Understanding Major Pains A Lal
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Understanding Headachesone

Headache (from heafod, head + acan, to ache) is a diffuse or throbbing pain, mild to severe in intensity, all over the head or at a particular site in the head, frontal, temporal (around the ears) or occipital (back of the head) region of the head. The pain may be continuous or intermittent and spasmodic like “bursting of a dam”, unilateral on one side of the head and over one eye (causing the eye to tear profusely) or bilateral (as if the pressure inside the head will blast it apart), penetrating (as if the brain tissue is being sliced into pieces by a knife) or piercing (as if the brain is being lynched by a sharp probe). All these explaining features apart, the simplest definition of headache is “pain in the head.” This is what 2headache means to a common man. Another essential attribute of headache lies in its certainty-it is as certain as “death and taxes” in man's catalogue of life's certainties, for everyone must suffer from it at sometime or the other. The only redeeming aspect of this most common affliction of mankind is that most of the headaches are just painful and annoying – only a third of headache sufferers consult a doctor. Instead they rely on OTC analgesics with a great degree of satisfaction.
 
MOST COMMON AFFLICTION
About 76 percent of women and 57 percent of men experience recurring headaches according to American Medical Association. Headache is the most troublesome companion of man which never spares any one. It is the most common complaint addressed by medical doctors world over. Available statistics on the prevalence of headache speak for themselves. In the United States alone, where epidemiological data are compiled more systematically, it has been worked out that 18.3 million outpatient visits to medical centers and hospitals are made each year to seek relief from headache. This works out 43.7 per 1000 outpatient visits each year.
A telephone survey of 10,169 residents between 12 and 29 years in a Washington county in the United States, reported that 57 percent males and 76 percent females had their most recent headache within the previous 4 weeks. Among them 6 percent males and 14 percent females reported four or more episodes of headache during this period. Average duration of the respondents' most recent encounter with headache was 5.9 hours for males and 8.2 hours for females. But the most outstanding fact which the survey brought out was that 85 percent of the males and 72 percent of the females never sought doctor's advice on their headache as if it was something normal—an essential part of living. This “couldn't care less” was, however, not uniform throughout because as 3women age they are more likely to seek medical advice for their problem. Another interesting feature of the survey emerging from Headache Prevalence Study which appeared in the Journal of American Medical Association (1989) was that never-married persons were more likely to neglect their headache and less likely to seek medical advice than those who were married or divorced.
The figures detailed above provide information on epidemiology of headache both in quantitative and qualitative terms. Similar data on widespread prevalence of headache emerge from other countries as well. In England, for example, a study states that a substantial proportion of school children (57% boys and 67% girls) miss school attendance due to headache each year. But all people are not equally susceptible to headache. “Certain individuals have a biological tendency to have headaches and thus they develop them at a lower threshold than others,” says Joel Saper, Director Michigan Head Pain and Neurological Institute in the United States. Again, headaches generally become less frequent as one gets older. May be because advanced age causes changes in the consistency of blood vessels which become more rigid and thus less prone to dilation. But when the older people do have headaches, they have more to do with general geriatric problems like glaucoma, cervical arthritis, diabetes, and other reasons. Thus while most headaches are not caused by an underlying organic cause, the odds of this being the case rises as a person ages. Clearly headaches are one of man's most significant non-lethal medical conditions. Although relatively few cases of headache are caused by life-threatening conditions like tumors or aneurysms, routine headaches wreck havoc on a person's quality of life.
 
