Headaches

Headaches are usually considered to be less severe than migraines with a lower intensity of pain, often aching in quality and variable in location. Headaches are not usually associated with aura like symptoms (such as visual changes or sensory disturbances), and infrequently associated with nausea, vomiting or other complaints.

It is commonly believed that headaches are the result of irritation to nerves and pain sensitive structures in the head and neck regions. Because of the way our nerves are arranged in the head and neck; pain in one area can travel or "refer" to another part of the head.

For example; pain in the back of the neck can refer up into the back of the head along a nerve, which supplies both the back of the head and upper neck areas. Pain messages travel along nerves back to the brain, which interprets the location of the pain according to which 'section' of the brain that nerve sends it's messages to; sometimes however the brain is unable to distinguish between one part of the same nerve and another part of that same nerve; hence a problem in one area of the head or neck can be perceived as pain in another area of the head or neck .

This is made even more complicated when you look at the multiple numbers of inter-connections between the different nerves of the head and neck region. It's a bit like a 'switch board', which receives electricity from a number of rooms in the house; and when a fuse burns out, it is hard to know which appliance, and in which room, the problem began.

It should also be noted that the level of pain is a poor indicator of the severity of the problem, and that recurring, persisting, or sudden onset headaches always need to be properly investigated.

What causes Headaches?
There are many different causes of headaches; put simply-anything which causes irritation to the nerves around the face, head, neck, or even inside the skull, can cause pain in the head. These may include: dental problems, neck strain, eyestrain, eye diseases, jaw problems, blood pressure problems, ear/nose or throat problems, muscular tension... etc. So you can see, there are many different causes, and this is why they should always be investigated by the appropriate trained professional(s) - especially if they persist, worsen, or begin suddenly. Migraines often have similar causes, and many patients suffer both; with headaches often progressing to migraines. For more information, see the head illustration on the home page and roll over the areas you want to know more about.

Does Stress cause Headaches?
Stress is associated with a number of different types of headaches, and often is cited by patients as an aggravating factor to their attacks. Whether stress alone is enough to induce an attack of head-pain, is debatable; but it is thought that stress may have an effect on the nervous system, altering it's control of muscle tone and pain tolerance.

Can Headaches be treated?
Most headaches are due to non-life threatening causes and can be relieved through appropriate treatment. It is always important to have them thoroughly investigated through consultation with your family doctor, and any specialists that may have unique insight into specific areas that your doctor believes need further investigating. Through following this simple model, the causes and aggravating factors can often be identified, and then addressed through the appropriate treatment(s). It should also be noted that there is often more than one factor involved in patient's headaches and it may be necessary to consult more than one practitioner to gain the necessary expertise and treatment to properly address the head-pain.

Does a more Severe Headache mean a more Severe problem?
Often a severe headache can be alarming to a patient, but there are no simple guidelines to follow here. This is why it is very important to have all headaches thoroughly diagnosed by experts, as even mild ones can herald major problems. Fortunately however, once diagnosed, the majority of headaches are quite treatable; and not due to serious problems.

There are many known causes of headaches and migraines and many more triggers, which set off attacks. 'Causes'- refers to conditions, which pre-exist and can make an individual more susceptible to a headache or a migraine (i.e.: eye-strain, sinusitis etc).

ìTriggersî- usually refers to factors, which make an attack of head-pain start, and is usually used in the literature when referring to migraines (i.e.: stress, some foods etc.). This is because the vast majority of headaches and migraines have more than one factor / or 'trigger' involved, and it is easier to put them all together as 'causes', as they can all contribute to head-pain at the end of the day!

This is an important point, because many headache and migraine sufferers have a number of factors which interact to produce an episode of head-pain; and many have tried one treatment or another without success- because the other problems have been left unaddressed and are enough to still produce a migraine or a headache. This may often involve a number of health-care professionals working together to ensure there are no 'serious' causes, and then addressing the ones which can be dealt with through therapy/ life-style modification/ diet modification/ home exercises etc

Your family doctor should be able to help co-ordinate the overall process.

Causes:

Hemorrhages

The blood vessels within the skull are sensitive to pain stimuli, as to are the surrounding membranes that hold the brain in the correct position.

When a blood vessel ruptures (either spontaneously or due to trauma / or pressure), it usually causes a sudden, severe headache, and may displace some of the brain tissue and membranes- causing a progressive stiffness in the neck, and problems with the nerves which control the head, face and even the rest of the body!

There are many conditions, which may make a patient susceptible to this type of problem, these include: high blood pressure, atherosclerosis, diabetes, aneurysms, head trauma, and aggressive brain tumors.

Whatever the case, all of these conditions require urgent medical attention, and can be diagnosed by well-established testing procedures, under the guidance of a medical expert, usually a Neurologist.

Nose & Sinus problems

"Headache Secondary to Diseases of the Ear, Nose & Throat"

Headache:

Introduction

In preparing notes for laypersons web site about the ear, nose and throat causes of headache, one must appreciate that only a brief and incomplete description of the causes, clinical presentation, investigation and management of these conditions can be provided.

