[Editor's note: This article is from 2007. Some newer treatments and current statistics are not included here. See further information on BrainWeb]
sections include: 'thunderclaps' and other serious headaches, tension headaches, headaches arising from structures in the face and neck, other benign headaches
We don’t expect pain to be a part of daily life. So why do so many people suffer from regular headaches?
Some of these pains serve a useful purpose as a warning of life-threatening disease, such as meningitis or cerebral hemorrhage. But often recurrent and severe headaches seem to serve no obvious purpose. They simply cast a shadow over the enjoyment of life.
Certain people seem especially prone to headaches, and the cause appears to lie in the brain. Our brains are equipped with an internal pain-control system that damps down the perception of unwanted stimuli. These feelings can be leg pain in a long-distance runner, or head pain from dilated blood vessels or excessive contraction of jaw, scalp, and neck muscles. The system depends on chemical neurotransmitters, serotonin (5-hydroxytryptamine) and noradrenaline, to pass the pain-control message from centers in the midbrain (periaqueductal gray matter and the locus ceruleus) downstream to the cells in the brain stem and upper spinal cord that receive pain impulses from the head and neck. It is likely that in people susceptible to headaches this pain control system is more delicate. Trigger factors such as excitement, emotional upsets, heat, glare, noise, strong perfumes, missing meals, or sleeping late can bring on undampened pain. This susceptibility is also often inherited.
A person who never suffers from an occasional headache is very lucky indeed. A survey of 1,000 people in Denmark found that over a person’s lifetime, the likelihood of ever experiencing a hangover headache was 72 percent, a tension headache 69 percent (including 3 percent in whom headaches recurred nearly every day), a migraine 15 percent, and the pain of sinusitis 15 percent. Disorders of the neck and headaches associated with coughing, exertion, and sexual activity had each affected 1 percent of the people surveyed. This section discusses each of these types of headaches except migraine, which is covered here.
Most headaches are not associated with any underlying problem in the head and are thus called benign. If you are subject to an occasional tension headache that disappears with acetaminophen, aspirin, or another over-the-counter pain reliever, you do not need to seek further remedy. But if your tendency to have headaches is recent or your headaches are becoming more frequent or severe, see your doctor. You may be referred to a neurologist for specific diagnosis and treatment. A few types of headache, and only a few, require urgent attention. Most forms can be treated satisfactorily to restore your natural freedom from pain.
'Thunderclaps' and Other Serious Headaches
Any bad headache occurring suddenly for the first time—a “thunderclap headache”—warrants immediate investigation. The sudden onset of a severe headache, particularly if accompanied by neck stiffness, can signal that blood is leaking into the subarachnoid space surrounding the brain, usually from a leaking aneurysm (a blowout of a major cerebral artery). This may lead to a hemorraghic stroke. A sudden surge of blood pressure can cause a similar thunderclap headache. Meningitis and other serious illnesses can also appear in this manner.
Sex headache. Another, more benign cause of thunderclap headache for some people is sex. As sexual excitement builds up, muscle tension in the head and neck increases. A person may feel this as a dull headache, and, if he or she proceeds to orgasm, may experience a sudden, severe explosive headache at the moment of climax. This feeling may persist for some hours afterward (the headache, unfortunately, not the climax). This variety of sudden, severe headache is caused by the rapid elevation of blood pressure at orgasm. (On occasion, that spurt in blood pressure has even caused some people to suffer a cerebral hemorrhage.) Sex headaches bear some relation to the exertional headaches mentioned, but they may also develop when a person becomes sexually excited even without physical exertion. Naturally, this explosive headache worries people, not to mention how it interferes with the enjoyment of life.
Once imaging and other tests have excluded more serious causes for this problem, people who have recently suffered from sex headache can simply desist from sexual activity when they feel a headache coming on. Fortunately, these headaches are capricious; they may occur a few times and then never again. If the tendency persists, using a noradrenergic beta-blocker like propranolol may prevent them.
Progressive headache. Less-than-severe headaches that grow progressively worse are also cause for worry. Following a blow to the head, even a minor one, bleeding from a cerebral vein can cause increasing pressure on the brain. Someone with this symptom should see a physician immediately. In people older than 55, scalp arteries can become inflamed (temporal arteritis); doctors should suspect and treat this condition early because the inflammation can spread to the arteries supplying the eyes and thus cause blindness.
