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What is a headache?

Headaches involve mild to severe pain in one or more parts of the head as well as the back of the neck. There are many different types of headache, with different patterns of pain and other related symptoms, and a variety of causes.

While painful and annoying, the majority of headaches are not a sign of a serious disorder and, if they are not a persistent problem, may be relieved by simple medicines and/or changes in lifestyle.

What causes headaches?

There is no single cause of headaches. A number of causes have been identified which fall into two general categories.

Tension headache: This type of headache results from contraction of head and neck muscles. It is the most common form of headache and accounts for 70 per cent of headaches. It can occur in people of either sex and at any age, but it's most common in adults and adolescents. Tension headache usually occurs in isolated incidents but can become chronic for some people. Possible causes of muscle contraction associated with tension headaches include:

    stress
    fatigue
    poor posture
    eye strain
    sensory overstimulation – loud noise, bright sunshine etc
    tobacco and alcohol use
    in women, hormonal changes occurring before and after a menstrual period.

Migraine headache: Migraine is the cause of 20 per cent of all headaches. The underlying problem that leads to migraines is still not clear but several theories exist.

They are probably the result of a series of complex changes in the nerves, blood vessels and chemical signalling within the brain. Migraine is usually experienced as a throbbing pain on one side of the head with an associated feeling of sickness and sensitivity to light and sound. However there are various types of migraine. The main ones are the following.

Migraine with aura: an aura is a warning symptom or sign that develops before the headache itself. Auras include flashing lights and visual changes, and neck stiffness. One in three people with migraine have auras.

Migraine without aura. Migraine without headache. Although migraines are a type of headache, some people find they get all the other symptoms, especially an aura but no headache develops. Migraines are known to affect more women than men and are often chronic. In extreme cases they may totally disrupt a person's daily life.

Below are some of the factors that have been identified as being associated with migraines:

    family history of migraine
    prolonged muscle tension and stress
    alcohol use
    smoking or exposure to tobacco smoke
    lack of sleep
    for women, menstrual periods and the use of oral contraceptives

certain foods such as chocolate, nuts and fermented or pickled condiments, as well as foods containing the amino acid tyramine (aged cheese, red wine, smoked fish) and foods containing preservatives and artificial sweeteners are linked to migraine. It was thought they might contain chemicals that could trigger a migraine, but other research suggests that one of the early symptoms of a migraine might be a craving for foods such as these.

What are the symptoms of tension and migraine headaches?

Tension headache:

    Pain is often felt in the generalised area of the head and neck as opposed to on one side.
    Pain may also be situated in the back of the head and neck and feel like a 'tight band'.
    Sometimes accompanied by muscle tightness in back of neck.
    Of relatively short duration if treated in time.

Migraine headache:

    Migraines tend to follow five stages.

A prodromal stage: this comes before the headache (often hours or even days before) and varies from person to person. Prodromal symptoms include generally feeling unwell, low mood, extremely tired, changes in appetite, craving certain foods, yawning and temperature changes in the extremities (such as hot ears or a cold nose). Many people with long standing migraine can recognise their prodromal stage even if they can't fully describe what they feel is wrong.

Aura: about one in three people get an aura – a warning symptom just before the headache starts which lasts 10 to 15 minutes. These aura often include visual symptoms such as flashing lights.

Headache

Resolution: symptoms gradually fade. Sleep can help this.

Postdromal or recovery: many people recognise certain symptoms once the headache has gone, especially exhaustion but sometimes hunger too.

When should you consult a doctor?

Most people with isolated tension headaches usually manage to control their symptoms with over-the-counter pain relievers and anti-inflammatories, such as paracetamol or ibuprofen, or simple self-treatment such as relaxation and sleep.

However, those with chronic headaches should be checked out by their GP to consider possible causes and prevention. If any of the below symptoms are present your GP should be contacted immediately.

    A sudden, severe headache accompanied by nausea and vomiting.
    Persistent and recurring headaches accompanied by memory problems, difficulty concentrating and tiredness.
    A high fever with neck stiffness (unable to bend the chin down to the chest).
    Convulsions (fits).
    Persistent vision disturbances (light flashes).
    Trouble controlling arms and legs.
    Loss of feeling in the arms and legs.
    Tiredness and apathy with difficulty communicating.

How does the doctor make a diagnosis?

An accurate history of any previous illnesses, family background, diet and lifestyle is crucial to help the doctor decide whether to perform further tests and to advise on treatment.

The doctor will ask for information about the headache, its length, duration, location, associated features, quality and causative factors. Bear in mind that the vast majority of headaches, even persistent ones, are not sinister.

However, when symptoms suggest that the headaches may be related to a chronic or more serious disorder, the following diagnostic procedures might be performed, usually following assessment by a specialist.

    Head CT (computerised tomography) scan.
    Head MRI (magnetic resonance imaging).
    Sinus X-rays.
    Temporal artery biopsy.
    Lumbar puncture.

What kind of treatment is available?

A headache diary is useful to help you and your doctor spot trigger factors and figure out what kind of treatment is most appropriate for your diagnosis.

The easiest way to do this is to write the dates of headaches on a calendar. Make a note of when the pain started and how long it lasts.

Note down any additional factors that seem important such as what has been drunk and eaten, the intake of medicines, weather conditions, daily activities, particular stresses and details about periods if you are a woman.

It is a good idea to keep up the diary for between one and two months so that any patterns can be identified.

By establishing what triggers the headaches, it is possible to learn to avoid factors that cause them.

If you're unable to find a connection, it might be a good idea to show the diary to your doctor – who may be able to ask pertinent questions that will help identify a pattern.

While each person will require their own form of treatment, generally over-the-counter pain relievers, such as paracetamol (eg Panadol), aspirin (eg Aspro clear) and ibuprofen (eg Nurofen), are quite helpful in relieving the symptoms of tension-like headaches.

Prescription medicines may be helpful for other types of headache pain such as chronic migraines. In migraine, it's very helpful to start by getting an explanation of the problem and identifying and avoiding trigger factors. Drug treatments may then be used to either treat an acute attack or prevent further headaches.

There are various treatments available for relieving acute attacks, starting with simple over-the-counter (OTC) painkillers such as paracetamol or ibuprofen. These are most effective if taken as early as possible into the attack, preferably in a soluble form. Some OTC medicines designed specifically for migraine also contain an antisickness medicine such as cyclizine. If OTC painkillers are ineffective your doctor may prescribe alternative treatments containing different antisickness medicines, stronger painkillers, or one of a group of antimigraine medicines called triptans, eg sumatriptan (Imigran) or zolmitriptan (Zomig) which are not painkillers but work on blood vessel changes which occur in migraine.

Sumatriptan can now be bought OTC under the guidance of a pharmacist. However, triptans don't work for everyone. NICE (National Institute for Health and Care Excellence) has recently approved a new treatment for migraine called transmagnetic stimulation (TMS).

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