Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
6 December 2006

THE PROBLEM OF HEADACHES

            A headache is one of the most common symptoms encountered by healthcare providers.  The severity ranges everywhere from being a slight nuisance to the disability that occurs with a true migraine syndrome.  The causes are very diverse and present a significant challenge in regard to diagnosing and treating the headache.

            By far the most common type of headache is the so called “tension headache”.  To understand the nature of this type of headache I would invite you to participate in a little experiment. Pick up a slightly heavy object and hold it out in front of you with your arm fully extended.  Keep doing this for a minute or two minutes or as long as you can until your arm begins to hurt.  As you put the object down and resume your arm back in a normal position, recognize that the pain in your arm was a message telling you that there was a strain that was harmful.  Now think about the muscles in your neck and your forehead.  Your neck can be held very loosely in place or if you “bow your neck” it can be held very tightly in place.  Think about what happens as a person becomes more stressed and how the muscles in the neck tighten up exactly the same way as the muscles in your arm were tightened to hold the object in front of you.  It is easy to recognize that your arm hurts because you are holding it in an abnormal position with a heavy weight.  But people do not recognize that they are bowing their neck and they don’t recognize that they are furrowing their brow and straining the muscles in their forehead and face.  After this strain has gone on for a long enough period of time, it is no wonder that it begins to hurt.  But since a person really isn’t conscious that they are bowing their neck and straining their foreheads, they don’t know enough to stop pulling on these muscles and the pain persists.  This is the source of the so called tension headache. 

            Tension headaches classically involve both sides of the head usually globally over the entire surface of the head.  They tend to last for hours and maybe relieved with pain pills or sedatives.  Just as there was no disease in your arm when it held the heavy object in front of you, there is no disease in the person’s head to explain the pain but rather just a strain pattern about which the person is unaware.  Tension headaches tend to recur frequently in response to stressful situations even though the stress may not even be recognized. 

            Tension headaches account for perhaps 90 percent of the headache problems that are present to healthcare professionals.

            The other 10 percent of all the headaches that occur are caused by a variety of problems.  Patients that seek medical attention because of their headaches are often concerned that it represents a brain tumor or an infection or other such problem.  But these causes are relatively rare.  Much more common is a so called “migraine headache”  Migraine headaches begin with a brief aura lasting minutes to an hour during which the person has flashing lights in one or both eyes or an unusual aroma or a buzzing or ringing sound in their ear followed by the headache which is limited to one side of the head.  In fact the pain is really located in the face.  The person doesn’t really describe pain in the back of the head so much as they describe a pain in the face often centered in the eye on one side.  There is no known inciting event that makes a migraine begin and there are no blood tests, x-rays or other diagnostic procedures which will make the diagnosis.  The diagnosis is based simply on the clinical story and the response to treatment.  Migraine headaches respond to a group of drugs introduced in the recent past called “triptans”.   Sumatriptan (Imitrex) was the first one on the market but there are now no fewer than six different commercial products available as injectables, pills, or lozenges that dissolve in the person’s mouth.  This type of medication is usually very effective in stopping the headache.  Left to the person’s natural history, the headache may last for three days, be totally disabling associated with marked negative sensitivity to light, nausea, vomiting, and sleeplessness.  Migraine headaches are ugly. 

            As a side note, people often describe themselves as having migraine headaches because their “tension” headaches are very severe to them.  The severity of the headache has nothing to do with it being a migraine.  Migraine headaches are classically limited to one side of the head.

            Cluster headaches are another type of headache.  Recently, a gentleman came to the hospital because of a severe headache that he had had for approximately three weeks.  It had become much worse over the previous several days.  It was constant, being present for much of the day but getting slight relief intermittently.  His pain was located in his right eye.  There were no other distinguishing features about his history.  The pain was severe enough that he was hospitalized.  An MRI scan was used to rule out the possibility that he might have a tumor or other such problem in his central nervous system.  No abnormality was identified on the tests that were done.  His headache is diagnosed as a “cluster headache”.  Cluster headaches are described as occurring intermittently with periods of normalcy for weeks or months between “clusters” of headaches.  This type of headache is most common in men (85%).  Headaches last for several days or several weeks and then go away again as mysteriously as they came.  The pain is described as located usually on one side often seemingly centered in the eye.  Those individuals that seek medical attention usually have relatively severe pain often requiring hospitalization such as this gentleman did.  Once the absence of a tumor or other such problem is ruled out, there are medications that can treat this headache and some medications that can prevent its recurrence if the clusters tend to come too often.

            Migraine and cluster headaches have no known cause and don’t seem to be related to anything that the person does to bring them on.

            There are many, many other types of headaches but in our elderly population one that deserves some attention is called “temporal arteritis”.  This type of headache involves the sides of the head usually near the ear and above it.  There is associated local tenderness when the person touches that area.  The headache is due to an inflammation in the arteries just in this part of the body and unfortunately can result in blindness.  Thus diagnosing this condition quickly and getting appropriate treatment is critical.

            Another type of headache is called “tic douloureux”.  By this type, the person has flashes of pain that are brought on by simple acts such as a breeze on the face or taking a bite of food or simply touching an area of the face.  These pains can be very severe but fortunately are effectively treated with a medication.  When the medication is inadequately effective, there is a procedure using radiofrequency waves to inactivate a nerve center in the face and completely cure this condition.

            The healthcare professionals at your local clinic deal with headache problems on a daily basis.  Most can be helped with simple measures available locally.  Occasionally referral onto a headache specialist or a neurologist maybe necessary but this can be arranged through your local clinics.