Headaches

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Headaches are one of the most common afflictions in life, with up to 90% of people reported to have suffered from headaches at some point in their lives.

Most headaches, other than being painful and bothersome, do not signify anything more serious. However, some types of headaches are signals of more serious conditions and require immediate medical attention.

A large community based study of headaches in Singapore (Ho KH, Ong BK. A community based study of headache diagnosis and prevalence in Singapore. Cephalalgia 2003 Feb;23(1):6-13) found that the overall lifetime prevalence of headaches in Singapore was 82.7%, and this did not vary between racial groups. The types of headaches were classified into: migraines (9.3%), episodic tension type headaches (39.9%), chronic tension type headaches (2.4%) and unclassified headaches (31.2%).

PATHOPHYSIOLOGY

As the brain itself does not have any pain receptors, the pain in headache is actually from several structures in the head and neck region. These include the scalp and neck muscles, meninges (brain lining), extra-cranial arteries, large veins, cranial and spinal nerves. Pain from sinuses, eyes and temporomandibular joint can also radiate to the head to cause headaches.

TYPES OF HEADACHES

Primary Headaches

Tension Type Headaches

Tension type headaches are by far the most common type of headaches experienced. They are sometimes also referred to as "stress headaches".

They may be classified according to the number of headache days a month: Episodic if < 14 days/month or Chronic if > 14 days/month on average for more than 3 months.

Symptoms:
Tension headaches are typically described as being mild to moderate in severity, the pain being a constant, pressing, heavy or pressure sensation, affecting the front, top or sides of the head.

There is generally no associated nausea or vomiting, and the pain is not aggravated by routine physical activity such as walking or climbing the stairs.

Tension headaches are often associated with fatigue, irritability, disturbed concentration, and muscle aches/tightness over the upper back and shoulder region.

Triggers:
Tension headaches usually occur as a result of an accumulation of factors.

These triggers may include:

• Emotional or mental stress
• Inadequate rest, fatigue
• Anxiety
• Overexertion
• Poor posture

Treatment:
Tension headaches respond to pharmacological as well as non-pharmacological treatments, either alone or in combination.

1. Treatment of acute attacks:
Simple pain-killers such as paracetamol (with or without a muscle relaxant) and the NSAID (non-steroidal anti-inflammatory drugs) group of medication, may be used for pain relief. The newer cyclooxygenase-2 inhibitors (COX-II inhibitors) can also provide relief.

2. Prophylactic treatment:
Prophylaxis (preventive) treatment should be considered with your doctor if your headaches are very frequent. Medication such as amitriptyline may be used for prophylaxis.

Migraine Headaches

Migraines are the second most common type of headaches, after Tension headaches. They tend to be hereditary, commonly running in families. Age of onset may vary, but most commonly begin in the 20s and 30s. Migraines rarely, however, commence in middle age or older.

Types of Migraine:
• Migraine without aura, also known as "common migraine".
• Migraine with aura
• Others: basilar artery migraine, hemiplegic migraine, ophthalmoplegic migraine, retinal migraine, abdominal migraine etc.

Symptoms:
The signs and symptoms of migraine attacks vary greatly among individuals. There are 4 phases of a migraine attack commonly described, but not all phases are experienced by all individuals.

1. Prodrome Phase:
Prodromal symptoms occurs in about 40 - 60% of migraine sufferers. Symptoms include altered mood, irritability, fatigue, yawning, craving for certain foods etc, and may precede the actual headaches by several hours or days.

2. Aura Phase:
These migraine auras may be visual, sensory or motor disturbances, with the visual auras being, by far, the most common. Visual disturbances may include flashes of light, zigzag lines, cloudy vision etc. These auras usually do not last more than an hour.

3. Headache Phase:
Migraine headaches are typically severe, throbbing/pulsating, one-sided headaches, lasting from several hours to as long as 3 days. The headaches are usually accompanied by nausea, with or without vomiting. Typically, migraine sufferers in this phase, get comfort by sleeping in a darkened and quiet room.

4. Postdrome Phase:
This is the "hangover" phase, where one feels tired and weak.

Triggers:
Many factors can potentially trigger a migraine attack. These factors include:

• Emotional, mental or physical stress
• Changes in sleep pattern
• Bright lights, loud noises, certain odours
• Weather changes
• Alcohol
• Smoking or exposure to smoke
• Alcohol
• Hormone related eg. menstrual cycle fluctuations, taking oral contraceptive pills
• Certain foods eg. foods containing tyramine (eg. red wine, aged cheeze), monosodium glutamate (MSG), nitrates (in bacon, salami, sausages), chocolates, nuts, banana, citrus, diary products, onions etc.

Management:
The management of migraine headaches involves treating the acute attacks and preventing future attacks by taking of prophylactic medication and avoiding triggers.

Treatment of acute attacks:
1. Simple pain-killers such as paracetamol (with or without a muscle relaxant) and the NSAID (non-steroidal anti-inflammatory drugs) group of medication, may be used for pain relief. An anti-emetic (anti-vomiting) may be added to control nausea.

2. Ergot derivatives eg. Ergotamine are also useful as abortive rescue medication for acute attacks.

3. Triptans eg. Sumatriptan, Zolmitriptan, Naratriptan, Eletriptan, are also effective in aborting acute attacks.

Prophylactic treatment:
Prophylaxis (preventive) treatment should be considered with your doctor if your headaches are very frequent. A whole range of medication can be used for prophylaxis and they may include beta blockers, calcium channel blockers, antidepressants, anticonvulsants, NSAIDS, angiotensin blockers etc.

