When is a headache more than just a headache?

In Canadian Medical Association Journal are two studies on migraine management. Migraine is quite common with some 8% of men and 18% of women experiencing migraines. Headaches are typically primary headaches meaning there is no underlying cause such as a tumor, injury, or an aneurysm. Of the common primary headaches, they can be tension headaches, cluster headaches, and migraines.

As physicians, we first want to rule out red flags that would tell us your headaches are more of a worry. Red flags include fever or weight loss. Knowing there is an underlying illness such as cancer would mean ruling outspread of the disease to the brain. Signs of confusion or change in alertness are worrisome as is if the headache is sudden and described as the worse headache of your life. Also, the onset of new and progressive headaches in people older than 50 without headache history can alert us to an inflammatory condition that might be causing the headache.

Some headaches are chronic daily headaches. To make the diagnosis of a migraine, typically there have been 5 or more attacks that last 4 to 72 hours and are usually one side of the head, pulsating, moderate to severe in nature, and are made worse with physical activity. Usually, there are complaints of nausea and vomiting. Light and sound can make it worse. There might be what we call an aura which usually is something that is seen and lasts less than an hour. It can happen before the headache starts.

A tension headache however can last half an hour to 7 days and does not have the associations with sound light or nausea and vomiting. It does not have the same impact on disability as a migraine does.

Headache diaries can help to make the diagnosis by listing when the headaches are, how frequent and severe, the frequency of medication being taken, and whether or not there are sensory or visual symptoms as well. Some people suffer from headaches because of medication overuse. These are medication rebound headaches and it is important to stop all medications for three months before a treatment plan can be put in place.

Patients with migraines can identify triggers such as weather, noise, glare, physical stresses such as exercise or lack of sleep, diet, and hormonal triggers such as chocolate, cheese, or menstrual cycles and emotional stresses as well.

Management of headaches includes changes in lifestyle and non-pharmacologic measures such as relaxation, biofeedback, and cognitive-behavioral therapy. Riboflavin, coenzyme Q10, and magnesium can be helpful. If medication is needed there are non-specific pain relievers and specific medications such as triptans. Also, if headache migraine frequency is often, patients can use preventive medications daily. In some cases, botox is offered.

One of the studies this week look at migraine management. The first is a study on acupuncture and as the editorial comment that goes along with the study points out- the harder a medical problem is to treat, the more treatment strategies exist. Studies have shown that acupuncture is beneficial in the treatment of acute migraine attacks. The current study on acupuncture found that acupuncture did have an effect compared to sham acupuncture and had a minor preventive effect for migraines.

Headaches and migraines impact the quality of life so if you are a headache sufferer, be sure to see your physician.