[Home] [Search] [Medical Forums] [Patient Network]For 2 years, Jim suffered the excruciating pain of cluster headaches. Night after night he paced the floor, the pain driving him to constant motion. He was only 48 years old when the clusters forced him to quit his job as a systems analyst. One year later, his headaches are controlled. The credit for Jim's recovery belongs to the medical staff of a headache clinic. Physicians there applied the latest research findings on headache, and prescribed for Jim a combination of new drugs.
An estimated 40 million Americans experience chronic headaches. For at least half of these people, the problem is severe and sometimes disabling. It can also be costly: headache sufferers make over 8 million visits a year to doctor's offices. Migraine victims alone lose over 64 million workdays because of headache pain.
Understanding why headaches occur and improving headache treatment are among the research goals of the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS). As the focal point for brain research in the Federal Government, the NINCDS also supports and conducts studies to improve the diagnosis of headaches and to find ways to prevent them.
Some headaches require prompt medical attention.
Why does it hurt?
What hurts when you have a headache? Several areas of the head can hurt, including a network of nerves which extends over the scalp and certain nerves in the face, mouth, and throat. Also sensitive to pain, because they contain delicate nerve fibers, are the muscles of the head and blood vessels found along the surface and at the base of the brain.
The bones of the skull and tissues of the brain itself, however, never hun, because they lack pain-sensitive nerve fibers.
The ends of these pain-sensitive nerves, called nociceptors, can be stimulated by stress, muscular tension, dilated blood vessels, and other triggers of headache. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a pan of the body hurts. The message is determined by the location of the nociceptor. A person who suddenly realizes "My toe hurts," is responding to nociceptors in the foot that have been stimulated by the stubbing of a toe.
A number of chemicals help transmit pain-related information to the brain. Some of these chemicals are natural painkilling proteins called endorphins, Greek for "the morphine within." One theory suggests that people who suffer from severe headache and other types of chronic pain have lower levels of endorphins than people who are generally pain free.
When you should 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 such as head injury and call for prompt medical care. These include:
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 specialist--perhaps an internist or neurologist. Additional referrals may be made to psychologists.
Diagnosis: What the physician looks for
Diagnosing a headache is like playing Twenty Questions. Experts agree that a detailed question-and-answer session with a patient can often produce enough information for a diagnosis. Many types of headaches have dear-cut symptoms which fall into an easily recognizable pattern.
A medical history often provides a physician with enough clues about a patient's headaches to make a diagnosis.
Patients may be asked: How often do you have headaches? Where is the pain? How long do the headaches last? When did you first develop headaches?
The patient's sleep habits and family and work situations may also be probed.
Most physicians will also obtain a full medical history from the patient, inquiring about past head trauma or surgery and about the use of medications. A blood test may be ordered to screen for thyroid disease, anemia, or infections which might cause a headache. X rays may be taken to rule out the possibility of a brain tumor or blood clot.
A test called an electroencephalogram (EEG) may be given to measure brain activity. EEG's can indicate a malfunction in the brain, but they cannot usually pinpoint a problem that might be causing a headache. A physician may suggest that a patient with unusual headaches undergo a computed tomographic (CT) scan. The CT scan produces images of the brain that show variations in the density of different types of tissue. The scan enables the physician to distinguish, for example, between a bleeding blood vessel in the brain and a brain tumor. The CT scan is an important diagnostic tool in cases of headache associated with brain lesions or other serious disease. Experts generally agree, however, that this sophisticated and expensive technology is not required to diagnose simple or periodic headache.
An eye exam is usually performed to check for weakness in the eye muscle or unequal pupil size. Both of these symptoms are evidence of an aneurysm--an abnormal ballooning of a blood vessel. A physician who suspects that a headache patient has an aneurysm may also order an angiogram. In this test, a special fluid which can be seen on an X ray is injected into the patient and carried in the bloodstream to the brain to reveal any abnormalities in the blood vessels there.
