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Migraine is the great masquerader. Many of the headaches people experience such as sinus, tension, or cluster are actually migraine.  Recent research has suggested that instead of people suffering from many different types of headache, there may be a common biological mechanism by which all headaches occur.  When migraine is not well controlled it can disturb nervous system function in many ways affecting mood, muscle tension, and sleep.  The philosophy of Headache Care Center is to go beyond teaching headache sufferers how to control headache attacks, by also teaching them how to live more successfully between episodes of headache.

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Understanding the process of headache and its many unique presentations allows for proper diagnosis and treatment.  Most headaches arise from a neurovascular mechanism centered in the brain.  This system can be activated by a variety of risk factors followed by a cascade of events that can produce a wide variety of headaches and neurologic symptoms.  Examples of these risk factors are hormones, especially changes in hormone levels during the menstrual cycle, chemicals such as from foods and beverages, emotional distress, disturbance of the sleep-wake cycle, and sensory stimulation such as bright light and strong odors.  Most headache sufferers describe more than one type of headache based on their different symptoms, such as location of the pain, nasal congestion, etc. 

Goals of Treatment

For Daily Intractable Migraine:
>No more than 3 headaches per month, and no more than 1 headache in any given week
>To reduce the functional impairment of headache with the ability resume normal activities
>To recognize the headache process early to improve treatment outcome
>To respond to acute therapy within 2 – 4 hours by being headache free and able to perform normal activities

For Intermittent Disabling Headache:

>To reduce the functional impairment of headache and resume normal activities
>To recognize the headache process early to improve treatment outcome
> To respond to acute therapy within 2 – 4 hours by being headache free and able to perform normal activities

Types of Headaches


Migraine

>Migraine is a common disabling primary headache disorder
>The most widely recognized form of headache for which patients seek medical care
>In adults, recurrent attacks last 4 - 72  hours
>In children, recurrent attacks last 1 - 72 hours
>Typical characteristics of the headache are its location on one side of the head, its pulsating or throbbing quality, moderate or severe intensity, aggravation by routine physical activity, such as walking or climbing stairs, with nausea and/or sensitivity to light (photophobia) and sound (phonophobia)
>Diagnosis of migraine requires the patient to have had at least 5 attacks that fulfill the International Headache Society criteria for migraine
>Neurologic and/or visual symptoms (aura) occur in approximately 15% of headache sufferers, and may include seeing sparkles or other visual changes, vertigo, problems with coordination, and tingling sensations
>Occasionally, neurologic symptoms may occur without headache pain
>Gastointestinal symptoms may include vomiting, diarrhea, and/or constipation


Aura


>Aura is the complex of neurological symptoms that occur just before or at the onset of migraine headache

>Most patients with migraine have attacks without aura
>Only 15% of migraine sufferers experience aura, and those with aura may not experience it with every headache
>Auras usually last 5 – 60 minutes
>Aura may occur without headache
>Symptoms may occur hours to a day or two before a migraine attack
>Typical aura consists of visual and/or sensory and/or speech symptoms, and may also include various combinations of fatigue, difficulty concentrating, neck stiffness, sensitivity to light or sound, nausea, blurred vision, yawning and paleness
> Sensory disturbances may occur in the form of pins and needles moving slowly from the point of origin and affecting part of one side of the body and face. Numbness may occur in its wake, but numbness may also be the only symptom. Speech disturbances occur less frequently.

