Perhaps the most common symptom our patients come in with is the headache. Very often these symptoms are related to vision or visual activity and we find and fix the vision-related cause. Most headaches that occur however do not result from a vision problem although a few may have visual symptoms. This may sound confusing to the patient when we explain it to them so we have developed this special report about headaches to teach you more about this significant medical problem.
Migraine
Some authorities have stated that up to one quarter of the population experience a migraine headache at some time in their life. It is a disease which usually starts in childhood, and peaks in the third and fourth decades, only to subside in many patients as they enter their fifties. Most but not all patients have a history of migraine in other family members.
Classic migraines can produce visual phenonema which include "fortification spectra" with a blurred vision zone surrounded by zig-zag type lines resembling an 1800's era fort.
Although the cause of migraine headaches is not known, the mechanism of pain and other symptoms seems to be related to exaggerated fluctuations in the size of the blood vessels to the brain and its surrounding structures. These contractions and relaxations of the muscles in the blood vessels may be due to abnormal concentrations of certain chemicals such as histamine, serotonin, and prostaglandins. In the classical episode, a period of narrowing causes decreased blood flow, followed by the dilating phase in which the onrushing blood stretches the pain sensitive lining tissues.
Symptoms
The typical case begins with a warning phase in which the patient has an “aura” of impending problems. There may be flashing lights in one eye, blurring, blind spots, or distortions of vision. Distortions may take the appearance of zig-zag lines. These are called “fortification spectra” — so named because of the similarity in appearance of the design of military forts 100 years ago. Tingling of the arms or face may occur. After about thirty to sixty minutes, the headache begins: usually on one side but sometimes becoming generalized, it is pounding, worse with movement or bending over, and can be excruciating. Nausea and vomiting may follow, with marked sensitivity to bright lights and loud noises. The sufferer may want to withdraw to a dark quiet room, yet the headache seems to follow him everywhere. Usually within 4 to 6 hours, it finally subsides.
The above description concerns a classic migraine; many or even most patients have variations on this theme. The more common “common migraine” may lack the warning symptoms, and the headache may be far longer lasting, although similar in nature. Irritability and depression may occur hours or days before the onset. Still other patients may have combinations or alternating episodes of headaches with exceptions to the above descriptions or other unusual symptoms including periods of paralysis, dizziness, or even loss of consciousness.
Precipitating factors are multiple–commonly mentioned examples include stress, sleep recovery after a period of deprivation (“Sunday morning headache”), fasting, alcohol in general and red wine in particular, menstruation, and caffeine excess or withdrawal. Birth control pills may cause or worsen migraines, and may be a risk factor for strokes. More women than men suffer with migraines, but not to an extreme degree.
DIAGNOSIS
Although the history is often virtually diagnostic, the careful physician will be alert to clues suggesting the presence of an alternative or additional diagnosis including tumors, hemorrhage, infection, or other disorders.
If there is any doubt, further tests of the blood, x-rays, and other neurologic evaluations may be necessary.
Treatment
Once the diagnosis is firm, obvious causes eliminated, and the patient reassured about the nature of the disorder, appropriate counseling is given to deal with any stress or other psychological elements at play. Medications may then play a major role in management.
Ergotamine and related drugs such as Cafergot, Ergomar, and Midrin contain blood vessel constricting agents. They are generally given by mouth, but some may be given by rectal suppository if vomiting is present. When given early, especially in the warning stage, they may successfully abort the headache within seconds to minutes. Repeated bouts of headaches may be prevented with weeks to months of prophylactic doses of similar drugs. Side effects include severe blood vessel obstruction, angina, and other symptoms, but are uncommon at the usual doses. These are potent drugs and should be taken under close supervision and only in the prescribed doses.