Thermography, an experimental technique for diagnosing headache, promises to become a Useful clinical tool. In thermography, an infrared camera converts skin temperature into a color picture or thermogram with different degrees of heat appearing as different colors. Skin temperature is affected primarily by blood flow. Research scientists have found that thermograms of headache patients show strikingly different heat patterns from those of people who never or rarely get headaches.
Scientists at this clinic use thermography to diagnose headache. An infrared camera converts skin temperature, which is influenced by blood flow, into a color picture or thermogram. Each type of headache produces a distinctive heat pattern on a thermogram, so investigators can "see" their patients' headaches in living color.
A physician analyzes the results of all these diagnostic tests along with a patient's medical history in order to arrive at a diagnosis.
Headaches are diagnosed as:
Vascular headaches--a group that includes the well-known migraine--are so named because they are thought to involve abnormal function of the brain's blood vessels or vascular system. Muscle contraction headaches appear to involve the tightening or tensing of facial and neck muscles. Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection. Some people have more than one. type of headache.
Migraine headaches: A painful malady
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.
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."
Basketball star and migraine sufferer Kareem Abdul-Jabbar (holding a ball) has played some of his best games after overcoming headache attacks.
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 is 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.
If you were about to experience a classic migraine headache, you might find it difficult to read this pamphlet. You could lose part of your vision temporarily and see zigzag lines and black dots. Such visual problems--and other neurological symptoms--often precede classic migraine.
Migraines involve blood flow changes in the brain.
The common migraine--a term that reflects the disorder's greater occurrence in the general population--is 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 times -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 creating a spasm in 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.
One theory of the migraine process: (a) a patient's nervous system responds to a trigger such as stress by creating a spasm in the arteries at the base of the brain. The spasm and the release of serotonin reduce blood flow to the brain. Blood-borne oxygen is decreased, causing the "aura" of neurological symptoms; (b) arteries in and around brain tissue then dilate or widen to meet the brain's energy and oxygen needs. Pain-producing chemicals are released and nerve endings on the scalp are stimulated. The patient then feels a throbbing pain in the head.
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 boys and girls seem to be equally affected by migraine, the condition is more common in adult women than in men. 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"--headaches around the time of their menstrual period--which 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 migrainous women 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 migrainous women in the hope of identifying the specific ways these naturally occurring chemicals cause headaches.
Triggers of headache. The existence of a migraine personality is a controversial theory which suggests that migraine patients are compulsive, rigid, and perfectionistic. Most scientists believe, however, that not all migraine patients have these traits and that not all individuals with these personality characteristics have migraine.
"Migraine is triggered by things that are not so terrible."
Rather than focusing on character traits, says one headache specialist, it would be better to view people who get migraines as having an inherited abnormality in the regulation of blood vessels. Many sufferers have a family history of migraine, but the exact hereditary nature of this condition is still unknown.
"It's like a cocked gun with a hair trigger," explains the 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, the weather, and even 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 arteries--the 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. The "Preacher Monday-Morning Headache" is named for those clergymen who get migraines a day after the stress of delivering a Sunday sermon. Migraines that wake people up in the middle of the night are also 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 vertigo--a 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 sight problems.
Basilar artery migraine involves a disturbance of a major brain artery. 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.
Treating migraine headache
During the Stone Age, pieces of a headache sufferer's skull were cut away with flint instruments to relieve pain. Another unpleasant remedy used in the British Isles around the ninth Century involved drinking "the juice of elderseed, cow's brain, and goat's dung dissolved in vinegar." Fortunately, today's headache patients are spared such drastic measures.
Common sense rather than scientific discovery was the basis of many early migraine remedies. This 19th century French cartoon shows a family responding to the needs of a migraine sufferer by creating a dark, quiet atmosphere.
Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from the diet are the most common methods of preventing and controlling migraine and other vascular headaches. Joan, the migraine sufferer, was helped by treatment with a combination of an antimigraine drug and diet control.
Regular exercise, such as swimming or vigorous walking, can also reduce the frequency and severity of migraine headaches. Joan found that yoga and whirlpool baths helped her relax.
