Authors: Lawrence Robbins
Still others may start a prescription medication but soon quit it, and they frequently never follow up with the doctor if it doesn’t work or causes too many side effects. Some headache sufferers so fear the shift from a medication-free life to one suddenly cluttered with strange pills that they refuse to take their medicines consistently or correctly.
Instead, people spend billions of dollars trying all kinds of treatments on their own. Although some of these nondrug, natural approaches, especially relaxation and coping techniques, diet, and exercise, can and do prevent some headaches, many people still needlessly suffer because they either do not effectively institute the lifestyle changes required or because their headaches also require medication for relief.
HEADACHES ARE A REAL PHYSICAL ILLNESS
Before we get into the nitty-gritty details of treatment strategies, we need to get something straight: headaches are not psychological illnesses simply induced by stress but are genuine medical illnesses as legitimate as ulcers, diabetes, or heart disease. Stress may contribute to the muscle tension in the head or changes in the brain’s blood vessels that cause pain, but researchers now know that headache mechanisms involve involuntary biochemical changes in the brain.
Those biochemical mechanisms in the brain seem to be inherited. In fact, migraine headaches, for example, are hereditary in up to 80 percent of sufferers. Researchers have evidence that the blood vessels in people with migraines are less sensitive and certain blood cells, called platelets, are less efficient than in non-sufferers in retaining serotonin, a neurotransmitter and chemical in the blood that not only helps reduce pain but constricts blood vessels. Its depletion is linked to migraine pain.
Other evidence for the physical basis of headaches stems from many studies that have revealed differences in the brain, arteries, and bloodstream in migraine patients. Mounting evidence from advanced brain scans shows similar differences in the brains of people with migraines as in those suffering anxiety. This finding is interesting because many people who have headaches are also anxious, and the two conditions seem closely linked in many people. It is also not coincidence that the drugs helpful for anxiety (such as the antidepressants) and headache (such as Imitrex) increase the level of serotonin. As scientists learn more about the physiology of migraines and anxiety, both conditions are increasingly being viewed as physical, genetic problems, just as many physical illnesses, once looked upon as “psychological” until the real causes were uncovered, are now known to be genetic and physiological.
As with many other conditions, the genetics of migraine are slowly being uncovered. A number of researchers have recently described the area of the “headache” gene, at least in certain fami lies. So far, the research has focused on families with a certain kind of headache called a “hemiplegic” migraine, a rare type of migraine in which one side of the body becomes weak or numb for hours to days. Soon, researchers will know much more about the location of the migraine genes, which in turn could lead to better therapies or maybe even a “cure.” Environment and stress play an important role, but headaches, like other physical illnesses such as asthma or diabetes, are the result of chemical and structural changes in the brain and bloodstream.
If you get chronic headaches, chances are you suffer from the bad luck of being born with a slightly different brain chemistry than most people, a sort of short circuit. Researchers strongly suspect that this different brain chemistry makes you more prone to painful dilated blood vessels in your head, and to the uncontrollable firing of the nerve cells in the transmission of pain signals. In other words, your brain chemistry makes you more likely to get headaches.
WHAT CAUSES AND TRIGGERS HEADACHES?
Although scientists still don’t know the exact causes of headaches, many are convinced that the primary culprits are imbalances in the brain’s chemicals and nerve pathways. The latest and most widely accepted theory is that the majority of headaches—namely tension headaches and migraines, which are thought to be on opposite ends of a spectrum—are caused by the depletion of the chemical serotonin, an important pain-reducing neurotransmitter (brain protein) that is involved in communication among nerve cells in the brain.
Serotonin plays an important role in regulating the diameter of blood vessels, that is, in constricting and expanding them, and, as we’ve said, it is the dilation of blood vessels which causes pain. Serotonin also stifles pain signals between nerve cells and influences sleep, anxiety, and mood (and is a factor in depression). Stress and other environmental factors are thought to influence levels of serotonin in the brain.
In normal cases, nerves that surround the blood vessels in the brain’s protective covering, the meninges, release normal levels of neurotransmitters like serotonin, and no pain occurs. In headache cases, however, certain factors, such as stress or a particular food, trigger a chain of events in people born with troublesome serotonin regulation. Researchers think that first a wave of electrical activity spreads over the brain. Then the level of serotonin surges, and blood vessels around the brain constrict. Consequently, as the serotonin seeps into surrounding tissues, levels of the neurotransmitter fall in the brain. This decrease in serotonin causes the blood vessels to become inflamed and swollen, irritating surrounding nerves and perhaps the trigeminal nerve, a large and complicated nerve that extends to the blood vessels around the brain and into the face. The inflammation of the blood vessels and the irritation of nerves cause pain.
The serotonin pathways that play a vital role in migraines and probably tension headaches are the same pathways that influence depression, anxiety, and insomnia. Researchers have recently discovered that people with migraines in particular have a higher risk of depression, anxiety, and mild insomnia. While frequent headaches may cause a person to feel depressed or anxious, studies show that the increased risk of these conditions is independent of the headaches themselves. Migraine sufferers do, however, have much higher rates of panic attacks and moderately higher levels of chronic mild anxiety and nervousness (especially when the headaches are out of control), as well as more depression than people in the general population. Depression may aggravate preexisting headaches, but it does not cause headaches.
Serotonin attaches only to certain receptors in the brain, and different receptors may be associated with different conditions, such as headache, depression, and anxiety. Medications that fit on the serotonin receptors, and thereby mimic serotonin (such as sumatriptan), or influence serotonin levels (such as DHE, dihydroergotamine, and antidepressants) can help prevent and relieve both migraine and tension headaches. Other kinds of medications may help by either blocking the pain message, by constricting the swollen and inflamed blood vessels, or by stabilizing the blood vessels so they don’t swell. Interestingly, many medications used for years because of their influence on blood vessels recently have been found to influence serotonin levels as well.