Preventive Treatment:

> individualized based on severity and frequency of headache
>Goal of treatment:  to limit headaches to 3 per month


Avoid headache risk factors:


>get plenty of sleep
>avoid dietary triggers
>reduce stress or learn new techniques to relieve stress, such as biofeedback
>eat at regular times and do not skip breakfast
> keep a headache diary to identify risk factors and monitor treatment outcomes

Acute Treatment:


>Goal: to safely and completely stop the migraine attack within 2 – 4 hours while preserving the ability to function
>Acute medication, such as many over the counter medications, is appropriate for treatment of headache if complete relief from the headache is obtained in 2 – 4 hours, but their use must be limited to 2 days or less per week to avoid developing analgesic rebound/medication overuse headache
> Prescription medication are used for severe headache and when response to over the counter medications is less than optimal

Cluster Headache

>
Attacks of excruciating, one-sided pain that is usually located around the eye
>Cluster headaches are less common than migraine and the headaches are of shorter duration, lasting 15 minutes to 3 hours
>Attacks usually occur in a series, or “clusters” of 1 – 8 headaches per day over a period of several weeks to months, separated by headache-free intervals that may last months or years.  However, about 10-15% of patients have chronic symptoms without remissions.
>The attacks are associated with one or more of the following, all of which occur on one side and on the same side of the head: red and/or tearing of the eye, nasal congestion, runny nose, forehead and facial sweating, contraction of the pupil, drooping eyelid, eyelid swelling
>Most patients are restless or agitated during an attack
>During a cluster period, attacks occur regularly and may be provoked by alcohol, histamine or nitroglycerine
>During the worst attacks the intensity of the pain is excruciating
>Patients are usually unable to lie down and characteristically pace the floor
>Headaches often occur at night >Age at onset is usually 20-40 years old
>Cluster headaches are 3 – 4 times more prevalent in men than in women
> Cluster headache may be inherited in about 5% of cases
>Preventive management of cluster headaches involves medications taken at the onset of the headaches and for the duration of the cluster period 
>Acute treatment is used to control the pain while the preventive medication takes effect

Tension-Type Headache

>
Infrequent episodes of headache lasting 30 minutes to 7 days
>The most common type of headache, but people rarely seek medical help because they can be easily treated with over the counter pain medication and stress management
>The pain is typically on both sides of the head, pressing or tightening in quality and of mild to moderate intensity
>The pain does not worsen with routine physical activity
>Frequently described as pain beginning in the neck that leads to headache
>Tension headaches typically are not associated with nausea, but photophobia (sensitivity to light) or phonophobia (sensitivity to sound) may be present
> Some describe the pain as a tight band around the head

Sinus Headache

>
Most sinus headaches are migraine or migrainous headache and meet the criteria for those headaches, and therefore, they should be treated the same as migraine headache
>Sinus headache is typically located in the sinus area of the face and forehead
>Common symptoms often include nasal stuffiness and drainage, often at the beginning of the attack
>As the headache develops, the symptoms begin to match those of migraine, such as moderate to severe pain with nausea and sensitivity to light and sound
>Many people with sinus headaches also have other forms of headache, such as migraine and tension-type
>Sinusitis, an acute infection of the sinuses, can produce headache and often is accompanied by fever and discolored nasal drainage.  Sinusitis requires X-ray confirmation and appropriate treatment of the infection
> Sinusitis is rarely the cause of recurrent of headache

Analgesic Rebound/Medication Overuse Headache

>Analgesic agents are prescription or over-the-counter medications used to control pain, including migraine and other types of headache 
>When used on a daily or near daily basis, these analgesics can perpetuate the headache process 
>The headache is typically located on both sides of the head and described as a pressing or tightening type of pain
>The head pain often persists to varying degrees throughout the day, fluctuating in intensity from mild to moderately severe
>Analgesic overuse headache is a result of taking analgesics on 15 or more days/month for more than 3 months; or opioid or combination medication 10 or more days per month for more than 3 months
>Initially, the medication may bring relief, but as it wears off the headache returns.  As the condition worsens, the medication becomes less effective.  Eventually, the medications used to treat headache perpetuate the headache cycle, and going without medication results in a severe “rebound” headache.