Further information can be obtained by searching key conditions either on the web or via libraries, textbooks, scientific journals, etc, or by seeking expert advice from suitably qualified health professionals.

On no account should any individual make any assumptions about symptoms they or others have based on the general information provided at this website. Patients with persistent symptoms should always seek appropriate advice from suitably qualified health professionals.

There is considerable overlap between the various health professionals in the management of patients presenting with headache and it is not uncommon for two or more experts to be involved in the care of some patients.

I hope those of you taking a look at this site find the following information useful, if not a little dry!! Remember that the objective of this site is to educate patients and other interested persons about the possible causes of headache. Donít expect an exhaustive account about each topic.

Pain causing headache is a common symptom for which there are many causes. From the perspective of the Ear, Nose and Throat Surgeon, such conditions are best described based on regional causes, i.e., the ear; nose and sinuses; and neck, including throat.

Headache secondary to nose and sinus disease is not uncommon and well-known patterns of headache are recognized according to the particular area of the nose and sinuses affected as well as the underlying disease process. There are four groups of sinuses: the maxillary, frontal, ethmoidal and sphenoidal sinuses. Most headaches due to nose and sinus disease are associated with other symptoms and most are due to either viral (common colds) or bacterial infection. It is common for there to be more than one underlying cause. Hence, there is great variation in how patients present.

The face, nose and sinus structures are predominantly supplied with sensation from a nerve coming through the skull base called the ìtrigeminal nerveî. It consists of three branches, upper (ophthalmic), middle (maxillary) and lower (mandibular). It is the fifth ìcranialî nerve and these branches are known as V1, V2 and V3 ! Pathology involving one of these branches can cause pain in the distribution of other branches or in more remote areas according to connections of the trigeminal nerve with other nerves in the skull. This is called ìreferred neuralgiaî.

An understanding of the anatomy and function of this nerve and its connections is necessary to explain and diagnose headache-causing conditions in this region.

Diet Problems

HYPO vs. HYPER-GLYCAEMIA

There is some evidence that suggests our blood sugar levels play a role in the causation of headaches and migraines. Blood sugar levels fluctuate according to intake of food and medications, and are regulated by a number of hormones, mainly Insulin and Adrenalin. Our bodies system for regulating sugar levels has developed over thousands of years with the consumption of natural sugars. Some researchers believe that our bodies are unable to adequately cope with our increasing consumption of refined sugars. When a natural sugar such as that found in sugar cane is refined, the fiber and nutrients (which aid correct absorption, storage and metabolism of the sugar component) are stripped away.

Ultimately, all sugars, natural or refined, end up as glucose in our blood stream, however it is the speed with which they get there that is important. The result of consuming refined sugar is a rapid rise in blood sugar levels (hyper-glycemia), which our body overreacts to, by producing large amounts of insulin. This release of Insulin then causes a rapid drop in the blood sugar level, which may then lead to a constriction of blood vessels in the brain, which corresponds to the aura stage of the migraine. Therefore the blood sugar goes from being abnormally high to abnormally low in a very short time.

When the blood sugar levels are too low (hypo-glycemia), the brain does not receive enough glucose to function properly. The body then responds by increasing the quantity of blood flow to the brain as well as releasing hormones, which in turn release stored glucose into the blood stream. This results in increased blood pressure, and a change in the blood vessels of the brain. It is this change in blood vessel diameter and blood flow dynamics that is believed to cause the headache pain.

To prevent these scenarios from occurring, it is important to;

1) Limit the consumption of foods containing large amounts of refined sugars.

2) Limit caffeine intake as this can affect blood sugar levels.

3) Avoid skipping meals as this results in blood sugar levels dropping too low.

Blood sugar level problems may be one of a number of potential triggers for any one migraine or headache sufferers' problems, and it is important to investigate thoroughly any / all potential triggers; and address them simultaneously.

Problems with blood sugar level regulation (i.e.: diabetes) as well as other dietary problems may further complicate the picture and need to be addressed by the appropriate specialist(s).

Blood Sugar Level Problems may contribute to Headaches and Migraines, so it is important to have them professionally addressed. It is also important to investigate for other potential causes, as many cases of Headaches and Migraines have more than one ingredient.

Eye Problems

For a person to obtain clear vision, the focusing power of the eye's cornea (front of eye) and lens (eye's focusing mechanism) must result in the image of an object falling on the retina (back of eye). When this does not occur, the eye is said to be ametropic. There are three different classes of ametropia (refractive errors):

… hyperopia (long sightedness),

… myopia (short sightedness),

… astigmatism (poorly shaped cornea).

In the cases of uncorrected hyperopia and astigmatism, the eye's muscles have to work harder in order to keep the image in focus. Consequently, a person may experience tired or aching eyes, poor concentration, headaches and blurring of vision particularly with close work.

