Headaches: A Big Pain in the Neck

Headaches generally include discomfort and pain around the neck, shoulders, skull, eyes, scalp, jaws, and/or forehead.  Types of headaches include migraines (vascular), tension headaches (muscle contraction), cluster headaches, sinus headaches, and what we call “Atypical Migraines” or “Painless Migraines”

Headache Symptoms

Common Migraine Symptoms

  • Focus on one side of the head (unilateral)
  • Pain or pressure around an eye (e.g., “metal spikes’ through the eye, pressure going in or out of the eye)
  • Incapacitating; intense
  • Cognitive difficulties (“Just can’t think straight, vision changes or loss of field of vision, etc.)
  • Nausea right before or during an episode
  • Photophobia (light sensitive)
  • Aura before or during (seeing spots, sparkles, etc)
  • Phonophobia (sound sensitivity)
  • An “Attack” usually lasting 1-3 days

Common Tension Headache Symptoms

  • Usually both sides of head (bilateral)
  • Not debilitating but nagging
  • “My head feels like it’s being squeezed…like a band around my skull”
  • Dull, aching, heaviness…”It’s just there”
  • Stiffness and tightness in neck and shoulders
  • Duration can be longer than Migraines but typically less intense

Migraine vs. Tension

The charts below illustrate some of the main symptom differences among the headache types:

Headache Type

Pain Type

Headache Factors
Tension—75% Steady Ache Stress
Migraine—6% of all Males

18% of all Females

 Throbbing, usually one side

Nausea

Photophobia

Aura
Cluster—1% of population

85% are male

Pain around one eye

Eye may be inflamed and watery

Possible nasal congestion on the affected side of the face

 Clusters lasting weeks or a month

“Alarm Clock” attacks

1-2 hours in duration

History of smoking and drinking is common

Alcohol may trigger
Rebound Overuse of pain medication

Tension vs. Migraine Headaches

Symptom

Tension

Migraine
Mild-to-moderate

•

•
Moderate-to-severe

•

•
Intense, pounding, throbbing and/or debilitating

•
Distracting but not debilitating

•
Steady ache

•

Location of Pain
One side of head

•
Both sides of head

•

•

Associated Symptoms
Nausea/vomiting

•
Photophobia and/or Phonophobia

•
Aura before onset of headache such as visual symptoms

•

Note: Rebound headache may have features of tension and/or migraine headache

Reference:

American Council for Headache Education.

19 Mantua Road | Mt. Royal, NJ 08061 | 856-423-0258 | fax 856-423-0082

How Headaches Work

The Process of Migraines vs. Tension Headaches

Migraines

Typically develop as a result of a combination of blood vessel spasms, constriction/relaxation of these vessels, and may include a muscle tension (i.e., muscle stiffness and tightness) component.  Although muscle tension may be a factor and may exacerbate symptoms and/or “trigger” a migraine, it is not a requirement.

The Migraine Process

Although there are still competing theories on how migraines develop, a “typical” migraine may occur after a period of time involving stress on the human nervous system (physiological, emotional and/or cognitive) in which muscles tense, blood vessels constrict (i.e., extra cold hands and feet), heart rate increases, etc and then when the system relaxes, it hits…blood vessels in the lining of the skull flood open, causing extreme symptoms of pressure as well other migraine pain symptoms.  In addition, researchers are also finding that certain chemicals relating to pain, inflammation, and tension may also be released with headache onset.

Common Migraine Triggers

In addition to the “stress” process above, migraines also have other triggers that can initiate the onset of a headache.  These include:

Menstrual Cycles and Hormonal Changes in Women

Although not conclusive, varying levels of estrogen may initiate migraines. Many women with migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen. Others have an increased tendency to develop migraines during pregnancy or menopause. Hormonal medications — such as oral contraceptives and hormone replacement therapy — also may worsen migraines, though some women find it’s beneficial to take them.

Foods

Certain foods have been identified as triggers for migraines.  Many foods containing Tyramine have been connected to migraine onset. Tyramine is a naturally occurring substance in some foods that is generated from protein breakdown as foods ages. Generally speaking, the longer a high-protein food ages, the greater the Tyramine content. Common migraine causing foods include alcohol (especially beer and red wine), aged cheeses, chocolate, aspartame, overuse of caffeine, and Monosodium Glutamate (MSG).  Skipping meals or fasting also can trigger migraines.

Stress

As noted above, stress can be a main factor in the onset of migraine headaches.

Sensory stimuli

Intense light and significant sun exposure can trigger migraines, as can loud sounds. Unusual smells — including pleasant scents, such as perfume, and unpleasant odors, such as paint thinner and secondhand smoke, can also trigger migraines.  Remember, these are “triggers” rather than the photophobia or phonophobia (and other stimuli sensitivity) that can occur during or before a migraine

Sleep Changes

Either missing sleep or getting too much sleep may serve as a trigger for migraine attacks in some individuals, as can jet lag.

Physical Overexertion

Intense physical activity, including sexual activity, may provoke migraines.

