by Edward Bruce Bynum, Ph.D., Director of Behavioral Medicine
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 headaches.
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 these.
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