Trigger Avoidance:
A "migraine diary" is useful in helping to identify possible triggers. Unless one knows what triggers one's migraine, it would be impossible to avoid them.

Cluster Headaches

Cluster headaches occur in "clusters", in that, they have a tendency to occur periodically, with regular bouts (clusters), and separated by spontaneous remissions.

They are relatively rare, and tend to occur mainly in men. It is thought that Thomas Jefferson, author of the US Declaration of Independence, suffered from cluster headaches. He wrote, "An attack of the 'periodical' headache came upon me ... rendering me unable to write or read without great pain."

Symptoms:
The pain of cluster headaches is often excruciating, developing in one eye and then spreading to the same side of the face, forehead or temple. The pain is constant, piercing and tearing in nature, causing its victims to clutch their heads, pacing up and down the rooms (unlike migraine sufferers who want to lie in a darkened, quiet room).

Associated with the headache may be drooping, swelling or redness and tearing of the eye. The nose may be runny as well. Nausea and vomiting are rare in cluster headaches.

The headaches are sometimes referred to as "alarm clock headaches" because of their ability to wake a person from sleep, and their seemingly precise regularity, both in terms of the individual attacks, and the clusters themselves.

Triggers:
Smoking is known to trigger cluster headaches.

Management:
The management of cluster headaches involves treating the acute attacks and preventing future attacks by taking of prophylactic medication.

Simple pain-killers such as paracetamol and NSAIDs typically are unfortunately ineffective as abortive treatment.

Treatment of acute attacks:
1. Sumatriptan.
2. Ergot derivatives eg. Ergotamine are also useful as abortive rescue medication for acute attacks.
3. Others methods such as inhalation of 100% oxygen, lignocaine spray up the nostrils, vigorous exercise, ice applied over the face etc.

Secondary Headaches

Secondary headaches are the symptom of an underlying condition and it is thus important for them to be recognized and not dismissed. Conditions which may cause secondary headaches include infections of the brain and meninges (lining of the brain), strokes, tumours, bleeding in the brain from some form of trauma, sleep apnoea , very high blood pressure , acute glaucoma and rhino-sinusitis.

"RED FLAG" SYMPTOMS ... which suggest a Secondary Cause.
You should seek immediate medical attention if you notice any of the following:

• Sudden, severe headache in someone previously headache-free.
• If you experience the "worst headache in your life"
• Sudden, severe headache in someone with hypertension, heart disease or kidney disease.
• Severe headache following a head injury, especially, if associated with vomiting, blurred vision, muscle weakness or drowsiness.
• Any headache accompanied by seizures (fits).
• Headache accompanied by fever (unless there are obvious reasons for the fever, such as a flu)
• Any headache accompanied by a decline in level of consciousness

Possible causes of Secondary Headaches:

• Intracranial bleeding (epidural, subdural, intracerebral hemorrhage)
• Subarachnoid hemorrhage
• Giant cell arteritis
• Cerebral venous thrombosis
• Intracranial hypertension from whatever cause
• Intracranial tumours
• Meningitis
• Encephalitis
• Severe hypertension
• Low cerebrospinal fluid pressure (eg. following a lumbar puncture)
• Rhinosinusitis
• Acute glaucoma

DIAGNOSIS OF HEADACHES

Your doctor will make an assessment of your headache by conducting a clinical interview, followed by a thorough neurological examination. If there are symptoms or physical signs suggestive of a more serious secondary cause, your doctor may recommend a referral to a neurologist or the Emergency Department.

Certain investigations are sometimes performed in the investigation of headaches. These would include:

• A Blood Count:
This would help in the diagnosis of infections.

• Neuroimaging (such as CT scan or MRI):
These imaging investigations help in the diagnosis of intra-cranial pathologies, such as a blood clot, tumour, arteriovenous malformation, hydrocephalus etc.

• Lumbar Puncture:
A sample of cerebro-spinal fluid is obtained from a needle inserted in the lower spine region. This fluid is sent for testing to help with the diagnosis of conditions such as meningitis.

MANAGEMENT OF HEADACHES

PRIMARY HEADACHES

Most primary headaches respond to simple measures.

Pain-killers
Pain killers such as paracetamol and NSAIDS (non-steriodal anti-inflammatory drugs) are often sufficient to control most headaches. For migraine and cluster headaches, specific medication such as ergotamine and triptans may be used.

Sleep
Having insufficient good quality sleep can contribute to headaches. Make sure that you get a good night's rest to enjoy more headache-free days.

Cold Therapy
An ice pack or cold pack placed over the painful area during an acute headache attack, can temporarily provide some relief by numbing the soreness and reducing tension.

Adequate Rest and Reduction of Anxiety
Tension and migraine type headaches are often precipitated by stress. Stress management methods, exercise, meditation and other relaxation techniques, can all help reduce and possibly prevent such headaches.

Healthy Eye Care
Eye strain from prolonged reading or computer work can trigger headaches. Ensure that you have properly prescribed glasses to correct for any vision problems, as short or long sightedness can aggravate eye strain.

SECONDARY HEADACHES

Management of secondary headaches would involve treatment of the underlying cause. For instance, in treating bacterial meningitis, antibiotics will have to be given to treat the underlying infection.

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