Drugs capable of producing rebound headache syndromes:


>over-the-counter analgesics, such as acetaminophen and acetaminophen-containing drugs >over-the-counter anti-inflammatory medications, such as high doses of aspirin, ibuprofen, ketoprofen, and naprosyn
>combination drugs, such as Excedrine, which contains acetaminophen, caffeine, and aspirin >pseudophedrine-containing decongestants
>prescription pain medication
>caffeine

>The only effective treatment is to withdraw from the medication responsible for the rebound phenomenon.  In some cases, prescription medications need to be tapered; therefore, you should consult your physician before stopping any medication. 
>When analgesics are discontinued, the headache may get worse for several days.  It may take up to 30 days to recover from the rebound process.  However, once this cycle is broken, headache intensity and frequency usually improves. 
> When the cycle has been broken, other acute medications may become more effective in managing the headache pain, but the use of these medications must be restricted to no more than two days in a row or three days a week to avoid returning to the rebound process.

Menstrual Migraine

Some women report having migraine headaches that are directly associated with their menstrual cycle.  This may be the only type of headache reported, or it may be one of several types of headache for these individuals.  This type of headache appears to be associated with changes in hormone levels.  When a definite pattern can be established, treatment may involve taking acute medication during the week prior to the onset of the menstrual cycle.

Therapeutic Phases of Migraine   

Migraine headache typically consists of 4 phases:  prodrome, aura, pain, and postdrome.  Some migraine sufferers do not experience all 4 phases.  Effective migraine management begins with the ability to recognize your pattern of headache.

Comprehensive migraine management requires a balance of lifestyle changes and treatment with proper medication.  Measures should be taken at the onset of prodrome to minimize risk factors.  To be most effective, medications should be taken before the pain reaches peak intensity.  Recognition of prodrome is an important link to minimize or possibly even prevent the pain of migraine.

Prodrome

>
Pre-headache phase that is the body’s warning that it is out of balance
>Caused by chemical changes in the brain and is an early signal that a migraine is brewing
>Symptoms are common in up to 75% of headache patients
>Symptoms vary from person to person, and may vary from headache to headache
>Symptoms may include, but are not limited to, changes in mood, irritability, nausea, stiff neck, muscle tension, muscle pain or tenderness, an increase or decrease in energy, sleepiness, yawning, an increase or decrease in appetite, nasal stuffiness or drainage, and changes in mental function
>Treatment at this phase may prevent the development of the pain phase of headache

Aura

>Occurs in 15% of headache sufferers
>Caused by electrical changes in the brain
>A typical aura lasts 5 – 60 minutes, and may occur before, during, or after headache, and may occur without headache pain
>The most common aura is characterized by visual distortions such as wavy lines, dots, or colored patternsin the visual field
>Alterations in taste and smell, numbness, and speech difficulties may also be a part of aura
> Treatment at this phase may prevent the development of the pain phase of headache

Pain Phase

>
During the mild to moderate pain phase, medication is more effective than later in the cycle >During the severe pain phase, medication is not as effective

Postrome

>
This phase follows the pain phase
>Also known as a “headache hangover”
>Commonly associated with fatigue

Phases of Headache

Risk Factors                                                                                          

>
Risk factors include anything that lowers your threshold to headache
>What once was thought to “trigger” a headache has since been recognized as things that increase your risk of having a headache
>Some people have sensitivity to certain odors or chemicals that consistently cause the onset of a headache
>Some people have sensitivity to certain odors or chemicals that sometimes cause the onset of a headache
> The more risk factors at work at any given time increase your risk for developing a headache.  For example, you have a cold, you are tired, you are under a lot of stress at work, and you have pizza and red wine for dinner.  When you combine all these factors, your threshold for a headache is lowered, and you are more likely to develop a headache.  However, if you are rested and your stress is under control, that pizza and wine may not cause a headache.
> Risk factors can be minimized by following simple lifestye changes, including regular exercise, eating a balanced diet which includes eating a source of protein at each meal, practicing stress management techniques such as biofeedback and deep breathing, drinking 8 glasses of water a day, and obtaining restful sleep.

