Headaches are one of the most common complaints among patients visiting their family practitioner. In the majority of cases, the symptom is not evidence of a dangerous disease, but nevertheless may cause significant damage to quality of life and daily functioning.
Although dangerous headaches are rare, it is important to identify dangerous situations and to turn to medical help in time.
Headaches secondary to a dangerous disease are usually expressed as new and especially strong pains or pains accompanied by a particular neurological disorder such as paralysis or double vision. Headaches accompanied by fever, confusion or change in consciousness require urgent arrival to the emergency room because they may be evidence of meningitis or bleeding in brain. Chronic headaches lasting many months are usually not dangerous.
Primary headaches (not secondary to a dangerous problem) are divided into different types. Two common types are tension headaches and migraine:
Tension headaches are the most common cause of headaches. According to a health survey conducted in Israel in 2003-2004, 13.7% of people aged 21 and over reported strong and frequent headaches in the year preceding the interview, 8.7% of men and 18.2% of women. The pains are seem to be caused by a combination of tension in the muscles of the forehead, temples or neck and an increase in sensitivity to pain. Headaches are usually characterized by pressure and have mild to moderate intensity. In most cases, the pain is aggravated by tension, but they are characterized by different triggers in different people.
Sometimes, headaches become more frequent and become chronic. The patients enter into a kind of vicious circle. The pains worsen the tension which in turn worsens the pain and so on. As a result, there is an increased consumption of analgesics which paradoxically can themselves cause chronic headaches.
The pain is usually moderate to severe and limits activity sometimes to complete disability. The pain is caused by the expansion of blood vessels in the brain and stretching of the nerves that innervate them. In many cases there is a family history of migraine. This is a chronic disease that may last years at varying intensity levels, from isolated attacks throughout life up to daily headaches.
Incidence of the disease
According to the survey mentioned above, the prevalence of migraine in Israel and among those aged 21 and over is 5.4%, of which 3.2% of men and 7.5% of women. The disease usually appears in adolescence or in the 20s and tends to decrease in older age. 15% of migraine sufferers have a presentiment of the appearance of a migraine, called an aura. This is generally a vision disorder that usually lasts about twenty minutes before the onset of pain and passes with its beginning.
How to diagnose migraine?
Migraine can be diagnosed by the history of the disease. There are clear criteria that define a migraine:
- At least five attacks of headache lasting from four hours to three days.
- One-sided headache, throbbing, moderate to strong, pain is worsened by physical activity (two of the four).
- Pain accompanied by nausea and vomiting, or sensitivity to noise and light.
Rare primary headaches
A rare headache that usually appears in men. The pain occurs in clusters, hence the name. Seizures can occur for several weeks every day at a fixed time, and disappear for many months. The pains are especially severe, usually concentrated around the eye and accompanied by lacrimation, redness of the eyes and a runny nose on the painful side of the head. Pain persists for half an hour to three hours and may respond to giving oxygen.
Neuropathic pain that appears on the face. The trigeminal nerve that innervates the sensation of the face "shoots" electrical impulses as a result of various stimuli and causes very intense pain. The pain lasts a few seconds each time. The feeling is of an electric current that affects the lower jaw or cheek and sometimes the forehead. The pain is unilateral (one-sided) and can be stimulated by local contact, such as shaving, cold wind and even food. The pain usually apears in those over the age of 50. The treatment for trigeminal neuralgia is based on anti-epileptic drugs. In some cases, it is possible to locate a blood vessel pressing on the origin of the nerve and stop the pain by special neurosurgical surgery that separates between the nerve and the blood vessels.
Who to turn to when suffering from headaches?
When suffering from significant headaches, it is important to see a family physician to rule out any other problems that cause headaches and can be dangerous. The physician will hear the story of the disease and perform a neurological test. If necessary, the physician will refer the patient for auxiliary testing, imaging or neurological consultation. There are headache units that specialize in treating patients suffering from severe headaches. It is worthwhile to contact a neurologist in every case of headache which has not improved sufficiently after treatment of a family physician. The correct approach is to refer to a neurologist in every case of trigeminal neuralgia, cluster headaches and chronic headaches of various types.
