These are some of the most common questions asked by headache
sufferers. The answers are not intended to be complete nor to specifically
address and individual patient. Rather, they are intended to help
orient and facilitate further exploration of the subject. We encourage
you to e-mail us with questions not answered here or with questions
about our answers. As headache sufferers, we are a community, and
the more we know, the better able are we to help ourselves.
Rob Cowan, M.D.
Medical Director
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Is my headache a migraine?
Migraine is the most common form of headache, but not all headaches
are migraines. The term “migraine” refers to a headache
which is usually (but not always) on one side of the head. It
is a headache that lasts from two to seventy-two hours, typically,
and it is often associated with nausea and/or vomiting, sensitivity
to light and/or sound. The character of the pain is typically
a throbbing pain.
There are several categories of migraine: migraines that are
preceded by a warning symptom, called an aura, are known as
Classic Migraine or Migraine with aura. Migraines that begin
with pain and no warning are known as Common Migraine or Migraine
without aura. Other less common forms include Complicated Migraine,
Hemiplegic Migraine, Basilar Migrainre, Ocular Migraine, Opthalmic
Migraine, and Acephalgic Migraine. Migraine can also be part
of a mixed headache pattern in which the patient has more than
one type of headache (e.g. Migraine + Tension-type). It is important
to know what type of headache you have because management varies
greatly for different headache types.
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Are Migraines hereditary?
In most cases, the short answer is yes. It is very unusual
to find migraine headaches in someone without any family history
of migraine. One very rare form of migraine, called Familial
Hemiplegic Migraine has actually be traced to a specific gene,
but as yet no gene has been identified for the more common forms
of migraine. There is a group of people who develop migraine-like
headaches after significant head trauma, and they may or may
not have a family history. Knowing your family history for headaches
(not just whether there is one, but what different family member
do for their headaches) is one of the most useful pieces of
information you can bring to your physician.
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What is a Cluster Headache?
Contrary to popular belief, a cluster headache is not simple
a collection of headaches that come in a bunch together. A cluster
headache is a type of headache which is relatively short-lived
(compared with migraine) lasting usually between 20 minutes
and two hours. It is always one-sided and is associated with
symptoms such as a stuffy nose on one side, tearing, an enlarged
pupil, or a droopy lid. The headaches tend to occur several
to many times a day for a period of days to weeks, and then
disappear for a variable amount of time, usually weeks to months.
Treatments for cluster differ significantly from treatments
for other headache types. Clusters are, by reputation, some
of the most painful headaches imaginable. It is important to
have a treatment plan in place before a cluster begins.
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Do we outgrow Migraines?
Some of us do. For about one third of women, Migraines disappear
or improve dramatically after the menopause. However, for others,
the headaches simply change in character or just continue as
before. Although less well-studied, men often lose their migraines
in their fifties or sixties as well. The reasons for improvement
in headaches with aging are not entirely understood, but it
most likely has to do with the evening out of fluctuations in
hormone levels that come with aging. Whenever there is a change
in the character or frequency of headaches, it is a good idea
to discuss the changes with you healthcare providers.
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Are Migraines dangerous?
By and large, they are not. Certain forms of headache are associated
with a slightly higher risk for stroke, specifically, complicated
migraine, hemiplegic migraine, basilar migraine, and to a lesser
degree, classic migraine. The statistical risk is based on a
patients overall likelihood of stroke over a lifetime, not during
an individual headache. Migraineurs who have other risk factors
for stroke such as smoking, hypertension, hypercholesterolemia,
low homocysteine levels, etc. should discuss appropriate changes
in lifestyle and medication with their doctors.
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What is a migraine trigger?
A migraine trigger is anything that consistently results in
a headache. Common triggers include, alcohol, lack or sleep,
and skipped meals. Many people have food triggers and smell
triggers. But everyone is different. One migraineur can eat
chocolate until they are three hundred pounds and not get a
headache while the next person with the same headache type can’t
walk by a candy counter without getting a headache. Rather the
listing all the things that ever gave anybody a headache, it
is better to be observant about the events that surround your
headaches and when you see a pattern, act accordingly.
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What is a migraine aura?
An aura is a phenomenon (called a sign or symptom) that occurs
in advance of the onset of pain. Typically aura precedes headache
by twenty or thirty minutes, but this varies quite a bit. The
most common aura type is visual. The visual aura can take the
form of squiggly lines or a blind spot or flashing lights, often
off to one side or the other. Visual changes in which there
is a complete loss of vision is not a typical aura and should
warrant a call to your doctor or a trip to the ER, unless they
are typical for your headaches. Other auras can include nausea,
excessive yawning, weakness on one side, numbness or tingling
on one side or virtually any other sensory or motor phenomenon.
