Boston Public Health Commission
VOL. 4 • NO. 12
© August 2010
Headaches: A universal pain in the neck In the vast and ever-growing world of human pain and suffering, the headache gets little respect. Ask Dr. Brian McGeeney, a neurologist and pain specialist at Boston Medical Center. He and a group of other doctors — affectionately called Headache on the Hill — have travelled to Washington, D.C. to talk about the urgent need for more federal funding for headache research. Not many congressmen are listening these days — just too many other headaches on the political agenda. But McGeeney is not giving up the fight. For him it’s personal. “My mother had migraine,” he said, noting that he witnessed her discomfort as a young child. “And I have migraine as well. They are universal.” He’s right. Most everyone has experienced a headache in one form or another. According to the International Classification of Headache Disorders, there are roughly 300 different types and subtypes of headaches. Migraine alone has about 20. When one considers all the conditions associated with headaches — ice cream, exercise, hormones and even sex — it’s a wonder we are pain free at all. Adding to the confusion is that though the pain is lodged in the head, the brain itself does not have pain receptors. Rather, headaches are usually caused by faulty blood vessels or nerves in the neck and head. Whatever the cause, the National Headache Foundation reports that more than 45 million Americans suffer from chronic, recurring headaches. That means 45 million suffer from headaches more than 15 days a month for at least three months. It’s no wonder then that between 2004 and 2005 more than 11 million out-patient visits were for headaches alone, one third of which occurred in hospital emergency departments. Fortunately, the World Health Organization (WHO), the medical arm of the United Nations, is arguing the case for headache respect before the international community. The agency now ranks migraines — just one type of headache — as nineteenth among all causes of years lived with disability worldwide. But even those efforts are not gaining traction yet — much
to the dismay of WHO. “Headache,” WHO explains, “… continues to be underestimated in scope and scale, and … remains underrecognized and under-treated throughout the world.” What’s worse, it may be particularly under-recognized and under-treated among blacks. According to a report in a 2006 article in Headache: The Journal of Head and Face Pain, researchers found that roughly 46 percent of African Americans interviewed compared to 72 percent whites sought professional treatment for their migraines or were diagnosed with it even though the respondents complained of moderate to severe headache-related disability. Furthermore, only 14 percent of blacks were prescribed medication to treat migraine compared to 37 percent of whites. Yet, blacks respond very well to migraine treatment, as noted in a later study in the journal Cephalalgia. The researchers found that African Americans as well as whites reported significant reductions in headache frequency and disability as well Bennie Smith was forced to switch occupations — from mechanic to cab driver as improvements in quality of life over a — because of his cluster headaches. The pain from clusters has been called “the 6-month treatment period for migraines. worst that humans experience.” (Ernesto Arroyo photo) The problem starts at home. All too often, the victims themselves are nonchalant about what many believe are simply their place of work because of headaches and 40 percent said their minor annoyances. They still show up for work, for instance, condition restricted their career. headache and all. Bennie Smith, 54, is one of them. But there’s a cost for their loyalty to work. “Presenteeism” “It’s hard to keep a job,” Smith said. “You can’t suddenly take a break until the headache subsides. You’d be right — working while impaired — results in a hefty toll, and can exout the door.” ceed the cost of absenteeism or health and disability benefits. And that’s just for those who were able to keep their jobs. Smith said he recognizes that employers expect job performance, but the attacks impaired his ability to do the A survey conducted in Denmark in 2007 found that 29 percent of the respondents reported that they had changed Smith, continued to page 4
Chronic condition may need stronger relief Hazel Reese decided it was better to write about her headaches rather than complain about them. She published “I Will Not Complain” in 2004 and is working on a follow-up book. Smith suffers from mixed (tension-migraine) as well as chronic daily headaches. (Photo courtesy of Hazel Reese)
azel Reese, 66, knows a lot about headaches. She should. She has suffered them for the last 50 years. Her migraine was hormone-related and returned like clockwork every month. Her father gently massaged her temples before she went to sleep. “When I woke up, they’d [her headache] be gone,” she said. At the time she didn’t know she had migraines, a particularly painful type of headache. What’s worse, nor did her doctors.