During a migraine headache, temporary relief can sometimes be obtained by using cold packs or by pressing on the bulging artery found in front of the ear on the painful side of the head.
Drug therapy. There are two ways to approach the treatment of migraine headache with drugs: prevent the attacks, or relieve symptoms after the headache occurs.
With biofeedback, migraine may become less frequent.
For infrequent migraine, drugs can be taken at the first sign of a headache in order to stop it or to at least ease the pain. People who get occasional mild migraine may benefit by taking aspirin or acetaminophen at the start of an attack. Aspirin raises a person's tolerance to pain and also discourages clumping of blood platelets. Small amounts of caffeine may be useful if taken in the early stages of migraine. But for most migraine sufferers who get moderate to severe headaches, and for all cluster patients, stronger drugs may be necessary to control the pain.
One of the most commonly used drugs for the relief of classic and common migraine symptoms is ergotamine tartrate, a vasoconstrictor which helps counteract the painful dilation stage of the headache. For optimal benefit, the drug is taken during the early stages of an attack. If a migraine has been in progress for about an hour and has passed into the final throbbing stage, ergotamine tartrate will probably not help.
Because ergotamine tartrate can cause nausea and vomiting, it may be combined with antinausea drugs. Research scientists caution that ergotamine tartrate should not be taken in excess or by people who have angina pectoris, severe hypertension, or vascular, liver, or kidney disease.
Patients who are unable to take ergotamine tartrate may benefit from other drugs that constrict dilated blood vessels or help reduce blood vessel inflammation.
For headaches that occur three or more times a month, preventive treatment is usually recommended. Drugs used to prevent classic and common migraine include methysergide maleate, which counteracts blood vessel constriction, propranolol, which stops blood vessel dilation, and amitriptyline, an antidepressant.
In a study of propranolol, amitriptyline, and biofeedback conducted by the Houston Headache Clinic, scientists found that migraine patients improved most on a combination of propranolol and biofeedback. Patients who had mixed migraine and muscle-contraction headaches received the greatest benefit from a combination of propranolol, amitriptyline, and biofeedback.
Another recent study showed that propranolol may continue to prevent migraine headaches even after patients have stopped taking the drug. The scientists who conducted the study speculate that long-term therapy with propranolol may have a. lasting effect on blood vessels, training them to react less than usual to the triggers of migraine.
Antidepressants called MAO inhibitors also prevent migraine. These drugs block an enzyme called monoamine oxidase which normally helps nerve cells absorb the artery-constricting chemical, serotonin.
MAO inhibitors can have potentially serious side effects--particularly if taken while ingesting foods or beverages that contain tyramine, a substance that closes down arteries.
Several new drugs for the prevention of migraine have been developed in recent years, including papaverine hydrochloride, which produces blood vessel dilation, and cyproheptadine, which counteracts serotonin.
All these antimigraine drugs can have adverse side effects. But they are relatively safe when used carefully. To avoid long-term side effects of preventive medications, headache specialists advise patients to reduce the dosage of these drugs and then to stop taking them as soon as possible.
Biofeedback and relaxation training. Drug therapy for migraine is often combined with biofeedback and relaxation training. Biofeedback is a space-age word for a technique that can give people better control over such body function indicators as blood pressure, heart rate, temperature, muscle tension, and brain waves. Thermal biofeedback allows a patient to consciously raise hand temperature. Some patients who are able to increase hand temperature can reduce the number and intensity of migraines. The mechanism of this hand-warming effect is being studied by research scientists.
An NINCDS grantee at the State University of New York in Albany instructs a headache patient in thermal biofeedback. A temperature-sensitive device attached to her forefinger is connected to a feedback meter that tells the patient if and how much she is warming her hands.
"To succeed in biofeedback," says a headache specialist, "you must be able to concentrate and you must be motivated to get well."
A patient learning thermal biofeedback wears a device which transmits the temperature of an index finger or hand to a monitor. While the patient tries to warm his hands, the monitor provides feedback either on a gauge that shows the temperature reading or by emitting a sound or beep that increases in intensity as the temperature increases. The patient is not told how to raise hand temperature, but is given suggestions such as "Imagine that your hands feel very warm and heavy."