It is always best to discuss the way you feel before a headache
with your doctor.
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What is a complicated migraine?
A complicated migraine is a migraine episode during which there
are non-pain-related neurologic signs. The most common of these
are weakness or sensory changes (usually numbness or tingling)
on one side of the body. But speech arrest (difficulty speaking
or understanding), vertigo, and visual changes have also been
described. The main difference between a complicated migraine
symptom and an aura is that in complicated migraine, the changes
are concurrent with the headache while in aura, they precede
it. Complicated migraines have some other implications for your
health which make it a good idea to seek neurologic advice regarding
prevention of these episodes.
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What is ophthalmic migraine?
These are visual disturbances, usually seen in people in their
fifties or later, in which visual aura occur but no headache
follows. They are usually short-lived, lasting only minutes,
and can occur off to one side of the visual field or another.
They are not dangerous, but it is important to make sure that
any visual change, especially when they first start, be evaluated
by your ophthalmologist.
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What is a migraine equivalent?
A migraine equivalent refers to a recurring neurologic deficit
that lasts about as long as a migraine, but is not associated
with pain and is not due to any other medical problem. For example,
some people (usually children) get “abdominal migraines”.
These are episodes of upset stomach, sometimes with nausea and
vomiting, that lasts for hours and then goes away for days or
weeks or months. They are often relieved with migraine medicines.
It is not uncommon for people to undergo elaborate and expensive
work-ups looking for obscure causes for this kind of complaint.
It is a diagnosis that should be made by a neurologist since
there are other things that can present in a similar fashion.
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Does migraine lead to stroke?
Not directly. There are several rare migraine variants that
do have a greater risk of stroke, and there have been cases
of people having a stroke during a complicated migraine. Statistically,
stroke may be more common in people with a history of classic
migraine, but this is not a risk factor we have any control
over. People who have migraine should take extra care not to
increase their risk by smoking, leaving high blood pressure
and high cholesterol untreated, not exercising, and so forth.
There are lots of reasons to treat migraines, and lots of reasons
to practice a “stroke-smart” life-style.
What is migraine prophylaxis?
Prophylaxis is another word for prevention. When headaches
are frequent enough to disrupt our lives, one of the best treatment
plans is to use a preventative or prophylactic medication, along
with modification of lifestyle and identification of triggers
to get things under control. There are several prescription
medications used for this and several alternative/complementary
supplements as well. This is an important part of headache management
and should be part of any discussion of treatment., although
not every headache sufferer needs prophylaxis.
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What is migraine rescue?
Migraine rescue refers to treatments aimed at breaking up a
headache that is already present. This is different from prophylaxis
which aims to prevent or at least decrease the frequency and
severity of headaches. Usually, rescue is accomplished with
medication, although there are some non-pharmacologic treatments
available for people who do not want or cannot tolerate medications.
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What are abortive medications?
Abortive is another term for rescue medications. They are used
to help stop a headache that is already present. They are most
effective when taken early on in the headache. Some abortives
can be bought over the counter , but the more potent and effective
are usually obtained by prescription. Choice of abortive agents
depends on a number of factors, including other medications
you are taking, the frequency, severity and duration of your
headaches, finanances, and other variables. There are many options
and these should be discussed with your headache doctor or health
professional.
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What are preventative medications?
Preventative medications are used when headaches occur often
enough or are disabling enough to disrupt your life. Generally,
there are four categories of preventatives used in Migraine:
neuromodulatory drugs, such as topiramate and valproic acid,
neurotransmitter modulators such as amitryptilene or olanzepine,
vascular agents such as propranolol or verapamil, and homeopathic
agents such as butterbur or feverfew. Preventative medications
should be one part of a treatment plan and are generally not
intended to “cure” or completely prevent headaches
on their own.
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Are there non-medication therapies
for headaches?
There are many many aspects to treating headaches, and while
medications can be very useful, they are just one aspect of
headache care. Lifestyle changes such as regular sleep schedule,
regular mealtimes and exercise are very important as are recognition
of triggers and other medical issues such as sleep agnea, jaw
clenching, etc. There is a variety of “non-traditional”
therapies that are used in headache treatment, including biofeedback,
yoga, and acupuncture. In addition there are non-medicine, traditional
modalities such as physical therapy and nutritional analysis
and counseling. Developing a treatment plan is a very individualized
process and requires close, ongoing collaboration between the
patient and healthcare providers.