They insisted she had sinus headaches. It wasn’t until 1982, when Reese was almost 40 years old, that she learned the nature of her headaches. By now, she knows exactly which type of headache she has. “Migraine with aura,” she proclaimed. Unfortunately for Reese, it’s not only migraines that attack. She also suffers from “mixed headaches,” or tension-migraine headaches. “It starts with pain on the left side of my head and a stabbing pain behind my left eye,” she said. All this is preceded by an aura. “I see flashing colored lights,” she said. The tension-type pain is then added to the mix. “That one begins in the back of the neck and moves to the shoulder,” she said. But Reese’s headaches fall under an even broader category — chronic daily headaches. Most people have headaches from time to time, but if a headache occurs 15 days or more a month for at least three months, it is considered a chronic daily headache. Reese says she is never completely without headache pain. “They never really go away completely,” Reese said.
“On a scale of 1 to 10, if I have a 5 or 6 headache, that’s like no headache at all.” Fortunately, most headaches can be treated at home. Overthe-counter (OTC) drugs, such as aspirin and ibuprofen and other NSAIDS (nonsteroidal anti-inflammatory drugs), are the first line of treatment. But overuse can be just as bad — in some cases worse — than the original headache. Internal bleeding or perforation of the lining of the intestines can result, according to the American College of Gastorenterology. Rebound headaches often occur when pain killers are taken more than three days a week or in a higher than recommended dose. Over-use is no trivial matter. Thousands — many of whom are elderly — die each year as a result. The good news is that with the advent of a class of drugs called triptans, many people suffering from migraines are living more comfortably with their condition. Often referred to as a “miracle drug” triptans do not prevent migraines, but instead are used to abort the symptoms of an attack. They are taken as needed. For those with more disabling chronic attacks, prescription drugs are taken daily as a preventive measure. “Many people take it for granted that a headache is something you can’t avoid,” said Dr. Eduard Vaynberg, an anesthesiologist who specializes in pain management at Boston Medical Center. “They view them as benign ailments.” Vaynberg understands that sort of fatalism. “Going to the doctor can be a hassle,” he admitted. “But when you can’t drive because you can’t move your Reese, continued to page 4
Relax, take a deep breath … stop that headache
ot a headache? Who doesn’t? The economy is still shaky. The first day of school is too far off for working parents. And the jackhammer down the street — or that heated argument moments ago — probably isn’t helping either. If you know which type of headache you have there are many strategies you can try to stop the pain. “Be patient: it can take time to sort out which option or combination works best. Usually, it’s safe to start with headache self-care strategies that don’t require a visit to the doctor or a trip to the drugstore. If headaches persist or are severe, you need to discuss the problem with your doctor,” said Dr. Jan Cook, medical director for Blue Cross Blue Shield of Massachusetts.
Relieving headaches without medications Five non-medicated approaches to ease the pain include the following:
Slow the full-court press When a headache strikes, take time to unwind. Use your fingertips to lightly massage tight muscles on the back of your neck, scalp, and shoulders. Moist heat at the back of the neck may help, too. Next, close your eyes and breathe deeply and evenly for several minutes. Mentally count from one to three as you inhale, pause for a moment, then count from three to one as you exhale. If possible, rest for a while with your eyes shut and your head propped comfortably on a pillow. Especially helpful for: Tension-type headaches
Hush the noise, dim the lights Rest in a quiet, dark room with a cool washcloth or ice pack on your forehead. Try to sip fluids, especially to replace fluids lost through vomiting. Especially helpful for: Migraine headaches
Adjust your lifestyle Get enough sleep. Eat a healthy diet and try skipping certain foods that can trigger the headache. Carve out time for daily meditation or other forms of relaxation to buffer stress. Quit smoking, avoid red wine and limit other alcohol. Be active: your health will be better all around and you’ll feel less anxious and stressed.
