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Headache
Hope
Through Research
Table
of Contents
For
2 years, Jim suffered the excruciating pain of cluster headaches.
Night after night he paced the floor, the pain driving him to
constant motion. He was only 48 years old when the clusters
forced him to quit his job as a systems analyst. One year later,
his headaches are controlled. The credit for Jim's recovery
belongs to the medical staff of a headache clinic. Physicians
there applied the latest research findings on headache, and
prescribed for Jim a combination of new drugs.
- * Joan was a
victim of frequent migraine. Her headaches lasted 2 days.
Nauseous and weak, she stayed in the dark until each attack
was over. Today, although migraine still interferes with her
life, she has fewer attacks and less severe headaches than
before. A specialist prescribed an antimigraine program for
Joan that included improved drug therapy, a new diet and relaxation
training.
* An avid reader, Peggy couldn't put down the new mystery
thriller. After 4 hours of reading slumped in bed, she knew
she had overdone it. Her tensed head and neck muscles felt
as if they were being squeezed between two giant hands. But
for Peggy, the muscle-contraction headache and neck pain were
soon relieved by a hot shower and aspirin.
An estimated 40 million
Americans experience chronic headaches. For at least half of
these people, the problem is severe and sometimes disabling.
It can also be costly: headache sufferers make over 8 million
visits a year to doctor's offices. Migraine victims alone lose
over 64 million workdays because of headache pain.
Understanding why
headaches occur and improving headache treatment are among the
research goals of the National Institute of Neurological and
Communicative Disorders and Stroke (NINDS). As the focal point
for brain research in the Federal Government, the NINDS also
supports and conducts studies to improve the diagnosis of headaches
and to find ways to prevent them.
Some headaches require
prompt medical attention.
What hurts when you
have a headache? Several areas of the head can hurt, including
a network of nerves which extends over the scalp and certain nerves
in the face, mouth, and throat. Also sensitive to pain, because
they contain delicate nerve fibers, are the muscles of the head
and blood vessels found along the surface and at the base of the
brain.
The bones of the
skull and tissues of the brain itself, however, never hurt,
because they lack pain-sensitive nerve fibers.
The ends of these
pain-sensitive nerves, called nociceptors, can be stimulated
by stress, muscular tension, dilated blood vessels, and other
triggers of headache. Once stimulated, a nociceptor sends a
message up the length of the nerve fiber to the nerve cells
in the brain, signaling that a part of the body hurts. The message
is determined by the location of the nociceptor. A person who
suddenly realizes "My toe hurts," is responding to
nociceptors in the foot that have been stimulated by the stubbing
of a toe.
A number of chemicals
help transmit pain-related information to the brain. Some of
these chemicals are natural painkilling proteins called endorphins,
Greek for "the morphine within." One theory suggests
that people who suffer from severe headache and other types
of chronic pain have lower levels of endorphins than people
who are generally pain free.
Not all headaches require
medical attention. Some result from missed meals or occasional
muscle tension and are easily remedied. But some types of headache
are signals of more serious disorders such as head injury and
call for prompt medical care. These include:
- Sudden, severe
headache
- Headache associated
with convulsions
- Headache accompanied
by confusion or loss of consciousness
- Headache following
a blow on the head
- Headache associated
with pain in the eye or ear
- Persistent headache
in a person who was previously headache free
- Recurring headache
in children
- Headache associated
with fever
- Headache which
interferes with normal life
A headache sufferer
usually seeks help from a family practitioner. If the problem
is not relieved by standard treatments, the patient may then
be referred to a specialist--perhaps an internist or neurologist.
Additional referrals may be made to psychologists.
Diagnosing a headache
is like playing Twenty Questions. Experts agree that a detailed
question-and-answer session with a patient can often produce enough
information for a diagnosis. Many types of headaches have dear-cut
symptoms which fall into an easily recognizable pattern.
A medical history
often provides a physician with enough clues about a patient's
headaches to make a diagnosis.
Patients may be asked:
How often do you have headaches? Where is the pain? How long
do the headaches last? When did you first develop headaches?
The patient's sleep
habits and family and work situations may also be probed.
Most physicians will
also obtain a full medical history from the patient, inquiring
about past head trauma or surgery and about the use of medications.
A blood test may be ordered to screen for thyroid disease, anemia,
or infections which might cause a headache. X rays may be taken
to rule out the possibility of a brain tumor or blood clot.
A test called an
electroencephalogram (EEG) may be given to measure brain
activity. EEG's can indicate a malfunction in the brain, but
they cannot usually pinpoint a problem that might be causing
a headache. A physician may suggest that a patient with unusual
headaches undergo a computed tomographic (CT) scan. The
CT scan produces images of the brain that show variations in
the density of different types of tissue. The scan enables the
physician to distinguish, for example, between a bleeding blood
vessel in the brain and a brain tumor. The CT scan is an important
diagnostic tool in cases of headache associated with brain lesions
or other serious disease. Experts generally agree, however,
that this sophisticated and expensive technology is not required
to diagnose simple or periodic headache.
An eye exam is usually
performed to check for weakness in the eye muscle or unequal
pupil size. Both of these symptoms are evidence of an aneurysm--an
abnormal ballooning of a blood vessel. A physician who suspects
that a headache patient has an aneurysm may also order an angiogram.
In this test, a special fluid which can be seen on an X ray
is injected into the patient and carried in the bloodstream
to the brain to reveal any abnormalities in the blood vessels
there.
Thermography,
an experimental technique for diagnosing headache, promises
to become a useful clinical tool. In thermography, an infrared
camera converts skin temperature into a color picture or thermogram
with different degrees of heat appearing as different colors.
Skin temperature is affected primarily by blood flow. Research
scientists have found that thermograms of headache patients
show strikingly different heat patterns from those of people
who never or rarely get headaches.
Scientists at this
clinic use thermography to diagnose headache. An infrared camera
converts skin temperature, which is influenced by blood flow,
into a color picture or thermogram. Each type of headache produces
a distinctive heat pattern on a thermogram, so investigators
can "see" their patients' headaches in living color.
