Heading Off Headaches
Berkeley Wellness
November 17, 2016

Headaches are one of the most common human ailments. For most people a headache is merely an infrequent annoyance, a passing discomfort. But for millions of others, headaches are a recurrent — and sometimes disabling — problem, resulting in more than 12 million visits to doctors in the U.S. each year. It’s estimated that 4 percent of adults have a headache on 15 or more days each month. Headaches cost Americans tens of billions of dollars each year — not only for medication and other medical care, but also for sick days and lost productivity.

Headaches are not completely understood by medical science, but researchers have advanced numerous theories to explain them, especially migraines. Brain tissue itself lacks pain-sensitive nerves and does not feel pain. Rather, headaches occur when pain-sensitive nerve endings in the skull, scalp, and other tissues in the head and neck send pain messages to the thalamus, the brain’s “relay station” for pain sensation from all over the body.

Headaches are classified as primary or secondary. Most are primary, meaning they have no identifiable cause; secondary headaches are a symptom of an underlying disorder, such as an infection, trauma, or neurological problem.

The great majority of primary headaches fall into four main categories: tension, migraine, cluster, and exertion. But any strict classification is open to debate, in part because the types often overlap.

If you have recurrent headaches or even a single severe headache for the first time, you should consult your doctor or other health care provider to get a proper diagnosis and then work together to treat or, if possible, prevent future occurrences.

Tension headaches
The most common kind of headache, tension headaches are sometimes called muscle-contraction or stress headaches. The name comes from the belief that such headaches are caused by excessive stress or tension leading to muscle contraction. Almost everyone gets this type of headache at least occasionally. The steady (not throbbing) dull ache is usually milder than migraine or cluster headaches. A band-like feeling of tightness around both sides of the scalp is typical; muscles in the back of the upper neck may feel knotted and tender to the touch. This type of headache is typically not aggravated by routine physical activity and not associated with additional symptoms like nausea.

It’s not known what causes tension headaches, but they are probably multifactorial. They may be associated with fatigue, depression, anxiety, missed meals, eyestrain, and, as noted earlier, stress (often the pain comes after the stress has ended). Assuming a posture that tenses muscles in your neck and head for long periods can trigger these headaches; so can jaw clenching (bruxism) or excessive gum chewing.

Migraines
It’s estimated that 13 percent of American adults have migraines each year, with women outnumbering men by about three to one. The word migraine is derived from the Greek, meaning “half a skull” — an apt description since the pain typically occurs on only one side of the head. However, the pattern of migraines can be variable, and the pulsating, throbbing pain that starts on one side can spread to involve the entire head.

About 30 percent of migraines are preceded by or start with an aura — neurological symptoms most commonly involving distorted vision, such as zigzag patterns of shooting lights, blind spots, or a temporary loss of vision. The aura usually lasts anywhere from 5 to 60 minutes. Occasionally, the aura involves other senses or causes speech or motor deficits.

The throbbing pain of a migraine can be incapacitating and can last from a fewhours to several days. It may be accompanied by nausea, vomiting, light-headedness, fatigue, and severe sensitivity to light (photophobia) and noise (phonophobia). The pain is usually worsened by routine activities.

Genetic factors play a role, as seen by the fact that about two-thirds of migraine sufferers have a parent or sibling with the ailment. Most people have their first attacks while in their teens or twenties, with the prevalence of migraines peaking in people in their thirties. At older ages, attacks usually become less severe and less frequent and may eventually stop.

In premenopausal women, hormonal changes may play a role, since migraines tend to occur right before or during menstruation and often increase in the months or years leading up to menopause. “Menstrual migraines” tend to last longer, be more debilitating, and respond more poorly to treatment than standard migraine attacks. Susceptible women often have more attacks if they take oral contraceptives; they tend to have fewer attacks during pregnancy and after menopause.

While the exact cause of migraines isn’t known, they are believed to begin in the brain as a neurologic dysfunction, with subsequent involvement of the trigeminal nerve (running through the head and supplying sensation to much of the face) and cranial vessels. Imbalances in brain chemicals, most notably serotonin (which helps regulate the perception of pain), are another likely factor. It’s also thought that people with migraines process and perceive sensory stimuli differently than people without migraines. They are often hypersensitive to touch, sight, sound, and smells even when not experiencing a migraine.