Especially helpful for: Tension-type, migraine and cluster headaches
Practice yoga Yoga, which means to unite in Sanskrit, is an Eastern form of exercise that “unites” mind, body and spirit to produce a state of balance and well-being. Yoga combines deep breathing with various body postures to promote relaxation and reduction in stress. Especially helpful for: Tension-type and migraine headaches
Meditate The deep, even breathing and sustained concentration meditation requires relaxes the body and brain. When practiced regularly, meditation helps ease many stress-related health
problems. Consider a meditation class or CD, or follow the steps described in “Meditation” under A Healthy Me on the Blue Cross Blue Shield of Massachusetts website (http://www.ahealthyme. com/topic/topic13868). Especially helpful for: Tension-type and migraine headaches
Help your doctor help you … … and keep a headache diary In order to pinpoint your type of headache, which will help to diagnose and treat it correctly, pay close attention when it surfaces.
Keep track of: •
the date of each headache
the time it started and the time it ended
type of pain and intensity on a scale of 1 to 10
where the pain is centered
foods and beverages you had during the last day
amount of sleep and caffeine
any sensitivity to light, sound or odors
the date of your menstrual cycle if you are female
type of treatment and its effect
your thoughts and actions shortly before the pain began
Discuss any frequent headaches with your doctor, who can recommend appropriate treatment. Call your doctor immediately if you experience a very severe, sudden, or explosive headache (especially after a head injury or if your headache is accompanied by stiff neck and fever, weakness, or difficulty speaking or seeing, which could signal more serious problems, such as meningitis or stroke).
When is medication needed? Headaches can be connected to health problems like colds or flu, or can occur independently. Certain types of headaches are hereditary — that is, they run in the family. So if your mother often had migraines, you may have them, too. Some headaches may occur repeatedly for days or weeks — boom, boom, boom — then disappear for a long stretch, only to start up again at a later date in time. People can have more than one kind of headache at the same time (a problem known as mixed headache). Forty-five million Americans suffer chronic headaches, reports the National Institute of Neurological Disorders and Stroke (NINDS). Non-medicated approaches alone may not do enough to quell certain headaches, especially migraines and cluster headaches. Over-the-counter pain-relievers ibuprofen (Motrin), acetaminophen (Tylenol) or naproxen sodium (Aleve) can help, though it’s best not to rely on these too often. Aspirin is another self-care choice (check with your doctor first since some people shouldn’t take it). Children should never be given aspirin due to a rare, life-threatening condition called Reye’s syndrome. Like any other medical problem, if your headaches are severe, contact your doctor. Prescription and over-the-counter medications should not be overused. Maintaining a healthy lifestyle — eating properly, exercising, and sleeping seven to eight hours a night — is key to avoiding many health problems, including headaches. For more information on headaches, headache relief or headache prevention, talk to your doctor.
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Questions & Answers 1. Are headaches hereditary? Heredity does play a role in headaches, but it is not yet known what specific abnormality or genes are responsible. According to the National Headache Foundation, 80 percent of migraine sufferers report a family history of migraines. The foundation further reports that a child has a 50 percent chance of having migraines if one parent suffers and a 75 percent chance if both parents suffer.
A closer look A contradiction in terms Do pain relievers treat a headache, or cause a headache?
Michele David, M.D., M.B.A., M.P.H., F.A.C.P. Associate Professor of Medicine Co-Director, Haitian Health Institute Boston Medical Center (David Keough photo)
2. Why do some foods, such as aged cheese, trigger headaches in some people? Tyramine is a form of protein found naturally in many foods, and is believed to precipitate headaches. Tyramine is found in aged cheeses, fermented sausages, sour cream and wine, to name a few. Experts theorize that certain foods cause constriction of blood vessels followed by expansion, which may contribute to throbbing pain. Regardless of the mechanism, it is important to pay attention to what you eat to identify potential foods that trigger headaches and avoid those specific foods.
