How to Treat and Prevent Headaches
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How to Treat and Prevent Headaches

Most of us get headaches, but we may not treat them with the best or newest methods. Step one: Be sure you know what type you have.

Dear Diary

Elizabeth Parker, 42, a mother of two school-age daughters in Charlotte, North Carolina, is normally upbeat and energetic. But every month, the day before her period, she develops a pounding headache so severe that only a prescription drug can relieve it. This has been going on since she began menstruating, at age 14.

While most of us -- 95 percent of women, says the American Headache Society -- get occasional headaches, most often triggered by stress or fatigue and mild enough to be cured with two aspirin and a good night's sleep, more troublesome pain like Parker's is also widespread. According to a World Health Organization report, 15 to 18 percent of women (two to three times the rate of men) experience migraines each year, and as many as one in 20 adults have a headache nearly every day.

Doctors recognize several types of headaches, such as the garden-variety tension type; migraines, including menstrual migraines; rebound headaches; and cluster headaches, the most severe kind. Fortunately, improved understanding and a growing number of effective new drugs have made headache treatment better than ever. To determine what type of headache you have, it's important to keep a diary of your symptoms for at least a few weeks to spot potential pain triggers, which might include hormonal changes right before your period, eating certain foods, drinking alcohol, changes in the weather, and stress. Our guide will give you the facts you need to pinpoint the problem, take the right steps to treat your headache, and better yet, prevent the pain entirely.

Tension Headaches

These are the annoying, run-of-the-mill headaches that everyone gets from time to time and that are usually mild. Most people experience them occasionally, but tension-type headaches can occur daily.

What causes them: Stress, poor posture, working with your head or neck in an unnatural position for long stretches of time, eyestrain, a noisy environment (or too-bright lighting), or skipping a meal. Underlying anxiety or depression may lead to chronic tension headaches.

What they feel like: A dull pressing or tightening ache in the forehead, temples, back of the head and neck. The pain is steady rather than throbbing and on both sides of the head.

Treatment options: Aspirin or other over-the-counter pain relievers such as acetaminophen or ibuprofen. Triptans, a class of migraine medication, can ease severe tension headaches, suggesting there may be a biological connection between these two headache types. Doctors may sometimes prescribe barbiturates such as Fioricet to treat tension headaches that are particularly severe.

Preventive measures: Get enough sleep, don't skip meals, and exercise regularly to diffuse stress. Frequent tension headaches may be prevented with the same drugs used to ward off migraines.

Migraines

Liz Garvey, 38, a Manhattan art dealer, knows a migraine is coming by "a slight pain in the neck that radiates up or a pain in one eye that radiates down" before developing into sharp throbbing behind the eye. She's one of 28 million Americans afflicted by this more severe type of headache. An estimated 18 percent of women, most commonly between 35 and 45, get migraines, though many don't realize it or have been misdiagnosed.

What causes them: The biology of a migraine isn't completely clear, but the theory is that chemical imbalances in the brain inflame blood vessels, irritating nearby nerves that carry pain signals. It is known, however, that a susceptibility to migraines is usually genetic. Triggers include hormones (related to birth control pills, perimenopause, and menstruation; see the following "Menstrual Migraines" section), stress, weather changes, lack of sleep, changes in altitude levels, chocolate, food additives such as MSG or nitrates, alcohol (especially red wine), and excess caffeine.

What they feel like: Throbbing pain that frequently begins on one side of the head, is often accompanied by nausea or vomiting and is made worse by bright light, noise, or physical activity. Research reveals that 75 percent of migraine patients experience neck pain, while another study found that almost half complain of eye tearing, runny nose, or nasal congestion. Only about 15 percent of migraine sufferers see flashing lights or other "visual aura" effects before the headache begins. Untreated, pain can last from four hours to three days.

Treatment options: Over-the-counter migraine remedies that include acetaminophen, aspirin, or ibuprofen and sometimes caffeine can relieve mild-to-moderate aches. For more severe migraines, however, doctors prescribe triptans, which constrict blood vessels and moderate chemical reactions in the brain. Best taken at the first twinge of a headache, these triptans include Imitrex, Zomig, Amerge, Frova, Maxalt, Axert, and Relpax. Some of these prescription medicines can be formulated to melt on the tongue, be inhaled as a nasal spray, or be self-injected for times when nausea makes ingesting oral medication impossible. Other remedies include ergotamines such as Wigraine, Cafergot, or DHE (a nasal spray). Narcotic pain relievers like Percocet or Demerol are prescribed as a last resort for severe migraines.