Many migraine sufferers are able to identify specific triggers that usually cause an attack (though migraines can happen without a discernible trigger). Avoiding such triggers is a key approach to migraine prevention. A headache diary (see below) can help identify them.

Triggers vary from person to person and sometimes even from one migraine attack to another in the same individual. Among the most common triggers are changes in sleep patterns, alcohol (especially red wine), certain foods, skipping meals, and changes in caffeine intake, as well as environmental factors such as changes in weather or altitude, glaring light, strong odors, noise, rocking motion, or air travel. As with many types of chronic pain, it’s difficult to know if depression causes migraines or vice versa. Many people experience a “migraine hangover” — that is, they feel exhausted or weak for hours or days following an attack.

Cluster headaches
Less common than other types of headaches, cluster headaches come in a group (hence the name) and are extremely painful. They usually last anywhere from 15 minutes to three hours and can recur daily for several weeks. Months may pass between attacks. Usually unilateral and often around or behind one eye, these headaches may produce tearing and redness in the affected eye, along with a congested, runny nose. They often occur during sleep and wake the person up. The pain can be so excruciating that cluster headaches have been called “suicide headaches.”

Cluster headaches are about six to nine times more likely to strike men than women and are more common in smokers; the first attack usually comes in early adulthood. They are sometimes misdiagnosed as a sinus disorder or even an abscessed tooth. Since these headaches often occur in the spring and fall, they may also be mistaken for allergies. Some studies suggest a connection between cluster headaches and a previous head injury. Alcohol is often a trigger.

Exertion headaches
Strenuous physical activities can cause exertion-related headaches. Football players,joggers, weightlifters, and other athletes can experience these headaches, which may be caused by abrupt dilation or constriction of blood vessels, but researchers have not been able to pinpoint the exact cause of the pain. The headaches often come during or right after exercise, are abrupt or even explosive in onset, and are very painful. Sexual activity can also cause exertion headaches.

All exertion-related headaches should be evaluated by a physician because they can be a sign of a
serious underlying condition, such as a brain hemorrhage. In addition, pending such evaluation, the activity that brought on the headache should be halted and avoided.

A headache diary
Migraines and other headaches can vary from person to person. Keeping a diary can help you identify your headache triggers (smartphone apps make this easy). After each headache, note the time of day when it occurred; its intensity and duration; activity immediately prior to its onset; any sensitivity to light, odors, or sound; use of medications; hours of sleep; any stressful events or emotional disturbances; foods and fluids consumed; if you have your menstrual period; and any other health conditions.

As many as half of migraine sufferers point to foods as triggers. Proving a definite link between food and migraines is difficult, however, since foods are seldom eaten alone, and the time between eating a food and the onset of a migraine can vary greatly.

Common food triggers include aged cheeses, caffeinated drinks, alcohol (especially red wine), freshly baked yeast products, chocolate, nuts, peanut butter, yogurt, sour cream, hydrolyzed vegetable protein, and cured or processed meats. Some of these may trigger headaches because they contain substances that dilate blood vessels in the brain. Major culprits are tyramine and other “amines” (found naturally in many foods), nitrites (used in cold cuts and hot dogs), and sulfite preservatives (in dried fruit and wine).

Self-treatment, plus some preventive steps
Most primary headaches will clear up on their own, though some can last for days. Because the pain from migraines and cluster headaches, in particular, can be debilitating, most people will want to take steps to relieve them — or, better yet, to prevent the headaches. The following treatments and steps may allow you to get by without prescription medications:

  • Avoid foods, beverages, or other factors that seem to trigger your headaches(see discussion of headache diary).
  • Try over-the-counter (OTC) pain relievers.There are three nonsteroidal anti-inflammatory drugs (NSAIDs) — aspirin, ibuprofen (such as Motrin or Advil), and naproxen (such as Aleve) — as well as acetaminophen (such as Tylenol). Note: Don’t use enteric-coated aspirin for pain relief, because it takes effect more slowly. A combination of acetaminophen, aspirin, and caffeine — such as Excedrin or other “migraine formulations” — is often effective, according to several panels of headache experts. Caffeine boosts the analgesic effect of aspirin, though in some people caffeine may actually trigger migraines. Many people with headaches, particularly migraines, find that it’s essential to take medication at the first sign of an attack. If one drug doesn’t provide sufficient relief, try another type. Big caveat: Though these drugs are available without a prescription, you should consult a health care provider if you need to take them regularly. All OTC pain relievers have risks (see Reducing Pain Reliever Risks). Moreover, if you overuse pain medications — OTC or prescription — they may become less effective, and they may result in rebound headaches, also called medication overuse headaches. Don’t take a pain reliever, even an OTC one, more than a couple of days a week on a regular basis without consulting a doctor. Do not exceed doses listed on the labels unless instructed otherwise.
  • Ice the pain.Reusable frozen gel packs wrapped across your forehead or around your neck may provide relief, as may running cold water over your head.
  • Or warm it.Heat, rather than cold, may help relieve some tension headaches. You can try a hot shower or bath, or moist heat applied to the back of the neck.
  • Learn to relax.This can reduce muscle tension and shift attention away from the pain. One common technique is progressive muscle relaxation. It calls for tensing and then relaxing specific muscle groups, working from the feet to the head, while focusing on deep, regular breathing. Yoga, meditation, or biofeedback may help.
  • Try massage.Many people find that gently massaging muscles in the neck, forehead, and temples promotes relaxation and offers some relief, especially for tension headaches.
  • Exercise regularly.For some people exercise helps relieve tension and thus may prevent some headaches, including migraines. Neck, back, and shoulder stretches may also be beneficial.
  • Check your posture.When working at a computer terminal, for instance, adjust your seat and table so that you don’t have to bend your neck or scrunch your shoulders for long periods (see our Guide to Good Posture).
  • Get adequate sleep. Follow a regular sleep schedule. Don’t oversleep on days off.
  • Review the medications you regularly take with your doctor or pharmacist if you frequently have headaches, which are a common side effect of many drugs.


Prescription medications
If over-the-counter pain relievers and other measures don’t help enough, prescription drugs are the next step. Many of these are meant to treat headaches when they occur — preferably they should be taken at the first sign of an attack. But for people whose migraines or other headaches are very severe or frequent, there are also drugs designed to be taken daily to prevent attacks. All of these medications have potential adverse effects, ranging from unpleasant to dangerous, so it’s always best to rely on non-drug treatments instead, when possible.

A wide variety of drugs are prescribed for migraines — triptans, NSAIDs, certain antidepressants, certain cardiovascular drugs (such as beta blockers and calcium channel blockers), muscle relaxants, ergot-containing drugs (vasoconstrictors), and some anti-seizure drugs. Narcotic pain relievers (opioids) and barbiturates (containing butalbital) should be used only as a last resort.

Triptans (serotonin-receptor agonists), the leading class of drugs to treat moderate to severe migraines, are effective in about 70 percent of migraine sufferers. They help restore normal levels of serotonin in the brain. Relief typically occurs within two hours of taking the oral drugs, which work best if used early in an attack. There are now seven triptans, most available as generics. For faster relief than regular tablets, some triptans are available as nasal sprays, self-administered subcutaneous injections, patches, and dissolvable tablets.

Keep in mind that overuse of triptans — more than, say, two or three days a week or ten days a month — can trigger rebound headaches and turn occasional migraines into chronic ones. If this happens, it’s important to consult your doctor. Triptans are not recommended for people with cardiovascular disease or uncontrolled hypertension.

Botulinum toxin (onabotulinumtoxinA, such as Botox), best known as an anti-wrinkle injection, is FDA-approved as a preventive treatment for chronic migraines, defined as 15 or more headaches a month, each lasting at least four hours. In April 2016 the American Academy of Neurology gave this migraine treatment its top rating. It is usually injected by a doctor once every 12 weeks or so into several areas of the head and neck.