3. Is it possible to cure a person of headaches? Headaches cannot be cured, but can often be prevented with certain medicine as well as non-medicine techniques. For instance, biofeedback teaches patients to reduce stress by controlling the physical changes that lead to headaches. Other relaxation practices are deep-breathing exercises, progressive muscle relaxation, which involves contracting then relaxing different muscle groups, and yoga. 4. Are over-the-counter medications, like aspirin, effective against headaches? If the headache is not severe, over-the-counter medicine like acetaminophen (Tylenol), and nonsteroidal anti-inflammatory drugs (NSAIDS) like aspirin, ibuprofen (Motrin) and naproxen (Aleve) can be effective. NSAIDS reduce pain, inflammation and fever. Aspirin is also a blood thinner, which is why it is often recommended to reduce the risk of heart attacks, strokes and blood clots. Frequent severe headaches, however, should be evaluated by a doctor.
Yes Regular use of pain relievers — including nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen — can actually cause headaches. “Rebound” or medication-overuse headaches can occur when the medication is taken more than two to three days a week or more than the recommended dosage. For reasons not fully understood, a drop in the level of drugs in the blood precipitates another headache, which in turn precipitates another dose. The cycle continues resulting in chronic daily headaches with more severe and frequent pain. Rebound headaches can occur with prescription drugs as well.
Triggers Although it is not always possible to prevent a headache, it may be possible to reduce its frequency by determining and avoiding what cause it. Triggers are factors that spark a headache. Most triggers are related to migraines but may be related to cluster and tension-type headaches as well. • Change in the weather, particularly heat and moisture • Fatigue • Emotional stress • Lack of sleep or too much sleep • Bright or blinking lights
• Loud noises • Strong smells, such as perfumes • Alcohol, particularly red wine • Smoking • Certain foods — Chocolate, caffeine, aged cheeses, processed meats
5. At what point should a person seek medical care for a headache? You should seek medical care if you have chronic severe headaches. If over-the-counter-drugs are not effective, prescription drugs are available that have proven to be very effective in not only treating headaches, but preventing them as well. Your primary care physician should be the first line of approach. However, for persistent, stubborn pain, a referral to a pain specialist, such as a neurologist or anesthesiologist, may be warranted. 6. Is it possible to prevent a headache? Yes. Headaches can often be prevented by making sure you get an adequate amount of sleep, avoid the factors that trigger the headache and engage in moderate regular exercise. Stress management techniques are also helpful. For those with severe chronic headaches prophylactic medications are available to reduce the intensity, frequency and duration of headaches. Examples of preventive medications include antiepileptic medications, antidepressants, beta-blockers and calcium channel blockers — both used to treat cardiovascular disease. 7. Is there a link between depression and headaches? Yes. Depression is more common among people with headaches than those without headaches. Women with severe headaches are four times more likely to be depressed. Depression and headaches may share a strong genetic link. Common genetic pathways may underlie both diseases, rather than one illness causing the other. 8. Is caffeine a headache treatment or a headache trigger? It can be both. Caffeine added to pain relievers makes them more effective in treating headaches by helping the body absorb the pain medicine more quickly, thereby speeding the action of the drug. On the other hand, too much caffeine — regularly consumed in coffee, tea and soda — can cause a withdrawal or rebound headache when you stop drinking it. The maximum amount of caffeine tolerated varies by individuals, so it’s up to you to determine your acceptable limit. 9. Are headaches life-threatening? It depends. Some headaches are caused by an illness or condition which can be life threatening. For example, if the headache is accompanied by weakness or numbness on one side, double or blurry vision or difficulty speaking, it may signal a stroke. A headache accompanied by fever, rash, mental confusion and stiff neck could be related to meningitis. In general, any severe headache that is out of the ordinary or one considered “the worst headache ever” should be evaluated by a doctor.
