by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D
Headaches are a pain or discomfort that can be generalized or local affecting any part of the cephalum (head). There are many causes of head aches, some originating from the head region itself. Others are referred from the neck and upper back, as well as ophthalmologic origins.
Most causes of headaches are benign and have no underlying significant pathology; however, it is important to have a physician or pain specialist rule out more severe causes before beginning headache treatment for the benign causes.
Headaches themselves are one of the most common complaints from people visiting a physician.
A headache specialist will then classify the headache as “primary” or “secondary.” Primary headaches are not caused by an underlying pathology or disease.
Primary headaches are benign headaches that can further be subdivided as cluster, tension, and migraine headaches. Secondary headaches are associated with a pre-existing pathology causing the pain, which may be benign or malignant of origin.
There are many causes of secondary headaches that should be excluded by a headache specialist before assuming a headache is of primary origin.
Some of the more severe causes that require immediate treatment are intracranial hemorrhages/ hematomas, meningeal infections (viral, bacterial, fungal), strokes, and malignant hypertension.
Other pathologies that are more subacute, or have an insidious onset, may be malignant tumors (primary or malignant) or ophthalmologic (glaucoma, cataract).
There are other diseases associated with headache, and these all should be evaluated by your physician before treating your headache.
Your physician may wish to order radiological studies (MRI, CT scan), neurological exam, blood work, or an eye/vision assessment to help rule out some of the causes of secondary headache. Primary headaches are much more common and can be broken down into three categories: cluster, tension, and migraine headaches.
In cluster headache, men are more commonly affected than women with a peak age of onset around 25 years.
Patients will present with a severe, unilateral, pulsatile, and periorbital pain that typically lasts anywhere from 20 minutes to three hours.
Patients describe the pain associated with cluster headache to be far more severe than is experienced in tension or migraine headaches.
Risk factors for cluster headaches include vasodilating medications as well as recent alcohol or illicit drug use.
A specific trait to cluster headaches are that they occur in “clusters,” meaning they affect the same location of the head, around the same time of day, during the same time of year.
Patients may also experience tearing from the eye on the same side of the head as the pain, as well as nasal discharge or stuffiness or neurological complications (Horner’s syndrome and ptosis).
In contrast with the other two types of primary headache, emotion and food are not triggers in cluster headaches.
Tensions headaches are considered the most common headache diagnosed in adults. The pain is described as a restrictive, band-like pain that is being wrapped around the patient’s head. Patients describe it as an insidious (slow) onset that can be exacerbated by bright lights, noise, and especially stress.
A patient experiencing tension headaches may also have associated depression, sleep disturbance, or poor concentration. These typically occur towards the end of the day and are located in the upper neck and occipital (back of head) region. Unlike cluster and migraines, tension headaches are not associated with any neurological disturbances and are usually a diagnosis of exclusion.
Migraines are more common in women and affect a significant portion of the population. Migraine headaches can be experienced in children, adolescents, adults, and geriatric patients and vary significantly with each person.
They can be seen in anyone! The pain associated with migraines is described as either unilateral (one-sided) or bilateral (both sides), intense and throbbing that typically lasts over an hour but less than 24 hours.
Migraines are further classified as “classical” and “common.” In classical migraines the pain is unilateral and is preceded by an aura.
A common migraine is often bilateral and has no associated aura or neurological manifestation. One of the known phenomena of a migraine headache is that many people, although not all, have an associated aura that may occur before, during, or after the onset of the migraine.
Some patients describe the aura as scintillating flashes of light, a particular smell, spots of vision loss, as well as numbness of one or both sides of the face, unsteadiness, weakness, or an altered level of consciousness.
Nausea and vomiting are also common among patients who suffer from migraine headaches. There are many occurrences that can trigger a migraine attack.
Some of the most commonly associated triggers are loud noise, bright lights, certain foods (chocolate, peanut butter, avocado, banana, citrus, dairy products, fermented/ pickled foods, and MSG), certain medications (birth control pills and migraine medications), menstrual cycle fluctuations, exertion activities, as well as underlying emotional and/or psychiatric diseases, such as depression.
Mechanism of Headaches
In the past scientists thought that migraines were caused by changes in blood vessels within the brain.
However, recent research has led scientists and physicians today to believe that the pain originates within the brain itself, involving various nerve pathways and the neurotransmitters within the brain in addition to the vasodilatory affects.
Cluster headaches are considered to be from the vasodilatation (opening) of the blood vessels in the brain. This causes the acute and severe pain by compressing and irritating the cranial nerve (trigeminal), which innervates the sensory and some motor function of the face.
The etiology of tension headaches are less understood; however, it is thought to be due to neurotransmitter or chemical changes surrounding the brain due to stress and emotional factors.
Another theory is that continued musculoskeletal (myofascial) irritations may cause tension headaches. Examples of continued myofascial irritation or stimulation includes jaw clenching as well as poor posture of the back or neck.
Migraine headaches are thought to be vascular in origin, similar to cluster headaches, and are also associated with a imbalance in the neurotransmitter serotonin. Migraines are also considered to be familial, which means there is a genetic link involved. The theory is that some patients with a family history of migraines have a gene that predisposes them to migraines.
A study conducted in 2003 by the Departments of Anesthesia and Critical Care of Harvard University showed that the cranial parasympathetic outflow contributes by sensitizing intracranial nociceptors producing peripheral or central desensitization occurring within a migraine attack.
This can intensify and aggravate the pain that is actually caused by the migraine. Sensitizing desensitization is a development involving both the peripheral nervous system (PNS) and the central nervous system (CNS).