4 Non-Drug Options for Headaches

  • Acupuncture. Several research reviews have found that acupuncture can be at least as effective as medication for the prevention of migraine, tension, or cluster headaches, with few side effects. The most recent study showing that acupuncture can help reduce migraine recurrence appeared in JAMA Internal Medicine in early 2017.
  • Biofeedback. This involves being hooked up to a device that provides readings on a physiological variable con*nected with headache pain — skin temperature, for instance, which is related to contraction of blood vessels. The feedback allows you to gain some control over the variable, decrease muscle tension, and reduce anxiety, all of which may contribute to pain relief.
  • Electrical or magnetic stimulation. In 2014 the FDA allowed the marketing of two prescription-only devices for migraines, which are backed by small clinical trials. Cefaly, a small battery-powered device worn on the forehead, applies an electric current to the skin and underlying tissues to stimu*late the trigeminal nerve, which is associated with migraines. It is supposed to be worn once a day for 20 minutes to help prevent migraines. A second device, SpringTMS, applies magnetic stimulation to the back of the head; it is supposed to be used when you feel a migraine coming on.
  • Special tinted glasses. For many migraine sufferers, bright light and other visual stimuli can bring on or worsen headaches. A few studies suggest that tinted lenses can be a way to get relief from such headaches. When cus*tomized to an individual’s color sensitivity, they are called precision tinted eyewear. An eye care professional may be able to determine if visual triggers are a prob*lem and suggest lenses that may help. The simplest option is to experiment with sun*glasses of different hues that are light enough to let you see well indoors.


5 Dietary Supplements (Alternative Remedies) for Headaches
The supplements listed below are com*monly used for headaches and have been evaluated by the American Academy of Neurology and the American Headache Society (AAN/AHS) in their 2012 guidelines on alternative treatments for migraines.

  • Butterbur. At least two clinical trials suggest that the herb butterbur (Petasites hybridus), in the daisy family, can help decrease the frequency, duration, and intensity of migraines when taken as a preventive. It is the only supplement rated “established as effective” by AAN/AHS. There’s no evidence it helps once a migraine has developed. However, butter*bur contains toxic substances (pyrrolizidine alkaloids), so the extracts used in supple*ments must be carefully purified to remove the toxins. The most studied butterbur supplement, Petadolex from Germany, has no detectable levels of alka*loids. Other brands may not be safe. Don’t use butterbur if you are pregnant, nursing, or aller*gic to plants in the daisy family.
  • Feverfew. This common flower (Tanacetum parthenium), also in the daisy family, is rated as “probably effective” by AAN/AHS, which singled out an extract called MIG-99. Feverfew may reduce inflammation as well as levels of the hormone-like substances known as prostaglandins; among other effects, some prostaglandins play a role in producing pain sensations and migraine. A few small studies have shown that feverfew can help prevent (not relieve) migraines.
  • Magnesium. AAN/AHS rated magnesium supplements as “probably effective” for migraine prevention. Researchers have found that people with migraines tend to have low brain magnesium levels during an attack and are more likely to have low magnesium overall. Two studies from the 1990s found that supplements helped reduce the frequency of attacks, though another study did not. Recommended doses range from 400 to 600 milligrams a day (the adult Recommended Dietary Allowance, or RDA, is 310 to 420 milligrams a day). People with kidney disease should not take magnesium supplements except under medical direction.
  • Riboflavin. This B vitamin has also been rated as “proba*bly effective” by AAN/AHS. Studies have found it effective at megadoses of 400 milli*grams a day. That’s about 300 times the daily RDA.
  • Coenzyme Q-10 (CoQ10). A small study in Neurology in 2005 found that this vitamin-like substance, at 300 milligrams a day, helped reduce the number of days per year people suffered from migraines. But the AAN/AHS rated it lower, as only “possibly effective.”


Headaches: When to Seek Immediate Medical Attention
People who suffer from migraines or cluster headaches should consult a health care provider about treatment. In addition, in a small number of cases, severe headaches may be a warning sign of a serious disorder, such as a dangerous infection, a stroke, or even a brain tumor or aneurysm.

Get immediate medical attention for the following:

  • The sudden onset of an unusually severe headache, especially if it’s the “worst one ever,” you never had a severe one before, or you are over 50.
  • A severe headache with a fever or stiff neck.
  • A headache following a head injury. (Even if the injury occurred weeks or months earlier, you should consult a doctor.)
  • A headache accompanied by altered mental status (such as confusion), loss of consciousness, numbness or weakness on one side of your body or face, difficulty speaking, or vision disturbance (other than an aura).
  • A severe headache during or immediately after physical exertion, including sexual intercourse, if you never had one before.
  • If you are immunosuppressed and have a new onset of headaches.


BOTTOM LINE: Nothing works for all headache sufferers, so work with your health care provider to find the treatment that offers the most relief with the fewest side effects. You may need to experiment.