A physician analyzes
the results of all these diagnostic tests along with a patient's
medical history in order to arrive at a diagnosis.
Headaches are diagnosed
as:
- Vascular
- Muscle contraction
- Traction
- Inflammatory
Vascular headaches--a
group that includes the well-known migraine--are so named because
they are thought to involve abnormal function of the brain's
blood vessels or vascular system. Muscle contraction headaches
appear to involve the tightening or tensing of facial and neck
muscles. Traction and inflammatory headaches are symptoms of
other disorders, ranging from stroke to sinus infection. Some
people have more than one. type of headache.
The most common type
of vascular headache is migraine. Migraine headaches are usually
characterized by severe pain on one or both sides of the head,
an upset stomach, and at times disturbed vision.
Basketball star Kareem
Abdul-Jabbar remembers experiencing his first migraine at age
14. The pain was unlike the discomfort of his previous mild
headaches.
"When
I got this one I thought, 'This is a headache'," he says.
"The pain was intense and I felt nausea and a great sensitivity
to light. All I could think about was when it would stop. I
sat in a dark room for an hour and it passed."
Basketball star and
migraine sufferer Kareem Abdul-Jabbar (holding a ball) has played
some of his best games after overcoming headache attacks.
Abdul-Jabbar's sensitivity
to light is a standard symptom of the two most prevalent types
of migraine-caused headache: classic and common.
The major difference
between the two types is the appearance of neurological symptoms
10 to 30 minutes before a classic migraine attack. These symptoms
are called an aura. The person may see flashing lights
or zigzag lines, or may temporarily lose vision. Other classic
symptoms include speech difficulty, weakness of an arm or leg,
tingling of the face or hands, and confusion.
The pain of a classic
migraine headache is described as intense, throbbing, or pounding
and is felt in the forehead, temple, ear, jaw, or around the
eye. Classic migraine starts on one side of the head but may
eventually spread to the other side. An attack lasts 1 to 2
pain-wracked days.
If you were about
to experience a classic migraine headache, you might find it
difficult to read this pamphlet. You could lose part of your
vision temporarily and see zigzag lines and black dots. Such
visual problems--and other neurological symptoms--often precede
classic migraine.
Migraines involve
blood flow changes in the brain.
The common migraine--a
term that reflects the disorder's greater occurrence in the
general population--is not preceded by an aura. But some people
experience a variety of vague symptoms beforehand, including
mental fuzziness, mood changes, fatigue, and unusual retention
of fluids. During the headache phase of a common migraine, a
person may have diarrhea and increased urination, as well as
nausea and vomiting. Common migraine pain can last 3 or 4 days.
Both classic and
common migraine can strike as often as several times a week,
or as rarely as once every few years, Both types can occur at
any time. Some people, however, experience migraines at predictable
times -near the days of menstruation or every Saturday morning
after a stressful week of work.
Research scientists
are unclear about the precise cause of migraine headaches. There
seems to be general agreement, however, that a key element is
blood flow changes in the brain. People who get migraine headaches
appear to have blood vessels that overreact to various triggers.
Scientists have devised
one theory of migraine which explains these blood flow changes
and also certain biochemical changes that may be involved in
the headache process. According to this theory, the nervous
system responds to a trigger such as stress by creating a spasm
in the nerve-rich arteries at the base of the brain. The spasm
closes down or constricts several arteries supplying blood to
the brain, including the scalp artery and the carotid or neck
arteries.
As these arteries
constrict, the flow of blood to the brain is reduced. At the
same time, blood-clotting particles called platelets clump together--a
process which is believed to release a chemical called serotonin.
Serotonin acts as a powerful constrictor of arteries, further
reducing the blood supply to the brain.
Reduced blood flow
decreases the brain's supply of oxygen. Symptoms signaling a
headache, such as distorted vision or speech, may then result,
similar to symptoms of stroke.
One theory of the
migraine process: (a) a patient's nervous system responds to
a trigger such as stress by creating a spasm in the arteries
at the base of the brain. The spasm and the release of serotonin
reduce blood flow to the brain. Blood-borne oxygen is decreased,
causing the "aura" of neurological symptoms; (b) arteries
in and around brain tissue then dilate or widen to meet the
brain's energy and oxygen needs. Pain-producing chemicals are
released and nerve endings on the scalp are stimulated. The
patient then feels a throbbing pain in the head.
Reacting to the reduced
oxygen supply, certain arteries within the brain open wider
to meet the brain's energy needs. This widening or dilation
spreads, finally affecting the neck and scalp arteries. The
dilation of these arteries triggers the release of pain-producing
substances called prostaglandins from various tissues and blood
cells. Chemicals which cause inflammation and swelling, and
substances which increase sensitivity to pain are also released.
The circulation of these chemicals and the dilation of the scalp
arteries stimulate the pain-sensitive nociceptors. The result,
according to this theory: a throbbing pain in the head.
Although boys and girls
seem to be equally affected by migraine, the condition is more
common in adult women than in men. Both sexes may develop migraine
in infancy, but most often the disorder begins between the ages
of 5 and 35.
The relationship
between female hormones and migraine is still unclear. Women
may have "menstrual migraine"--headaches around the
time of their menstrual period--which may disappear during pregnancy.
Other women develop migraine for the first time when they are
pregnant. Some are first affected after menopause.
The effect of oral
contraceptives on headaches is perplexing. Scientists report
that some migrainous women who take birth control pills experience
more frequent and severe attacks. However, a small percentage
of women have fewer and less severe migraine headaches when
they take birth control pills. And normal women who do not suffer
from headaches may develop migraines as a side effect when they
use oral contraceptives. Investigators around the world are
studying hormonal changes in migrainous women in the hope of
identifying the specific ways these naturally occurring chemicals
cause headaches.
The existence of a
migraine personality is a controversial theory which suggests
that migraine patients are compulsive, rigid, and perfectionistic.
Most scientists believe, however, that not all migraine patients
have these traits and that not all individuals with these personality
characteristics have migraine.
"Migraine
is triggered by things that are not so terrible."
