Headaches that keep coming back again and again, until they become almost daily, can be a debilitating problem. Your headache is bad, so you take a pill. It comes back again, so you take another one. But if you keep it up and do it often enough, you may actually be bringing on your next headache. If you are taking painkillers for headache three or more days a week, there is a good likelihood that this may be happening to you.

Some people think that in order for their headaches to be termed a “rebound headache” the pattern must be one of taking a pill one day, and then experiencing a headache the next day. While this can be a common pattern seen in analgesic-induced headaches, it is not the only pattern seen. This is one of the reasons the preferred name has been changed in the medical literature to “medication overuse headache”. Some affected people simply have chronic head pain and do not necessarily take analgesics every single day; it is more about a pattern of use. If you are particularly susceptible to developing medication overuse headache, as little as two days a week may be all it takes to maintain chronic headache.

There is a transition that occurs as you take more and more medication, and sometimes you don’t even notice that your headaches symptoms are changing because it occurs so gradually. The pain may become less throbbing and more dull. The headache may involve more of your head, and become less localized, harder to pinpoint. You may not notice as much nausea or acute sensitivity to light or noise as you did with your migraine attacks. You may not be completely unable to think or concentrate like during a migraine. You just feel somewhat bad all the time. Some people in this transition phase still get migraine attacks on top of having daily or near-daily headaches. Eventually, those may go away and only daily head pain is the result, often awakening you in the morning or in the pre-dawn hours.

If you find yourself slipping into the pattern of frequent painkiller usage, this may indicate the need for a headache preventative medication. Only about 10% of those who would benefit from preventative medications are on an effective regimen. If you are already on a medication for prevention, you should work with your doctor to make certain it is as effective as it could be, and to decrease your pain medications to make sure you are not in danger of developing medication overuse headache. Oh, and by the way—over-the-counter painkillers are just as guilty of causing problems as prescription painkillers are.

Chronic Daily Headache may not be due to medication

Between three and four per cent of the population have chronic daily headache. Not everyone with daily headache has medication overuse, however, and in many cases the daily headaches came first, and the medication overuse occurs as a result. It is therefore difficult to interpret studies that say 50% to 86% of chronic daily headaches are due to medication overuse. It may just be that the same person has both. At US headache clinics, between 30% and 86% of new patients seen have medication overuse headache as a component of their problems. It is the third most common type of headache encountered by primary care physicians.

A recent large population-based study (Bigal et al, 2008) found that barbiturate-containing medications, such as butalbital, and opioids (narcotic analgesics) were the most likely to cause a transformation from episodic migraine to chronic headache. The prevalence of transformed migraine is 2.5%, and that due to medication was found to be 1.5%.

There are long-term risks to taking daily pain medications, even over-the-counter ones. These include stomach irritation, ulcers, gastrointestinal bleeding, and acid reflux disease (heartburn) from aspirin-containing headache remedies and anti-inflammatory medications. Long-term use of NSAIDs and acetaminophen can cause kidney damage, and excessive use of acetaminophen can result in liver damage.

The treatment for medication overuse headache is simple, but that doesn’t mean that it’s easy: stop taking daily pain medication. Depending on how long you have been taking pain medications and on how much you have been taking, the recovery period can vary from three weeks to three months. It tends to be longer if the medication you have been overusing includes narcotic painkillers. No one can wave a magic wand to make you instantly better, but headache specialists can help support you through the process. Preventive medications can help, but take time to work, and may not be fully effective until you have weaned off the analgesic medications. Behavioral treatment strategies such as cognitive behavioral therapy, relaxation training, biofeedback, and hypnotherapy can also be helpful.

The best strategy? Avoid medication overuse in the first place. If you have frequent headaches, and you are using medication more than nine days a month or more than two days each week, you may be suffering from medication overuse headache. Think twice before grabbing that medication bottle. Seek help instead.

1. Bigal, ME, Serrano, S, Buse, D, Scher, A, Stewart, WF, Lipton, RB, Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study, Headache, 2008; 48(8):1157-1168

Almost everyone who has ever had an aggravating headache has been worried at some point in time that they might have had a brain tumor. Let’s talk about what a brain tumor headache feels like.

And now for some reassuring facts: although up to 70% of people with various brain tumors have a headache at the time of diagnosis, only about 8% of tumor patients have headache as their first and only symptom. In the past, older textbooks and other sources have described a “classic” brain tumor headache as being worse in the morning, and more likely to be a dull pain, but with nausea and vomiting.

However, neurologist and cancer specialist Dr. Casilda Balmaceda, Assistant Professor of Neurology at Columbia University College of Physicians and Surgeons in New York, states that there is no typical brain tumor headache.

