What is a headache?
Headache is one of the most common pains experienced. A headache is usually a condition in itself and this is called primary headache. The 3 types of primary headache are Migraine, Tension and Cluster Headache. Headache may also be a symptom of an illness and in this instance, it is called a secondary headache. Illnesses which may include the symptom of headache are eye disorders, sinus disease and conditions of the brain or the nervous system, such as a head injury.
Diagnosis of headache
When a doctor is consulted about a headache they will usually take a full detailed history and carry out a physical examination in order to rule out any other conditions or illnesses which might be causing the headache. Based on the history and physical examination the doctor will offer advice and treatment depending on the type of headache diagnosed. If treatment is not helpful and frequent and severe headaches continue then the doctor may refer their patient to a headache specialist. This doctor is usually a Neurologist (a doctor who specialises in disorders of the brain and nervous system).
Migraine
Migraine is a condition that causes frequent episodes or attacks of headaches. A migraine can range from a mild headache to a severe throbbing headache. The headache is usually made worse by physical activity and other symptoms can include nausea, vomiting, photophobia (sensitivity to light) and visual disturbance such as blind spots, zigzag lines or a partial loss of vision. Migraine is a common disorder – about 1 in 4 women and 1 in 12 men developing the condition in their lifetime. Most people will develop migraine before the age of 30 with the condition usually improving as they age.
Types and symptoms of migraine
- Migraine without aura is the most common type of migraine. It is typically on one side of the head, usually at the front or the side but can sometimes be on both sides of the head. It often begins in the morning but can begin at any time day or night. It progressively worsens and peaks after 2 – 12 hours then slowly eases off although it may last from 4 – 72 hours.
- Migraine with aura occurs in about 10% of people. These people will experience symptoms shortly before the headache starts. These symptoms are referred to as an ‘aura’ and include visual disturbances such as flashes of light or a temporary loss of vision. Other types of aura include numbness or pins and needles which usually start in the hand and then move up the arm involving the face, lips and tongue. A disturbance in speech, an awareness of odd smells or food cravings may also occur.
Causes and triggers of migraine
The cause of migraine is not yet clear. One theory is that blood vessels in parts of the brain spasm (become narrower) accounting for the aura. The blood vessels are thought to then dilate (open wide) quickly which accounts for the headache. Another theory is that certain chemicals in the brain increase in activity which causes part of the brain to send out confusing signals which may contribute to the symptoms. The exact change in brain chemicals or why people develop these changes is not known. Although episodes of migraine can begin with no apparent cause some people find that they have triggers:
- Diet
Irregular meals, certain foods such as cheese or citrus fruit, red wine and a food additive called tyramine have been reported as triggers
- Environment
Smoking, smoky areas, computer screens, loud noises and strong smells have all been associated with the onset of a migraine
- Psychological
Anxiety, anger, tiredness and depression have all been associated with migraine. Sufferers of migraine often cope well with stress but find that once stress is removed and they relax they will suffer a migraine (referred to as a ‘weekend migraine’)
Diagnosis of migraine
There is no one test used to diagnose migraine. It is usually confirmed by a description of the typical symptoms. If a doctor recognises the characteristic symptoms of migraine and a physical examination rules out any other abnormality then the condition may be confidently diagnosed. However, in instances where a person presents with non-typical headache patterns then tests may be ordered to rule out another possible condition.
Treatment of migraine
There is no cure for migraines but there are medications which can help with the condition. It is important for people to be aware of their triggers and by avoiding these they may be better able to manage the condition.
- Analgesia
Over-the-counter pain medication such as paracetamol, aspirin (children under 16 years of age should not take aspirin for any condition), or ibuprofen may be effective for milder forms of migraine headaches. If analgesia is taken early enough (when symptoms start) they may reduce the severity or even stop the migraine completely.
- Anti-nausea tablets
Medication such as Metoclopramide may be helpful in managing the symptoms of nausea and vomiting. As with analgesia it is best to take anti-nausea medication as soon as symptoms begin. If a person vomits or is very sick during a migraine attack their doctor may prescribe an anti-nausea suppository.
- Triptans
This group of medication (including Imigran) works by interfering with a chemical in the brain called 5HT (a variation in this chemical is thought to be involved in migraine) and are an alternative to analgesia if not effective and for people with severe migraines. Taking a triptan will often reduce or stop a migraine attack. Unlike analgesia which should be taken as soon as possible after the onset of a migraine, triptans should be taken when the headache pain is starting to develop and not during the aura stage. It is thought that taking the medication too early may reduce its effectiveness. Side effects of triptans can include tiredness, dizziness and drowsiness.
Tension type headache
78% of headaches are mild, infrequent, tension type headaches. The pain is on both sides of the head and is a dull ache which does not throb. These kinds of headaches can be associated with tension in the muscles of the head, neck, jaw and shoulders. Tension type headaches are slightly more common in women, do not improve with age, are not aggravated by physical activity and are not normally associated with nausea.