Rather than focusing
on character traits, says one headache specialist, it would
be better to view people who get migraines as having an inherited
abnormality in the regulation of blood vessels. Many sufferers
have a family history of migraine, but the exact hereditary
nature of this condition is still unknown.
"It's like a
cocked gun with a hair trigger," explains the specialist.
"A person is born with a potential for migraine and the
headache is triggered by things that are really not so terrible."
These triggers include
stress and other normal emotions, as well as biological and
environmental conditions. Fatigue, glaring or flickering lights,
the weather, and even certain foods can set off migraine. It
may seem hard to believe that eating such seemingly harmless
foods as yogurt, nuts, and lima beans can result in a painful
migraine headache. However, some scientists believe that these
foods and several others contain chemical substances such as
tyramine which constrict arteries--the first step of the migraine
process. Other scientists believe that foods cause headaches
by setting off an allergic reaction in susceptible people.
While a food-triggered
migraine usually occurs soon after eating, other triggers may
not cause immediate pain. Scientists report that people can
develop migraine not only during a period of stress but also
afterwards when their vascular systems are still reacting. The
"Preacher Monday-Morning Headache" is named for those
clergymen who get migraines a day after the stress of delivering
a Sunday sermon. Migraines that wake people up in the middle
of the night are also believed to result from a delayed reaction
to stress.
In addition to classic
and common, migraine headache can take several other forms: Patients
with hemiplegic migraine have temporary paralysis on one
side of the body, a condition known as hemiplegia. Some people
may experience vision problems and vertigo--a feeling that the
world is spinning. These symptoms begin 10 to 90 minutes before
the onset of headache pain.
In ophthalmoplegic
migraine, the pain is around the eye and is associated with
a droopy eyelid, double vision, and other sight problems.
Basilar artery
migraine involves a disturbance of a major brain artery.
Preheadache symptoms include vertigo, double vision, and poor
muscular coordination. This type of migraine occurs primarily
in adolescent and young adult women and is often associated
with the menstrual cycle.
Benign exertional
headache is brought on by running, lifting, coughing, sneezing,
or bending. The headache begins at the onset of activity, and
pain rarely lasts more than several minutes.
Status migrainosus
is a rare and severe type of migraine that can last 72 hours
or longer. The pain and nausea are so intense that people who
have this type of headache must be hospitalized. The use of
certain drugs can trigger status migrainosus. Neurologists report
that many of their status migrainosus patients were depressed
and anxious before they experienced headache attacks.
Headache-free
migraine is characterized by such migraine symptoms as visual
problems, nausea, vomiting, constipation, or diarrhea. Patients,
however, do not experience head pain. Headache specialists have
suggested that unexplained pain in a particular part of the
body, fever, and dizziness could also be possible types of headache-free
migraine.
During the Stone Age,
pieces of a headache sufferer's skull were cut away with flint
instruments to relieve pain. Another unpleasant remedy used in
the British Isles around the ninth Century involved drinking "the
juice of elderseed, cow's brain, and goat's dung dissolved in
vinegar." Fortunately, today's headache patients are spared
such drastic measures.
Common sense rather
than scientific discovery was the basis of many early migraine
remedies. This 19th century French cartoon shows a family responding
to the needs of a migraine sufferer by creating a dark, quiet
atmosphere.
Drug therapy, biofeedback
training, stress reduction, and elimination of certain foods
from the diet are the most common methods of preventing and
controlling migraine and other vascular headaches. Joan, the
migraine sufferer, was helped by treatment with a combination
of an antimigraine drug and diet control.
Regular exercise,
such as swimming or vigorous walking, can also reduce the frequency
and severity of migraine headaches. Joan found that yoga and
whirlpool baths helped her relax.
During a migraine
headache, temporary relief can sometimes be obtained by using
cold packs or by pressing on the bulging artery found in front
of the ear on the painful side of the head.
There are two ways to
approach the treatment of migraine headache with drugs: prevent
the attacks, or relieve symptoms after the headache occurs.
With biofeedback,
migraine may become less frequent.
For infrequent migraine,
drugs can be taken at the first sign of a headache in order
to stop it or to at least ease the pain. People who get occasional
mild migraine may benefit by taking aspirin or acetaminophen
at the start of an attack. Aspirin raises a person's tolerance
to pain and also discourages clumping of blood platelets. Small
amounts of caffeine may be useful if taken in the early stages
of migraine. But for most migraine sufferers who get moderate
to severe headaches, and for all cluster patients, stronger
drugs may be necessary to control the pain.
One of the most commonly
used drugs for the relief of classic and common migraine symptoms
is ergotamine tartrate, a vasoconstrictor which helps counteract
the painful dilation stage of the headache. For optimal benefit,
the drug is taken during the early stages of an attack. If a
migraine has been in progress for about an hour and has passed
into the final throbbing stage, ergotamine tartrate will probably
not help.
Because ergotamine
tartrate can cause nausea and vomiting, it may be combined with
antinausea drugs. Research scientists caution that ergotamine
tartrate should not be taken in excess or by people who have
angina pectoris, severe hypertension, or vascular, liver, or
kidney disease.
Patients who are
unable to take ergotamine tartrate may benefit from other drugs
that constrict dilated blood vessels or help reduce blood vessel
inflammation.
For headaches that
occur three or more times a month, preventive treatment is usually
recommended. Drugs used to prevent classic and common migraine
include methysergide maleate, which counteracts blood vessel
constriction, propranolol, which stops blood vessel dilation,
and amitriptyline, an antidepressant.
In a study of propranolol,
amitriptyline, and biofeedback conducted by the Houston Headache
Clinic, scientists found that migraine patients improved most
on a combination of propranolol and biofeedback. Patients who
had mixed migraine and muscle-contraction headaches received
the greatest benefit from a combination of propranolol, amitriptyline,
and biofeedback.
Another recent study
showed that propranolol may continue to prevent migraine headaches
even after patients have stopped taking the drug. The scientists
who conducted the study speculate that long-term therapy with
propranolol may have a. lasting effect on blood vessels, training
them to react less than usual to the triggers of migraine.