"I have a good imagination," says one headache sufferer who traded in her medication for thermal biofeedback. The technique decreased the number and severity of headaches she experienced.
In another type of biofeedback called electromyographic or EMG training, the patient learns to control muscle tension in the face, neck, and shoulders.
Either kind of biofeedback may be combined with relaxation training, during which patients learn to relax the mind and body.
Biofeedback can be practiced at home with a portable monitor. But the ultimate goal of treatment is to wean the patient from the machine. The patient can then use biofeedback anywhere at the first sign of a headache.
The antimigraine diet. Scientists estimate that a small percentage of migraine sufferers will benefit from a treatment program focused solely on eliminating headache-provoking foods and beverages.
Other migraine patients may be helped by a diet to prevent low blood sugar. Low blood sugar, or hypoglycemia, can cause dilation of the blood vessels in the head. This condition can occur after a period without food: overnight, for example, or when a meal is skipped. People who wake up in the morning with a headache may be reacting to the low blood sugar caused by the lack of food overnight.
Treatment for headaches caused by low blood sugar consists of scheduling smaller, more frequent meals for the patient. A special diet designed to stabilize the body's sugar-regulating system is sometimes recommended.
For the same reason, many specialists also recommend that migraine patients avoid oversleeping on weekends. Sleeping late can change the body's normal blood sugar level and lead to a headache.
Beyond migraine: Other 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. Hot dogs and other meats containing sodium nitrite can also cause headaches.
"Chinese restaurant headache" can occur when a susceptible individual eats foods prepared with monosodium glutamate (MSG)--a staple in many Oriental kitchens. Soy sauce, meat tenderizer, and a variety of packaged foods contain this chemical which is touted as a flavor enhancer.
Vascular headache can also result from exposure to poisons, even common household varieties like insecticides, carbon tetrachloride, and lead. Children who eat flakes of lead paint may develop headaches. So may anyone who has contact with lead batteries or lead-glazed pottery.
Painters, printmakers, and other artists may experience headaches after exposure to art materials that contain chemicals called solvents. Solvents, like benzene, are found in turpentine, spray adhesives, robber 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 remedies for the pain, including ergotamine tartrate. 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 in groups or 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.
The typical cluster patient is tall and muscular.
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 can strike several times a day or night for several weeks or months. Then, mysteriously, they may 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. Research scientists have observed certain physical similarities among people who experience cluster headache. The typical cluster patient is a tall, muscular man with a ragged facial appearance and a square, jutting or dimpled chin. The texture of his coarse skin resembles an orange peel. Women who get clusters may also have this type of skin.
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 duster 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 a futile effort 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. By the time medicine is absorbed into the body, the attack is often over. However, research scientists have identified several effective drugs for these headaches. The antimigraine drug ergotamine tartrate 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.
A thermogram of a normal person shows a symmetrical heat pattern on the individual's forehead.
A cluster headache patient's thermogram shows a cold area (appears white) of reduced blood flow on the left side of the forehead.
Some cluster patients can prevent attacks by taking propranolol or methysergide. Investigators have also discovered that mild solutions of cocaine hydrochloride applied inside the nose can quickly stop cluster headaches in most patients. This treatment may work because it both blocks pain impulses and it constricts blood vessels.
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 type. Since sudden rapture of a cerebral blood vessel can also occur during orgasm, this type of headache should be promptly evaluated by a doctor.
Muscle-contraction headaches: The everyday menace
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.
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 scalps-even combing one's hair can be painful.
Many scientists believe that the primary cause of the pain of muscle-contraction headache is sustained muscle tension. Other studies suggest that restricted blood flow may cause or contribute to the pain.
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.
It's election night, November 1982, and the reporters at this busy newspaper could be prime candidates for tension headaches. Circumstances that might trigger headaches include deadline pressure and glaring lights.
