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Headaches

What are the causes of headaches?

Headaches are a result of irritation of nerves and pain sensitive structures such as the nerves arising from the brain, the blood vessels and muscles in the head and neck region. Dilatation of the blood vessels of the brain is also a cause of migraines and certain other types of headaches.
What are the various types of headaches and their treatments?

There are many classifications for the categorisation of headaches. They may be classified as primary and secondary. Primary headaches are those that do not have a direct underlying cause. They include migraine, cluster and tension headaches. Secondary headaches are the result of an identifiable structural or organic cause, such as lesions of the brain, irritation of the meninges (the covering of the brain), injury and pressure changes within the head.

Some common varieties of headaches are:
Migraine with aura: These are usually one sided headaches that may last from 4 to 72 hours. This type of headache is preceded by an aura with blurred vision, colored lights, tingling in the skin, appearance of zig-zag lines in front of eyes and confusion. Aura's usually last for 5 minutes to 60 minutes. Headache are associated with nausea, vomiting and aversion to sunlight which may follow after sometime. Treatment with a daily preventive medication is required usually when someone has more than 4 headaches a month. During the attack, depending on the type of migraine, different medications ranging from NSAIDS to specialized migraine medications like triptans can be used.
Migraine without aura: This is just like migraine but has no warning aura. It is throbbing and one-sided and precipitated by certain foods, strong smells or even the menstrual cycle in females. This is more common in females. The time and day of onset varies. Treatment is similar to migraines with aura.
Tension headaches: This is also known as muscle contraction headache. The typical features include both sided, band-like pain that does not get worse with activity. It gets precipitated with stress. Preventive medications like amitriptyline have shown data to help treat such headaches if they are frequent. For less frequent attacks, mild pain killers like paracetamol are also effective. One should try and minimize the use of pain killers to not more than 2 times a week as frequent use can cause rebound headaches.
Cluster headaches: This is one of the most painful type of headache. It is more common in males.Some features are
- It is usually on one side around the eye.
- Attacks can last anywhere from 1 hour to 3 hours and frequently occur at night. Patient is very restless in this headache due to the severe pain.
- During headache the eye gets red or there is watering of eye or nose or swelling in the region.
- Attacks come in clusters so we get daily attacks for 3-6 weeks and then it stops and reappears after 6 months or a year and again comes in clusters. The attacks might be season related. Preventive medication can be used to prevent such attacks if someone notices a pattern related with a particular time. Options include medications like calcium channel blockers, anti-epileptics and steroids. At times, lithium is also used in severe attacks.
Rebound headaches: They develop from taking too much pain medicine, too often. Research suggests taking medication with caffeine or ergotamine too often, results in this type of headache. A pressing, dull, diffuse pain felt typically over the head is present in this case. A cycle of medication use, followed by partial headache relief, followed by another headache can be indicative of rebound headaches.
Sinus headache: It occurs in conjunction with upper respiratory tract infection or allergic rhinitis and sinusitis. Sinus headache is usually dull and constant, gets worse when bending forward and may be associated with nasal discharge. Treatment includes antibiotics supplemented by interventions to promote nasal drainage, such as nasal sprays and drops and steam inhalation.
Headache due to head injuries: It is characterized by a steady acute pain affecting both sides of the head, occurring almost everyday. Bouts of severe or moderately severe headache, similar to migraine may also occur. Dizziness, ringing of the ears, blurring, anxiety and sleep disturbances are associated complaints. Headache following a head injury usually subsides after sometime.

Some examples of rare headaches include “Ice-cream headache” which occurs between the eyes after eating or drinking something very cold; Sex-induced or exertional headache, a throbbing pain over the back of the head, associated with sexual exertion. Other causes of headache are:
- Referred pain from eye, ears.
- Headache associated with systemic infection eg. Malaria.
- Headache due to metabolic disorders eg. Less oxygen and more carbon-dioxide in blood due to lung disease.
- Headache associated with vascular disease eg. Haemorrhage and some forms of hypertension.
- Most important are headaches associated with raised pressure in the head which includes headache with tumours. These headaches are recognised by the presence of associated neurologic deficit eg. weakness in one leg or vision loss. Two other features of these headaches are that they wake the patient up from sleep and they are associated with vomiting without nausea. So vomiting comes out without warning (projectile vomiting).

How is headache assessed?

Most symptoms of primary and secondary headaches are the same and a thorough evaluation is therefore important.

A detailed history is essential.
The patient should maintain a record of headaches, and an account of sleep, diet, emotional episodes and other contributing factors, leading to headaches.
A neurological examination involving assessment of the cranial nerves, reflexes and brain function is essential. Other tests that may be asked for include CT scan or MRI.
Blood tests including a complete blood count and chemistry profile may also be helpful.

The focus of management in headaches is basically preventive. Simple relaxation techniques may be helpful in minimizing headaches. Addictive medications should be avoided. Nonsteroidal anti-inflammatory drugs and anti-depressants are often effective. Analgesics taken too often can actually induce headaches and should, therefore, be discouraged.

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