Everyone reading this article has at some point in the
past had a headache. In fact, during a course of a year most of us have at least
several headaches. Usually these headaches are mild tension headaches or stress
headaches. They subside with rest and perhaps occasionally a little aspirin.
They often occur around normal stressful life episodes. Sometimes alcohol and
the rebound from alcohol can exacerbate headaches, as can some medications. Some
headaches, however, are more troublesome. These headaches are the more intense,
recurrent, and exacerbating headaches associated sometimes with certain kinds of
food, allergies, ecological and environmental conditions, and place a drain upon
our system. Certain foods such as monosodium glutamate will exacerbate a
headache. Certain conditions such as intense sunlight are known to bring on
certain kinds of headaches. These headaches also usually pass with time or can
be avoided with a little planning.
Other types of headaches, however, are more clinically
significant headaches and each has it's own pathophysiology. In the following we
shall describe several of these headaches along with their neural and somatic
physiology and the specific symptoms associated with them and their association
with other syndromes. The most common variety of headache is the muscle
contraction or tension headache. This usually occurs on one side of the face but
sometimes can occur bilaterally. Often the neck and shoulders are associated
with this situation. There is a great deal of tension in the neck and shoulders
and sometimes in the mouth and jaw. Sometimes the conditions of bruxism and
temporal mandibular joint pain occur with these kinds of muscle contraction
Another common variety of headaches are the migraine
headaches. There are essentially three different kinds of migraine headaches. A
migraine headache is a vascular headache, which is to say it involves the veins
and arteries primarily in the body. This is how it is different than the muscle
contraction and tension headache which involves mostly muscle tension. The
migraine headaches involve vascularvaso constriction. In the common migraine
headache this vaso constriction has two phases. The first phase is one of vaso
constriction in which a person may experience some coolness in the hands and
fingers, some sensitivity to light, occasional nausea, and a sense of mild
dread. In the classical form of this migraine headache there is a slight aura
perceived around objects. This is due to the fact that the vaso constriction is
occurring primarily in the back of the head, the occipital regions of the brain
where visual stimuli and information are processed. The third form of migraine
headache is the mixed migraine headache, which a mixture of both the common and
the classical migraine headache. In some rare instances there are headaches that
involve more complicated and serious medical disorders such as stroke and
hemorrhage. Stroke, which is referred to as a cerebral thrombrosis, accounts for
about 55% of all cases of stroke. Also there is a form of headache called a
hypertensive headache, which develops when the hypertension or high blood
pressure becomes moderate or severe. The headaches are usually occipital,
moderately severe and nagging and throbbing in character as are other migraine
headaches. This is again how migraine headaches are somewhat different in
general than muscle contraction headaches. Migraine headaches tend to throb,
whereas muscle contraction headaches do not throb as much. This of course is not
absolute. Finally, there is a cerebral hemorrhage referred to as a subarachnoid
hemorrhage which produces a particularly intense kind of headache. This kind of
headache is caused by an aneurysm in 50% of the cases and by arteriovenous
malformation in approximately 10% of the cases. The other 40% are made up by
causes such as hypertensive intercranial hematoma or blood dyscrasia. The latter
three headaches of course are the ones that we are most frightened of. The
headaches that result from brain tumors are also exceedingly rare. Headache is
the initial symptom in about 20% of patients with brain tumors and is present
during the course of the illness in about 90% of patients.
The other kind of common headache is a sinus headache.
This headache occurs as a result of congestion and blockage in the sinus areas.
It is related to the condition of sinusitis, rhinitis, and other upper
respiratory complications. Finally, the other major form of common headache is
called the cluster headache. Unlike the muscle contraction headache and the
migraine headache, the cluster headache has no warning and can hit very quickly.
In this way it is somewhat similar to the sinus headache, although in the sinus
headache one usually has a sense that one's sinuses are congested and so there
is some warning. There are very few prophylactic measures that can be taken with
a cluster headache other than prophylactic medication.
Mixed and multiple headaches are those headaches that
involve both migraine and muscle contraction elements. They can be episodic.
Also it is not unusual for a person to have clearly muscle contraction headaches
at some times and migraine headaches at other times. The cluster headache is
represented by sudden and intense feelings of pain throughout the face and head.
After the headaches described above, particularly the
migraine headaches and the cluster headaches, it is not unreasonable for a
person to experience a great deal of fatigue and increased irritability. With
migraine headaches in particular, there tends to be an increase in the desire to
escape it by going to sleep. Depressive reactions are common in all situations.
It is rare, however, that the muscle contraction, migraine, or sinus headache
leads to incapacitation to do work. Transiently, the cluster headache, however
is capable of rendering a person almost useless to do work. In all three
situations there can be increased fatigue, irritability, loss of efficiency at
work, appetite loss and decreased concentration.
As was stated above, all of these headaches with the
exception of the neurological headaches, tend to be relatively common in most
people. This is to say that it is not unreasonable for a person to have a
migraine headache once or twice a year or a muscle contraction headache two or
three times a year. However, there are times when headaches are a concern and
should be referred to a clinician for evaluation. These include the times when
there is sudden onset and no diminishment of the pain over time. Also when there
is a loss of visual or auditory capacity for long periods of time. Also when
there is a loss of balance and a passing out or a loss of consciousness. Also
critical are unusual tastes or smells such as metallic tastes or a spoiled
substances. When these occur it is very important to refer this to a clinician
for evaluation. In most cases a regular medical or other reason can be found for
In the most common varieties of headache there are some
very simple and straight forward measures that can be taken to significantly
decrease the headaches. The first is that when symptoms are common, exercise,
relaxation, decrease in alcohol intake, decreased stress, and prudent use of
occasional over-the-counter medication is very helpful. Often diet changes and
lifestyle changes are extremely helpful. Some people develop headaches after
drinking substances such as red wine or too much caffeine. Some respond with
headaches after ingesting too much monosodium glutamate or other things. There
are also other peculiarities that a person's system may be responsive to. When
symptoms are more troublesome and or persistent, consultation with a University
Health Services physician or nurse practitioner or nurse may be prudent. After
their evaluation they may refer the patient for medication or brief counseling.
In certain situations such as migraine headache, muscle contraction headache and
mixed headache, the patient may be referred to the behavioral
medicine/biofeedback clinic. This is when it is assessed that the headaches are
primarily psychogenic in nature, and not medical in that a person can learn to
decrease their headache tendencies and their stress level by learning
psychophysiological self regulation through biofeedback and behavioral medicine.
Usually this can be learned in anywhere from 4 -6 sessions with practice outside
of sessions. Occasionally someone may be referred for longer term psychotherapy
in conjunction with behavioral medicine. In rare circumstances a person may be
referred to a neurologist, a specialist in disorders involving the cerebral
area. Also under certain circumstances and MRI or CAT scan may be employed.
Primarily however, most headaches are common and respond to treatment relatively
easily and quickly without recourse to serious medication.
Seymour Diamond, MD and Jose L. Medina, MD, Headaches. Clinical Symposium,
Vol. 33, No. 2 (1981)
George D. Fuller, Ph.D., Biofeedback: Methods and Procedures in Clinical
Practice, San Francisco, CA