ACCOMPANYING SYMPTOMS
Medical significance of headaches varies widely, and so too are the symptoms which accompany headache.4
Proportion of subjects reporting symptoms that accompanied their most recent headache within 4 weeks of interview in the headache prevalence study, Washington county, Maryland, the US
Symptom
Males
Females
(n=2510)
(n=3865)
1. Nausea/vomiting during headache
6.8%
4.0%
2. Unilateral headache pain
23.6%
27.7%
3. Unilateral soreness of scalp during headache
2.6%
4.7%
4. Numbness/tingling/peculiar feeling in one arm/leg during headache
2.6%
2.8%
5. Spots/lines/heat waves before headache
6.4%
8.8%
6. Partial loss of vision
2.4%
1.1%
7. Awakened from sleep by headache
3.9%
5.9%
8. Headache on sleeping longer than usual
9.0%
9.5%
9. Pain in the back of the head, neck or shoulders
18.9%
22.8%
10. Feeling of tight band around the head
14.9%
14.7%
Source: Journal of American Medical Association(1989)
The telephone survey of the American county referred above provides a microanalysis of such accompaniment in a tabular form which is given on next page.
 
MEDICAL SIGNIFICANCE
Medical significance of headache has to do with the contributing cause/causes of headache. Such causes may be relatively minor ones like a temporary emotional distress or sleep deprivation to extremely serious, but very rare, causes like a brain tumor as when headache has occurred for months or brain hemorrhage marked by a sudden origin, unbearably painful and different than previous pattern or when it becomes more frequent in occurrence. Such headaches require urgent and a closer look by the physician. Fortunately, the incidence of headaches because of these two causes is infinitesimally low. In fact, these should be the least worry of a headache victim.5
 
BRAIN TUMOR
Headaches because of brain tumor, benign or malignant, are rare to come by in the ordinary course of general practice. For example, on an average, a general practitioner in the Britain is consulted by 10 to 20 headache patients a week. This translates into approximately 500 to 1000 headache cases a year. The average number of cases of brain tumor is close to 2500 a year for the whole of Britain. To put it differently, a general physician may come in contact with just one case of brain tumor in 5 to 10 years of practice ! This indeed is a very optimistic prognosis for headache patients to put their mind at ease. Moreover, a headache due to brain tumor rarely exists alone, for there are always some other accompanying symptoms like epilepsy. “A headache of more than one year's duration without physical sign is not due to structural lesions” is a workable diagnostic aphorism of Sir Charles Symonds.
But when a tumor takes birth in the brain on the rarest of rare occasion, it is a frightening event with very little chance of recovery. It does not matter if the tumor is benign(innocent) or malignant (cancerous), for both result in the same severity and frequency of headaches. Any kind of growth in the head needs room to grow further within the skull which eventually displaces the adjoining tissues, cerebral nerves and blood vessels inside the skull and destroying the tissues in the process. This is why headache due to a tumor is felt only in a particular area of the head especially in the early stages of its growth. The pain usually changes in character with a change in posture. Nature of damage and impairment of motor/sensory functions of the brain depends upon the exact location of the tumor. The brain itself is immune to pain sensations, for it can be cut, probed and sliced by a surgeon's knife without evoking pain. It is the pressure or stretching of the tumor as it grows or stretches or any other kind of build-up 6in the brain, which are the reasons for excruciating pain in the head.
A headache because of a tumor in the brain has tell-tale signs as a part of a bigger medical problem, otherwise, a headache, per se, is not a sign of tumor but a combination of many other signs including nausea and vomiting. Apart from the fact, as explained above, headache due to tumor is localised in nature especially in its early stages of growth, there are other signs such as dizziness, slurred speech, unsteady gait, loss of hearing and vision and general weakness in one arm or a leg. The classical symptom of brain tumor is that the pain becomes worse when one lies down and according to journal Neurology (1993), unlike other types of headaches, pain is the first thing as severe and worse on awakening in the morning, but it goes away during the day. Occasionally the pain is accompanied by nausea and vomiting. As the tumor grows in size, frequency of headaches increase and mental faculties deteriorate. These are the alarm signals of more serious nature requiring prompt attention and urgent intervention rather than the feeling of pain in the head.
 