Preventive measures: Lifestyle consistency is key. "Change is what triggers migraines -- hormones, stress levels, what you eat or drink -- even the weather," says Cincinnati headache specialist Lisa K. Mannix, MD. So try to maintain sleep, eating, and exercise routines every day. Several drugs, including some anti-seizure medications, low doses of antidepressants, and beta-blockers and calcium channel blockers (used to treat high blood pressure), are now being used for migraine prevention. After a year on a preventive drug, you may be able to taper off and still retain the improvements, says Mark W. Green, MD, director of the Columbia University Headache Center, in New York City. A recent study also reveals that taking two 75-milligram tablets daily of an extract of the herb butterbur can cut migraine frequency in half. Biofeedback, which teaches you to relax muscles during times of stress, may help some people. The latest weapon against frequent migraines, Botox, best known for its ability to smooth out wrinkles, can keep patients headache-free for a few months. Injected at various points in the head, neck, and face, it can stop the muscle contractions of migraines. But because Botox is considered an experimental migraine treatment, most health insurance plans don't cover the cost, $400 or more for each round of shots. (Always discuss with your doctor any herbal, alternative, or experimental therapy you want to try.)

Menstrual Migraines

Since she was a teenager, Wanda Bernier would develop pounding headaches around the start of her period. Sometimes she'd retreat to her bedroom for as long as five days. "I had to stay in complete darkness and quiet," recalls the now 36-year-old mom from Philadelphia. More than 5 million American women get these menstrual migraines, which can occur anytime from two days before to four days after the onset of menstruation.

What causes them: The drop in estrogen levels right at the start of your period. The exact mechanism isn't clear, but hormonal fluctuations seem to be key, because menstrual migraines often disappear during pregnancy, when levels of estrogen are high but stable, and after menopause, when they are consistently low.

What they feel like: The same throbbing pain as other migraines.

Treatment options: Over-the-counter nonsteroidal anti-inflammatory drugs or prescription migraine medicines help. Some physicians prescribe narcotic pain relievers, like Percocet or Demerol, when a severe headache doesn't respond to other medications.

Preventive measures: You may stave off menstrual migraines by keeping your body's estrogen levels steady by skipping the placebo week of the birth control pill and going right into the next cycle of pills or by wearing an estrogen patch. Also, in 2004, researchers at Thomas Jefferson University Hospital, in Philadelphia, found that as many as half the women in their study who took two daily tablets of the triptan Frova right before and during their period completely avoided hormonal headaches; almost 40 percent of participants reported complete relief by taking just one daily tablet. And even when their headaches didn't disappear, women in the study said the drug dramatically reduced the severity and duration of their pain.

Rebound Headaches

For years, Yasmin Akhavan, 47, treated her near-daily migraines with over-the-counter pain relievers. As soon as the drug wore off, she'd pop a second dose in anticipation of another attack. Chasing each headache with medicine eventually led her to suffer from what's called rebound or medication-overuse headaches, a constant ache that worsens as the drugs taken to relieve it wear off. Rebound can occur among people with migraine or tension-type headaches. The condition affects an estimated 2 percent of the population. Doctors are just beginning to appreciate the scope of this problem.

What causes them: "If you take pain medication for headaches more than two days a week for several months, you could get rebound headaches," says Steven Graff-Radford, DDS, codirector of the Pain Center at Cedars-Sinai Medical Center, in Los Angeles. Although the exact cause of rebound headaches has not been proved, some scientists suspect that repeated doses of analgesics may lower serotonin levels in the brain, which triggers the brain to create more serotonin receptors. Over time you develop a tolerance to the drug. Increasing the dose further alters the serotonin balance and results in more headaches. While over-the-counter drugs seem to be the biggest culprits, any painkiller, including triptans, can lead to rebound.

What they feel like: A throbbing headache that's usually there when you wake up and gets worse as the day goes on.

Treatment options: Give up caffeine, since overnight withdrawal from this common ingredient in pain medication contributes to early-morning pain, and stop taking the offending medication. But do the latter with the help of your doctor or a headache specialist, since quitting painkillers, whether cold turkey or by weaning off over several weeks, can bring on a severe headache that lasts for days as well as other withdrawal symptoms, such as chills and jitters. Physicians can prescribe other drugs to ease the transition and may hospitalize some patients to help them get through the worst, first phase of withdrawal. The choice of medication used to help you through the transition depends on the drug you've been overusing. Even after the offending medication is out of your system, it may take months for your brain chemistry to normalize and rebound headaches to resolve.

Preventive measures: Don't exceed recommended doses of drugs for headaches. "Most of the labels on over-the-counter headache medications say to not take more than the directed dose or to stop if pain lasts more than a specified time, but nobody reads the small print," says neurologist Christine Lay, MD, of the Headache Institute at St. Luke's-Roosevelt Hospital Center, in New York City.