Schematic section of the human eye.

Hyperopia (long sightedness) is where the light is focused behind the retina and consequently the image is blurred close up. Hyperopia is corrected by spectacles or contact lenses.

Resting long-sighted eye: image is blurred.

With spectacles or contact lenses the image is focused by bending light rays.

Astigmatism is another type of visual defect and can accompany myopia or hyperopia. Astigmatism is when the cornea is not a perfect spherical shape so that images will be more blurred in some particular directions. Astigmatism may cause a blurring of objects at all distances and even a tendency for the person to squint in order to improve vision. Astigmatism is also correctable with spectacles and contact lenses.

Presbyopia is another type of eye condition and frequently occurs with the ageing process. As a person ages, the lens (inside the eye) starts to change it's structure as well as lose the flexibility necessary for focusing on near objects (focusing on near objects is called accommodation- and requires the lens to change shape).   This loss in the elasticity of the lens makes it difficult for a person to focus on near objects, and tasks such as reading and sewing become difficult. This blurring up close, may be worse in dim lighting or more noticeable when the person is tired. Other symptoms may include tired & sore eyes, slow adjustment in changing focus from one distance to another, headaches, and even a disinterest in reading. Onset of Presbyopia is usually around the age range of 40-60 years of age, and there is no known cure. However, Presbyopia can be easily corrected with glasses or contact lenses, which may need to be periodically adjusted up to the age of 60 years.

Eye Problems may contribute to Headaches and Migraines, so it is important to have them professionally addressed. It is also important to investigate for other potential causes, as many cases of Headaches and Migraines have more than one ingredient.

Dental Problems

The joint of the lower jaw is known as the Temporo-mandibular joint (TMJ), and it joins the skull in close proximity to the ears. Problems arising within either of these joints are often referred to as Temporo-mandibular joint disorders, or (TMD).

TMD can arise from many factors and sources, including:

… External sources of trauma; these include motor vehicle accidents, (MVA), often involving whiplash, or single blow to the head or neck, either as a result of a motor vehicle accident (MVA) or from a fall, fight or sports injury; trauma may also result from Oral Surgery procedures.

… Internal trauma; this involves habits in which the joint is involved, for example, grinding or clenching the teeth; lip, cheek or nail biting, or holding foreign objects between the teeth e.g. pipe smoking, pen/pencil chewing.

… Muscle overactivity; when muscles associated with chewing are over used or used in an abnormal manner, either when awake or sleeping. This may also include abnormal head and neck posture.

… Occlusion; this relates to the way the teeth bite together. An uneven "bite" can often produce TMD; similarly, if there are teeth missing, the teeth and jaw cannot function properly or evenly

… Systemic or general health factors; degenerative arthritis rheumatoid arthritis traumatic and infectious arthritic conditions can afflict the TMJ and affect joint function.

… Internal joint structure; if there is an irregularity or structural problem with the joint and the cartilage on which it moves, (the disc), this produces a mechanical dysfunction

SYMPTOMS:

Pain

Pain is a very common symptom associated with TMD. The pain may be localized to a specific area, e.g. the muscles associated with chewing, in the area of the joint, (i.e. near the ear, mimicking ear ache), neck pain, headache or migraines. If the teeth are the cause of the TMD, then any or all of the teeth may be sore, even to the point of individuals seeking to have the nerve removed from the tooth or even have the tooth extracted.

Joint sounds & jaw function

When the jaw is moved there should be no noises emanating from the joint area. In some cases of TMD, there are varying joint sounds, which may occur when the jaw opens, and/or closes. Extreme joint problems may result in the jaw being "locked" open or "locked" shut so that the individual has difficulty either opening or closing the mouth. Normal jaw function involves a simple closure of the jaw without any deflection. This means that all the teeth should touch at the same time without the jaw being deflected out of a simple closing action. A so-called, premature contact, would occur when one or more teeth are out of alignment and correct dental interdigitation or "meshing together" of the teeth does not occur. Consequently, instead of the jaw closing smoothly, it is deflected out of its correct position. As a result of this, the TMJ is unable to close smoothly, this in turn, causes the muscles to be strained to varying degrees. It is this abnormal muscle activity that contributes to TMD and can contribute to headaches and migraines..

Jaw Problems may contribute to Headaches and Migraines, so it is important to have them professionally addressed. It is also important to investigate for other potential causes, as many cases of Headaches and Migraines have more than one ingredient.

Neck Problems

Cervical Joint Dysfunction:

Upper neck problems are a common cause of referred pain into the head region. Research has demonstrated how the nerves in the upper neck (when irritated), can send pain signals into the head and face regions; researchers believe this happens because the nerves supplying the skin and other sensitive structures in the neck have connections with the nerves supplying the face, forehead, temples, and even behind the eyes.