Environmental Changes

A change of weather or barometric pressure can prompt a migraine.

Medications

Certain medications can aggravate migraines.

Reference:

Mayo Clinic “Migraine” http://www.mayoclinic.com/print/migraine-headache/DS00120/DSECTION=all&METHOD=print

Tension Headaches and Causality

Tension headaches generally stem from muscle tension in the neck, trapezius (shoulders), scalp, and/or other facial stiffness and tightness.  Stress, certain injuries, and poor posture (which cause tightening in the neck and scalp), are common causes. Furthermore, symptoms are often exacerbated by noisy, hot, and stuffy environments.  Many times tension headaches begin at the base of the shoulder/neck region and come over the top of a head in the shape of a “Ram’s Horn.”  The below figure illustrates this type of headache.

Typical “Ram’s Horn” Tension Headache

Migraine Treatment

Medications

Analgesic Pain Relievers/Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Ibuprofen (Advil®, Motrin®, others) or aspirin, may help relieve mild migraines. NSAIDs specific to migraines typically involve a combination of acetaminophen, aspirin, and caffeine (e.g., Excedrin Migraine®). This combination has been known to help both mild and moderate symptoms.  Be careful because overuse can lead to ulcers, gastrointestinal bleeding, liver problems, and rebound headaches.

Triptans

For more severe Migraines. Triptans are effective for most migraine symptoms including pain, nausea, photo, and phonophobia. Includes sumatriptan (Imitrex ®), rizatriptan (Maxalt®), naratriptan (Amerge®), zolmitriptan (Zomig®), almotriptan (Axert®), frovatriptan (Frova®) and eletriptan (Relpax®). Side effects include nausea, dizziness and muscle weakness. Furthermore, they aren’t recommended for people at risk for strokes and heart attacks. A combination of sumatriptan and naproxen sodium (Treximet®) may be more effective than either alone.

Ergot

Ergotamine (Migergot®, Cafergot®) is much less expensive, but also less effective than triptans. It seems most effective in those whose pain lasts for more than 48 hours. Dihydroergotamine (Migranal®) is an ergot derivative that is more effective and has fewer side effects than ergotamine.

Anti-Nausea Medications

Because migraine attacks are often accompanied by nausea with or without vomiting, medication for nausea is appropriate and is usually combined with other medications. Frequently prescribed medications are metoclopramide (oral) or prochlorperazine (oral or suppository).

Butalbital combinations

Medications that combine the sedative butalbital with aspirin or acetaminophen (Butapap®, Phrenilin Forte®) are sometimes used to treat migraine attacks. Some combinations also include caffeine or codeine (Esgic-Plus®, Fioricet®). These medications, however, have a high risk of rebound headaches and withdrawal symptoms so should be used infrequently.

Opiates

Medications containing narcotics, particularly codeine, are sometimes used to treat migraine pain when people can’t take triptans or ergot. Narcotics are habit-forming and are usually used only as a last resort.

Migraine Prevention

Medications

Beta Blockers

(Typically for hypertension and coronary artery disease) can reduce the frequency and severity of migraines. These drugs are considered among first-line prevention/treatment agents.

Calcium Channel Blockers

Verapamil (Calan®, Isoptin®), also may be helpful in preventing migraines and relieving symptoms from aura.

Anti-Hypertensives

Lisinopril (Prinivil®, Zestril®) and candesartan (Atacand®) are useful in reducing the length and severity of migraines. Side effects can include dizziness, drowsiness or lightheadedness.

Antidepressants

Most effective are tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor®), and protriptyline (Vivactil®). These medications are considered among first-line prevention/treatment agents and may reduce migraines by affecting the level of serotonin and other brain chemicals.

Anti-seizure drugs

Divalproex (Depakote®), topiramate (Topamax®), and gabapentin (Neurontin®), seem to reduce the frequency of migraines. Be careful, however, at higher doses side effects can include nausea and vomiting, diarrhea, cramps, hair loss, and dizziness.

Cyproheptadine

Cyproheptadine is an antihistamine that specifically affects serotonin activity. Doctors sometime give it to children as a preventive measure

Botulinum toxin type A (Botox)

Although mixed results in the research, this medication has been shown effective in some migraine patients.  Injections are made in muscles of the forehead and neck. When this is effective, the treatment typically needs to be repeated every three months.

NOTE: Please remember to work closely with your primary care physician and/or other licensed medication providing health care provider to find the right medication for you.

Reference:

Mayo Clinic “Migraine” http://www.mayoclinic.com/print/migraine-headache/DS00120/DSECTION=all&METHOD=print

Non-Pharmacological Treatments and Prevention of Headaches

Relaxation Exercises

Muscle and general relaxation exercises (with or without the addition of Biofeedback), meditation, yoga, mindfulness practices, etc can be very helpful in reducing the stress capable of generating a headache. You can learn these exercises in classes or at home using books or tapes. Furthermore, you can create your own “techniques” for relaxation that can potentially reduce headaches such as listening to music, gardening, taking a hot bath, or reading.