Antidepressants called
MAO inhibitors also prevent migraine. These drugs block an enzyme
called monoamine oxidase which normally helps nerve cells absorb
the artery-constricting chemical, serotonin.
MAO inhibitors can
have potentially serious side effects--particularly if taken
while ingesting foods or beverages that contain tyramine, a
substance that closes down arteries.
Several new drugs
for the prevention of migraine have been developed in recent
years, including papaverine hydrochloride, which produces blood
vessel dilation, and cyproheptadine, which counteracts serotonin.
All these antimigraine
drugs can have adverse side effects. But they are relatively
safe when used carefully. To avoid long-term side effects of
preventive medications, headache specialists advise patients
to reduce the dosage of these drugs and then to stop taking
them as soon as possible.
Drug therapy for migraine
is often combined with biofeedback and relaxation training. Biofeedback
is a space-age word for a technique that can give people better
control over such body function indicators as blood pressure,
heart rate, temperature, muscle tension, and brain waves. Thermal
biofeedback allows a patient to consciously raise hand temperature.
Some patients who are able to increase hand temperature can reduce
the number and intensity of migraines. The mechanism of this hand-warming
effect is being studied by research scientists.
An NINDS grantee
at the State University of New York in Albany instructs a headache
patient in thermal biofeedback. A temperature-sensitive device
attached to her forefinger is connected to a feedback meter
that tells the patient if and how much she is warming her hands.
"To
succeed in biofeedback," says a headache specialist, "you
must be able to concentrate and you must be motivated to get
well."
A patient learning
thermal biofeedback wears a device which transmits the temperature
of an index finger or hand to a monitor. While the patient tries
to warm his hands, the monitor provides feedback either on a
gauge that shows the temperature reading or by emitting a sound
or beep that increases in intensity as the temperature increases.
The patient is not told how to raise hand temperature, but is
given suggestions such as "Imagine that your hands feel
very warm and heavy."
"I have a good
imagination," says one headache sufferer who traded in
her medication for thermal biofeedback. The technique decreased
the number and severity of headaches she experienced.
In another type of
biofeedback called electromyographic or EMG training, the patient
learns to control muscle tension in the face, neck, and shoulders.
Either kind of biofeedback
may be combined with relaxation training, during which patients
learn to relax the mind and body.
Biofeedback can be
practiced at home with a portable monitor. But the ultimate
goal of treatment is to wean the patient from the machine. The
patient can then use biofeedback anywhere at the first sign
of a headache.
Scientists estimate
that a small percentage of migraine sufferers will benefit from
a treatment program focused solely on eliminating headache-provoking
foods and beverages.
Other migraine patients
may be helped by a diet to prevent low blood sugar. Low blood
sugar, or hypoglycemia, can cause dilation of the blood vessels
in the head. This condition can occur after a period without
food: overnight, for example, or when a meal is skipped. People
who wake up in the morning with a headache may be reacting to
the low blood sugar caused by the lack of food overnight.
Treatment for headaches
caused by low blood sugar consists of scheduling smaller, more
frequent meals for the patient. A special diet designed to stabilize
the body's sugar-regulating system is sometimes recommended.
For the same reason,
many specialists also recommend that migraine patients avoid
oversleeping on weekends. Sleeping late can change the body's
normal blood sugar level and lead to a headache.
After migraine, the
most common type of vascular headache is the toxic headache produced
by fever. Pneumonia, measles, mumps, and tonsillitis are among
the diseases that can cause severe toxic vascular headaches. Toxic
headaches can also result from the presence of foreign chemicals
in the body. Other kinds of vascular headaches include "clusters,"
which cause repeated episodes of intense pain, and headaches resulting
from a rise in blood pressure.
Repeated exposure to
nitrite compounds can result in a dull, pounding headache that
may be accompanied by a flushed face. Nitrite, which dilates blood
vessels, is found in such products as heart medicine and dynamite.
Hot dogs and other meats containing sodium nitrite can also cause
headaches.
"Chinese restaurant
headache" can occur when a susceptible individual eats
foods prepared with monosodium glutamate (MSG)--a staple in
many Oriental kitchens. Soy sauce, meat tenderizer, and a variety
of packaged foods contain this chemical which is touted as a
flavor enhancer.
Vascular headache
can also result from exposure to poisons, even common household
varieties like insecticides, carbon tetrachloride, and lead.
Children who eat flakes of lead paint may develop headaches.
So may anyone who has contact with lead batteries or lead-glazed
pottery.
Painters, printmakers,
and other artists may experience headaches after exposure to
art materials that contain chemicals called solvents. Solvents,
like benzene, are found in turpentine, spray adhesives, robber
cement, and inks.
Drugs such as amphetamines
can cause headaches as a side effect. Another type of drug-related
headache occurs during withdrawal from long-term therapy with
the antimigraine drug ergotamine tartrate.
Jokes are often made
about alcohol hangovers but the headache associated with "the
morning after" is no laughing matter. Fortunately, there
are several suggested remedies for the pain, including ergotamine
tartrate. The hangover headache may also be reduced by taking
honey, which speeds alcohol metabolism, or caffeine, a constrictor
of dilated arteries. Caffeine, however, can cause headaches
as well as cure them. Heavy coffee drinkers often get headaches
when they try to break the caffeine habit.
Cluster headaches,
named for their repeated occurrence in groups or clusters, begin
as a minor pain around one eye, eventually spreading to that side
of the face. The pain quickly intensifies, compelling the victim
to pace the floor or rock in a chair. "You can't lie down,
you're fidgety," explains a cluster patient. "The pain
is unbearable." Other symptoms include a stuffed and runny
nose and a droopy eyelid over a red and tearing eye.
The typical cluster
patient is tall and muscular.
Cluster headaches
last between 30 and 45 minutes. But the relief people feel at
the end of an attack is usually mixed with dread as they await
a recurrence. Clusters can strike several times a day or night
for several weeks or months. Then, mysteriously, they may disappear
for months or years. Many people have cluster bouts during the
spring and fall. At their worst, chronic cluster headaches can
last continuously for years.