Local tissue injury and inflammation activate the PNS, which sends signals through the spinal cord to the brain.
Central sensitization is where there is an increase in the excitability of neurons within the CNS (brain and spinal cord), so that normal inputs from the PNS begin to produce abnormal responses.
Low-threshold sensory fibers activated by very light touch of the skin activate neurons in the spinal cord that normally only respond to noxious, or more severe, stimuli.
As a result, an input that would normally produce a harmless sensation now produces significant pain. This occurrence is classically seen in patients who suffer from primary headaches, especially migraines.
Pharmacologic treatment for primary headaches can be classified as abortive or preventive. Abortive therapy and other therapies are directed at terminating the pain immediately.
Although this may provide relief from the headache, it does not decrease the frequency or intensity or prevent the attack from recurring. They also are not equally effective each time and efficacy varies from person to person.
Typical over-the-counter medications have no use for cluster headaches. Some commonly used abortive therapies for headaches are:
- Oxygen (most commonly used acutely in cluster headache)
- Butalbital with aspirin or acetaminophen
Although many patients may experience relief with these headache treatments, there is also a concern of overuse and dependence that may develop.
In May 2007 the National Neurological Institute in Italy published an article stating that “Most patients with frequent headaches eventually overuse their medications, and when this happens, the diagnosis of medication-overuse headache is clinically important, because patients rarely respond to preventive medications whilst overusing acute medications.”
Therefore it is very important to monitor a patient on abortive therapy because if overusing their medications, their headaches may become refractory to the preventive therapy causing their attacks to be more frequent and severe.
Medications and techniques that are considered preventive therapies are directed at reducing the frequency and severity of the attacks. Unfortunately, most of these medications are not able to terminate an acute episode, so they are typically used in conjunction with abortive therapies during an attack.
Some of the common preventive medications are:
- Antiseizure medications
- Cardiovascular drugs (beta blockers or calcium channel blockers)
In a recent publication, the relationship between depression and anxiety disorders in people with migraines were evaluated and showed a linked association. Therefore it is recommended that people who are experiencing migraines or migraine-like symptoms should also be screened for depression or anxiety disorders.
By treating both aspects, the physical and the mental, the quality of life and symptom management may improve. Treatment for these disorders can be through medication or behavioral therapy.
An extremely important aspect to treating headaches is through behavioral interventions and modifications.
Behavioral modifications, including biofeedback training, mind and body relaxation (yoga, acupuncture, and massage), and cognitive behavior therapy, have been identified as successful treatments for migraine headache.
The Minnesota Institute for Pain Management know the importance of these headache treatments and therefore offer for their patients:
- Exercise and nutrition counseling
- Vitamin supplements
- Cognitive behavioral therapy
- Group therapy
- Chiropractic manipulations
- Hormone supplements
Recently there has been a flood of investigations going on to determine the efficacy of botulinum A toxin (Botox) injections for the treatment of migraines.
Some people receiving Botox injections for their facial wrinkles have noted improvement of their headaches. Essentially, Botox is injected in the same or similar locations as is for the treatment of wrinkles in cosmetic practices.
In 2007, the Chicago Medical School at Rosalind Franklin University of Medicine and Science compared results of two large trials that investigated the efficacy of Botox for the treatment of migraines and tension headaches.
They reported there were positive findings in the association of the treatment of these headaches with Botox. Another publication in 2006 stated that 75% of patients treated with Botox injections for the prophylactic treatment of migraines reported compete relief of their headache.
No adverse effects were reported by the treatment group either and was therefore quoted as “Botox (BTX-A) showed good efficacy and tolerability as a prophylactic agent.”
Qualified pain physicians such as those at the Minnesota Institute for Pain Management offer an array of injections and procedures that have proven efficacious in treatment of headaches, including the Botox injections.
Some of the other injections and treatments they offer are:
- Occipital nerve stimulation
- Botox injections
- Cervical facet injections
- Cervical epidural steroid injections
- Sphenopalatine nerve blocks
- Occipital nerve blocks
- Supratrochlear nerve blocks
- Supra/infraorbital nerve blocks
There have been numerous studies and publications on the effectiveness of these treatments for the relief of headaches.
Many of them stated that the conventional therapies are often not effective in treating the associated facial pain and peripheral/central desensitization that is commonly associated with migraines.
In a study, 85% of patients responded positively with a favorable response when treated with blockade of the supraorbital and greater occipital nerves in the treatment for migraines. Researchers therefore concluded that the blockade of the supraorbital and greater occipital nerves were shown to be effective in the treatment of migraine headache.
Transnasal sphenopalatine ganglion (SPG) block injections are also helpful in migraines, but have also had positive results in treating medication-resistant cluster headaches. A number of surgical treatments have been attempted in cases of cluster headache resistant to pharmacologic therapy, of which SPG blockade has been shown to have the most successful results.
“These results should be considered rather good because, unlike other frequently used techniques, SPG blockade is not invasive and should therefore always be attempted before submitting patients to more invasive surgical approaches.”
Also printed in 2006 was “Transnasal sphenopalatine gangion block provides a safe, low-cost, therapy that, if effective, oftentimes can be self-administered for pain relief.” Another author published “The nerve stimulator-guided occipital nerve blockade significantly relieved cervicogenic headache and associated symptoms at two weeks following injection.”
A combination of therapies have been proven to reduce the symptoms associated with migraines and other headaches. You should discuss what the best and most beneficial options would be for your particular headache and associated complaints with your headache specialist. Contact us today to schedule a consultation.