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What is a Hypnic Headache?
This is a rare headache form that occurs in people between
the ages of 40 and 80. It is unique in that it is a headache
that occurs exclusively at night, typically lasting between
15 and 60 minutes. The headaches tend to occur at the same time
each night tend to be global (not just on one side) and are
not associated with runny nose, tearing or other “cluster”
features. There are specific treatments for this kind of headache
which does not typically respond to the usual headache medications.
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What is Hemicrania Continua?
This is a chronic headache that is typically one-sided, moderately
severe. It tends to be constant with intermittent jolts of increased
pain that are very short-lived. This headache is unique in that
it will almost always respond to one specific medicine, Indomethacin.
It also typically has features such as tearing from the eye
on the same side as the headache, a stuffy nose on that side,
or a droopy eyelid. Hemicrania Continua shares features with
migraine and with cluster headaches and usually requires diagnosis
by a neurologist or headache specialist.
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What is Temporal Arteritis?
Also called Giant Cell Arteritis, this is a syndrome which
includes a new headache in someone in their seventh decade of
life. Typically, it is a global headache, throbbing in nature,
often associated with tenderness over the temples. It can be
associated with jaw pain and visual changes but none of these
findings must be present for diagnosis. A blood test called
an Erythrocyte Sedimentation Rate is a useful test when this
diagnosis is suspected. When confirmed, immediate treatment
with steroids is indicated. Left untreated, temporal arteritis
can threaten your eyesight.
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What is Paroxysmal Hemicrania?
This rare headache form can occur as an episodic or chronic
headache. The pain is always on the same side, typically lasting
from two to 45 minutes. Usually there are five or more attacks
per day. The attacks are typically associated with tearing,
nasal fullness , droopy eyelid, red eyes or swollen eyes. These
headaches usually respond rapidly and completely to Indomethacin.
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What is SUNCT Syndrome?
Probably one of the rarest headaches, Short-lasting, Unilateral
Neuralgiform Headaches with conjunctival injection and Tearing,
consists of anywhere from three to 100 very brief stabbing pains,
typically lasting less than a minute. The pain is usually around
one eye and sometimes triggered by touching certain parts of
the face or head. Anyone with SUNCT should be evaluated in a
headache specialty clinic.
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Does Biofeedback Work?
There are several types of biofeedback. The most common kind
measures muscle tension and the amount of electrical activity
in the muscle is displayed either visually or aurally in a way
that allows patients to learn to relax their muscles. Another
form using the amount of moisture on the skin surface as the
feedback source. Two newer technologies allow for the feedback
source to be cardiac activity and brainwave (alpha) activity
to be monitored. There have been several quality studies that
show a benefit for muscle biofeedback, particularly in tension
headache. The other modalities are being used with good effect
in selected patients but there are no definitive studies comparing
this approach with pharmacologic or other approaches. Certainly
from an intuitive viewpoint, it makes sense that biofeedback
would benefit certain headache sufferers.
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Does Marijuana Help Headache?
Without going into the legal quagmire surrounding Marijuana
as a medical tool, the substance has been promoted for headache
relief for literally thousands of years. There have been several
controlled studies which show significant benefit, particularly
in patients with prominent nausea as part of their headache
syndrome.
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Do over-the-counter headache medicines
work?
For people whose headaches are mild to moderate and relatively
infrequent, this class of medicines ( aspirin, acetoaminophen,
ibuprofen or naproxen, sometimes combined with caffeine) can
be very effective. The danger comes with overuse. When these
medications are taken too often or in excess dosing, they result
in a chronic, daily headache syndrome known as Medication Overuse
Headache (MOH). Overuse can also lead to cardiac, liver and
kidney problems. A good rule of thumb for over the counter medicines
is “no more than two days per week.” If you need
treatment more often than this, it is probably time to consult
your doctor.
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How important are lifestyle changes?
Most headache specialists will tell you they are at least as
important as the medications. Very often it is the little things
we do that set us up for headaches. In general, migraine sufferers
do best when they have a routine. Regular meal times, regular
sleep patterns, regular menstrual cycle and regular exercise
schedule. Again, there is a lot of variability from person to
person, and it is best to discuss your daily and weekly activities
with a medical professional skilled in headache management.