Cluster Headaches

Recognized as the worst headaches of all, these come on suddenly, often during sleep. Cluster headaches are relatively uncommon, affecting only about 1 million Americans; as many as 90 percent of them are men. The painful episodes, which appear to be related to an explosive release of nerve impulses by the hypothalamus, tend to come in a "cluster" over a period of days, weeks, or even months and typically last from 30 minutes to three hours.

What causes them: The specific cause is unknown, but cluster headaches are more common among heavy smokers (quitting doesn't help immediately but may over time), and alcohol, glare, stress, and certain foods may also trigger attacks. Because the headaches tend to occur at the same time every day, researchers theorize that the body's biological clock may be involved.

What they feel like: Sudden, explosive pain usually on one side of the head, concentrated around the eye, which may tear and redden; nasal congestion is also common.

Treatment options: Oral drugs generally take too long to work on these brief headaches, although injectable forms of triptans can help. Inhaling pure oxygen for 15 minutes (via a mask attached to an oxygen tank that you can get for home use with a prescription) relieves the headaches in up to 80 percent of cases.

Preventive measures: Avoid alcohol during a cluster period (it can set off an immediate attack). Your doctor may prescribe calcium channel blockers or the steroid drug prednisone (which shouldn't be used longterm because of serious side effects, including bone loss). The antidepressant lithium, taken during cluster periods, also prevents episodes. A recent study found that injection of an anesthetic drug that acts as a nerve block (comparable to Novocain) and a small dose of steroid can prevent the headaches for an average of 13 days.

The Sinusitis Myth

Many people assume that if they have nasal congestion and head pain, they must be suffering from a classic sinus headache. But true sinus headaches due to infection are rare. In fact, a recent Mayo Clinic study suggests that fewer than 2 percent of Americans suffer from chronic sinusitis, far less than previously believed.

Headache specialists have been trying to educate their patients and other physicians that the nasal congestion, runny nose, and facial pain often associated with a sinus headache are, in fact, also migraine symptoms. What's more, a change in the weather, which many people blame for their sinus troubles, is a notorious migraine trigger, too.

"With a true sinus headache, you have to have thick green or yellow nasal drainage and fever," explains neurologist Susan M. Rubin, MD, director of the Women's Neurology Center at Evanston Northwestern Healthcare, near Chicago. "You have to be sick with an infection." When patients complaining of sinus headaches are evaluated in headache clinics, more than 90 percent prove to have migraines, notes Edmund Messina, MD, a neurologist and headache specialist with the Michigan Headache Treatment Network, in Lansing.

If you have a true sinus headache, breathing in warm steamy air (from a humidifier or hot shower) may relieve discomfort. See your doctor, who may prescribe antibiotics to treat the underlying infection and recommend antihistamines or decongestants to ease your nasal symptoms. But if your headache subsides only to come back later, you may actually have migraines; talk to your doctor about tracking your headaches and taking the right medications.

Do You Need a Specialist?

Morning Headache? See a Dentist

For years Julie Hannan, 42, would wake up with a bad headache. Eventually she noticed that her jaw hurt, too, from clenching her teeth in her sleep. Her dentist confirmed that a misalignment in the temporomandibular joint (TMJ) of Hannan's jaw was a culprit. "Sometimes these cases go unrecognized by physicians whose training may not equip them to understand the relationship between the teeth and jawbone and the alignment of the jaws and the rest of the body," says Atlanta dentist Debra King, DDS.

Some 10 million Americans suffer from TMJ problems. The headaches sometimes are brought on by habitual teeth-clenching and grinding during sleep and problems with the way the teeth fit together, or occlude. Both problems stress the jaw and the surrounding muscles, leading to headaches and facial pain.

A dentist sometimes treats TMJ by adjusting the bite so that teeth fit together correctly, which may help the jaw realign. Also, wearing a mouth device during sleep called the Nociceptive Trigeminal Inhibition Tension Suppression System, which fits over the two front teeth, can prevent the nighttime teeth clenching that contributes to jaw problems and headaches. Finally, learning to relieve emotional stress via counseling, biofeedback, or relaxation training can stop troublesome teeth-clenching and grinding.

Seeking Specialists

Headaches can be easy for doctors to dismiss because we all get them occasionally. One study recently found that one in four migraine sufferers were misdiagnosed by their primary-care doctors. If you're experiencing troublesome or recurring head pain, seek out help from a specialist. The physicians most qualified to treat recurring headaches (and least likely to misdiagnose them) are neurologists or doctors with a special interest in headaches. To find one of these specialists in your area, ask your primary-care doctor for a referral or check with your local hospital or medical society. You can also contact the American Council for Headache Education (856-423-0258; www.achenet.org) or the National Headache Foundation (888-643-5552 or www.headaches.org). To find a headache clinic, contact the Migraine Awareness Group: A National Understanding for Migraineurs (703-739-9384 or www.migraines.org/help/helpclin.htm).

Originally published in Ladies' Home Journal, June 2005.

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