It therefore follows that injuries such as 'Whiplash' and 'Neck strain' can affect these nerves, and may cause pain in the head many years after the initial injury - (i.e.: following poor healing and/or repetitive re-aggravation)

Even more common is the slow progressive onset of neck problems, which occurs with day to day 'wear and tear' due to poor postures in the work place and poor postural habits at home (i.e.: sitting all day with the head down over a keyboard; sleeping on your stomach every night and having your neck turned to one side)

Often these people report a slow worsening of the intensity, and frequency of their headaches, and sometimes they may start to have migraines as well.

In short, neck problems are a common source of irritation for headache and migraine sufferers; even where other problems may be the obvious initiators of attacks (i.e.: menstrual migraines).

The various components of these types of headaches can be readily addressed through treatment.

Neck Problems may contribute to Headaches and Migraines, so it is important to have them professionally addressed. It is also important to investigate for other potential causes as many cases of Headaches and Migraines have more than one ingredient.

Medication Misuse Problems

Certain medications are known to affect and possibly cause headaches and migraines. It is important that you inform your Doctor if you believe this is the case, as sometimes a different drug or dose may be more appropriate.

MEDICATION MISUSE HEADACHE (MMH)

This type of headache may occur when Aspirin or prescriptive painkillers are used more than three times a week as treatment for chronic headache. Commonly, the person using the medication will experience a headache as the analgesic effects of the drugs wears off, which prompts the sufferer to take more medication, leading to a cycle of abuse.

DRUG INDUCED HYPO-GLYCAEMIA (LOW BLOOD SUGAR LEVELS)
Certain drugs affect blood sugar levels, which as discussed in the diet section can trigger headaches and migraines.

CHEMICAL NAME:
bishydroxycoumarin- anticoagulant
chlorpromazine - psychiatric
oxytetracycline - antibiotic
phenylbutazone -anti-inflammatory
propoxyphene-painkiller
salicylates -painkiller/anti-inflammatory
sulfisoxazole-antimicrobial
sulfonylureas - diabetes treatment
phenformin - diabetes treatment

ORAL CONTRACEPTIVES AND HRT
Both can aggravate pre-existing migraines particularly if history shows a relation to hormonal fluctuations. (See our section on Hormone related headaches)

FOR MORE INFORMATION ON MEDICATION RELATED HEADACHES, SEE YOUR FAMILY DOCTOR.

Problems with medications may contribute to Headaches and Migraines, so it is important to have them professionally addressed. It is also important to investigate for other potential causes, as many cases of Headaches and Migraines have more than one ingredient.

When Should You See a Physician?

Not all headaches require medical attention. Some result from missed meals or occasional muscle tension and are easily remedied. But some types of headache are signals of more serious disorders, and call for prompt medical care. These include:

… Sudden, severe headache

… Sudden, severe headache associated with a stiff neck

… Headache associated with fever

… Headache associated with convulsions

… Headache accompanied by confusion or loss of consciousness

… Headache following a blow on the head

… Headache associated with pain in the eye or ear

… Persistent headache in a person who was previously headache free

… Recurring headache in children

… Headache which interferes with normal life

A headache sufferer usually seeks help from a family practitioner. If the problem is not relieved by standard treatments, the patient may then be referred to a specialistóperhaps an internist or neurologist. Additional referrals may be made to psychologists.

When is Headache a Warning of a More Serious Condition?

Like other types of pain, headaches can serve as warning signals of more serious disorders. This is particularly true for headaches caused by traction or inflammation.

Traction headaches can occur if the pain-sensitive parts of the head are pulled, stretched, or displaced, as, for example, when eye muscles are tensed to compensate for eyestrain. Headaches caused by inflammation include those related to meningitis as well as those resulting from diseases of the sinuses, spine, neck, ears, and teeth. Ear and tooth infections and glaucoma can cause headaches. In oral and dental disorders, headache is experienced as pain in the entire head, including the face. These headaches are treated by curing the underlying problem. This may involve surgery, antibiotics, or other drugs.

Characteristics of the various types of more serious traction and inflammatory headaches vary by disorder:

… Brain tumor. Brain tumors are diagnosed in about 11,000 people every year. As they grow, these tumors sometimes cause headache by pushing on the outer layer of nerve tissue that covers the brain or by pressing against pain-sensitive blood vessel walls. Headache resulting from a brain tumor may be periodic or continuous. Typically, it feels like a strong pressure is being applied to the head. The pain is relieved when the tumor is treated by surgery, radiation, or chemotherapy.

… Stroke. Headache may accompany several conditions that can lead to stroke, including hypertension or high blood pressure, arteriosclerosis, and heart disease. Headaches are also associated with completed stroke, when brain cells die from lack of sufficient oxygen.

… Many stroke-related headaches can be prevented by careful management of the patient's condition through diet, exercise, and medication.