Cluster attacks can
strike at any age but usually start between the ages of 20 and
40. Unlike migraine, cluster headaches are more common in men
and do not run in families. Research scientists have observed
certain physical similarities among people who experience cluster
headache. The typical cluster patient is a tall, muscular man
with a ragged facial appearance and a square, jutting or dimpled
chin. The texture of his coarse skin resembles an orange peel.
Women who get clusters may also have this type of skin.
Studies of cluster
patients show that they are likely to have hazel eyes and that
they tend to be heavy smokers and drinkers. Paradoxically, both
nicotine, which constricts arteries, and alcohol, which dilates
them, trigger duster headaches. The exact connection between
these substances and cluster attacks is not known.
Despite a cluster
headache's distinguishing characteristics, its relative infrequency
and similarity to such disorders as sinusitis can lead to misdiagnosis.
Some cluster patients have had tooth extractions, sinus surgery,
or psychiatric treatment in a futile effort to cure their pain.
Research studies
have turned up several clues as to the cause of cluster headache,
but no answers. One clue is found in the thermograms of untreated
cluster patients, which show a "cold spot" of reduced
blood flow above the eye.
The sudden start
and brief duration of cluster headaches can make them difficult
to treat. By the time medicine is absorbed into the body, the
attack is often over. However, research scientists have identified
several effective drugs for these headaches. The antimigraine
drug ergotamine tartrate can subdue a cluster, if taken at the
first sign of an attack. Injections of dihydroergotamine, a
form of ergotamine tartrate, are sometimes used to treat clusters.
A thermogram of a
normal person shows a symmetrical heat pattern on the individual's
forehead.
A cluster headache
patient's thermogram shows a cold area (appears white) of reduced
blood flow on the left side of the forehead.
Some cluster patients
can prevent attacks by taking propranolol or methysergide. Investigators
have also discovered that mild solutions of cocaine hydrochloride
applied inside the nose can quickly stop cluster headaches in
most patients. This treatment may work because it both blocks
pain impulses and it constricts blood vessels.
Another option that
works for some cluster patients is rapid inhalation of pure
oxygen through a mask for 5 to 15 minutes. The oxygen seems
to ease the pain of cluster headache by reducing blood flow
to the brain.
In chronic cases
of cluster headache, certain facial nerves may be surgically
cut or destroyed to provide relief. These procedures have had
limited success. Some cluster patients have had facial nerves
cut only to have them regenerate years later.
Chronic high blood
pressure can cause headache, as can rapid rises in blood pressure
like those experienced during anger, vigorous exercise, or sexual
excitement.
The severe "orgasmic
headache" occurs right before orgasm and is believed to
be a vascular type. Since sudden rapture of a cerebral blood
vessel can also occur during orgasm, this type of headache should
be promptly evaluated by a doctor.
It's 5:00 p.m. and
your boss has just asked you to prepare a 20-page briefing paper.
Due date: tomorrow. You're angry and tired and the more you think
about the assignment, the tenser you become. Your teeth clench,
your brow wrinkles, and soon you have a splitting tension headache.
Tension headache
is named not only for the role of stress in triggering the pain,
but also for the contraction of neck, face, and scalp muscles
brought on by stressful events. Tension headache is a severe
but temporary form of muscle-contraction headache. The pain
is mild to moderate and feels like pressure is being applied
to the head or neck. The headache usually disappears after the
period of stress is over.
By contrast, chronic
muscle-contraction headaches can last for weeks, months, and
sometimes years. The pain of these headaches is often described
as a tight band around the head or a feeling that the head and
neck are in a cast. "It feels like somebody is tightening
a giant vise around my head," says one patient. The pain
is steady, and is usually felt on both sides of the head. Chronic
muscle-contraction headaches can cause sore scalps-even combing
one's hair can be painful.
Many scientists believe
that the primary cause of the pain of muscle-contraction headache
is sustained muscle tension. Other studies suggest that restricted
blood flow may cause or contribute to the pain.
Occasionally, muscle-contraction
headaches will be accompanied by nausea, vomiting, and blurred
vision, but there is no preheadache syndrome as with migraine.
Muscle-contraction headaches have not been linked to hormones
or foods, as has migraine, nor is there a strong hereditary
connection.
It's election night,
November 1982, and the reporters at this busy newspaper could
be prime candidates for tension headaches. Circumstances that
might trigger headaches include deadline pressure and glaring
lights.
Research has shown
that for many people, chronic muscle-contraction headaches are
caused by depression and anxiety. These people tend to get their
headaches in the early morning or evening when conflicts in
the office or home are anticipated.
Emotional factors
are not the only triggers of muscle-contraction headaches. Certain
physical postures--such as holding one's chin down while reading--can
lead to head and neck pain. Tensing head and neck muscles during
sexual excitement can also cause headache. So can prolonged
writing under poor light, or holding a phone between the shoulder
and ear, or even gum-chewing.
More serious problems
that can cause muscle-contraction headaches include degenerative
arthritis of the neck and temporomandibular joint dysfunction,
or TMJ. TMJ is a disorder of the joint between the temporal
bone (above the ear) and the mandible or lower jaw bone. The
disorder results from poor bite and jaw clenching.
Treatment for muscle-contraction
headache varies. The first consideration is to treat any specific
disorder or disease that may be causing the headache. For example,
arthritis of the neck is treated with anti-inflammatory medication
and temporomandibular joint dysfunction may be helped by corrective
devices for the mouth and
Acute tension headaches
not associated with a disease are treated with muscle relaxants
and analgesics like aspirin and acetaminophen. Stronger analgesics,
such as propoxyphene and codeine, are sometimes prescribed.
As prolonged use of these drugs can lead to dependence, patients
taking them should have periodic medical checkups and follow
their physicians' instructions carefully.
Nondrug therapy for
chronic muscle-contraction headaches includes biofeedback, relaxation
training, and counseling. A technique called cognitive restructuring
teaches people to change their attitudes and responses to stress.
