Difficulties diagnosing headaches

Main Category: Headache / Migraine
Article Date: 28 Sep 2003 - 0:00 PDT

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There's probably not a person on the planet who hasn't had at least one headache in their lifetime. In most cases, a headache is a minor and passing problem, but more than 45 million Americans have recurring headaches and 28 million have migraines.

Such headaches cost the U.S. economy billions of dollars each year because they routinely keep people home from work, sending them instead off to their doctors and pharmacies.

But are people needlessly suffering from their headache disorders? Some experts argue that recurrent debilitating headaches are often due to inadequate diagnosis and treatment, and even overuse of medications taken to relieve headache.

'The real gap is between the treatment that is available and the treatment that is delivered,' says Dr. Richard B. Lipton, professor and vice chair of neurology at Albert Einstein College of Medicine in Bronx, New York.

For people who are diagnosed properly, there are usually a number of behavioral and drug treatment options. Below, Dr. Lipton reviews different headaches types, and factors that can contribute to misdiagnosis.

What types of headaches usually bring people to the doctor? The two most common types of headache that bring people to the doctor are migraine and tension-type headaches.

Migraine affects 12 percent of the population and episodic tension-type headaches affect 40 percent of the population. The most common headache type that brings people to the headache specialist is called chronic daily headache.

Both migraine and tension headaches usually occur once or twice a week, once a month, and they may occur only once a year. Chronic daily headaches occur 15 or more days per month, and a full 5 percent of the U.S. population has headaches more days than not.

What characterizes migraine headaches?

Migraine headaches are characterized by pain and associated symptoms. The pain of migraine is typically on one side of the head. It's typically throbbing or pulsating. It's typically moderate or severe, and very often people report that routine physical activity makes the pain worse. So climbing stairs, bending over, coughing and sneezing can all make the pain worse.

The pain of migraine is always associated with some other feature. Most commonly it's associated with nausea or vomiting, or unusual sensitivity to light and heightened sensitivity to sound.

Sometimes it's associated with something called aura, which is a visual display that consists of graying out of vision or spots, seeing spots, lines and heat waves, often beginning just on one side of the visual field, and then expanding to encompass a greater and greater area.

Migraine attacks typically last four to 72 hours. They usually interfere with routine function, and almost everyone with migraine takes some medication, though most people take over-the-counter medications.

Migraine also runs in families, so any given relative of a person with migraine is twice as likely to have migraine as the general population. For some subtypes of migraine, we know the specific gene that causes it.

What kind of pain do tension headaches cause?

Tension-type headaches are defined in contrast to migraine. Where migraine pain is one-sided, tension-type headache pain is on both sides of the head. Where migraine pain is throbbing, tension headache pain is a pressure pain. Where migraine is moderate or severe, tension headache pain is usually mild or moderate.

Where movement makes migraine pain worse, and migraine sufferers like to hibernate and in a dark, quiet room not moving, tension headache sufferers do not experience pain exacerbation with movement in general. And where migraine is always associated with at least aura, nausea, or sensitivity to light and sensitivity to sound, tension headache isn't associated with any of those features.

What characterizes chronic daily headaches?

There are four types of the primary chronic daily headaches. One is called chronic or transformed migraine, and that's a disorder where a person starts out with episodic migraine, and their migraine gets worse over time.

The second one is called chronic tension-type headache, and that's a disorder where a person starts out with episodic tension-type headache, and their headaches get worse and comes more frequently over time.

The third disorder is called new daily persistent headache, where people out of the blue go from basically not been headache people at all to having headaches that never go away. So you wake up one morning with a headache, and that's it. It's there all the time for months or years. And that's a very difficult disorder to treat.

The final kind of chronic daily headache is a disorder called hemicrania continua, which is characterized by pain on one side of the head that waxes and wanes in severity. When the pain gets severe, very often people report that their eye tears, their eyelid droops, their nose gets stuffy, or their eye gets red.

How do doctors know if a headache indicates something more serious?

The thing that makes headache diagnosis difficult is that it can be a symptom of something as benign as being under a little bit of stress to something as serious as a rapidly growing brain tumor.

So a mistake that is not very common, but is very feared, is thinking someone has a primary headache, which is a headache disorder that doesn't have an obvious underlying cause, when in reality they have brain tumor. Headaches that are due to underlying cause are referred to as secondary headaches.

There's a set of features called headache alarms or red flags that both the general public and doctors can use to distinguish primary headaches from secondary headaches.

The red flags include features such as onset of a new type of headache after the age of 55; headaches associated with fever or stiff neck; headaches that are associated with weakness on side of the body or other neurologic symptoms other than typical aura. The presence of those features is a good reason to seek medical care.

What are serious underlying causes of headache other than cancer?

Headache can be caused by stroke, bleeding into the brain, head injury and infection. People who are HIV-positive get a set of infections whose initial manifestation can be headache.