Very often modest ‘tweaking” of lifestyle can result
in huge decreases in the frequency and severity of headache.
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What causes Migraines?
There are three ways to look at this question: What causes
humans to get migraine?, What causes an individual migraine
attack?, and What causes your head to hurt when you get a migraine?
The first question is fascinating to headache specialist because
there is no definite answer. For the vast majority of people,
migraine is a genetic disease – it runs in families. It
probably represents an overly sensitive response by the brain
to changes in the environment (internal or external). The second
question – what causes an individual attack is better
understood. When a noxious stimulus reaches the trigeminal nerve
(one of the cranial nerves that mediates sensation in the head),
it triggers the release of chemicals called vasoactive peptides
that create changes in the diameter of blood vessels in the
membrane that lines the brain. It also causes changes in the
ability of nerves within particular parts of the brain to fire
properly. Finally, it causes the brain to become overly sensitive
to sensory input. The third question is an individual one and
we don’t know why one person’s headache is triggered
by red wine and the next person will have an apparently identical
headache from strong perfume but never from red wine. This is
an area of intense interest among scientists studying headache.
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What is menstrual Migraine?
Many women report that their headaches are worse with their
periods. However true menstrual migraine is a headache that
occurs only in association with the menstrual cycle. This may
turn out to be an artificial distinction. Fluctuations in estrogen
levels remain one of the most consistent triggers for migraine.
For this reason, migraineurs often do better when they are on
constant hormone replacement. Often women with regular cycles
and predictable headaches will “pulse prophylax”
by taking a preventative medication only during the time during
which they are at risk for the headache.
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Do Migraines go away with Menopause?
For many women, headaches decrease dramatically or disappear
completely with menopause. However in the perimenopause, that
period leading up to menopause, many women experience a worsening
of their headaches or a change in their character, sometimes
with increased auras but decreased headaches. All of these phenomena
are almost certainly related to changes in estrogen and possibly
progesterone that occur during this stage of life. Estrogen
levels can be manipulated to minimize these effects. And estrogen
as well as other hormones can be measured when perimenopause
is suspected as the cause for changes in headache pattern.
- Can Children get Migraines?
Absolutely. Migraine should be suspected when children (of
any age) go through bouts of crying and crankiness, possibly
with vomiting or diarrhea, that happen repeatedly, last for
several hours, then falls asleep and is fine upon awakening.
Be especially suspicious if one or both parents or other siblings
or close relatives also experience migraine. Typically these
children will have been to many specialists looking for stomach
and other problems before anyone thinks to consider migraine.
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How do you stop a migraine?
The most important factor in stopping a headache is early recognition.
The earlier you treat a headache, the more likely the treatment
will work. It is important to have a treatment plan in place.
That means working out, in advance, what you are going to do
when a headache starts. It is hard to think clearly when your
head hurts so it should be a simple plan. Next, if it involves
medication, be sure you have the medication on hand and available.
This means having medication in the glove compartment, in your
desk at work, in your briefcase, medicine cabinet, etc. It is
also important to have a place you can go when you get a headache
and to educate those around you as to the accommodations you
may require. Finally, it is important to have a plan B if you
need it. This should all be worked out with your headache specialist,
neurologist or primary care doctor at a time when you are headache-free.
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What is a Tension Headache?
Tension-type headache is probably the second most common headache
type after migraine. They are often referred to as “hatband”
headaches because they typically painful around the back of
the head, the temples and forehead, as if a tight hat were in
place. They tend to be pressure-like at onset and can last from
hours to days. Tension-type headaches can co-exist with migraine,
and one can transform or trigger the other. Tension-type headache
is often responsive to physical therapy, relaxation therapy
and anti-inflammatories or muscle relaxants. It is a myth that
tension-type headaches are less painful or less disabling than
migraines.
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How do you prevent headaches?
At least with respect to migraines, it is a chronic disease.
That means it is a condition to be managed. Unfortunately, we
have no complete cure. The goal of headache treatment is to
make headaches an infrequent and relatively painless event rather
than a constant, disabling focus of one’s life. Prevention
means paying attention to the things that seem to bring on or
worsen headaches and modifying your lifestyle to avoid or minimize
them. Often, prevention will include medication or other modalities
such as biofeedback or physical therapy to help control the
headaches. There is no secret formula that works for everyone,
but everyone can positively effect (that means reduce the frequency
and severity) their headaches by working with their doctors
to develop a treatment plan.