… Mild to moderate headaches are associated with transient ischemic attacks (TIA's), sometimes called "mini-strokes,î which result from a temporary lack of blood supply to the brain. The head pain occurs near the clot or lesion that blocks blood flow. The similarity between migraine and symptoms of TIA can cause problems in diagnosis. The rare person under age 40 who suffers a TIA may be misdiagnosed as having migraine; similarly, TIA-prone older patients who suffer migraine may be misdiagnosed as having stroke-related headaches.

… Spinal tap. About one-fourth of the people who undergo a lumbar puncture or spinal tap develop a headache. Many scientists believe these headaches result from leakage of the cerebrospinal fluid that flows through pain-sensitive membranes around the brain and down to the spinal cord. The fluid, they suggest, drains through the tiny hole created by the spinal tap needle, causing the membranes to rub painfully against the bony skull. Since headache pain occurs only when the patient stands up, the "cure" is to remain lying down until the headache runs its courseóanywhere from a few hours to several days.

… Head trauma. Headaches may develop after a blow to the head, either immediately or months later. There is little relationship between the severity of the trauma and the intensity of headache pain. In most cases, the cause of the headache is not known. Occasionally the cause is ruptured blood vessels which result in an accumulation of blood called a hematoma. This mass of blood can displace brain tissue and cause headaches as well as weakness, confusion, memory loss, and seizures. Hematomas can be drained to produce rapid relief of symptoms.

… Temporal arteritis. Arteritis, an inflammation of certain arteries in the head, primarily affects people over age 50. Symptoms include throbbing headache, fever, and loss of appetite. Some patients experience blurring or loss of vision. Prompt treatment with corticosteroid drugs helps to relieve symptoms.

… Meningitis and encphalitis headaches are caused by infections of meninges-the brain's outer covering-and in encephalitis, inflammation of the brain itself.

… Trigeminal neuralgia. Trigeminal neuralgia, or tic douloureux, results from a disorder of the trigeminal nerve. This nerve supplies the face, teeth, mouth, and nasal cavity with feeling and also enables the mouth muscles to chew. Symptoms are headache and intense facial pain that comes in short, excruciating jabs set off by the slightest touch to or movement of trigger points in the face or mouth. People with trigeminal neuralgia often fear brushing their teeth or chewing on the side of the mouth that is affected. Many trigeminal neuralgia patients are controlled with drugs, including carbamazepine. Patients who do not respond to drugs may be helped by surgery on the trigeminal nerve.

… Sinus infection. In a condition called acute sinusitis, a viral or bacterial infection of the upper respiratory tract spreads to the membrane, which lines the sinus cavities. When one or more of these cavities are filled with fluid from the inflammation, they become painful. Treatment of acute sinusitis includes antibiotics, analgesics, and decongestants. Chronic sinusitis may be caused by an allergy to such irritants as dust, ragweed, animal hair, and smoke. Research scientists disagree about whether chronic sinusitis triggers headache.

What Are Migraine Headaches?

The most common type of vascular headache is migraine. Migraine headaches are usually characterized by severe pain on one or both sides of the head, an upset stomach, and at times disturbed vision.

Former basketball star Kareem Abdul-Jabbar remembers experiencing his first migraine at age 14. The pain was unlike the discomfort of his previous mild headaches.

"When I got this one I thought, 'This is a headache'," he says. "The pain was intense and I felt nausea and a great sensitivity to light. All I could think about was when it would stop. I sat in a dark room for an hour and it passed."

Symptoms of migraine. Abdul-Jabbar's sensitivity to light is a standard symptom of the two most prevalent types of migraine-caused headache: classic and common.

The major difference between the two types is the appearance of neurological symptoms 10 to 30 minutes before a classic migraine attack. These symptoms are called an aura. The person may see flashing lights or zigzag lines, or may temporarily lose vision. Other classic symptoms include speech difficulty, weakness of an arm or leg, tingling of the face or hands, and confusion.

The pain of a classic migraine headache may be described as intense, throbbing, or pounding and is felt in the forehead, temple, ear, jaw, or around the eye. Classic migraine starts on one side of the head but may eventually spread to the other side. An attack lasts 1 to 2 pain-wracked days.

Common migraineóa term that reflects the disorder's greater occurrence in the general populationóis not preceded by an aura. But some people experience a variety of vague symptoms beforehand, including mental fuzziness, mood changes, fatigue, and unusual retention of fluids. During the headache phase of a common migraine, a person may have diarrhea and increased urination, as well as nausea and vomiting. Common migraine pain can last 3 or 4 days.

Both classic and common migraine can strike as often as several times a week, or as rarely as once every few years. Both types can occur at any time. Some people, however, experience migraines at predictable timesófor example, near the days of menstruation or every Saturday morning after a stressful week of work.

The migraine process. Research scientists are unclear about the precise cause of migraine headaches. There seems to be general agreement, however, that a key element is blood flow changes in the brain. People who get migraine headaches appear to have blood vessels that overreact to various triggers.