BRAIN HEMORRHAGE
Very rare but extremely worrisome is the headache which comes suddenly like a “bolt from the blue” due to what in common parlance is called brain hemorrhage. Pain is caused by the blood from ruptured blood vessels within the head which fills the spaces between the skull and the brain, compressing the brain tissue and meninges(brain covering) and resulting in extremely severe headache.
Blood vessels in the brain are very vulnerable to hypertension (high blood pressure). Headache results as tiny blood vessels in the brain rupture due to hypertension or due to ruptured angioma—a tangled knot of blood vessels 7containing abnormal interconnections between arteries and veins—again due to hypertension. Or else intracranial bleeding can also take place from bursting (again due to hypertension) of blood-filled tiny blisters or sacs called aneurysms and blood gushes out into the subarachnoid space which raises intracranial pressure and distorts intracranial structures. Hemorrhage may be precipitated by hypertension. Chances for such “bursts” are higher in women than in men, and they are more frequent between the age of 30 and 60 years. There may be some warning leaks before a full blown burst which often produces severe headaches typically described by a patient as “the worst headache I ever had.” At this stage the patient may also complain if photophobia (as in migraine) or stiff neck (as in tension headache). Under such critical situation immediate medical intervention through diagnostic tests including CT scan to pin-point the source of trouble and biochemical analysis of cerebrospinal fluid followed by emergency medical treatment may help relieve pressure on the brain.
 
LOOKING FOR CAUSES
Finding the real cause of headaches is a daunting task. Causes of headache are buried everywhere; they need only a nociceptive stimulus to excite them to action. At the same time some headaches arise for no apparent reason. Normally, there is no correlation between the cause of headache and severity of pain.
Organically speaking, headaches arise from two sets of causes; some of which lie within the skull itself (intracranial) or they may lie outside the skull (extracranial); the latter are by far the most common sources of headaches. Intracranial headaches are partly due to an excessive distention of blood vessels and muscle contraction or due to inflammation of nerve fibers or, as explained above, when a tumor or 8hemorrhage exerts pressure on meningeal tissue at the base of the brain. This is a highly pain-sensitive membrane surrounding the brain and the spinal cord. When blood vessels dilate or constrict too rapidly they generate pain sensations (as in hypertension) due to constriction of brain's blood vessels. Additional causes of intracranial headaches may be due to biochemical imbalance from malfunctioning of brain's production of chemical neurotransmitter and serotonin.
More than 90 percent of all headaches, however, are extracranial and occur from a variety of causes. The most important cause of extracranial headache is dilation and distention of arteries that supply the surface tissue of the head, sustained contraction of the skeletal muscle of the neck, face and scalp (a major reason for tension headache) which result from frustration, resentment, anxiety or depression; infections of the sinus and teeth, inflammation of some specific nerves (neuritis or neuralgia), direct injury to the head or some unusual growth involving extracranial tissues, blood clots causing ischemic action in some part of the brain, bacterial infection of ear, nose or throat. Even infections from areas far remote from the head like appendix, kidneys, gallbladder or general infections as in typhoid, malaria, influenza, tuberculosis or fever lie at the root of headaches. Other diseases like diabetes, anemia, congestive heart failure, endocrine disorders (adrenal and ovarian tumors) gynecological events like dysmenorrhea, premenstrual tension, menstruation, pregnancy and menopause have also been recognised as important causes of headache. The list of such extracranial causes is a long one; even constipation and dyspepsia have been cited as causes of headache.
Psychoneurological factors in the etiology of headache are of no less importance. Among the more important ones, such factors as nervous breakdown, anxiety, excitement and 9epilepsy play a major role in headaches of psychoneurological origin. A headache may start every time one has to confront a tense moment and it occurs regularly unlike migraines. In addition diseases of special sense organs like glaucoma, conjunctivitis, adenoids, deviated septum of nose, organic disease exerting pressure such as abscess, cyst, hydrocephaly, hematoma and encephalitis are mentioned by headache scientists among the possible causes. In fact, name any disease, and it is there directly or indirectly implicated in the pathogenesis of headache.
The occurrence of headache due to deviated septum of the nose has been reckoned as a leading cause of general headache. A study in British Medical Journal (1984) advised that nasal origin of headache should always be looked into when headache cannot be explained otherwise. The casual link between the two is direct and distinct because such headaches vanish after corrective surgery on deviated septum. The study established that this surgical procedure helps all irrespective sex, age, family history or severity of the problem.
There are many more reasons for headaches. Sunstroke and dehydration, motion sickness and high altitude hypoxia (oxygen deficiency), sinuses by dust particles and pollens, fatigue and sleep deprivation—almost any disturbance in the normal functioning of the body can be a cause of headache. Environmental air pollution from poor ventilation, industrial gases and vehicular emissions, high decibel noises, drugs (including morphine, quinine, atropine or histamine), tobacco, alcohol are the major contributing factors in headache. Sinus headache, also called “barometric headache” is caused by air pressure, usually affecting the region of eyes, cheek or forehead. Generally, this type of headache is worse in the morning on awakening, but often gets better after a hot bath.10
 