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--such as holding one's chin down while reading--can lead to head and neck pain. Tensing head and neck muscles during sexual excitement can also cause headache. 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 TMJ. TMJ 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 temporomandibular joint dysfunction may be helped by corrective devices for the mouth and
Acute tension headaches not associated with a disease are treated with muscle relaxants and 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.
Nondrug 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 scene--such 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.
When headache is a warning
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.
This research patient is rating the intensity of heat-induced acute pain transmitted by electrodes. From her ratings, investigators hope to determine whether a chronic pain drug she is taking for facial pain and headache is effective against acute pain.
Traction and inflammatory headaches are treated by curing the underlying problem. This may involve surgery, antibiotics or other drugs.
Characteristics of the various types of traction and inflammatory headaches vary by disorder:
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 so-called "little strokes," or transient ischemic attacks (TIA's), 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.
Headaches are also caused by infections of meninges, the
brain's outer covering, and phlebitis, a vein
inflammation.
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.
Acute sinusitis headaches can occur when one or all four of the sinus cavities fill with bacterial or viral fluid. The particular cavity affected determines the location of the sinus headache.
A patient in the throes of a tic douloureux attack feels sudden, violent jabs of pain in the face, mouth, and head.
This child has a good chance of controlling her headaches with thermal biofeedback therapy, say NINCDS-supported scientists conducting migraine research at the State University of New York, Albany.
A childhood problem
Like adults, children experience the infections, trauma, and stresses that can lead to headaches. In fact, research shows that as young people enter adolescence and encounter the stresses of puberty and secondary school, the frequency of headache increases.
Migraine headaches often begin in childhood or adolescence. According to a recent health interview survey, over a million children age 16 and under experience migraine and other vascular headaches.
Children with migraine often have nausea and excessive vomiting. Some children have periodic vomiting, but no headache--the so-called "abdominal migraine." Research scientists have found that these children usually develop headaches when they are older.
Phenobarbital, cypropheptadine, and certain anticonvulsant drugs are used to treat migraines in children. A diet may be prescribed to protect the child from foods that trigger headache. Sometimes psychological counseling or even psychiatric treatment for the child and the parents is recommended. NINCDS-supported scientists at the State University of New York in Albany find that thermal biofeedback can help children with migraines control their headaches.
About 90 percent of chronic headache patients can be helped.
Childhood headache can be a sign of depression. Parents should alert the family pediatrician if a child develops headaches along with other symptoms such as a change in mood or sleep habits. Antidepressant medication and psychotherapy are effective treatments for childhood depression and related headache.
Research intervenes
Modern methods of diagnosis and treatment enable physicians and psychologists today to help about 90 percent of chronic headache patients, according to the director of a major U.S. headache clinic. These methods are based on years of scientific research. New research should lead to even more advanced techniques of headache management.
Some scientists explore the role that certain foods play in causing this disorder. Others are more concerned with the function of the autonomic nervous systems of headache-prone people. The autonomic nervous system automatically controls a variety of essential body functions, including the flow of blood throughout the body and the working of the pupils of the eyes.
At the Philadelphia College of Osteopathic Medicine, scientists supported by the National Institute of Neurological and Communicative Disorders and Stroke are gauging the autonomic nervous system activity of normal controls and headache patients with a technique called "pupillometry." This technique measures the response of the iris, or eye muscle, to light and darkness. Migraine, cluster, and muscle-contraction headache patients are included in the study. Each patient sits in a chair with his or her head in a chin rest. The eye is stimulated with light and then with darkness. A television camera in front of the patient picks up the reaction of the iris and translates it into a graph which provides clues about the functioning of the patient's autonomic nervous system.
NINCDS-supported scientists at the Philadelphia College of Osteopathic Medicine study a headache patient's reaction to stress. The stress, in this case, is cold water into which the patient dips her arm.
Another experiment with the pupillometer involves measuring eye muscle reaction to light and darkness after stress. In this study, stress is simulated by dipping the patient's arm in very cold water for up to 20 seconds.