Sleep

Getting enough sleep (7-8hrs per night) had been shown as a reduction factor in headache frequency, duration, and intensity.

Ice and Heat

Generally speaking, there is some data to support that by applying heat for tension headaches (reduce muscle tension) and ice to the skull/head for migraines (reduce the inflammation and constrict the open blood vessels) can reduce headache duration.   People may prefer one or the other.  With the guidance of your health care provider and your own physiology and experience, you decide which works best for you.

Headache Diary

In some cases, I have found that people benefit from keeping a headache log.  It may help you learn more about what triggers your headaches and what treatments are most effective for you.  Essentially, you are creating your own personal research study and with the guidance of your health care provider, you may be able to come to some conclusions about what may help reduce your headaches.

Acupuncture

In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points. A number of clinical trials have found that acupuncture may be helpful for headache pain.  For more information about this treatment, please consult a licensed or certified acupuncturist.

Biofeedback

Using special equipment to teach you how to monitor and control certain physical responses related to stress and other headache related physiology for the goal of headache reduction (See “What is Biofeedback?” Section).

Massage

Massage may help reduce the frequency of headaches by reducing system wide physiological tension, stress levels, as well as muscle tension levels. And it can improve the quality of your sleep, which can, in turn, help prevent migraines.

Herbs, vitamins and minerals

There is some evidence that the herbs feverfew and butterbur may prevent migraines or reduce their severity. A high dose of riboflavin (vitamin B-2) also may prevent migraines by correcting tiny deficiencies in the brain cells. Coenzyme Q10 supplements may be helpful in some individuals. Oral magnesium sulfate supplements may reduce the frequency of headaches in some people, although studies don’t all agree on this issue. Magnesium taken intravenously seems to help some people during an acute headache, particularly people with magnesium deficiencies. Don’t use feverfew or butterbur if you’re pregnant.

NOTE: Again, when using supplements, herbs, and vitamins like these make sure your physician or psychiatrist is aware of exactly what you are taking.  They may have interactions with other medications you are taking or may harm your body in some other way.Ask your doctor if these treatments are right for you.

Avoid triggers

If certain foods seem to have triggered your headaches in the past, avoid those foods. If certain scents are a problem, try to avoid them. In general, establish a daily routine with regular sleep patterns and regular meals. In addition, try to control stress.

Exercise

Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, because sudden, intense exercise can cause headaches. Obesity is also thought to be a factor in migraines, and regular exercise can help you keep your weight down.

Psychotherapy

Working with a mental health provider to explore thoughts, behaviors, and emotions responsible for stress and/or tension in your life that may affect the frequency, duration, and intensity of your headaches.  One factor in the likelihood of an occurring headache is how the body and mind interpret information and whether this interpretation causes system stress.

Reduce the effects of estrogen

If you’re a woman with migraines and estrogen seems to trigger or make your headaches worse, you may want to avoid or reduce the amount of medications you take that contain estrogen. These medications include birth control pills and hormone replacement therapy. Talk with your doctor about the best alternatives or dosages for you.

Reference:

Mayo Clinic “Migraine” http://www.mayoclinic.com/print/migraine-headache/DS00120/DSECTION=all&METHOD=print

Headache Prevention and Treatment with Dr. Schwartz

Stopping the Pattern

One interesting fact about headaches, both migraine and tension, is they typically follow a pattern…they have a process.  Although triggers can create almost immediate episodes, generally migraines occur over a period of stress in the system and happen when people are relaxed (e.g., weekends) while tension headaches occur due to the build up of muscle tension and stress.  Unfortunately, once headaches hit, there is the potential for a cycle to begin, in which the initial headache creates tension and imbalance in the system, ultimately leading to the development of a new headache; thus beginning the cycle.  This pattern is similar to a cycle that may occur in chronic pain (See “Pain Management” Section).  Part of the treatment for headaches is breaking this cycle through identifying the parts of your particular cycle and problem solving through them.  Specifically, this may take the form of combining medication, physiological and psychological awareness, psychotherapy (to explore cognitive, emotional, and behavioral headache factors), and problem-solving any additional headache factors.

Potential Goals with Dr. Schwartz

Get back my life from the headaches!; gain control

  • Exploring psycho-physiological factors that may influence my headaches: Triggers?  Do I need to start a diary? Stress level?

  • Keep blood vessels open all the time and keep muscle tension levels down!
  • Awareness!  Awareness! Awareness!  (e.g., Am I aware that a migraine in “brewing” during my hectic week? My hands are freezing and my neck and shoulders are killing me??
  • Do I need to make any lifestyle changes?  Diet? Exercise? to take control of the headaches

Summary

With the help of Dr. Schwartz, combining biofeedback, psychotherapy, behavioral training, and other therapeutic tools can be a very effective approach in reducing the frequency, duration, and intensity of both migraine and tension headaches. Learn how to increase skin temperature, decrease muscle tension levels, stabilize overall system tension, as well as modify other factors (see above) to prevent and treat headaches.