Scientists have devised one theory of migraine which explains these blood flow changes and also certain biochemical changes that may be involved in the headache process. According to this theory, the nervous system responds to a trigger such as stress by causing a spasm of the nerve-rich arteries at the base of the brain. The spasm closes down or constricts several arteries supplying blood to the brain, including the scalp artery and the carotid or neck arteries.

As these arteries constrict, the flow of blood to the brain is reduced. At the same time, blood-clotting particles called platelets clump together-a process, which is believed to release a chemical called serotonin. Serotonin acts as a powerful constrictor of arteries, further reducing the blood supply to the brain.

Reduced blood flow decreases the brain's supply of oxygen. Symptoms signaling a headache, such as distorted vision or speech, may then result, similar to symptoms of stroke.

Reacting to the reduced oxygen supply, certain arteries within the brain open wider to meet the brain's energy needs. This widening or dilation spreads, finally affecting the neck and scalp arteries. The dilation of these arteries triggers the release of pain-producing substances called prostaglandins from various tissues and blood cells. Chemicals, which cause inflammation and swelling, and substances, which increase sensitivity to pain, are also released. The circulation of these chemicals and the dilation of the scalp arteries stimulate the pain-sensitive nociceptors. The result, according to this theory: a throbbing pain in the head.

Women and migraine. Although both males and females seem to be equally affected by migraine, the condition is more common in adult women. Both sexes may develop migraine in infancy, but most often the disorder begins between the ages of 5 and 35.

The relationship between female hormones and migraine is still unclear. Women may have "menstrual migraine"óheadaches around the time of their menstrual periodówhich may disappear during pregnancy. Other women develop migraine for the first time when they are pregnant. Some are first affected after menopause.

The effect of oral contraceptives on headaches is perplexing. Scientists report that some women with migraine who take birth control pills experience more frequent and severe attacks. However, a small percentage of women have fewer and less severe migraine headaches when they take birth control pills. And normal women who do not suffer from headaches may develop migraines as a side effect when they use oral contraceptives. Investigators around the world are studying hormonal changes in women with migraine in the hope of identifying the specific ways these naturally occurring chemicals cause headaches.

Triggers of headache. Although many sufferers have a family history of migraine, the exact hereditary nature of this condition is still unknown. People who get migraines are thought to have an inherited abnormality in the regulation of blood vessels.

"It's like a cocked gun with a hair trigger," explains one specialist. "A person is born with a potential for migraine and the headache is triggered by things that are really not so terrible."

These triggers include stress and other normal emotions, as well as biological and environmental conditions. Fatigue, glaring or flickering lights, changes in the weather, and certain foods can set off migraine. It may seem hard to believe that eating such seemingly harmless foods as yogurt, nuts, and lima beans can result in a painful migraine headache. However, some scientists believe that these foods and several others contain chemical substances, such as tyramine, which constrict arteriesóthe first step of the migraine process. Other scientists believe that foods cause headaches by setting off an allergic reaction in susceptible people.

While a food-triggered migraine usually occurs soon after eating, other triggers may not cause immediate pain. Scientists report that people can develop migraine not only during a period of stress but also afterwards when their vascular systems are still reacting. For example, migraines that wake people up in the middle of the night are believed to result from a delayed reaction to stress.

Other forms of migraine. In addition to classic and common, migraine headache can take several other forms:

Patients with hemiplegic migraine have temporary paralysis on one side of the body, a condition known as hemiplegia. Some people may experience vision problems and vertigoóa feeling that the world is spinning. These symptoms begin 10 to 90 minutes before the onset of headache pain.

In ophthalmoplegic migraine, the pain is around the eye and is associated with a droopy eyelid, double vision, and other problems with vision.

Basilar artery migraine involves a disturbance of a major brain artery at the base of the brain. Preheadache symptoms include vertigo, double vision, and poor muscular coordination. This type of migraine occurs primarily in adolescent and young adult women and is often associated with the menstrual cycle.

Benign exertional headache is brought on by running, lifting, coughing, sneezing, or bending. The headache begins at the onset of activity, and pain rarely lasts more than several minutes.

Status migrainosus is a rare and severe type of migraine that can last 72 hours or longer. The pain and nausea are so intense that people who have this type of headache must be hospitalized. The use of certain drugs can trigger status migrainosus. Neurologists report that many of their status migrainosus patients were depressed and anxious before they experienced headache attacks.

Headache-free migraine is characterized by such migraine symptoms as visual problems, nausea, vomiting, constipation, or diarrhea. Patients, however, do not experience head pain. Headache specialists have suggested that unexplained pain in a particular part of the body, fever, and dizziness could also be possible types of headache-free migraine.

Besides Migraine, What Are Other Types of Vascular Headaches?

After migraine, the most common type of vascular headache is the toxic headache produced by fever. Pneumonia, measles, mumps, and tonsillitis are among the diseases that can cause severe toxic vascular headaches. Toxic headaches can also result from the presence of foreign chemicals in the body. Other kinds of vascular headaches include "clusters," which cause repeated episodes of intense pain, and headaches resulting from a rise in blood pressure.