- Episodic (intermittent) tension-type headache are headaches that are frequent, severe and usually very distressing to the sufferer. They usually occur several times a month.
- Chronic tension-type headache sufferers may have a daily constant headache (at least 15 times per month).
What causes a tension type headache?
There are several theories about what causes tension-type headaches. One is that that they are caused by muscle tension around the head, neck and shoulders. Another is that persistent teeth clenching may cause an ongoing contraction of a muscle at the side of the skull, the temporal muscle. They are also thought to be caused by a faulty pain filter in the brain stem which misreads information from the temporal or other muscles in the head as pain.
Other factors which sufferer’s state may trigger a tension-type headache include:
- irregular mealtimes or hunger
- uncomfortable position or bad posture
- eye strain
- lack of sleep
- caffeine
- changes in the weather
- stress (these kinds of headaches may occur after a stressful day or stressful event such as an exam)
Diagnosis of tension type headache
A doctor will take a detailed history and carry out an examination. They may diagnose tension type headache if the headaches last from 30 minutes to 7 days and the headaches have at least two of the following characteristics:
- pain affects both sides of the head
- pain is pressing or tightening
- pain is mild or moderate
- not accompanied by nausea or vomiting
- not worsened by physical activity
- not caused by another condition
Treatment of tension type headache
Pain medication such as aspirin, paracetamol and ibuprofen are effective for mild tension-type headaches.
Physiotherapy, hot and cold packs, exercise and relaxation may also be effective.
Analgesic rebound headache
The overuse of pain medication for simple tension-type headache may cause intermittent headaches to become chronic daily headaches. Treatment of this type of headache involves slowly reducing pain medication under medical supervision. It is recommended that people with chronic headaches have at least two pain medication free days a week.
Cluster headache
Cluster headache is a very uncommon condition affecting about one in 1000 people and is a pain syndrome of the nervous system. As the name suggests, it is characterised by a cluster of headaches occurring frequently for two to three months followed by a headache free period which lasts for months or years. The pain of a cluster headache is intense and severe on one side of the head. Attacks often occur at night and at the same time.
Unlike other types of headaches, cluster headache is more common in men with the first attack occurring between the age of 20 and 40 years of age. Cluster headache is associated with smoking, head trauma and a family history of the condition.
Causes of cluster headache
The cause of cluster headaches is not known. However, research has shown that when a cluster headache occurs there is an increase in activity in the area of the brain known as the hypothalamus. It is thought that the hypothalamus releases chemicals that may trigger a cluster headache by causing blood vessels to widen which increases blood flow to the brain. It is not known why this happens however some people report that their cluster headaches are triggered by alcohol or an extreme increase in temperature.
Symptoms of cluster headache
The pain of a cluster headache usually starts quickly, is very severe and comes on without any warning. The pain is steady rather than throbbing. The headache affects one side of the head (however it can move to the opposite side) and is usually felt around the eye, the forehead and the cheeks. The headache usually lasts between 15 minutes to 3 hours but most commonly lasts less than 1 hour.
Attacks of headaches occur in groups (clusters) which take place one to eight times a day. These can occur every day for several weeks or even months and are then followed by a period of no headaches. This may last for months or years although the average time reported is one year.
Other symptoms that might be present with a cluster headache:
- inflammation or redness of eye
- drooping or swelling of eyelid
- smaller pupil during the attack
- watery eye
- facial sweating
- blocked or runny nose on affected side of face
- many people feel restless during an attack and are unable to remain still, preferring to pace up and down
Diagnosis of cluster headache
There is no one test to diagnose cluster headache. A doctor will take a detailed history and carry out a physical examination to rule out any other conditions.
Treatment of cluster headache
Over-the-counter pain medication such as paracetamol and ibuprofen are not effective in treating cluster headaches as they work too slowly. Most people will be treated by a specialist who will provide treatment to prevent cluster headaches and to relieve symptoms if they occur.
- Triptans (such as Imigran) work in a similar way to a brain chemical called 5HT which causes blood vessels to narrow, reducing blood flow to the brain. Taking a triptan will often reduce or stop a cluster headache. It is usually given as an injection at the onset of the headache and it usually works very quickly (within 10 minutes).
- Verapamil is a medication usually used to treat heart problems but can also be effective at preventing cluster headaches. The heart is closely monitored if the dose of Verapamil is increased.
- oxygen therapy has been shown to be a useful treatment for cluster headaches. Pure oxygen is breathed through a high flow oxygen mask for 15 minutes a day.
- a procedure called an occipital nerve block is sometimes used to help with the pain of cluster headaches. The occipital nerve runs from the top of the spine to the scalp and is involved in the pain of cluster headaches. An occipital nerve block involves an injection of a local anaesthetic into the back of the head to relieve the pain of cluster headaches for a period of time (usually several weeks). Although there is a lack of evidence regarding this form of treatment it has been reported to be useful for some patients with cluster headaches
Support services
A support group called Headache Australia provides support for people suffering with headache: headacheaustralia.org.au