Sometimes the ergot class of drugs are not successful. In the acute case, pain relievers including narcotics may occasionally be needed. Other drugs including methysergide and cyproheptadine are occasionally used. Propranolol and amitryptilline are two of the most commonly used preventive drugs, and are useful when headaches are occurring with sufficient frequency to interfere with productive daily activities, or when excessive doses of ergots are required. A promising new development is the discovery that a class of drugs called “calcium channel blockers” can dramatically treat even the most resistant cases at times, and possibly may have a preventive role as well. Nifedipine is such a drug. Still experimental for this disease (although in wide use for certain heart conditions), calcium channel blockers may have a vital role in migraine therapy of the near future.
Cluster Headaches
Somewhat similar to common migraines, cluster headaches differ in their tendency to occur over several weeks or months in rapid sequence–daily or several times weekly, then disappearing for months at a time, i.e. clusters of headaches. Typically, they strike young adult males, often awakening the sufferer at night, confined to one side of the face or head, and often accompanied by tearing or nasal discharge. The pain may be the most severe ever experience, and victims have been said to commit suicide to escape the pain. Thankfully they are usually self-limited and disappear after an hour or so.
Therapy has traditionally been similar to that of migraine, although a preventive emphasis is often more prominent. Calcium blockers, as discussed above, may revolutionize therapy as their role becomes better established. Lithium, prednisone, and indomethacin have also been useful at times.
Tension Headaches
The commonest of headaches, tension headaches are caused by the involuntary sustained contraction of the muscles surrounding the skull and face. Prolonged mental concentration, stress, and a variety of individual factors may bring on the pain. Young people are affected most often, though the headaches may persist for life. Almost no one escapes at least an occasional tension headache.
Common pain patterns are those involving the back of the head and upper neck, the forehead (like a hat that is too tight), and around the eyes. The pain is a steady ache, lasting hours to days. Other than fatigue and mild depression, other symptoms are usually absent. It is not uncommon to have a tension headache not during periods of stress, but rather after the stress is relieved. Rarely do tension headaches awaken a patient.
Treatment involves the use of hot or cold applications, relaxation or meditation techniques, and simple pain relievers such as aspirin, acetaminophen, or ibuprofen. These drugs are far more effective taken early in the course of the headache, as opposed to waiting until the pain is severe. Anecdotally, regular exercise of aerobic intensity often reduces the incidence of tension headaches. The prognosis is benign, but interference with normal activities can be significant. In that event, medical attention may be necessary, and judicious use of anti-anxiety agents, formal counseling, and other measures may be necessary.
Diagnosis rests upon ruling out other causes of headache, which can usually be done without the use of extensive testing. At least initially, a physician diagnosis should be made for this common entity, although recurrences may be quite familiar to the patient, and rarely require medical attention.
Mixed Headache Syndrome
Until fairly recently, the usual headache sufferer was classified as either having migraine or tension headache. Treatment would be given for one or the other, and the results would be observed. Although most did quite well, there remained a sizable number of patients who would continue to suffer despite treatment. Many would get partial relief only.
It is now recognized that many patients actually have elements of both tension and migraine or “vascular” headaches, or so-called “mixed headache syndrome.” As might be assumed, treatment involves delicately balancing the treatment to allow for both components, with variations depending on the nature of the headache, the patients ability to differentiate the two, all the while avoiding the tendency toward overmedication. Diagnosis rests on a very carefully obtained history and examination by a caring physician, who may then use selected additional tests when indicated. The main point is that a clearcut categorization into the previously discussed types of headaches is not always accurate, necessary or beneficial to the patient.
Temporal Arteritis
This disease is is mentioned here only to state that any headache which comes on for the first time in a person over 50 years of age should be considered as possible temporal arteritis until ruled out by a simple blood test. The risk of missing this diagnosis is sudden onset of blindness or possibly even death. It is an inflammation of blood vessels (vasculitis) and can be treated with medications once diagnosed. Pain with chewing, pain over the scalp when combing one’s hair, or pain in the temple area of the head upon rubbing are signs which should result in an immediate call to your doctor if you are over 50.