Patients might be encouraged, for example, to imagine that they
are coping successfully with a stressful situation. In progressive
relaxation therapy, patients are taught to first tense and then
relax individual muscle groups. Finally, the patient tries to
relax his or her whole body. Many people imagine a peaceful
scene--such as lying on the beach or by a beautiful lake. Passive
relaxation does not involve tensing of muscles. Instead, patients
are encouraged to focus on different muscles, suggesting that
they relax. Some people might think to themselves, Relax
or My muscles feel warm.
People with chronic
muscle-contraction headaches my also be helped by taking antidepressants
or MAO inhibitors. Mixed muscle-contraction and migraine headaches
are sometimes treated with barbiturate compounds, which slow
down nerve function in the brain and spinal cord.
People who suffer
infrequent muscle-contraction headaches may benefit from a hot
shower or moist heat applied to the back of the neck. Cervical
collars are sometimes recommended as an aid to good posture.
Physical therapy, massage, and gentle exercise of the neck may
also be helpful.
Like other types of
pain, headaches can serve as warning signals of more serious disorders.
This is particularly true for headaches caused by traction or
inflammation.
Traction headaches
can occur if the pain-sensitive parts of the head are pulled,
stretched, or displaced, as, for example, when eye muscles are
tensed to compensate for eyestrain. Headaches caused by inflammation
include those related to meningitis as well as those resulting
from diseases of the sinuses, spine, neck, ears, and teeth.
Ear and tooth infections and glaucoma can cause headaches. In
oral and dental disorders, headache is experienced as pain in
the entire head, including the face.
This research patient
is rating the intensity of heat-induced acute pain transmitted
by electrodes. From her ratings, investigators hope to determine
whether a chronic pain drug she is taking for facial pain and
headache is effective against acute pain.
Traction and inflammatory
headaches are treated by curing the underlying problem. This
may involve surgery, antibiotics or other drugs.
Characteristics of
the various types of traction and inflammatory headaches vary
by disorder:
- * Brain tumor.
Brain tumors are diagnosed in about 11,000 people every year.
As they grow, these tumors sometimes cause headache by pushing
on the outer layer of nerve tissue that covers the brain or
by pressing against pain-sensitive blood vessel walls. Headache
resulting from a brain tumor may be periodic or continuous.
Typically, it feels like a strong pressure is being applied
to the head. The pain is relieved when the tumor is destroyed
by surgery, radiation, or chemotherapy.
* Stroke.
Headache may accompany several conditions that can lead
to stroke, including hypertension or high blood pressure,
arteriosclerosis, and heart disease. Headaches are also
associated with completed stroke, the latter occurs when
brain cells die from lack of sufficient oxygen.
Many stroke-related
headaches can be prevented by careful management of the patient's
condition through diet, exercise, and medication.
Mild to moderate
headaches are associated with so-called "little strokes,"
or transient ischemic attacks (TIA's), which result from a temporary
lack of blood supply to the brain. The head pain occurs near
the clot or lesion that blocks blood flow.
The similarity between
migraine and symptoms of TIA can cause problems in diagnosis.
The rare person under age 40 who suffers a TIA may be misdiagnosed
as having migraine; similarly, TIA-prone older patients who
suffer migraine may be misdiagnosed as having stroke-related
headaches.
- * Spinal tap.
About one-fourth of the people who undergo a lumbar puncture
or spinal tap develop a headache. Many scientists believe
these headaches result from leakage of the cerebrospinal fluid
that flows through pain-sensitive membranes around the brain
and down to the spinal cord. The fluid, they suggest, drains
through the tiny hole created by the spinal tap needle, causing
the membranes to rub painfully against the bony skull. Since
headache pain occurs only when the patient stands up, the
"cure" is to remain lying down until the headache
runs its course--anywhere from a few hours to several days.
* Head trauma.
Headaches may develop after a blow to the head, either immediately
or months later. There is little relationship between the
severity of the trauma and the intensity of headache pain.
One cause of trauma headache is scar formation in the scalp.
Another is ruptured blood vessels which result in an accumulation
of blood called a hematoma. This mass of blood can displace
brain tissue and cause headaches as well as weakness, confusion,
memory loss, and seizures. Hematomas can be drained to produce
rapid relief of symptoms.
* Arteritis
and meningitis. Arteritis, an inflammation of certain
arteries in the head, primarily affects people over age
50. Symptoms include throbbing headache, fever, and loss
of appetite. Some patients experience blurring or loss of
vision. Prompt treatment with corticosteroid drugs helps
to relieve symptoms.
Headaches are
also caused by infections of meninges, the brain's outer
covering, and phlebitis, a vein inflammation.
* Tic douloureux.
Tic douloureux, or trigeminal neuralgia, results from a
disorder of the trigeminal nerve. This nerve supplies the
face, teeth, mouth, and nasal cavity with feeling and also
enables the mouth muscles to chew. Symptoms are headache
and intense facial pain that comes in short, excruciating
jabs set off by the slightest touch to or movement of trigger
points in the face or mouth. People with tic douloureux
often fear brushing their teeth or chewing on the side of
the mouth that is affected. Many tic douloureux patients
are controlled with drugs, including carbamazepine. Patients
who do not respond to drugs may be helped by surgery on
the trigeminal nerve.
* Sinus infection.
In a condition called acute sinusitis, a viral or bacterial
infection of the upper respiratory tract spreads to the
membrane which lines the sinus cavities. When one or all
four of these cavities are filled with bacterial or viral
fluid, they become inflamed, causing pain and sometimes
headache. Treatment of acute sinusitis includes antibiotics,
analgesics, and decongestants.
Chronic sinusitis
may be caused by an allergy to such irritants as dust, ragweed,
animal hair, and smoke. Research scientists disagree about whether
chronic sinusitis triggers headache.
Acute sinusitis headaches
can occur when one or all four of the sinus cavities fill with
bacterial or viral fluid. The particular cavity affected determines
the location of the sinus headache.
A patient in the
throes of a tic douloureux attack feels sudden, violent jabs
of pain in the face, mouth, and head.
This child has a
good chance of controlling her headaches with thermal biofeedback
therapy, say NINDS-supported scientists conducting migraine
research at the State University of New York, Albany.