Preliminary findings from these studies suggest that, under stress-free conditions, the autonomic nervous systems of both people with common migraine and of people without headaches react normally. Paradoxically, migraine patients during stress show reduced autonomic nervous system activity, a condition that should prevent the decreased blood flow thought to cause headaches.
However, NINCDS-supported scientists at Southern Illinois University in Carbondale report a different connection between blood flow and migraine headache.
Using an infrared light sensor that measures the diameter of blood vessels, the investigators have found that, after stress, blood flow returns to normal more quickly in headache-free people than in patients with migraine and muscle-contraction headache. This finding supports the theory that restricted or decreased blood flow may cause or contribute to headache.
The scientists also found that different types of headaches are characterized by different blood flow patterns.
An NINCDS grantee at the State University of New York; Albany, monitors the results of a biofeedback study that compares home-based headache programs with office-based programs.
After stress, the temporal arteries in the foreheads of migraine patients expand to a greater degree than the arteries of muscle-contraction headache patients. People with the same type of headache also show differences in blood flow patterns--offering evidence that there are a variety of causes for each headache type.
Testing new treatments. Scientists are also developing new therapies and analyzing the effectiveness of current treatment methods for headache. The research team at Southern Illinois University is comparing a biofeedback method that monitors blood flow with a method that monitors muscular tension in the head. This research should lead to improved understanding of individual differences in treatment response.
Several scientists are studying the value of biofeedback and other forms of treatment carried out in the patient's home. Home-based programs may be a boon to patients in rural areas who have limited access to medical care and cannot afford frequent visits to headache specialists.
In NINCDS-supported research at the State University of New York in Albany, scientists are comparing the effectiveness of a standard office-based relaxation training program for muscle-contraction, migraine, and mixed-headache patients with a similar program conducted by patients at home. Patients in the home-based program are seen in the office once a month but rely heavily on manuals, cassettes, and portable biofeedback devices.
Preliminary results suggest that home-based and office-based programs are equally effective. "If these relaxation techniques are learned at home," speculates the investigator, "they may transfer more readily to the home situation--where they will be used to cope with daily stresses."
Furthermore, at the University of Washington in Seattle an NINCDS-supported investigator is finding that home-based treatment involving only dietary changes is as effective in treating migraine patients as a home-based program of biofeedback and stress management.
Thermal biofeedback training, which involves the conscious warming of parts of the body through thought control, is believed to work because it gives people a feeling of control over their headaches. An NINCDS-supported study at Midwest Research Institute in Kansas City, Missouri, raises the possibility that this feeling of control is a more important factor in decreasing headaches than is the actual warming of the hands.
Patients who had frequent migraines were told that they would be given one of two types of biofeedback: "real temperature biofeedback," where a sound indicated their real hand temperature, or "bogus biofeedback," where a prerecorded sound emitted from the monitor would be unrelated to the patient's effort to warm the hands. Neither the patients nor the technicians training them knew whose feedback was real or bogus. Throughout the 6 weeks of training, the scientists emphasized to the patients that biofeedback should become an integral pan of their lives because it was giving them control over their headaches.
Patients in the bogus biofeedback group had a success rate that rivaled the one in the real biofeedback group. More than 80 percent of patients in both groups reduced the frequency and intensity of their headaches, as well as the quantity of medication they had been taking to control pain.
"It isn't so much the physical mechanism of migraine that matters," explains the principal investigator, "but a person's ability to cope with the syndrome and to take charge of his or her body. The emphasis on self-control is what made these people improve."
Another important area of research is the study of beta-blocking drugs like propranolol, which are used to prevent migraine.
Beta-blockers stop the activities of beta receptors-cells in the brain and heart which control the dilation of blood vessels. The ability of beta-blockers to halt the dilation of blood vessels in the brain is believed to be a major reason for their antimigraine action. But because the drugs also affect heart receptors--slowing the heart rate--they cannot be used by people who have certain heart conditions.
Scientists at Massachusetts General Hospital study these tiny brain blood vessels in the hope of developing migraine drugs with fewer side effects.