The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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Smith, continued from page 1
occur infrequently and are related to temporary stress, anger, anxiety or fatigue. simplest of tasks. Trained as a mechanic, But it’s migraine headaches that have Smith was forced to change careers. He now attracted the most attention and research. drives a cab during the day. “I’m basically The pain from migraines is typically a my own boss,” said Smith. “If a headache throbbing or pulsing of moderate to severe comes I can stop a while.” intensity on one side of the head. People It’s a good thing he has some alone complain of sensitivity to light, noise, time. As Smith tells the story, migraines, sound, nausea and vomiting. Movement can from which he suffers periodically, are exacerbate the pain. Migraneurs — those nothing in comparison to the headaches that suffer from migraines — get relief by that have plagued him for nearly the last resting quietly in a darkened room. two decades. Certain factors can trigger a migraine Smith gets cluster headaches, a rare but — changes in the painful headache that weather, odors, fatigue, occurs more frequently tobacco, skipped meals, in men and, according to and certain foods. mayoclinic.com, is more Despite the common in blacks. The pain from existing knowledge on clusters has been called headaches, it’s ironic “the worst that humans then that many sufferexperience.” Some ers are not diagnosed women have reported properly. it as being more severe “I didn’t know than childbirth. what it was,” said Smith. Unfortunately, “Migraine is nor did many docnothing compared to tors. When asked how cluster,” Smith said. many doctors he had “Migraines don’t come seen about his condiback.” But cluster headtion, he answered, “I aches do. “I timed it Brian McGeeney, M.D. can’t count them all.” once at one hour and 45 Assistant Professor of Neurology But then someminutes,” Smith said. Boston University School of Medicine Clusters are aptly Staff Neurologist thing good happened. called suicide headSmith was referred to Boston Medical Center aches. “Sometimes it Dr. McGeeney, who fihurts so bad, you feel like standing in front nally diagnosed him with cluster headaches, of a train,” Smith said. “You can’t stand and prescribed medication for his pain. noises. You just want to stay in a quiet “On the second day the headache was room for half an hour. You don’t want to completely gone,” said Smith. “You don’t hear people talking.” And you can’t stand know the relief.” still. But Smith is not completely out of For Smith, the pain starts in the the woods — headaches generally canshoulder, travels to the neck and up to not be cured, but they can be treated and one side of the head. It then travels to often prevented. Smith is learning how to the ear and only ends when it hits right minimize the intensity and occurrence of behind an eye. Smith knows that alcohol his headaches. When he feels it coming on, and smoking are related to the attacks. he finds that exercising his shoulder and He says the alcohol is out, but the smokneck help. ing is still a challenge. And Smith said he has even more good While cluster headaches are the least news — he is ready for a full-time job. common of the major headaches, tensionSo common and disabling are type headaches are the most common. Up headaches that many hospitals have to 80 percent of the U.S. population suffer established pain management or headache from this type of headache from time to clinics staffed by a variety of specialists time. They are triggered by fatigue, emoand services, including biofeedback and tional stress, even faulty posture. stress reduction. Cases not easily manThe pain from tension-type headaches aged by primary care are often referred to is quite distinctive. By all accounts, it desuch clinics. serves the apt description “it feels like my “It’s important to not blame yourself head is in a vice.” Usually, the pain occurs if you get headaches,” said McGeeney. on both sides of the head, is not associated “People aren’t giving it to themselves. with nausea, is not aggravated by exercise There is a big genetic predisposition, and is mild to moderate in intensity. but environmental factors are also very For the most part, tension headaches important.”
Not just any headache! Most headaches are annoying inconveniences, but some may signal a serious condition — such as meningitis or stroke — that require prompt medical attention. People may complain of the “worst headache ever.” • A severe headache with sudden onset • Headaches that first develop after the age of 50 • Headaches that increase with coughing or abrupt movement • Persistent headache after a blow to the head • Headache pain that feels like an explosion or thunderclap • Headache pain that gets worse and won’t go away • Headache accompanied by any of these symptoms – stiff neck and fever – severe pain when bending over – decreased alertness or mental confusion – persistent, severe vomiting
• Headaches accompanied by neurological symptoms – visual disturbances – slurred speech – weakness or numbness on one side – seizures
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WHICH ONE IS IT? The three most common types of headaches vary in their symptoms, but it is possible to have overlap of symptoms or two different headaches occurring at the same time.
