Tension headache
Tension headaches, which were recently renamed tension type headaches
by the International Headache Society, are the most common type
of headaches. The pain can radiate from the neck, back, eyes, or other
muscle groups in the body. Nearly everyone will have at least one tension
headache in their lifetime.
Frequency and duration
Tension headaches can be episodic or chronic. Episodic tension headaches
are defined as tension headaches occurring less than 15 days a month,
whereas chronic tension headaches occur 15 days or more a month for at
least 6 months. Tension headaches can last from minutes to days or even
months, though a typical tension headache lasts 4-6 hours.
Pain
Tension headache pain is often described as a constant pressure, as if
the head were being squeezed in a vise. The pain is frequently bilateral
which means it is present on both sides of the head at once. Tension headache
pain is typically mild to moderate, but may be severe. In contrast to
migraine, the pain does not increase during exercise.
What causes these headaches
The exact cause of tension headaches is still unknown. It has long been
believed that they are caused by muscle tension around the head and neck.
However although muscle tension may be involved, there are many forms
of tension headaches and some scientists now believe there is not one
single cause for this type of headache. One of the theories is that the
pain may be caused by a malfunctioning pain filter which is located in
the brain stem. The view is that the brain misinterprets information,
for example from the temporal muscle or other muscles, and interprets
this signal as pain. One of the main molecules which is probably involved
is serotonin. Evidence for this theory comes from the fact that tension
headaches may be successfully treated with certain antidepressants. Another
theory says that the main cause for tension type headaches and migraine
is teeth clenching which causes a chronic contraction of the temporalis
muscle.
Treatment
Episodic tension headaches generally respond well to over-the-counter
analgesics, such as acetaminophen or aspirin. However, these medications
should be avoided in cases of chronic tension headache, due to the risk
of rebound headaches. Chronic tension headaches are more difficult to
treat. Suggested therapies include:
- Swimming two to three times a week
- Acupuncture
- Biofeedback
- Massage
- Heat pillow
- The NTI Tension Suppression System
- Amitriptyline
- Doxepine
- Imipramine
Relaxation techniques like:
- Jacobson's Progressive Muscle Relaxation
- Autogenous training
Tension headaches are exacerbated by states or activities that induce
muscle tension, such as stress. Avoiding such states can lessen the frequency
of tension headaches. Tension headaches can also be secondary to other
conditions, such as an upper respiratory infection or other virus.
Often the best treatment for a mild tension headache that does not impair
a person's ability to function is simple endurance. Many tension headache
sufferers receive relief from sleep.
Migraine
Migraine is a form of headache, usually very intense and disabling. It
is a neurologic disease of vascular origin characterized by attacks of
sharp pain involving (usually) one half of the skull and accompanied by
nausea, vomiting, photophobia and occasionally visual (or rarely other)
disturbances known as aura. The symptoms and their timing vary considerably
among migraine suffers, and to a lesser extent from one migraine attack
to the next.
In some cases, migraine can cause seizures such as a tonic-clonic seizure.
Stroke symptoms (passing or permanent) are seen in very severe subtypes.
Symptoms
Migraine is often caused by the expansion of the blood vessels of the
head and neck. Classical migraine (migraine with aura) is forerun by a
group of symptoms called aura, whereas common migraine does not have any
indicator for the impending headache. A few (perhaps fortunate) people
actually get aura without migraine. Cluster headaches have similar symptoms,
but tend to recur in minutes or hours, rather than days, and affect a
different area of the face.
Migraine can accompany, in some cases, another type of headache called
Tension headache.
Migraine often runs in families and starts in adolescence, although some
research indicates that it can start in early childhood or even in utero.
Migraine occurs more frequently in women than men, and is most common
between ages 15-45, with the frequency of attacks declining with age in
most cases.
Because their symptoms vary, an intense headache may be misdiagnosed
as a Migraine by a layperson. Where possible, see a doctor to determine
if the headaches are a symptom of something else.
Treatment
Treatment focuses on three areas:
- Elimination of triggers
- Abortive drugs
- Preventive drugs
In many patients the incidence of migraine can be reduced through diet
changes to avoid certain chemicals present in such foods as cheddar cheese
and chocolate, and in most alcoholic beverages. Other triggers may be
situational and can be avoided through lifestyle changes.
Many people have found that eliminating most tannins from their diet
can substantially reduce their migraines. This can happen even if they
have known triggers, such as time-of-the-month for women, certain weather
patterns, or going hungry. Some of the foods containing tannins are regular
tea, apple juice, orange-coloured cheese, many alcoholic drinks, many
herbs and spices.
Until the introduction of sumatriptan (Imitrex®/Imigran®) around
1985, ergot derivatives (see ergoline) were the primary oral drugs available
to stop a migraine once it was underway. Analgesics and caffeine were
used to provide some relief, though they are not effective for most sufferers.
