Treatment for Headache & Migraine
Different types of headache
Not all headaches are the same and, as with all pain, patients with head pain will have their own unique experiences. This is not just how they describe their symptoms but also how their condition affects them psychologically and how this impacts their daily routines including work or school, their social interactions and quality of life generally.
Headache Diagnosis
The International Headache Society (IHS) has created a classification system based largely on how patients report their symptoms. Clinicians working with headache patients can make diagnoses based on this system and to some degree this can be useful. However, there is considerable overlap in these diagnoses and there are lots of lots of them to consider. Fortunately, for practical purposes, most headaches can be put into a few main categories. The key features are listed below:
Primary Headache
Tension Type Headache (TTH)
TTH is generally lower in intensity and patients can usually continue work and activity as normal. Most will reported their pain as a tight band around the whole head and often associated with neck stiffness or discomfort. Patients with TTH do not usually require medication unless it become a more frequent problem when preventative drugs can help in some individuals.
Migraine
Migraine is more common in women but only in their reproductive years suggesting a hormonal influence. Head pain in migraine is moderate to high intensity, often affecting one side of the head at a time. Pain is usually pulsating or throbbing in nature and patients often report nausea and sometimes vomiting as well as sensitivity to light, sound and sometimes smell. Most patients are unable to continue normal activity and want to lie down in a quiet, dark room and sleep to help them recover. Some patients can have ‘aura’ prior to the head pain - this is mostly visual disturbance but can involve other sensory disruption. Migraineurs can sometimes respond really well to medication but unfortunately migraine is under-diagnosed and some sufferers are therefore not aware of medical treatment options.
Trigeminal Autonomic Cephalalgia’s (TACs)
This is the least common group of primary headache conditions. It is more common in men than women and is characterised by very severe head pain usually behind one eye; unlike migraine, patients will often be agitated and resort to pacing around rather than being able to lie down and sleep. As well as headache, patients have some autonomic features such as watery eyes, drooping eye lid, blocked nose and ears or redness around the eye.
The most common of the TACs is called Cluster Headache as it often comes in clusters of episodes repeating at intervals through the year. It is also referred to as alarm-clock headache as it often wakes patients in the night at exactly the same time and there is some research suggesting a strong link with cluster headache and sleep patterns (it is particularly prevalent around the time of the year when the clocks go back/forward). Cluster headache is also often called ‘suicide headache’ due to the overwhelming intensity of pain. TACs are usually provoked easily with even small amounts of alcohol.
Medication is often useful so be sure to discuss this with your GP if you think this sounds familiar.
Secondary Headache
Secondary headaches are generally those which have an underlying, potentially serious, medical basis and so we definitely want to screen for this early on to get those patients to the right medical practitioners for appropriate investigation and treatment.
Cervicogenic Headache
Interestingly, secondary headache also includes headaches due to disorders of the cervical spine (neck). We call these cervicogenic headaches (CeH) as they result from sensory inputs from structures in the neck.
Many experienced practitioners working with headache patients recognise that there is a considerable overlap between many of the primary headache diagnoses and also between these and CeH. The symptoms of CeH are often quite similar to both migraine and TTH.
Many patients will tell us that they feel that their neck pain is in some way related to their headaches. Although it is true that neck pain or stiffness can be secondary to migraine rather than its cause, it is also quite possible that the same patient has migraine as well as CeH headache at the same time. Patients often have more than one headache type.
We recommend a thorough physical examination to rule in or rule out the involvement of neck stiffness or pain in all primary headache conditions so that this potentially important factor is not overlooked. This is done with a specialist physiotherapist who is familiar with all the different types of headache diagnosis but is also able to undertake a really thorough neck examination. Treatment for CeH is very effective in most cases.
What actually causes head pain?
The sensory nerves that supply the head and face are called the trigeminal nerves. This is a cranial nerve meaning that it originates in the brain itself. So we could say that anything that makes the trigeminal nerve sensitive could be a potential source of head pain. We know that there are changes in the way that the membranes of these nerve cells work during a headache but the real question should be, ‘what is it that influences these changes?’ It turns out that there are lots of variables that can influence this and with a really thorough patient interview as well as both neurological and musculoskeletal examination we aim to identify as many of these factors as possible in each individual patient so that we do not miss anything that could be useful in treatment.
‘Headache Threshold’
Our body systems, including the nervous system, are undergoing constant stress to try and regulate themselves; this is called homeostasis. We are all capable of having headaches and most of us do from time to time. This happens when a certain threshold is breached and our cellular physiology is challenged to the point where it struggles to maintain ‘normal’ function. During a headache episode this threshold is exceeded because enough different physiological stressors are present to a critical level at this point in time. This ‘perfect storm’ tips the balance and the nervous system reacts accordingly. There are lots of potential stressors for headache including:
Genetics. Most migraine sufferers will have a first order relative with migraine and this may account for around 50% of migraine vulnerability due to the way in which their nerve cells function.
Anxiety and depression. There is a two way relationship between common mental health conditions and migraine for example.
Chronic musculoskeletal aches and pains. There are strong links between headaches and chronic neck pain and even neck stiffness that patients may not be so aware of but is picked in in physical examination.
Poor sleep quality. There is growing evidence that disrupted sleep patterns and poor sleep quality play an important role in headache and this is a key area of treatment for many headache sufferers.
Hormonal influences. Migraine is much more common in females but only during their reproductive years suggesting that the menstrual cycle can be involved in this type of headache. Many women with migraine will notice that they have more attacks around the start of the menstrual cycle and this is when levels of oestrogen are falling.
Others stressors include dehydration, dietary sensitivity
Treatment for headache including migraine
Rule out secondary headache where serious medical pathology might be a factor and get a prompt referral to the right specialist as needed.
General education; reassurance through understanding about primary headache goes a long way to reducing the stress surrounding the condition which in turn can reduce symptoms.
Management of triggers for headache to raise the headache threshold (less stress, better quality sleep, a healthier musculoskeletal system etc). Importantly, for a given individual, treating any trigger can mean that the others on their own added together eventually fall below that persons headache threshold and the likelihood of headache attacks is reduced.
Treatment for associated musculoskeletal aches and pains. We know that the upper part of the neck is involved in many headache conditions. Importantly this might be chronic stiffness rather than overt and obvious neck pain. There is also a link between both CeH and migraine, for example, and hypermobility. This could be benign hypermobility where there is ligament laxity generally in the body but no underlying medical disorder. Or it could be associated with systemic disorders such as Ehlers Danlos Syndrome or rheumatoid arthritis.
Medical management, particularly for migraine and TACs and for TTH that have become more chronic. There is a balance between using medication to help prevent headache and mange symptoms when an attack is coming, and avoiding what we call ‘Medication Overuse Headache’. If you suffer from persistent and frequent headaches we recommend that you keep talking to your GP, preferably one with a specialist interest in headache to manage and monitor medication use.