Symptoms for headaches associated with brain tumors

Nausea and vomiting do not usually occur until the tumor has grown large enough to put pressure on the brain. Morning headaches can also occur due to this increased pressure phenomenon. However, morning headaches are far more likely to be due to sleep disorders like sleep apnea.

A brain tumor headache can link to the spot where the brain tumor is. So if you always get a headache in the same spot, there is a possibility that it could mean a brain tumor—but it’s not a very big chance. If most of your headaches are on one side, but a few are on the other, your headaches are still most likely to be migraines.

Migraine patients who have had the misfortune to later develop a brain tumor report that the headaches due to the tumor are different from their migraine headaches. Do you always get a headache with a brain tumor? No—many times you get other symptoms instead, like weakness or a personality change.

Children with brain tumors are more likely to experience headaches than are adults.

References:

1. http://www3.interscience.wiley.com/journal/119263829/abstract
2. http://www.ncbi.nlm.nih.gov/pubmed/2022972

What are Ice Pick Headaches?

Ice pick headaches (called primary stabbing headache now in the International Headache Diagnostic Criteria) are defined as either a single stab or a series of stabs felt in the orbital region, temporal area, or parietal area of the head. Stabs occur with irregular frequency. On days that they occur, they may occur only once, or may occur many times per day, but with no regularity. Duration of stabs is short, usually a few seconds.

Stabbing headache or ice pick headaches can occur as an isolated headache type, but occur more commonly in migraine or cluster headache sufferers. The pain experienced can be very intense, and tends to hit without warning. If you experience tears, redness of the eye, and nasal stuffiness in conjunction with stabbing pains in the temporal region or the orbital region, it is likely that you have a rare headache type known as SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjuctival injection and Tearing), which is one of the Trigeminal Autonomic Cephalgias.

Headache textbooks tend to be somewhat dismissive of stabbing headache, indicating that reassurance should be offered, since this headache type does not indicate underlying pathology such as a tumor or aneurysm. This, however, is not terribly helpful to the sufferer who is experiencing the sensation of needles, ice picks or tiny knives being jabbed into their head on a recurring but unpredictable basis.

Some sufferers of stabbing headaches indicate that they started to experience them in childhood. Most attacks of ice pick headache occur randomly and without warning, although some sufferers have identified emotional or other stressors as triggers. Treatment is problematic, since the attacks are so short. In some cases, indomethacin taken preventatively will be helpful, but this is by no means universally so. As with many headache types, more information is needed before we more fully understand the underlying causes and can offer a meaningful solution.

Of course it is possible for the migraine sufferer to develop a sinus infection, especially if you also have seasonal allergies. In fact, many suspected sinus headaches are migraines. Here’s how that works: the sinus cavities are lined by sensitive tissues whose nerves are fed mostly by a branch of the trigeminal nerve. This is the same nerve responsible for migraine headaches. When you have sinus congestion, it can confuse the nerves and cause what is called referred pain, sending pain to distant areas in the face and head, away from the sinuses themselves. So, sinus headaches may cause pain that is not in the sinus region, and migraines can cause pain that is in the sinus region. Just to make things even more confusing, some migraine sufferers experience nasal congestion or watery eyes with their migraine attacks. This is because the trigeminal nerves can release neurotransmitter chemicals that cause blood vessels to dilate, which is why your eyes get red and watery and your nose gets congested. It isn’t clear why this happens more to some people and not to others with migraine.

The Sinus, Allergy and Migraine Study investigated 100 subjects self-diagnosed with sinus headaches. They were then evaluated by headache specialists, and 63% were diagnosed with either migraine with aura or migraine without aura, and 23% with probable migraine. Only 3% actually had sinusitis. Interestingly, 62% reported that exposure to allergens was a significant headache trigger.

Although the symptoms can overlap, these general guidelines can help somewhat in telling migraine and acute sinus infection apart. Sorting out chronic sinus headache is more difficult, especially if there is also another type of chronic headache present.

SINUS INFECTION

Usually bilateral
Fever*
Discharge thick, yellowish-green*
Diminished or absent sense of smell*
Minor factors: halitosis (bad breath), cough, headache,
dental pain, ear pressure, fatigue
Facial pain or pressure—more likely to be non- throbbing
Sinus CT or direct examination positive

MIGRAINE

Often (not always!) one-sided*
No fever
Discharge thin, clear if present
Heightened or altered sense of smell or avoidance of odors
Occasional symptom: watery, red eyes

Facial pain or pressure—more likely to be throbbing or pulsating*

Diagnosis based on symptoms.