ANALGESIC HEADACHE
Then there is an unusual type of headache; unusual in the sense that analgesics, the most common “cure” for headaches, become the “cause” of headache. This is called “analgesic headache”, so-called because it is caused by large daily doses of analgesics. The offending drugs include both over-the-counter analgesics, sedatives and tranquilizers, triptans and ergotamine tartrate—among other. Headache improves dramatically after medication is stopped. One explanation for this is that daily or almost daily regimen of analgesics interferes with body's own pain fighting mechanism, eventually making the person more prone to headache as soon as the analgesic effect begins to wear off. But an old person, who has been habitually taking his analgesics for many years finds it difficult to admit that analgesics may be the problem. “I have used these for so many years without any problem” is the typical response. Nevertheless, the exact mechanism of this type of headache remains unclear except the fact that analgesics induce headaches only in people who already suffer from headaches and not when given for other conditions like arthritis, etc. May be pain pathways in people with headaches get sensitized by daily large doses of analgesics or else analgesic headache is a psychosomatic phenomenon with the patient constantly obsessed with headache and analgesics. It is a well known fact that an increased attention is known to increase sensitivity to painful stimuli which may be a factor in lowering pain threshold. However, there are some useful suggestions to tackle analgesic headaches. To begin with the patient should be advised not to take analgesics every day as if it is a some sort of ritual to be performed daily; one can zigzag doses to alternative days or a maximum of 15 days a month. When analgesics like ergotamine or sumatriptan are used for migraine headache, they should not be used for more than 1110 times a month. Overuse of ergotamine has been found to contribute to chronic daily headaches through rebound effect. Morphine-based analgesics should be used sparingly because of their addictive potential and withdrawal effects. Compound analgesics should be avoided as far as possible. Excessive indulgence with symptomatic medication for relieving headache may also render preventive treatment ineffective. But on the other hand, discontinuing overused medication abruptly also carries the risk of withdrawal symptoms.
Treating headaches with non-prescription over-the-counter analgesics sometimes does more harm than good. Dr Robert W Gilbert of Peachtree Neurological Clinic in Atlanta, US, estimates that half of the headaches are analgesic headaches caused from non-prescription pain killers and decongestants. “Simply weaning such patients from medications can relieve the vast majority of symptoms. In the worst cases, overuse of analgesics leads to serious health problems.” The bottom line is that a headache sufferer should seek professional help rather than “just going to the drug store and buying a painkiller” says Gilbert.
 