Narcotic pain medications, and antipsychotic drugs such as thorazine and
compazine, are effective but have debilitating side effects at the doses
required to achieve control.
Ergotamine tablets, usually with caffeine, are sometimes used. Dihydroergotamine
(DHE), which must be injected or inhaled, is also effective. These drugs
can be used either as preventive or abortive therapy.
Imitrex (sumitriptan) and the related 5-hydroxytryptamine (serotonin)
receptor agonists are now available and are the therapy of choice for
severe migraine that is relatively infrequent. They are highly effective
and have few side effects when used occasionally. Some members of this
family of drugs are sumatriptan (Imitrex®, Imigran®), zolmitriptan
(Zomig®), naratriptan (Amerge®), rizatriptan (Maxalt®), eletriptan
(Relpax®) and frovatriptan (Frova®).
Evidence is accumulating that these drugs are effective because they constrict
certain blood vessels in the brain. They do this by acting at serotonin
receptors on nerve endings. This action leads to a decrease in the release
of a peptide known as CGRP. In a migraine attack, this peptide is released
and produces pain by dialating cerebral blood vessels.
These drugs are available by prescription only (U.S.). Many migraine
sufferers do not use them only because they have not sought treatment
from a physician.
For patients who suffer frequent, intractable and severe symptoms, preventive
and prophylactic medications can be used. A large number of medications
with varying modes of action can be used. Selection of a suitable medication
for any particular patent is a matter of trial and error, since the effectiveness
of individual medications varies widely from one patient to the next.
Beta blockers such as propranolol and atenolol are usually tried first.
Antidepressants such as amitriptyline may be effective. Antispasmodic
drugs are used less frequently. Sansert was effective in many cases, but
has been withdrawn from the U.S. market.
Migraine sufferers usually develop their own coping mechanisms for intractable
pain. A warm bath, or resting in a dark and silent room may be more helpful
than any other medication for many patients.
Alternative approaches
Some migraine sufferers find relief through acupuncture which is usually
used to help prevent headaches from developing. Sometimes acupuncture
is used to relieve the pain of an active migraine headache.
Supplementation of Coenzyme Q10 has been found to have a beneficial effect
on the condition of some sufferers of migraines.
The plant feverfew (Tanacetum parthenium) is a traditional herbal remedy
believed to reduce the frequency of migraine attacks. Clinical trials
have been carried out, and appear to confirm that the effect is genuine
(though it does not completely prevent attacks).
According to a recent survey (http://nccam.nih.gov/news/2004/052704.htm),
3.1% of the adult American population (http://nccam.nih.gov/news/report.pdf
p9) use complementary and alternative medicine to treat migraine and severe
headache.
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Cluster headache
Cluster headaches are rare headaches that occur in groups or clusters.
Cluster headache sufferers typically experience very severe headaches
of a piercing quality near one eye or temple that last for between 15
minutes and three hours. Cluster headaches are frequency associated with
drooping eyelids, red, watery eyes, and nasal congestion on the affected
side of the face. The headaches are unilateral and occasionally change
sides. The neck is often stiff or tender in association with cluster headaches,
and jaw and teeth pain is sometimes reported.
In episodic cluster headache, these headaches occur once or more daily,
often at the same times each day, for a period of several weeks, followed
by a headache-free period lasting weeks, months, or even years. Approximately
10-15% of cluster headache sufferers are chronic; they can experience
multiple headaches every day for years. Cluster headaches are occasionally
referred to as "alarm clock headaches", as they can occur at
night and wake a person from sleep. Other synonyms for cluster headache
include Horton's syndrome and "suicide headaches" (a reference
to the excruciating pain and resulting desperation).
Medically, cluster headaches are considered benign, but they are extremely
painful and can be debilitating. The location and type of pain has been
compared to a 'brain-freeze' headache from rapidly eating ice cream; this
analogy is limited, but may offer some insight into the cluster headache
experience. Persons who have experienced both cluster headaches and other
painful conditions (childbirth, migraines) report that the pain of cluster
headaches is far worse. During a cluster headache attack, a person often
alternates between pacing and laying still. Sensitivity to light (seeking
the dark) is more typical of a migraine, as is vomiting but they can be
present in some sufferers of cluster headache.
Whereas other headaches, such as migraines occur more often in women,
cluster headaches occur in men at a rate 2.5 to 3 times greater than
in women. Between 1 and 4 people per thousand experience cluster headaches
in the U.S. and Western Europe; statistics for other parts of the world
are fragmentary. Latitude plays a role in the occurrence of cluster headaches,
which are more common as one moves away from the equator towards the poles.
It is believed that greater changes in day length are responsible for
the increase.
