first 100 consecutive patients with acute migraine in a tertiary care center. Headache (February 1994), volume 34(2), pages 67-72.
Shimell, Fritz, and Levien, 1990. A comparative trial of flunarizine and propranolol in the prevention of migraine. South African Medical Journal (January 20, 1990), volume 77(2), pages 75-7.
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The information above is provided solely for your education and enrichment. It should NOT be relied upon for personal diagnosis, treatment, or any other medical purpose. If you believe that a particular therapy applies to YOU, please contact your doctor before trying it.