FOOD FACTOR
More than any other factor, food has been implicated in a large number of headaches. Lack of it or too much of it or some specific types of food can cause headache; lack of it, because a fall in blood sugar level cause blood vessels in the brain to dilate, resulting in headache. Too much of food may also cause headache by causing dyspepsia and acid reflux. Again there are a number of headache triggers. Consuming too much of coffee can bring a headache by altering the quantity of blood supply to the brain. But an abrupt cutting of consumption of coffee can also cause headache through withdrawal effect. The four “C's”, cheese, chocolate, citrus 12and coffee have been labeled as most offending foods contributing to headaches. A number of headaches can actually be traced to them. However, this may not be always true because some headache patients can eat potentially troublemakers when their lives are running smoothly, but during times of stress, sleeplessness, fatigue or at certain times of the menstrual cycle, the same substances turn into headache triggers.
Food allergies are the most common cause of headaches. Chinese food served in restaurants contain monosodium glutamate or MSG, sometime masquerader under name such as “textured protein”. It is used as a meat tenderizer, flavour enhancer or used in canned meats and fish. This can trigger short-lived headache in some people. In about one-third people it gives rise to a feeling of tightness around their faces. Aspartment or the artificial sweetener, so commonly used in various preparations, is another grossly-abused food additive implicated in some headaches. It is said to contain a chemical that can even cause brain damage in susceptible individuals. Fermented soya and fish sauce often served in Chinese cuisine, tyrosine which is an amino acid found in pickled, and fermented products, chocolates which contain phenylethylamine and foods containing nitrates have been labeled as major headache triggers. Chillies, spices and alcohol can produce acidity in the stomach and one ends up with headache. Even such innocently looking common foods like milk, cheese, wheat and eggs do not get a clean chit on this count. Some allergy specialists go to the extent of pronouncing that 70 percent of all headaches are because of food factor in one way or the other. But it is going too far merely on the basis of conjectural evidence. Still in such matters “better safe than sorry” principle calls for prudence and one should better avoid eating substances which one believes will turn on pain process.13
In addition, there are some unusual headache triggers which appear to be remotely connected to the problem. Some of these factors are nothing more than idiosyncrasies. For example, footwears with extra high heels throw the whole body out of alignment, stretching both skeletal and muscular system and resulting in headache. Very cold ice cream and other iced cool drinks also do not escape the blame-their first sip or bite suddenly chills the palate of the mouth causing local nerves in that area send signals directly to the brain which feels like a sharp headache. Certain people are sensitive to perfumes, scent or aroma from food and suddenly feel a surge of pain signals in the head while it is being cooked or served.
In pain pathology food factor plays its role in yet another way as well. A drop in body glucose below an optimum level has been known to cause headache in some, if not in all individuals. Meals should, therefore, be eaten at regular intervals because long gaps in between can trigger headache. In particular, breakfast should never be skipped for it has to energise the body for rest of the day. Wherever possible, a helping of oily fish like salmon and mackerel or alternatively capsules of fish oil should form a part of daily diet because they have a gentle analgesic anti-inflammatory action on the entire body. Of course, these are long-term dietary measures and the benefit from them will not be experienced immediately, but after a period of eight to twelve weeks. Meanwhile, the consumption of large quantities of alcoholic drinks, tea and coffee should be moderated.
 
SLEEP FACTOR
Normal sleep helps relax and destress to provide relief from headache, but in some people it has the opposite effect by way of nocturnal headaches which may be the result of low serotonin levels in the blood during sleep. On the other hand, 14sleep deprivation is universally recognised cause of headache, but then too much of sleep also causes headache. Caffeine intake, alcohol consumption or smoking near bedtime or simply poor sleeping habits like covering up the face with a blanket and thereby restricting oxygen intake into the system, or a poor sleeping posture which exerts pressure on neck's skeletal system may also be counted among the contributing factors in the origin of many types of headaches. People not used to physical exertion on doing some strenuous physical work may feel headache because their blood vessels may not respond fast enough to cope with a sudden surge of blood supply. In such cases, excess blood may pool up in the head, making it feel as if the head is going to burst apart. Indeed, there are so many causes of headache, that it is becoming a cottage industry in the medical field.
 