(Common in men and women)
What does it feel like? Dull, non-throbbing mild to moderate steady pain Usually both sides of head Tenderness in neck and shoulder muscles “Feels like head is in a vice” What sets it off? Stress, hidden depression How long and how often? 30 minutes to 7 days. Infrequent to daily
What does it feel like? Excruciating one-sided pain Rapid development without warning Excessive tearing and redness in eye of affected side Pain frequently wakes person from sleep Restlessness What sets it off? Alcohol, excessive smoking How long and how often? 15 minutes to 3 hours. Several each day
Migraines (Mostly women)
What does it feel like? Moderate to severe throbbing pain One or both sides of the head Pain worsens with physical activity Often accompanied by nausea, vomiting, sensitivity to light, sound and smell What sets it off? Certain foods, changes in weather, stress Hormonal changes in women Not enough or too much sleep Alcohol, smoking How long and how often? 4 to 72 hours. Recurrent, with widely variable frequency
Reese, continued from page 1
between the bones become impaired and the pathway for the intricate system of nerves head, that poses a problem.” can narrow. Diagnosing headaches correctly is a When conventional treatments fail, challenge. “People can suffer from headvarious interventions are offered, according aches for 10 years and no one has been able to Vaynberg, who specializes in the treatment to diagnose it correctly,” he said. of cervicogenic headaches. Anesthesiologists Headaches are divided into two catcan perform an anesthetic block to the nerve egories — primary and secondary. Primary or muscle trigger points. Local anesthetics headaches are not caused by a disease or and steroids mixtures are commonly used. condition — the headache itself is the problem. Migraine, tension and cluster headaches Botulinum toxin is sometimes used when local anesthetics give short fall into the primary term relief and in some category. Secondary cases has been successheadaches, on the other ful. However, its use is hand, are symptoms of considered experimenan underlying disorder, such as infections, tal and it is not covered by insurance. tumors and neurological aberrations. Radiofrequency is another technique, Cervicogenic, or neck-based headache, which cauterizes the nerve endings in the is a secondary headneck, thus providing a ache. Although not as long-term relief of pain. common as tension“Headaches are type, they make up 20 very challenging,” percent of the patients Vaynberg admits. “We with chronic pain treatoften know what works, ed in pain management Eduard Vaynberg, M.D. but don’t always know clinics, according to a Anesthesiologist why they work.” recent study published Boston Medical Center in the Journal of the Either way, Reese is not complaining. Although the American Osteopathic Association. migraines precipitated her retirement 22 The pain from neck-related headaches is distinctive and is sometimes confused with years ago — earlier than she had anticipated — she says she’s doing all right. migraine pain. It is characterized by moderate to severe pain on one or both sides of She knows her triggers. Perfume and loud noises can set it off. “The biggest trigthe head often triggered by neck movement. ger is the weather,” she offered. “Rain and Some may experience nausea, vomiting and warm temperatures in particular.” There are sensitivity to sound and light. Some experts attribute this problem to also foods she steers clear of — especially overload — just two or three small bones in chocolates, hot spices or beans. “If I eat the neck bear the brunt of most of the move- something I’m not supposed to, within the ments of the head and neck, let alone the first 15 minutes, I can feel it,” she said. Because of other serious medical weight of the head itself. The head is roughly problems, she is now on a “restrictive” 12 percent of a person’s total body weight. medication for her headaches. That’s an awful lot of repetitive stress “Over the years you learn to live and strain for two or three small bones. And with it,” she said. “[But] I’m in conit can come with a price. Eventually the trol now.” bones show signs of wear and tear, the links
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