September 25, 2014It’s Just a Headache - Or Is It?
Headache is a universal complaint, so consider yourself lucky if you are in the small minority of people who have never experienced one.
Not to be cruel, but many headache sufferers wish everyone (including doctors) would experience just one headache to understand how bad it can be, so they could be taken seriously. They wish to no longer be teased by “not tonight, I have a headache” jokes, or accused of “just having an excuse to get out of things,” or pitied for an inability to deal with stress, or told to try that medicine advertised on TV that “works great for headaches.”
Having limited my practice to headache management and research for more than 20 years, I can tell who gets it and who doesn’t. Within minutes of learning my profession, a patient or physician is either animatedly chatting with me about headaches as if we were old friends, or there is a blank stare, as if I am practicing quackery. The fact is, many people experience headaches and are not appropriately treated; this leads to unnecessary suffering and a reduced quality of life. Not many providers specialize in headaches, and those that do are often booked out for a half year or more, giving testimonial to the need for better headache care.
There are more than 300 headache diagnoses. For the most part, physicians diagnose headaches based on subjective complaints given to us by our patients. There are no objective/structural findings for most headaches. In fact, the “history taker” (physician) must be skilled in making the “story teller” (patient) give the details necessary to confidently formulate a diagnosis. The good news is that most headaches are benign, meaning they may be painful, but they won’t kill you. The bad news is that life-threatening types of headaches may have the same types of symptoms as harmless headaches.
It takes an astute physician to pick through the details for subtle clues that prompt further investigation. In the end, it is the physician’s clinical judgment that determines the course of action. Red flags that make us more suspicious for an ominous headache include:
- Late onset (first headache over age 50)
- Rapid peak of pain (so called “thunderclap headache”)
- Abnormal neurologic exam
- Pain always in the same location without shifting sides
- Change in headache frequency, severity, or characteristics over time (even patients with longstanding benign headaches can develop a new serious headache)
- Presence of other pertinent symptoms or diagnoses (i.e. fever, neck pain, infection, HIV, cancer, rheumatologic diseases, blood clot tendencies, head trauma).
While tension-type headaches (TTHs) are the most common type, most sufferers will self-treat these rather than consult a physician. TTH’s are “featureless headaches,” described as a mild-to-moderate pressure on both sides of the head or a vise around the head, without associated nausea, vomiting, light or sound sensitivity. More than 90% of patients who go to a doctor for recurrent headaches suffer from migraines, and an estimated 43% of women experience migraine during their lifetime. Sixty percent of migraines are on one side of the head, throbbing in quality, and may be associated with nausea, vomiting, light and sound sensitivity. Pain is often increased with exertion and many prefer lying in a dark quiet room when the headache is severe. Up to 30% have associated vision (flashing, blurred or loss of vision) or sensory (numbness and tingling) changes just prior to or with the onset of a migraine headache. The majority of migraine sufferers do not experience these auras, but if you experience headaches with ANY of these features, you likely have migraines.
The good news is we have effective treatment options. Our goal with acute medications is consistent relief within an hour, allowing full functioning with minimal side effects, such as sedation. For frequent or hard-to-treat migraines, a daily preventive medication - such as a low-dose antidepressant, blood pressure, or antiepileptic drug - may reduce headache frequency and/or severity. Whether you get rare, incapacitating headaches or frequent, annoying headaches, it’s worth getting a proper diagnosis and effective treatment plan.