Headache Types and Treatment Options

What is headache?

Headache is a term used to describe aching or pain that occurs in one or more areas of the head, face, mouth, or neck. Headache involves the network of nerve fibers in the tissues, muscles, and blood vessels located in the head and at the base of the skull.

Almost everyone has occasional headaches, especially when they are sick, tired or otherwise under stress. Headache is the result of pain signals caused by interactions between the brain, blood vessels, and surrounding nerves. During a headache, the pain comes not from the brain. It comes from specific nerves surrounding the skull, head muscles, and blood vessels that are activated and send pain signals, interpreted by the brain as a headache. The reasons why these nerves are activated are not clearly understood. Most headaches go away on their own or are easily treated with over the counter (OTC) drugs.

Headache types

There are two main categories of headache: primary and secondary.
The major types of primary headaches include:

• Tension headache



• Cluster headache



• Migraine

Primary headaches are not caused by other underlying medical conditions. More than 90% of headaches are primary.

Secondary

Secondary headaches result from other medical conditions, such as cerebrovascular disease, head trauma, infection, tumor, and metabolic disorder. These account for fewer than 10% of all headaches. Head pain also can result from syndromes involving the eyes, ears, neck, teeth, or sinuses. In these cases, the underlying condition must be diagnosed and treated. Also, certain types of medication produce headache as a side effect.
Many people have occasional headaches that get better on their own or go away with OTC drug treatment. Most of these people never see a healthcare provider for their headaches, however, there are several circumstances in which an evaluation by a physician may be useful or important:

• Headaches that are getting worse over time



• Severe headaches that start suddenly



• Headaches that start after a head injury



• Headaches that always occur on the same side of the head



• Headaches that are not responding to treatment



• Severe headaches that interrupt work or the enjoyment of daily activities



• Daily headaches



• Aggravated by exertion, coughing, bending, or sexual activity

Tension Headache

Tension headaches are the most common type of headaches. They affect up to 75% of all headache sufferers. Tension headache is usually episodic but may be chronic, occurring daily or almost daily for more than 15 days a month. This type of headache is linked with tension in neck and scalp muscles, affecting blood flow within the skull.

Tension headaches often start in the afternoon or early evening. The pain is typically on both sides of the head, pressing or tightening. Some people get tension headaches in response to stressful events. Tension headaches usually do not get worse with physical activity (such as walking or climbing stairs).

Treatment

The occasional tension headache can be alleviated by a hot shower, massage, sleep, and through patient recognition and avoidance of stress factors.

For episodic tension headaches that occur less than three times per week, OTC pain relievers such as aspirin, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) are convenient and effective. Combination products of pain medication with caffeine may help some people, but also may be habit forming. Use of any OTC pain reliever should be limited to no more than two or three days per week. If pain medications are overused, rebound headaches may occur on the days that medications are not taken.

Chronic tension headaches are more difficult to treat, because rebound headaches are common when pain relievers are stopped. The most effective medications for treatment of chronic tension headaches are tricyclic antidepressants (amitriptyline HCl, doxepin HCl, nortriptyline HCl). However, it is often more effective to prevent these headaches than to treat them.

Some people are able to treat their tension headaches without medications. An ice compress, a heating pad or a massage to any tight areas in the neck and shoulders can be extremely helpful. Relaxation techniques, such as deep breathing exercises or acupuncture, may help to decrease the frequency of headaches.

Cluster Headache

Cluster headaches are relatively rare, affecting about 1% of the population. They are distinct from migraine and tension headaches. Cluster headaches primarily affect men between the ages of 20 and 40. Attacks usually occur in a series, or "clusters" of 1 - 8 headaches per day over a period of several weeks to months. The pain is extremely severe but the attack is brief, lasting 15 minutes to 3 hours. The pain of cluster headache almost always occurs on one side of the head. During cluster headaches, the eye on the same side as the pain may become teary or droopy or develop a small pupil. There may also be nasal congestion on the affected side of the face.

About 80% of cluster headaches occur at night, and in about 70% of patients, drinking alcohol can trigger a cluster headache. Unlike migraine sufferers, those with cluster headache often feel better if they keep moving during the headache.

Treatment

It is difficult to stop the pain of a cluster headache that is in progress, because the headache usually disappears by the time the patient reaches the emergency room or doctor's office. Because the onset of cluster headache attacks is rapid and may occur several times a day, the best approach to treatment is with daily preventive drugs to decrease the severity and frequency of headaches. Lithium (Carbolith, Duralith, Lithane, Lithobid, Lithonate and others) and verapamil (Isoptin, Calan, Chronovera, Verelan, Novo-Veramil) are the two drugs that are most effective at accomplishing this. Other drugs used for this purpose include prednisone (Deltasone, Meticorten, Orasone 1, Winpred and others), cyproheptadine (Periactin) and methysergide (Sansert). Prophylactic medications usually are begun early during a cycle of cluster headaches and continued for two weeks longer than the usual cycle.

Abortive treatments include inhalation of 100% oxygen. Inhaling 100% oxygen for about 15 minutes through a facemask has proven to be helpful when it is done at the first signs of an attack. This oxygen must be prescribed by a doctor and obtained through a medical supplier. Other types of drugs that may be effective when used at the outset of cluster pain include the triptans (Imitrex, Maxalt, Zomig, Axert, Amerge), ergotamine (Cafergot) and indomethacin (Indocin).