Things I can do to Help My Headaches:

>Always eat breakfast, and eat at predictable mealtimes.
>Wake up at the same time each morning.
>Exercise a minimum of 30 minutes at least 3 times a week.
>Reduce the amount of caffeine and the use of artificial sweeteners in my diet.
>Drink plenty of water.
>Keep a headache diary to learn the pattern of headache and the characteristics of prodrome.
>Practice biofeedback daily.
>Avoid overuse of over the counter pain medication.
>Strive to maintain my normal weight.
>Devote at least 30 minutes every day to reducing stress.

Biofeedback

An integrated treatment approach to headaches includes learning to control stress in one’s life.  At Headache Care Center, we have found that learning to control stress and its effect on the body helps those who have migraine headaches to control them, to reduce the amount of medication and sometimes gain the skill to head them off at the first indication of a headache.  Controlling stress also, of course, helps relieve or prevent tension headaches.

We use temperature and EMG biofeedback to measure stress and tension levels.  In learning to raise one’s finger temperature, relax various muscle groups and breathe properly, one can gradually teach his or her nervous system to respond less dramatically (maybe even to relax) when faced with stressful situations.  Research has shown that 70% of headache sufferers get 50% relief in pain through learning relaxation techniques and practicing them twice a day.

Physical Therapy

Physical therapy offers assessment and treatment of the structure of the body.  Tight muscles may be due to tension, leading to headache.   But the neurochemical process of headache may actually trigger muscle tightness in the neck area that often precedes the onset of headache.  Your physical therapist can assist you in reducing the physical stress on your body by performing the following:

>training you to stand, sit, and move in “balanced posture”
>rebalancing tight versus over-stretched and weakened muscles
>treating segmental dysfunction of the bones of the skull, spinal column, and pelvis
> teaching you self-treatment techniques and exercises to maintain mobility, strength, and body awareness

Diet and Exercise

People who suffer with headaches share many characteristics, such as not eating breakfast.  Skipping breakfast causes a drop in blood sugar, and changes in blood sugar can trigger a headache.  It is important to eat meals at regular times to avoid big changes in blood sugar levels.  There is not one diet that is recommended for headache, but other factors may indicate a need for a particular diet.  A high protein/low carbohydrate diet may be indicated for the person who is overweight or has dysmetabolic syndrome.  A high fiber diet may be indicated for the person with irritable bowel syndrome.  The most important factor is that the person prone to headache must learn to eat meals at regular times.

Regular aerobic exercise for 30 minutes at least 3 times a week is recommended to maintain weight and promote good health. This is also true for headache sufferers.  Other exercises that may be of benefit would be taught by a physical therapist, and may include exercises to increase the range of motion of the neck, reduce muscle tension, and strengthen specific areas of the body.

Breathing

Breathing is the mechanism used to get oxygen into the body.  Oxygen is necessary to sustain life. Oxygen enters the body through the lungs, travels into the bloodstream, and circulation sends that oxygen throughout the body.  The lungs are shaped like two triangles, with the smaller section at the top, and they work like a bellows.  Many people take very shallow breaths, which utilizes only the smaller upper portion of the lungs.  When you use the diaphragm, the primary muscle for breathing, oxygen is pulled deeply into the larger portion of the lower lungs, bringing more oxygen into the body.    People with a lot of muscle tension in the neck and shoulders may use the muscles in the neck to breathe more than the diaphragm, which adds to the muscle tension and pain.  Abdominal breathing, or diaphragmatic breathing, focuses on using the diaphragm to take full breaths.  By using the diaphragm more effectively, more oxygen gets into the body and the neck muscles do not have to work as hard.  Deep breathing also promotes the relaxation response.  With practice, taking a few deep breaths become a signal to the body to relax, adding another tool to deal with stress and tension.

Drinking Water

Many people are dehydrated without knowing it.  One of the symptoms of dehydration is headache.  Some people will notice a decrease in headache pain and frequency by increasing the amount of water they drink.

Conditions That May Be Associated with Headache

>Irritable Bowel Syndrome (IBS) and gastric disorders
>Dysmetabolic Syndrome
>Asthma
>Depression/anxiety/bi-polar disorder/PTSD
>Sleep disturbances
>Muscle and joint pain/fibromyalgia.