Like adults, children
experience the infections, trauma, and stresses that can lead
to headaches. In fact, research shows that as young people enter
adolescence and encounter the stresses of puberty and secondary
school, the frequency of headache increases.
Migraine headaches
often begin in childhood or adolescence. According to a recent
health interview survey, over a million children age 16 and
under experience migraine and other vascular headaches.
Children with migraine
often have nausea and excessive vomiting. Some children have
periodic vomiting, but no headache--the so-called "abdominal
migraine." Research scientists have found that these children
usually develop headaches when they are older.
Phenobarbital, cypropheptadine,
and certain anticonvulsant drugs are used to treat migraines
in children. A diet may be prescribed to protect the child from
foods that trigger headache. Sometimes psychological counseling
or even psychiatric treatment for the child and the parents
is recommended. NINDS-supported scientists at the State University
of New York in Albany find that thermal biofeedback can help
children with migraines control their headaches.
About 90 percent
of chronic headache patients can be helped.
Childhood headache
can be a sign of depression. Parents should alert the family
pediatrician if a child develops headaches along with other
symptoms such as a change in mood or sleep habits. Antidepressant
medication and psychotherapy are effective treatments for childhood
depression and related headache.
Modern methods of diagnosis
and treatment enable physicians and psychologists today to help
about 90 percent of chronic headache patients, according to the
director of a major U.S. headache clinic. These methods are based
on years of scientific research. New research should lead to even
more advanced techniques of headache management.
Some scientists explore
the role that certain foods play in causing this disorder. Others
are more concerned with the function of the autonomic nervous
systems of headache-prone people. The autonomic nervous system
automatically controls a variety of essential body functions,
including the flow of blood throughout the body and the working
of the pupils of the eyes.
At the Philadelphia
College of Osteopathic Medicine, scientists supported by the
National Institute of Neurological and Communicative Disorders
and Stroke are gauging the autonomic nervous system activity
of normal controls and headache patients with a technique called
"pupillometry." This technique measures the response
of the iris, or eye muscle, to light and darkness. Migraine,
cluster, and muscle-contraction headache patients are included
in the study. Each patient sits in a chair with his or her head
in a chin rest. The eye is stimulated with light and then with
darkness. A television camera in front of the patient picks
up the reaction of the iris and translates it into a graph which
provides clues about the functioning of the patient's autonomic
nervous system.
NINDS-supported
scientists at the Philadelphia College of Osteopathic Medicine
study a headache patient's reaction to stress. The stress, in
this case, is cold water into which the patient dips her arm.
Another experiment
with the pupillometer involves measuring eye muscle reaction
to light and darkness after stress. In this study, stress is
simulated by dipping the patient's arm in very cold water for
up to 20 seconds.
Preliminary findings
from these studies suggest that, under stress-free conditions,
the autonomic nervous systems of both people with common migraine
and of people without headaches react normally. Paradoxically,
migraine patients during stress show reduced autonomic nervous
system activity, a condition that should prevent the decreased
blood flow thought to cause headaches.
However, NINDS-supported
scientists at Southern Illinois University in Carbondale report
a different connection between blood flow and migraine headache.
Using an infrared
light sensor that measures the diameter of blood vessels, the
investigators have found that, after stress, blood flow returns
to normal more quickly in headache-free people than in patients
with migraine and muscle-contraction headache. This finding
supports the theory that restricted or decreased blood flow
may cause or contribute to headache.
The scientists also
found that different types of headaches are characterized by
different blood flow patterns.
An NINDS grantee
at the State University of New York; Albany, monitors the results
of a biofeedback study that compares home-based headache programs
with office-based programs.
After stress, the
temporal arteries in the foreheads of migraine patients expand
to a greater degree than the arteries of muscle-contraction
headache patients. People with the same type of headache also
show differences in blood flow patterns--offering evidence that
there are a variety of causes for each headache type.
Scientists are also
developing new therapies and analyzing the effectiveness of current
treatment methods for headache. The research team at Southern
Illinois University is comparing a biofeedback method that monitors
blood flow with a method that monitors muscular tension in the
head. This research should lead to improved understanding of individual
differences in treatment response.
Several scientists
are studying the value of biofeedback and other forms of treatment
carried out in the patient's home. Home-based programs may be
a boon to patients in rural areas who have limited access to
medical care and cannot afford frequent visits to headache specialists.
In NINDS-supported
research at the State University of New York in Albany, scientists
are comparing the effectiveness of a standard office-based relaxation
training program for muscle-contraction, migraine, and mixed-headache
patients with a similar program conducted by patients at home.
Patients in the home-based program are seen in the office once
a month but rely heavily on manuals, cassettes, and portable
biofeedback devices.
Preliminary results
suggest that home-based and office-based programs are equally
effective. "If these relaxation techniques are learned
at home," speculates the investigator, "they may transfer
more readily to the home situation--where they will be used
to cope with daily stresses."
Furthermore, at the
University of Washington in Seattle an NINDS-supported investigator
is finding that home-based treatment involving only dietary
changes is as effective in treating migraine patients as a home-based
program of biofeedback and stress management.
Thermal biofeedback
training, which involves the conscious warming of parts of the
body through thought control, is believed to work because it
gives people a feeling of control over their headaches. An NINDS-supported
study at Midwest Research Institute in Kansas City, Missouri,
raises the possibility that this feeling of control is a more
important factor in decreasing headaches than is the actual
warming of the hands.
Patients who had
frequent migraines were told that they would be given one of
two types of biofeedback: "real temperature biofeedback,"
where a sound indicated their real hand temperature, or "bogus
biofeedback," where a prerecorded sound emitted from the
monitor would be unrelated to the patient's effort to warm the
hands. Neither the patients nor the technicians training them
knew whose feedback was real or bogus. Throughout the 6 weeks
of training, the scientists emphasized to the patients that
biofeedback should become an integral pan of their lives because
it was giving them control over their headaches.