Chemical culprits. Repeated exposure to nitrite compounds can result in a dull, pounding headache that may be accompanied by a flushed face. Nitrite, which dilates blood vessels, is found in such products as heart medicine and dynamite, but is also used as a chemical to preserve meat. Hot dogs and other processed meats containing sodium nitrite can cause headaches.

Eating foods prepared with monosodium glutamate (MSG) can result in headache. Soy sauce, meat tenderizer, and a variety of packaged foods contain this chemical, which is touted as a flavor enhancer.

Headache can also result from exposure to poisons, even common household varieties like insecticides, carbon tetrachloride, and lead. Children who ingest flakes of lead paint may develop headaches. So may anyone who has contact with lead batteries or lead-glazed pottery.

Artists and industrial workers may experience headaches after exposure to materials that contain chemical solvents. These solvents, like benzene, are found in turpentine, spray adhesives, rubber cement, and inks.

Drugs such as amphetamines can cause headaches as a side effect. Another type of drug-related headache occurs during withdrawal from long-term therapy with the antimigraine drug ergotamine tartrate.

Jokes are often made about alcohol hangovers but the headache associated with "the morning after" is no laughing matter. Fortunately, there are several suggested treatments for the pain. The hangover headache may also be reduced by taking honey, which speeds alcohol metabolism, or caffeine, a constrictor of dilated arteries. Caffeine, however, can cause headaches as well as cure them. Heavy coffee drinkers often get headaches when they try to break the caffeine habit.

Cluster headaches. Cluster headaches, named for their repeated occurrence over weeks or months at roughly the same time of day or night in clusters, begin as a minor pain around one eye, eventually spreading to that side of the face. The pain quickly intensifies, compelling the victim to pace the floor or rock in a chair. "You can't lie down, you're fidgety," explains a cluster patient. "The pain is unbearable." Other symptoms include a stuffed and runny nose and a droopy eyelid over a red and tearing eye.

Cluster headaches last between 30 and 45 minutes. But the relief people feel at the end of an attack is usually mixed with dread as they await a recurrence. Clusters may mysteriously disappear for months or years. Many people have cluster bouts during the spring and fall. At their worst, chronic cluster headaches can last continuously for years.

Cluster attacks can strike at any age but usually start between the ages of 20 and 40. Unlike migraine, cluster headaches are more common in men and do not run in families.

Studies of cluster patients show that they are likely to have hazel eyes and that they tend to be heavy smokers and drinkers. Paradoxically, both nicotine, which constricts arteries, and alcohol, which dilates them, trigger cluster headaches. The exact connection between these substances and cluster attacks is not known.

Despite a cluster headache's distinguishing characteristics, its relative infrequency and similarity to such disorders as sinusitis can lead to misdiagnosis. Some cluster patients have had tooth extractions, sinus surgery, or psychiatric treatment in futile efforts to cure their pain.

Research studies have turned up several clues as to the cause of cluster headache, but no answers. One clue is found in the thermograms of untreated cluster patients, which show a "cold spot" of reduced blood flow above the eye.

The sudden start and brief duration of cluster headaches can make them difficult to treat; however, research scientists have identified several effective drugs for these headaches. The antimigraine drug sumatriptan can subdue a cluster, if taken at the first sign of an attack. Injections of dihydroergotamine, a form of ergotamine tartrate, are sometimes used to treat clusters. Corticosteroids also can be used, either orally or by intramuscular injection.

Some cluster patients can prevent attacks by taking propranolol, methysergide, valproic acid, verapamil, or lithium carbonate.

Another option that works for some cluster patients is rapid inhalation of pure oxygen through a mask for 5 to 15 minutes. The oxygen seems to ease the pain of cluster headache by reducing blood flow to the brain.

In chronic cases of cluster headache, certain facial nerves may be surgically cut or destroyed to provide relief. These procedures have had limited success. Some cluster patients have had facial nerves cut only to have them

regenerate years later.

Painful pressure. Chronic high blood pressure can cause headache, as can rapid rises in blood pressure like those experienced during anger, vigorous exercise, or sexual excitement.

The severe "orgasmic headache" occurs right before orgasm and is believed to be a vascular headache. Since sudden rupture of a cerebral blood vessel can occur, this type of headache should be evaluated by a doctor.

What Are Muscle-Contraction Headaches?

It's 5:00 p.m. and your boss has just asked you to prepare a 20-page briefing paper. Due date: tomorrow. You're angry and tired and the more you think about the assignment, the tenser you become. Your teeth clench, your brow wrinkles, and soon you have a splitting tension headache.

Tension headache is named not only for the role of stress in triggering the pain, but also for the contraction of neck, face, and scalp muscles brought on by stressful events. Tension headache is a severe but temporary form of muscle-contraction headache. The pain is mild to moderate and feels like pressure is being applied to the head or neck. The headache usually disappears after the period of stress is over. Ninety percent of all headaches are classified as tension/muscle contraction headaches.