*Major features of each disorder.

Sinusitis occurs in 15% of the population— and that is even higher than migraine, unless we take into consideration the possibility of overdiagnosis of acute sinusitis in the migraine population.

Contact Point Headache

As if this were not confusing enough, there is another headache type called Contact Point headache. This occurs when you have a deviated septum or bone spurs in the nose, and the bone from the center of your nose comes in contact with the sensitive tissue on the other side of your nose. This can cause headaches that can feel very much like a migraine.

What Should You Do About Sinus Pain and Congestion?

If you think you have allergies causing allergic rhinitis, or allergies your triggering migraines, it might be worthwhile to see an allergist. Specific treatment of allergies may reduce your migraine frequency. If you think you have a sinus problem, it may be worthwhile to see an ear, nose, and throat physician (the technical name is otorhinolaryngologist). Treatment of a mechanical problem like a deviated septum, bone spurs, or other physical sinus problems can be helpful if you truly do have chronic sinusitis. Gastric reflux can also be a cause of chronic sinusitis. Be careful about treating yourself with over-the- counter sinus medications, especially if you do so on a frequent basis. This can result in rebound rhinitis, causing more nasal congestion than you might otherwise have had. They can also cause rebound headaches if used frequently. It is always best to see your doctor for examination, particularly since this can be such a confusing diagnostic challenge. One thing is for sure, though—antibiotics are not the best treatment for migraine!

So don’t just pick up the phone and ask for a prescription. If there is any doubt, go in and be seen.

Tension-type headaches, the official name for tension or stress headaches, are a non-throbbing, pressure pain in part or all the head, and may be associated with neck pain or tightness. A tension headache is often described as a “tight band” around the head, or feeling like the head is “in a vise”. A stress headache or tension-type headache is usually not associated with nausea, or with avoidance of light or sound. It is not made worse by routine physical activity, and is of mild or moderate pain intensity. Tension-type headache is the most commonly occurring headache type of headache worldwide.

Tension-type headaches used to be called muscle contraction headaches, but not everyone who gets these headaches has tight muscles or has sore muscles in the scalp when they are touched or pressed.

Are tension headaches due to stress?

While stress can increase the frequency of this headache type, just like it can increase the frequency of migraines, it is not felt to be the cause of this type of headache. Stress management can help with management of tension-type headaches; it also helps with the management of migraine.

The majority of people with tension-type headaches have episodic headaches, which means that you have less than 15 days of headache a month.  This can often be managed with over-the-counter medication or non-medication strategies such as massage. (The International Headache Society makes a distinction between “infrequent” tension-type headaches at less than ten headaches a month, and “frequent” tension-type headaches, between 10 and 15 headache days a month.) Chronic tension-type headaches, defined as more than 15 headache days a month, is more likely to require medical attention.

Migraine pain can be unilateral or bilateral, and is most often pulsating or throbbing in quality. Fifty per cent of migraine sufferers report the onset of migraine pain in the occipital region (back of the head), and up to 80% of migraineurs may experience posterior pain during an attack.  Regardless of where pain begins, it often settles into a one-sided headache. Often, migraine pain is made worse by routine physical activity, such as climbing stairs. The vast majority of migraine attacks are of moderate to severe pain intensity.

If not treated early, up to 80% of migraine sufferers can develop a highly sensitized pain called allodynia, in which a usually normal level of touch is perceived as painful.  While this usually affects the face and head, it can on occasion spread to the upper torso and extremities as well, and migraine sufferers will find it uncomfortable to put up with usual things, like jewelry, eyeglasses, neckties, clothing, hats and similar things.

There is usually associated avoidance of light, sound, or even smell. There is often nausea or loss of appetite. Many migraine sufferers have difficulty thinking or concentrating during an attack. Some experience dizziness, lightheadedness or vertigo.

About 20% of migraine sufferers report a prodrome preceding their headaches, consisting of vague symptoms like mood changes, yawning, food cravings, thirst, or excessive urination.  This can be brief, lasting a few minutes, or can be prolonged, lasting hours, a day, or longer.

Fifteen to twenty per cent of migraine sufferers sometimes or always have an aura preceding their headaches. Auras are neurologic symptoms, most often affecting vision with spots, colors, sparkles, or vision loss. An aura can also cause stroke-like symptoms like tingling, numbness, or weakness in the face, an arm, or sometimes an entire side.  Most auras last 15-30 minutes; some will last up to an hour.  If an aura lasts longer than an hour, and this is not your characteristic aura pattern, it would be prudent to seek medical evaluation.