Patients in the bogus
biofeedback group had a success rate that rivaled the one in
the real biofeedback group. More than 80 percent of patients
in both groups reduced the frequency and intensity of their
headaches, as well as the quantity of medication they had been
taking to control pain.
"It isn't so
much the physical mechanism of migraine that matters,"
explains the principal investigator, "but a person's ability
to cope with the syndrome and to take charge of his or her body.
The emphasis on self-control is what made these people improve."
Another important
area of research is the study of beta-blocking drugs like propranolol,
which are used to prevent migraine.
Beta-blockers stop
the activities of beta receptors-cells in the brain and heart
which control the dilation of blood vessels. The ability of
beta-blockers to halt the dilation of blood vessels in the brain
is believed to be a major reason for their antimigraine action.
But because the drugs also affect heart receptors--slowing the
heart rate--they cannot be used by people who have certain heart
conditions.
Scientists at Massachusetts
General Hospital study these tiny brain blood vessels in the
hope of developing migraine drugs with fewer side effects.
An NINDS-supported
neurologist at Massachusetts General Hospital prepares brain
tissue for a study of beta receptors--cells that control the
dilation of blood vessels. This research could lead to the development
of new medications for vascular headache.
"I have learned
not to worry."
This problem may
be resolved by NINDS-supported research at Massachusetts General
Hospital in Boston. A research team there is using biochemical
techniques to find out if there is a certain type of beta receptor
that exists in the blood vessels of the brain but not in the
heart. The discovery of this receptor could lead to the development
of beta-blocking agents that would affect brain receptors only.
Another NINDS-funded
study at the University of Kansas Medical Center is comparing
the effectiveness of propranolol with that of the antidepressant
amitriptyline in the prevention of migraine. Physical and psychological
characteristics of migraine patients are being correlated with
their responses to the two drags.
Investigators supported
by the National Institutes of Health General Clinical Research
Center at the University of Colorado in Denver are studying
the antimigraine properties of a class of drugs called calcium-channel
blockers. Research on these drugs is also under way at the U.S.
Air Force Medical Center, Wright-Patterson AFB in Ohio. Calcium-channel
blockers interfere with the constriction of arteries, an effect
that appears to be responsible for reducing the frequency of
headaches in patients studied so far.
Physicians of the future
may diagnose their patients' headaches with the aid of a computer.
A computer might take a patient's medical history, store information
on headache characteristics, and keep data on patients and their
treatments. Programs might even be devised to explain to patients
the way to take prescribed medications and the side effects of
those drugs.
Scientists at Beth
Israel Hospital in Boston are taking the first steps toward
computer-assisted headache practice in a study funded by the
National Library of Medicine. They are creating a working model
for a headache interview program in which a computer will collect
patient histories and symptoms. The scientists envision that
an "automated physician' s assistant" will eventually
free health care providers from collecting routine medical information,
allowing them to devote more time to physical examination and
treatment.
If you suffer from
headaches and none of the standard treatments help, do not despair.
Some people find that their headaches disappear once they deal
with a troubled marriage, pass their law board exams, or resolve
some other stressful problem. Others find that if they control
their psychological reaction to stress, the headaches disappear.
"I had migraines
for several years," says one woman, "and then they
went away. I think it was because I lowered my personal goals
in life. Today, even though I have 100 things to do at night,
I don't worry about it. I learned to say no."
For those who cannot
say no, or who get headaches anyway, today's headache research
offers hope. The work of NINDS-supported scientists around the
world promises to improve our understanding of this complex
disorder and how to treat it.
The following organizations
are concerned with pain problems, including pain caused by headache.
They are excellent sources of additional information, research
updates, and specific help and referrals:
- American Chronic
Pain Association, Inc.
- P.O. Box 850
- Rocklin, CA. 95677-0850
- (916) 632-0922
- American Council
for Headache Education (ACHE)
- 875 King's Highway,
Suite 200
- Woodbury, NJ 08016
- (609) 845-0322
- (800) 255-2243
- National Chronic
Pain Outreach Association, Inc.
- 7979 Old Geogetown
Road, Suite 100
- Bethesda, MD.
20814-2429
- (301) 652-4948
- National Headache
Foundation
- 428 W. St. James
Pl., 2nd Floor
- Chicago, IL. 60614-2750
- (312) 388-6399
- (800) 843-2256
The Chronic Pain
Lettter is a bimonthly review of new pain treatments, books,
and resources for people who live with pain. For subscription
information, write:
- Robert J. Fabian
Memorial Foundation
- Chronic Pain Letter
- P.O. Box 1303
- Old Chelsea Station
- New York, NY 10011
Inquiries about NINCDS
research on headache may be directed to:
- Office of Scientific
and Health Reports
- National Institute
of Neurological and
- Communicative
Disorders and Stroke
- Building 31, Room
8A-06
- National Institutes
of Health
- Bethesda, Maryland
20205
- (301) 496-5751
Photograph Credits:
Dr. Leonard S. Rubin,
Philadelphia College of Osteopathic Medicine, Cover, page 30.
Bill Branson, NIH,
pages 3, 5. Associated Press/Wide World Photos, Inc., page 6.
Adapted from Oliver
W. Sacks, Migraine, The Evolution of a Common Disorder, 1970,
University of California Press, page 7.
Adapted from an original
painting by Frank H. Netter, M.D., in Clinical Symposia, copyright
by CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation,
page 9.
National Library
of Medicine, page 13.
Will Yurman, State
University of New York, Albany, pages 16, 28, 31.
Dr. Ninan T. Mathew,
Houston Headache Clinic, page 20 (upper and lower).
Courtesy of The Washington
Post, page 22.
John Crawford, NIH,
page 24.
Adapted from drawing,
Massachusetts General Hospital News, November 1982, page 27
(upper).
National Institute
of Dental Research,. page 27 (lower).
Dr. James A. Nathanson,
Massachusetts General Hospital, page 33 (upper and lower).
® Prepared
by the Office of
Scientific and Health Reports
National Institute of
Neurological Disorders and Stroke
NATIONAL INSTITUTES OF HEALTH
Bethesda, Maryland 20205
NIH Publication No. 84-158
September 1984
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