By contrast, chronic muscle-contraction headaches can last for weeks, months, and sometimes years. The pain of these headaches is often described as a tight band around the head or a feeling that the head and neck are in a cast. "It feels like somebody is tightening a giant vise around my head," says one patient. The pain is steady, and is usually felt on both sides of the head. Chronic muscle-contraction headaches can cause sore scalpsóeven combing one's hair can be painful.

In the past, many scientists believed that the primary cause of the pain of muscle-contraction headache was sustained muscle tension. However, a growing number of authorities now believe that a far more complex mechanism is responsible.

Occasionally, muscle-contraction headaches will be accompanied by nausea, vomiting, and blurred vision, but there is no preheadache syndrome as with migraine. Muscle-contraction headaches have not been linked to hormones or foods, as has migraine, nor is there a strong hereditary connection.

Research has shown that for many people, chronic muscle-contraction headaches are caused by depression and anxiety. These people tend to get their headaches in the early morning or evening when conflicts in the office or home are anticipated.

Emotional factors are not the only triggers of muscle-contraction headaches. Certain physical postures that tense head and neck musclesósuch as holding one's chin down while readingócan lead to head and neck pain. So can prolonged writing under poor light, or holding a phone between the shoulder and ear, or even gum-chewing.

More serious problems that can cause muscle-contraction headaches include degenerative arthritis of the neck and temporomandibular joint dysfunction, or TMD. TMD is a disorder of the joint between the temporal bone (above the ear) and the mandible or lower jaw bone. The disorder results from poor bite and jaw clenching.

Treatment for muscle-contraction headache varies. The first consideration is to treat any specific disorder or disease that may be causing the headache. For example, arthritis of the neck is treated with anti-inflammatory medication and TMD may be helped by corrective devices for the mouth and jaw.

Acute tension headaches not associated with a disease are treated with analgesics like aspirin and acetaminophen. Stronger analgesics, such as propoxyphene and codeine, are sometimes prescribed. As prolonged use of these drugs can lead to dependence, patients taking them should have periodic medical checkups and follow their physicians' instructions carefully.

Non-drug therapy for chronic muscle-contraction headaches includes biofeedback, relaxation training, and counseling. A technique called cognitive restructuring teaches people to change their attitudes and responses to stress. Patients might be encouraged, for example, to imagine that they are coping successfully with a stressful situation. In progressive relaxation therapy, patients are taught to first tense and then relax individual muscle groups. Finally, the patient tries to relax his or her whole body. Many people imagine a peaceful sceneósuch as lying on the beach or by a beautiful lake. Passive relaxation does not involve tensing of muscles. Instead, patients are encouraged to focus on different muscles, suggesting that they relax. Some people might think to themselves, Relax or My muscles feel warm.

People with chronic muscle-contraction headaches my also be helped by taking antidepressants or MAO inhibitors. Mixed muscle-contraction and migraine headaches are sometimes treated with barbiturate compounds, which slow down nerve function in the brain and spinal cord.

People who suffer infrequent muscle-contraction headaches may benefit from a hot shower or moist heat applied to the back of the neck. Cervical collars are sometimes recommended as an aid to good posture. Physical therapy, massage, and gentle exercise of the neck may also be helpful.

Cervicogenic Headache Definition

Dr. Peter Rothbart, President of the World Cervicogenic Headache Society, explains cervicogenic headache, "Cervicogenic headache is a headache which has its origin in the area of the neck. The source of pain is found in structures around the neck, which have been damaged. These structures can include joints, ligaments, muscles, and cervical discs, all of which have complex nerve endings. When these structures are damaged, the nerve endings send pain signals up the pathway from the upper nerves of the neck to the brain. During this process they intermingle with the nerve fibers of the trigeminal nerve. Since the trigeminal nerve is responsible for the perception of head pain, the patient therefore experiences the symptoms of headache."

While many patients who are diagnosed with cervicogenic headache have the traditional symptoms of tension headache, some of the patients who have the traditional symptoms of migraine (and cluster migraine) headache also respond to cervicogenic headache diagnosis and treatment.

Diagnostic Tests

Diagnostic blocks involving the use of very small amounts of local anesthetics to the suspected structure in the neck are used to determine the existence of cervicogenic headache.

When patients are first seen, preliminary physical examinations can determine areas of tenderness, spasm or pain. Once discovered, a diagnostic block can establish for certainty that specific damaged structures are the cause of headache.

Diagnostic blocks used in the diagnosis of cervicogenic headache include the following:

Facet/Paravertebral Nerve Blocks are injected into the side of the neck to assess and treat inflamed facets in the neck, which cause pain and stiffness. (Facets are the joints that connect each vertebrae to the next.)

Injection of dye into a cervical disc (provocative discography), which reproduces the headache, and immediately afterwards, injection of local anesthetic which alleviates the headache (alleviating discography), is another example of a diagnostic block.