Migraine Headache

Migraine headaches are less common than tension headaches. About 6% of all men and 18% of all women experience a migraine headache at some time. Migraine headache occurs on one or both sides of the head. The pain is typically pulsating or throbbing in nature. Nausea, with or without vomiting, as well as sensitivity to light and sound often accompany migraines. Migraines are made worse by activity, bright lights and bright noises. In most cases, migraine attacks are occasional, or sometimes as often as once or twice a week, but not daily. Women who have migraines often find that their headaches occur or worsen around the time of their menstrual periods.

One unique feature of migraines is an unusual sensation that a migraine is about to occur. This sensation is called a prodrome. Prodrome symptoms can include fatigue, hunger and nervousness. Not all people who get migraines have prodromes.

An aura is a complex of neurological symptoms that occur just before or at the onset of migraine headache. An aura involves a disturbance in vision that may consist of brightly colored or blinking lights in a pattern that moves across the field of vision. Most patients with migraine have attacks without aura. About one in five migraine sufferers experiences an aura.

Treatment

How your migraines are treated will depend on the frequency and severity of attacks. People who have a headache several times per year often respond well to nonprescription pain relievers.
There are two types of medications to treat migraines:

• abortive medications - drugs that are taken when a headache starts



• preventive medications - drugs that are taken every day to prevent migraines

Abortive Medications

Migraine-specific abortive medications usually are necessary for moderate to severe migraine headaches. When possible, an abortive medication should be taken immediately after an aura or migraine headache starts. However overusing abortive medications can lead to chronic headaches, that occur day after day without a specific cause or diagnosis. Several prescription and nonprescription drugs are used as abortive medications: aspirin, ibuprofen (Advil, Apsifen, Motrin, Nuprin and other brand names) or naproxen (Aleve, Anaprox, Naprosyn)
Effective agents available by prescription include:

• Triptans - sumatriptan (Imitrex), naratriptan (Amerge), zolmitriptan (Zomig) and rizatriptan (Maxalt). Triptan drugs are effective in 60% to 65% of patients, completely or significantly relieving migraine pain and associated symptoms within 2 hours of administration. Triptans reduce inflammation and constrict the blood vessels. The triptan with the longest history of use is sumatriptan (Imitrex).



• Ergots - sublingual ergotamine (Ergomar) and dihydroergotamine (Migranal). Ergots cause constriction of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and their effects on the heart are more prolonged than the triptans. Ergots are not as safe as the triptans.



• Midrin. It is a combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild sedative)

Preventive Medications
Preventive medication are prescribed when migraine attacks that don't respond well to abortive medications or adverse reactions to abortive medications occur, migraine attacks occur too often, complicated migraines. Many drugs are listed as potentially useful to prevent recurrent migraine attacks. The drugs in the following classes are useful to prevent recurrent migraine attacks:

• Beta-blockers. Propranolol (Inderal) and nadolol (Corgard) have a good track record of being safe and effective. Metoprolol (Lopressor) and atenolol (Tenormin) are reasonable alternatives. Beta-blockers have been used for many years to prevent migraine headaches. It is not known how beta-blockers prevent migraine headaches.



• Tricyclic antidepressants. These medications are very effective, but often have troublesome side effects such as sedation, blurred vision, dry mouth and constipation. The first choice is often amitriptyline (Elavil). Nortriptyline (Pamelor, Aventyl), doxepin (Sinequan), imipramine (Tofranil) also can be tried.



• Anticonvulsants. Of the drugs in this class, valproate (Depakote, Epival) has the best evidence to support using it for prevention. Gabapentin (Neurontin) and topiramate (Topamax) also are effective. It is not known how anticonvulsants work to prevent migraine headaches.



• Serotonin antagonists. Methysergide (Sansert) has been available for many years and is very effective. Methysergide prevents migraine headaches by constricting blood vessels and reducing inflammation of the blood vessels. However, this medication has side effects that are potentially very serious and therefore is not widely used.

Rebound Headache
Increasing headache over time with repeated use of pain medicines can lead to a rebound headache. The headache is typically located on both sides of the head and is described as a pressing or tightening type of pain. When headache sufferers use too much pain medicine, their headaches often recur. This leads to a repeated cycle of taking more medicines and still having headaches. Rebound headache may appear if:

• taking analgesics on 15 or more days per month for more than 3 months



• taking opioid or combination medication 10 or more days per month for more than 3 months

When analgesics are discontinued, the headache may get worse for several days and it may take up to 30 days to recover from the rebound process. Non-drug approaches, such as biofeedback, relaxation therapy, and exercise, can be helpful in reducing both headache frequency and need for medication.

Headache Triggers
Triggers are not direct causes of the headache, but they facilitate or provoke the beginning of an attack. Anything that stimulates the pain receptors in the head and neck can cause a headache. Some of the more common triggers for headache:

• Emotional triggers: problems at work, success at work or school, anticipation, anxiety, an emotional crisis, a new job. Emotions can bring on headaches, keep them going, and make them worse. Emotions don't cause your headaches, they just make you more vulnerable to them.



• Environmental triggers: bright light, different kinds of aromas like perfume, tobacco, odors (such as gasoline), loud noises, altitude, barometric pressure changes.



• Stress triggers: strenuous exercise, excessive physical work at the work place or at school, physical sickness, not enough sleep or too much sleep



• Chemical triggers: changes in hormone levels (that occur during the premenstrual period, during the post-menstrual period), low blood sugar.



• Food and beverage triggers: caffeine, alcohol (especially red wine), hard cheese, vinegar, hot dogs, chocolate, nuts, MSG (monosodium glutamate), pizza, pork. Foods containing nitrites as preservatives can also trigger headaches. Fasting or missing meals is a major headache trigger.



• Changes in the weather can change body chemistry, and have been known to trigger headaches.



• Heavy cigarette smoking.

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