Brain tumors may also cause headaches of progressive severity as the growing tissue presses against the arteries of the brain (brain tumors, tumors of childhood). Fortunately, these are rare compared with the many other types of headaches in life. Pressure within the cranium may also increase without any brain tumor being present. This is called idiopathic intracranial hypertension, and it usually occurs in obese young women. It is usually associated with blurred vision and must be treated before it can cause blindness. (The opposite condition, low intracranial pressure, is uncommon except after a person has had a lumbar puncture it appears as a headache that starts when the person stands up.)
Cough headache. Headache brought on by coughing, sneezing, or straining can be a serious symptom. It may indicate a valvelike obstruction blocking the normal cerebrospinal fluid channels in the brain (the ventricles), or a displacement of pain-sensitive blood vessels by a brain tumor. Once these unpleasant possibilities have been ruled out by computed tomography (CT) scanning or magnetic resonance imaging (MRI) of the brain, the problem is labeled “benign cough headache.” People suffering from this condition, usually middle-aged, benefit from having the blood flow in their carotid and vertebral arteries, which feed the brain, checked to ensure that they are not narrowed by fatty material (atheroma). Physicians do not have to inject anything into the arteries to do this; they can use an ultrasound tool instead. Cough headaches usually respond to indomethacin, a medication that reduces inflammation.
Vascular Headaches. Some pains stem from the blood vessels in the head: dilated arteries set up a headache that throbs with each pulse. On occasion, sufferers notice that arteries in their forehead and temple become swollen and tender, and that pressure on these areas may ease the pain. The most common of these headaches is migraine.
Cluster headache. An uncommon but intriguing syndrome is cluster headache. This mainly affects males, while migraine and tension headaches affect women more usually. Cluster headaches generally start in a person’s teens or twenties, but some cases start in infancy. The name cluster headache derives from the unusual pattern of headaches recurring in bouts lasting for weeks or months, separated by periods of freedom for months or years. During each bout the victim experiences one or more episodes of severe pain for several hours at a time, usually felt behind one eye but often radiating over the head or down the face. The eye on the affected side reddens and waters, the eyelid droops, and the nose becomes stuffy.
Cluster headaches may come on at a particular hour of the day, as though set by an internal alarm clock. If sufferers travel from New York to California, they continue to have their headaches on New York time until their sleep cycles and other internal clocks adapt. This internal timekeeper probably lies in the hypothalamus, where positron-emission tomography (PET) scanning has shown a “hot spot” of increased metabolism during headache episodes.
Bouts of cluster headache can usually be suppressed by such medication as verapamil (Calan SR), methysergide (Sansert), or prednisone (Cortan). Most people can shorten the duration of the pain if they inhale 100 percent oxygen or, if the headaches are truly debilitating, inject the drug sumatriptan (Imitrex).
Exertional headache. Headaches provoked by exercise are quite common in young people because the blood vessels in the cranium swell up and become sensitive to pain. These headaches can often be avoided by taking a vasoconstricting agent such as ergotamine just before one plans to exercise. After the headaches have started, they usually respond well to the anti-inflammatory agent indomethacin.
Hangover. Alcohol can cause headache by dilating blood vessels in the head. Wines contain substances that may precipitate this headache in some unfortunate people. In most countries, drinkers blame red wine for the worst hangovers, but in France, for some obscure reason, headaches are attributed more often to white wine. The “morning after” headache probably results from the breakdown of the alcohol into acetaldehyde and acetate—these chemicals cause a painful relaxation of arteries inside the skull.
Caffeine. Coffee, tea, and many soft drinks contain caffeine, which constricts blood vessels. They can thus help relieve those types of headaches in which blood vessels are dilated. But that effect wears off in a few hours, sometimes leading to caffeine withdrawal headaches. Often a person relieves that pain with more caffeine, thus starting a cycle.
Marijuana. Cannabis dilates blood vessels and thus may bring on a mild frontal headache. On the other hand, tension headaches may be relieved because of the relaxation this substance induces. Of course, the legal problems that marijuana possession can create are a different and more troubling sort of headache.
The all-too-common tension headache is a constant tight or pressured feeling, like a band around the head or a weight on top of it. It may be brought on by concentration, worry, emotion, fatigue, eyestrain, or exposure to flickering light, glare, or noise. In many cases a tension headache is associated with poor posture, frowning, or jaw clenching; some sufferers recognize that they grind their teeth in their sleep. If a person is also feeling anxious or depressed, the frequency of tension headaches may increase until they occur every day and persist all day.