Rupturing of a blood vessel can be a serious cause of headache. There are literally hundreds of causes of headache, and it's hard to even begin to give an exhaustive list.

The good news is that in the overwhelming majority of people, particularly in people who have had a recurrent headache problem where the pain comes and goes for an extended period of time, there is not a serious cause present.

Are there any other issues that make diagnosis challenging?

One issue is thinking it's one type of primary headache and it's actually another primary headache. The reason headache diagnosis is so important is that the treatment of various disorders is very different.

Another reason for diagnostic difficulty is that you might have two headache types, and the doctor only focuses on one of them. It isn't that unusual for people to have migraine and tension-type headache, for example, or other combination headache types.

If you miss one of the types of headache present, you'll make one headache better but not the other one better, and you might not be able to figure out what's going on unless you differentiate the headache types that are present.

What factors can complicate treatment?

People don't get better if there's a factor exacerbating their headaches. When individuals undergo the transition from episodic headache to chronic daily headache, the most common exacerbating factor is, far and away, the overuse of medications.

Physicians are well attuned to prescription drugs, but very often, if you say to a patient, 'Well, what medications are you taking,' the patient won't even tell you about their over-the-counter medications unless you specifically ask.

When someone has medication overuse headache, the drug wearing off actually triggers the next headache that the person gets. What happens is you get into a cycle of medication taking, medication withdrawal, which produces pain, which leads to more medication taking, which leads to pain relief, which leads to medication withdrawal.

The only way to get them better is to break the cycle of medication overuse. This is sometimes called a rebound headache.

What can trigger a headache?

Other exacerbating factors are stress, fluctuating barometric pressure, too much sleep, too little sleep, dietary triggers, including alcohol, red wine and soft cheese.

Hormones are an important trigger. The predominant hormone trigger for migraine is estrogen withdrawal. When women get headaches in association with their periods, it is the falling estrogen levels that occur in anticipation of menstruation that triggers the migraine. When women get headache exacerbations at the time of menopause, it's the fluctuating estrogen levels that are usually the trigger.

Triggers vary markedly from person to person, but have relatively consistent effects for individual people. So people with headache need to try to identify their headache triggers, and it's important for clinicians to try to help them do that, because if you can identify and avoid a headache trigger, you can do much to reduce the frequency of headache.

What are some effective lifestyle modifications one can make?

Far and away the most important thing is learning to identify and avoid headache triggers. If anxiety is a trigger, stress management can be very helpful.

If you have dietary triggers, learning the foods to avoid can be very helpful. Biofeedback can be helpful, particularly for people who have stress as a trigger.

Regular sleep hygiene, going to bed at the same time every night and getting up at the same time every morning can be very helpful, because actually changes in sleep cycles sometimes trigger headaches. Skipping meals can be a trigger, so doing things in a regular, predictable fashion can be extremely helpful as a behavioral management strategy.

What drug treatments are available for migraine?

There are over-the-counter medications, which are useful for people who have the milder spectrum of migraine.

On the prescription drug side, there are prescription analgesics such as nonsteroidal antiinflammatories, which are useful.

The combination analgesics that have caffeine or barbiturate are useful for some people. Particular caution is needed with those medications, because they're the ones most likely to cause rebound headache.

Now, the most widely used class of acute migraine treatments is the triptans. There are seven different triphans available in the United States, with large number of routes of administration and a large number of doses.

What kinds of preventative therapies are available for migraine?

For preemptive therapy, the idea is if your headaches occur in a predictable fashion, you can take medication in anticipation of the headache coming on. The best example of preemptive therapy at the moment is for menstrual migraine.

For women who have regular cycles and almost always get headache with the onset of menstrual flow, taking either a nonsteroidal antiinflammatory or a triptan around the time the headache is expected, before headache begins, can usefully preempt headache.

The final category of treatment is full-blown prevention, which is when you take a medicine every day whether or not you have a headache. Preventive medication is given if people have headaches with a high enough frequency that they're at risk for headache progression. Or if patients are experiencing frequent, disabling headaches that are disrupting their lives, that's a reason to give a preventive therapy as well.

Of the preventive treatments, the common categories are beta blockers, tricyclic antidepressants, and then the most recent addition to migraine prevention are drugs that were originally developed for epilepsy that have proven effective for preventing migraine as well.

What treatments are available for tension-type headache?

Treatment strategies for tension-type headache can also be divided into behavioral, acute and preventive strategies.

The acute treatments for tension-type headache do not include the migraine specific agents such as triptans. The best acute treatments are probably nonsteroidal anti-inflammatory agents. The best preventive agents for tension-type headache are probably the tricylic antidepressants such as amitryptilline.

What is your advice to someone suffering from a headache disorder?

Educate yourself. If you have headache red flags or if you need help go to your doctor. Be prepared to describe how your headaches begin, where the pain occurs, how long they last and the features which go along with the pain. Keep a headache diary and try to identify your headache triggers. Do not live with more pain and suffering than you have to. Take charge of your headaches and your life.

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