An NINCDS-supported neurologist at Massachusetts General Hospital prepares brain tissue for a study of beta receptors--cells that control the dilation of blood vessels. This research could lead to the development of new medications for vascular headache.
"I have learned not to worry."
This problem may be resolved by NINCDS-supported research at Massachusetts General Hospital in Boston. A research team there is using biochemical techniques to find out if there is a certain type of beta receptor that exists in the blood vessels of the brain but not in the heart. The discovery of this receptor could lead to the development of beta-blocking agents that would affect brain receptors only.
Another NINCDS-funded study at the University of Kansas Medical Center is comparing the effectiveness of propranolol with that of the antidepressant amitriptyline in the prevention of migraine. Physical and psychological characteristics of migraine patients are being correlated with their responses to the two drags.
Investigators supported by the National Institutes of Health General Clinical Research Center at the University of Colorado in Denver are studying the antimigraine properties of a class of drugs called calcium-channel blockers. Research on these drugs is also under way at the U.S. Air Force Medical Center, Wright-Patterson AFB in Ohio. Calcium-channel blockers interfere with the constriction of arteries, an effect that appears to be responsible for reducing the frequency of headaches in patients studied so far.
High technology in diagnosis. Physicians of the future may diagnose their patients' headaches with the aid of a computer. A computer might take a patient's medical history, store information on headache characteristics, and keep data on patients and their treatments. Programs might even be devised to explain to patients the way to take prescribed medications and the side effects of those drugs.
Scientists at Beth Israel Hospital in Boston are taking the first steps toward computer-assisted headache practice in a study funded by the National Library of Medicine. They are creating a working model for a headache interview program in which a computer will collect patient histories and symptoms. The scientists envision that an "automated physician' s assistant" will eventually free health care providers from collecting routine medical information, allowing them to devote more time to physical examination and treatment.
A final word of hope
If you suffer from headaches and none of the standard treatments help, do not despair. Some people find that their headaches disappear once they deal with a troubled marriage, pass their law board exams, or resolve some other stressful problem. Others find that if they control their psychological reaction to stress, the headaches disappear.
"I had migraines for several years," says one woman, "and then they went away. I think it was because I lowered my personal goals in life. Today, even though I have 100 things to do at night, I don't worry about it. I learned to say no."
For those who cannot say no, or who get headaches anyway, today's headache research offers hope. The work of NINCDS-supported scientists around the world promises to improve our understanding of this complex disorder and how to treat it.
Where to get help
Finding a clinic or physician who specializes in headache is a task made easier by the National Migraine Foundation. The foundation provides a list of clinics in the U.S. as well as the names of physicians in a specific geographic area who are members of the American Association for the Study of Headache. The foundation also supports research and education in migraine headache.
National Migraine Foundation
5252 North Western Avenue
Chicago, Illinois 60625
(312) 878-7715
Inquiries about NINCDS research on headache may be directed to:
Office of Scientific and Health Reports
National Institute of Neurological and
Communicative Disorders and Stroke
Building 31, Room 8A-06
National Institutes of Health
Bethesda, Maryland 20205
(301) 496-5751
Photograph Credits:
Dr. Leonard S. Rubin, Philadelphia College of Osteopathic Medicine, Cover, page 30.
Bill Branson, NIH, pages 3, 5.
Associated Press/Wide World Photos, Inc., page 6.
Adapted from Oliver W. Sacks, Migraine, The Evolution of a Common Disorder, 1970, University of California Press, page 7.
Adapted from an original painting by Frank H. Netter, M.D., in Clinical Symposia, copyright by CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation, page 9.
National Library of Medicine, page 13.
Will Yurman, State University of New York, Albany, pages 16, 28, 31.
Dr. Ninan T. Mathew, Houston Headache Clinic, page 20 (upper and lower).
Courtesy of The Washington Post, page 22.
John Crawford, NIH, page 24.
Adapted from drawing, Massachusetts General Hospital News, November 1982, page 27 (upper).
National Institute of Dental Research,. page 27 (lower).
Dr. James A. Nathanson, Massachusetts General Hospital, page 33 (upper and lower).
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