Another cause of chronic daily headaches is the frequent use of acetaminophen, aspirin, or other medications to relieve tension or migraine headaches; the headaches rebound the next day, leading to a further intake of analgesics, which sets up a vicious circle perpetuating the headache. If people suffering from episodic migraine headaches become anxious or depressed, or if they overuse pain relievers, their headaches become more frequent and may appear daily (a condition called transformed migraine). People suffering from daily headaches need to avoid any underlying source of stress whenever possible, practice muscular relaxation (with or without some form of biofeedback), maintain a comfortable upright posture (“think tall”), and learn to manage any associated psychological problem or depression.
Interestingly, the most effective treatments for frequent tension headaches are the tricyclic antidepressants amitriptyline, dothiepin, and imipramine taken daily; this treatment often controls these headaches even when a person is not depressed. They probably act on the brain’s pain control pathway by increasing the supply of serotonin and noradrenaline. The newer antidepressants called selective serotonin reuptake inhibitors (SSRIs) are not nearly as effective in relieving headaches as the older tricyclics. In fact, they may sometimes exacerbate the problem.
Headaches Arising from Structures in the Face and Neck
Sinusitis. Sinuses are cavities in the forehead (frontal sinuses), behind the bridge of the nose (ethmoid and sphenoid sinuses), and in the cheek bones (maxillary sinuses). Normally they contain air, and they open into the nasal cavity so that any mucus in them can drain freely. If the nostrils or the openings from the sinuses into the nose are blocked, however, mucus accumulates in these cavities under pressure and may become infected. People may then experience pain and tenderness over one or more of the sinus areas.
The treatment for sinusitis involves constricting the swollen vessels in the lining of the nostrils through nose drops and sometimes pills containing pseudoephedrine (Sudafed). This enlarges the airway and allows free drainage from the sinuses into the nose. If you are having headaches and facial pain at regular intervals without a blocked nose, you probably have a vascular headache such as migraine rather than sinusitis.
Temporomandibular joint (TMJ) dysfunction. An irregular bite and a tendency to grind the teeth while sleeping or to clench the jaw during the day can lead to pain and crackling noises in the hinge joints of the jaw. TMJ pain can radiate up or down from the area immediately in front of the ears and cause headache and facial pain. A person with this problem, also called Costen’s syndrome, may need to wear protective dental splints at night. Often, however, being aware of the cause, doing relaxation exercises, and taking a small dose of amitriptyline at night to promote muscular relaxation are enough to relieve the trouble.
Neck problems. The back of the head is served by nerves in the second and third cervical roots. Degeneration of the side joints of these upper cervical vertebrae can produce pain. Because the impulses coming into the spinal cord at this level converge on the same cells that convey sensation from the face and head, a person may end up feeling pain in the eye and forehead on the affected side. This is an example of “referred pain.”
In an interesting variation on this condition, a person can feel pain and numbness in the upper neck along with a feeling of numbness or movement in half the tongue on the same side when he or she rotates the neck forcibly. This is particularly common in adolescents playing tennis or any sport in which the neck turns suddenly. It has been called the neck-tongue syndrome and is usually nothing to worry about, but people who notice this problem should avoid extreme neck movements.
Neuralgia. Any disturbance of the cranial nerves conveying pain from within the skull may set up a stabbing or continuous pain, termed neuralgia. The most common type istrigeminal neuralgia, or tic douloureux, a severe jabbing pain in the jaw or cheek. It is usually caused by a small artery touching the trigeminal nerve and can generally be controlled with carbamazepine or other medications and cured by a surgical procedure.
Other Benign Headaches
Ice cream. Swallowing a cold drink or ice cream can evoke a sudden pain in the palate, throat, or forehead. Such “ice-cream headaches” are more common in people prone to migraines. They are easy to avoid.
Cold and pressure. Exposure to icy winds or diving into very cold water can rapidly induce a headache through excessive stimulation of the scalp nerves. The same nerves can be squeezed by a tight hat or goggles worn while swimming (“swim-goggle headache”).
Foods and fasting. Nitrites are added to some cured meats to maintain their red color. A few people are sensitive to nitrites, even the small amounts used, and thus suffer “hot-dog headache” as the chemicals dilate the blood vessels in their heads. Monosodium glutamate (MSG) is also widely used as a food additive and may cause headaches on occasion. Low blood sugar after missing meals or fasting for a day not uncommonly induces headaches.
As we described at the start of this section, most of the headaches people experience are benign— passing annoyances that home treatment can remedy. Talk to your doctor about any headaches that are sudden, severe, recurrent, or growing progressively worse.
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