While the immediate cause of pain is in the trigeminal nerve, the true
cause(s) of cluster headache is complex and not fully understood. Among
the most widely accepted theories is that cluster headaches are due to
an abnormality in the hypothalamus. This can explain why cluster headaches
frequently strike around the same time each day, and during a particular
season, as one of the functions the hypothalamus performs is regulation
of the biological clock. Certain immune dysfunctions and metabolic abnormalities
have also been reported in patients. There is a genetic component to cluster
headaches, although no single gene has been identified as the cause. As
a group, cluster headache patients are more likely to have suffered brain
trauma than the general population. Sinus problems, damage to the jaw,
and sleep apnea are also more common in cluster headache patients, but
these factors do not adequately explain the disease.
Many doctors are unfamiliar with this disease, and cluster headaches
often go undiagnosed for many years. Paroxysmal Hemicrania (PH) is a condition
similar to cluster headache, but PH responds well to treatment with the
anti-inflammitory drug indomethacin and the attacks are very much shorter,
often lasting seconds only.
Over the counter pain medications (such as aspirin, acetaminophen, and
ibuprofen) have no effect on the pain from a cluster headache. Some have
reported partial relief from narcotic pain killers, but the frequency
of their use in a cluster cycle (1-3 times a day) often disqualifies them
from use. However, some newer medications like fentanyl have shown great
promise in early studies and use.
Medications to treat cluster headaches are classified as either abortives
or prophylactics (preventatives). The most successful abortives include
breathing pure oxygen (12-15 liters per minute in a non-rebreathing apparatus)
and triptan drugs like sumitriptan and zolmitriptan. A wide variety of
prophylactic medicines are in use, and patient response to these is highly
variable. Preventitives include muscle relaxants, lithium, calcium channel
blockers such as Verapimil, ergot compounds, anti-seizure medicines, and
atypical anti-psychotics.
Magnesium supplements have been shown to be of some benefit in about
40% of patients. Melatonin has also been reported to help some. Hot showers
have helped about 15% of people who try it. Feverfew, a herb used to treat
migraine, is not clearly beneficial according to anecdotes from web forums.
Suggestions that psilocybin (mushrooms) and LSD may be able to abort
cluster cycles have not yet received any scientific proof and should be
taken with extreme care and skepticism.
Some people with extreme headaches of this nature (especially if they
are not unilateral) may actually have something else: an ictal headache.
Anti-convulsant medications can significantly improve this condition,
so make sure you talk with your doctor about this possibility if you think
you might be affected.
Rebound headaches
Rebound headaches occur when medication is taken too frequently to relieve
headache pain. Rebound headaches frequently occur daily and can be very
painful. A diagnosis of rebound headaches can be easy or difficult, as
the cause is very easy to identify but very difficult to diagnose. Overuse
of painkillers can be confirmed simply by asking the patient if his or
her headaches assumed a new pattern or became more severe after taking
painkillers excessively (generally classified as more than 3 times per
week). However, the only way to make a certain diagnosis of rebound headache
is to withdraw the patient from medication for anywhere up to 6 months.
It should be noted that withdrawal from medication will actually intensify
the headaches for the first few weeks. After this period, the headaches
will gradually recede.
Following treatment, many patients revert to their prior headache pattern.
A physician should be consulted before re-use of medications.
Ice cream headache
Brain Freeze or ice cream headache is a term used to refer to the pain
sometimes inflicted by devouring something cold like ice cream or a cold
beverage, often very quickly.
The reaction is (obviously) triggered by the cold ice cream or beverage;
coming into contact with the roof of the mouth. It triggers nerves that
give the brain the impression of a very cold environment. To heat up the
brain again, blood vessels start to swell, which causes the headache-like
pain for approximately 30 seconds.
The temperature change in the roof of the mouth has to be rather drastic;
this is why brain freeze often occurs on warm days.
The pain can be relieved by putting the tongue to the roof of the mouth,
which logically will heat it up.
Ictal headache
Ictal headaches are headaches associated with seizure activity. They
may occur either before (pre-ictal), after (post-ictal), or most rarely
during a seizure. Many cases of ictal headache may be misdiagnosed as
migraine with aura, or even cluster headache. However, whereas these conditions
usually involve just one side of the head (are unilateral), an ictal headache
may be centrally situated or cover the entirety of the head.
Severity of ictal headaches can vary from a slight pressure or "cloud"
to an intensity far beyond migraine. Some have called it a "suicide
headache" in the worst instances. Temporary blindness may also occur
in some cases.
Ictal headaches can be controlled with anti-convulsant medications, in
many cases.
Note that other symptoms besides headache may be either present or absent,
and may include unusual thoughts or experiences. In these cases it is
especially important to obtain a correct diagnosis. Many people with these
experiences are accidentally diagnosed with conditions such as psychosis
or even schizophrenia and given anti-psychotic medications which ironically
may increase seizure activity. An EEG is recommended to detect other signs
of epilepsy in all cases, however even when this does not prove determinative,
anti-convulsants may be a first line of treatment if these symptoms are
present with headache.
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