Should every patient suffering from headaches undergo a CT scan?
As mentioned, the vast majority of those suffering from headaches suffer from primary headaches not caused by any dangerous situation so when a diagnosis of migraine or other primary headaches such as tension headaches has been made, it is not necessary to perform a CT or other imaging test. The doctor may recommend performing auxiliary tests when he suspects the headache is secondary to another problem.
How to treat headaches?
Treatment of headaches including prophylaxis and treatment of the seizures themselves.
Triggers - First, evaluate the factors that preempt the appearance of seizures. Seizures can occur following stress and intensive lifestyle, hormonal changes such as menstruation or pills, foods such as red wine, cheese or chocolate. The triggers are individual to each patient and therefore it is useful to log an "attacks" diary to evaluate what the triggers are and learn to avoid them. When stress is a significant factor, it is important to learn techniques for coping with stress.
Prophylaxis - When the frequency of seizures is four times a month or more, pharmacological prophylaxis should be considered (there are a range of medications and the decision to use them is based on the drug's efficacy versus side-effect profile), or preventative non-medication treatment such as relaxation and biofeedback.
Treatment during an attack - there is a very wide range of drugs that can be adapted for the treatment of headaches. For most types of pain, anti-pain medications that do not require a prescription can be taken satisfactorily. For migraine attacks that do not respond to the usual drugs, specific migraine medications from the family of triptans, that require a doctor's prescription, can be used. It is important to inform your doctor about all treatment including drugs that do not need a doctor's prescription in light of side effects that may be caused by the drugs and in light of their impact on other medications the patient is taking.
What to be careful of when taking medication?
- First, it is important to know that excessive consumption of painkillers can cause chronic headaches. Patients taking pain medication of any kind for over ten days a month need to reduce the amount of pain medication and even go through withdrawal if necessary. In many cases, the cessation of pain medication itself will significantly improve headaches.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may cause damage to the digestive system and therefore should be taken only after meals. In case of epigastric pain and heartburn stop taking these medicines immediately and inform the family doctor about the problem. (Advil, Nurofen, Voltaren, Naproxen, etc. belong to this family.)
- It is forbidden for patients with heart disease such as angina pectoris to take medications from the family of triptans used to treat migraine (Rizalt, Imitrex, Relert, and Zomig belong to this family).
Are unconventional therapies effective?
- Any treatment that helps relieve stress and control physical tension such as biofeedback, hypnosis, relaxation and guided imagery can help prevent headaches.
- Acupuncture - there have been a number of papers comparing acupuncture with placebo. These studies found significant improvement in both groups but no significant difference between the placebo and acupuncture. The response to placebo is evidence that there is a psychological element significantly influences headaches. Still, some patients did report a significant improvement in headaches after acupuncture treatment, and it seems that it may be beneficial for some patients.
At the Headache clinic at Hadassah Ein Kerem, we understand that headaches are a multidimensional problem. Beyond the biological aspect, there are emotional, social and functional components that cannot be ignored. We understand that no two patients are the same and our challenge is to connect to the patient with the aim of arriving at relief and healing.
Chronic pain treatment is a treatment consisting of several components: If the patient needs analgesics for more than ten days a month, they need to reduce the amount of pain medication being taken. Sometimes it is difficult to stop the painkillers and we help with the detox process. The second component is to raise the pain threshold. It is possible to raise the pain threshold with medication or by teaching self-relaxation and guided imagery with hypnotic techniques. The patient can choose their preferred treatment and combine treatments as needed. When learning self-relaxation, the patient becomes a partner in the therapeutic process, becoming more aware of the various triggers that affect the pain and then gaining better control of their physical responses to it. The third component that can contribute to improving the patient's condition is increased physical activity. It is recommended that they maintain physical activity 3-4 times a week, 30 to 40 minutes of exercise each time. Sometimes the emotional component is significant and there is a need for psychological counseling while also providing medical care. We work in cooperation with the Medical Psychology Unit of Hadassah Ein Kerem for patients interested in this aspect.
To summarize: We believe that the healing process from chronic pain is a complex process that requires cooperation of both the patient and a number of professionals and workers to give the best chance for a cure.