The muscles in the head may also contribute to headache pain by tightening up. But this occurrence is now believed to be the result of the headache mechanism rather than a cause of it. Nevertheless, once the muscles contract, they may contribute to the pain by releasing a toxic by-product, lactic acid, and reducing the amount of blood and oxygen that can get into the muscles.
Of course, not everyone gets chronic headaches. In fact, some people (the lucky ones) virtually never get a headache, regardless of what goes on in their lives, whether lack of sleep, illness, changes in hormones, or consumption of red wine. These people probably have the right chemical makeup in the brain to “protect” themselves against headaches. But if you are prone to headaches, probably because of some genetic or biochemical predisposition, serotonin imbalances probably occur more easily in you than in other people due to certain environmental, chemical, physical, and psychological factors. These triggers, which differ among individuals, include certain foods like chocolate and alcohol, bright lights, hunger, a changing sleep schedule, a hormonal shift, or psychological conditions like stress, anxiety, and depression. Sometimes even high altitudes, orgasm, and exercise may trigger headaches. Again, these factors aren’t the causes of headaches; rather, they aggravate the biological condition that promotes the headaches. But by identifying which factors trigger your headaches and how to avoid them, you can learn how to relieve and prevent them.
TOO MUCH OF A GOOD THING: REBOUND HEADACHES
Ironically, people who suffer from chronic headaches all too often unwittingly make themselves sicker by overusing headache medications in their quest for relief. Too much caffeine—more than what is in three or four cups of coffee a day or in a more-than-twice-weekly dose of some pain relievers or decongestants—can seriously aggravate headaches. Even just two aspirin and some caffeine every day can turn occasional headaches into a chronic and severe headache problem while also making you less sensitive to many medications that might have helped you relieve or prevent the headache in the first place. Some 50 to 80 percent of all headache sufferers unknowingly fall victim to rebound headaches.
Unfortunately, it’s all too easy to get caught in the rebound headache trap. Here’s a typical scenario: You get a headache and find that a lot of caffeine or an analgesic, such as aspirin, ibuprofen (Motrin, Nuprin, Advil), acetaminophen (Tylenol), or a prescription vasoconstrictor (ergotamine) relieves it. Because it is so effective, you start taking it more freely. As your headaches escalate, so does your use of the caffeine or analgesic. As a result of the overuse, however, the substance becomes increasingly less effective—either because your blood vessels become somewhat immune to the substance or because the substance interferes with your body’s ability to produce endorphins (natural morphinelike substances produced by your brain). As you become less sensitive to the caffeine or medication, you may try taking even more or try a new medication. The final result is that you end up with more frequent and severe headaches, and if you cut down, you still get headaches. In the case of caffeine, you may get weekend headaches if you drink far less coffee on Saturdays and Sundays than during the week.
So the very medications that can be most useful for headache relief can become your worst enemy. This syndrome is so common that some experts describe rebound headaches as an “unrecognized epidemic” in this country. In some cases, people must be hospitalized to go through the uncomfortable withdrawal process, which includes severe headaches. Ironically, withdrawal is all that is required in many cases to achieve significant relief from a chronic headache problem.
Because rebound headaches are so common among all kinds of headache sufferers, learning how to balance your use of medications and caffeine can determine whether these substances will be among your best friends or ugly enemies.
HOW DOCTORS TREAT HEADACHES
If you suffer frequently from chronic headaches, your first goal is to do everything you can to avoid them by becoming well informed about foods and substances that may trigger them and how relaxation and coping skills, exercise, caffeine, and over-the-counter (OTC) pain relievers may help. If these approaches don’t work, you should consult a doctor and ask about stronger, abortive medication to relieve a headache. Commonly, abortive medications, such as Midrin or Norgesic Forte, are used to prevent a mild or moderate headache from becoming severe. Other abortive medications, such as sumatriptan (Imitrex), can relieve a headache that has already become severe.
If you suffer from moderate to severe headaches more than three times a month and these episodes are severe enough to interfere with your family, job, or social life, then your doctor may recommend a preventive medication as well. Such drugs are not always completely effective, but they can minimize the frequency of headaches and the disruption to your life.
Many people don’t want to take preventive medication because it means daily pill-popping. However, if you get frequent severe headaches that seriously impair your ability to get on with life’s routines, your doctor may suggest switching from abortive medication each time you get a headache to preventive medication. Preventives are not only more benign than the abortives, but you end up taking less medication with preventives than if you just chase the pain with abortives. Also, abortive medications tend to be more addicting and have more side effects than preventive medication. We’ll discuss guidelines for these strategies in subsequent chapters.
You must realize that trying a medication regimen is not a permanent decision with lasting side effects. Medications may be used as temporary stopgaps to control a period when the headaches seem particularly overwhelming. After a spell, when the brain’s misfirings seem to quiet down, you may go for months using only lifestyle techniques to prevent attacks. Then, for unpredictable reasons, if your biological mechanisms fire up again and set off another bad run of headaches, you may need abortive or preventive medications again for some time.
This is why becoming familiar with a headache doctor’s medical approach is so important. By understanding the basic strategy—abortive versus preventive, as well as the options, risks, and benefits of each—you can make appropriate, well-informed decisions with your doctor. Then, using a rational, trial-and-error approach, you can decide together how to proceed if a medication is ineffective or has too many side effects.
TRIAL AND ERROR
Although lifestyle strategies that involve diet, exercise, relaxation, and the moderate use of caffeine and over-the-counter pain relievers (see Chapter 2) can help prevent headaches, when they fail to work as reliably as you’d hoped, prescription medications are the next resort. Only they can compensate for the differences in the brain chemistry or blood vessel changes that cause pain.