Other Potential Factors
Chronic sinusitis accompanied by low grade fever, a thick coloured discharge from the nose or dripping in the back of the throat or tenderness over the sinuses around the eyes and cheeks is yet another important cause of headache which, of course, is not of a chronic type. A course of antibiotics and decongestants typically relieves such headache in a few days.
Very rarely a headache results from referred pain from other structures in and around the head such as eyes and ears or TMJ (temporal mandibular joint) syndrome. The clue to TMJ syndrome, which involves lower jaw joint and nearby chewing muscles in biting movement, is that the pain worsens by chewing and yawning.
A disease that can cause sudden headache and is more common in older individuals is giant cell arteritis. It is marked by growth of abnormal cells that can block arterial passages including the temporal artery on the side of the head. If the arteries to the eyes are blocked blindness can result. However, 15a simple test called “sedimentation rate” can easily determine if such a condition exists.
Other diseases which increase with age and are predisposing cause of headache include tumors (both benign and malignant) glaucoma, depression and arthritis of the neck and spine. But an old person with headache who experiences blind spot or sudden visual loss should be evaluated to rule out TIA (transient ischemic attack).
Heredity too has a role in some headaches. A hereditary chemical imbalance in the brain influences one's susceptibility to headache. The chemical involved is serotonin—the chemical neurotransmitter that relays messages from one cell to another.
 
TENSION AND CLUSTER HEADACHES
Unless a headache is a symptom of some very serious condition like a brain tumor or intracranial hemorrhage, 9 out of 10 patients who seek medical relief for their head pain have a migraine, tension headache or cluster headache. Migraine, unlike a brain tumor or brain hemorrhage, does not kill, but is an extremely debilitating and a traumatic experience. Fortunately, all headaches are not migraine related. A brief distinction between migraine and other types of headache may be in order. An ordinary headache does not impair visual faculty which migraine does by way of unusual auras and flashing lights. An ordinary headache may cause nausea but generally no vomiting, while migraine causes both nausea and vomiting. An ordinary headache comes without warning while migraine headache have premonitory signals like yawning or sudden craving for food. It is fashionable to link migraine to 4Cs (cheese, chocolate, coffee and citrus), but these 4Cs play a relatively minor role in ordinary headaches. Most of the ordinary headaches can be diagnosed fairly easily in 3 to 5 minutes of history taking with questions 16on nature of pain, timing, frequency, duration of each episode, localization of pain and accompanying symptoms which provide reasonable clues to the type of pain and remedies to be prescribed. But history taking of migraine type of pain is a long, cumbersome and arduous task because of a variety of factors involved in its pathogenesis. This being so, migraine headache is being dealt with in a separate chapter titled Probing Migraine Mystery which follows this chapter, while discussion on two other major types of headache, namely, “cluster” headache and “tension” headache is laid below.
 
CLUSTER HEADACHE
As the term “cluster” implies, this is a type of headache which appears in clusters several times a day over a short period followed by a long period of remission. The remission period may last from a few weeks to few months, and occasionally it can last for years before another patterned cluster of headaches reappears. During the attack phase, the first cluster occurs abruptly in the early hours of the morning, and in more than 50 percent of the cases such headaches occur with a clockwork regularity. The headache is so severe that the victim may be jolted out of sleep with an excruciating pain, first felt deep in and around the eyes which spreads to the sides of the forehead and onto the temporal regions of the face. The pain reaches its peak in 10 to 15 minutes and generally last for from 45 to 60 minutes. During the actual attack phase the carotid artery in the neck and temporal arteries of the same side of the head may feel “soft, silky and tender to palpitate.” The throbbing area appears reddish.
One salient feature of cluster headache is that it is confined to one side of the head/face, with orbital or temporal location. The pain is one of the worst known to man and characterized by deep redness in one eye as if the affected eye is being pushed forward. In some cases the pain is so intense that the 17patient clenches his fingers so tightly the finger nails get into the palms of the hands. The pain subsides as rapidly as it begins for no apparent reason, leaving its victim completely exhausted and broken down by the ordeal.
Dr TN Blau, a world authority on headache pathology, in his article “Behavior During Cluster Headache” in the Lancet (1993) provides a graphic clinical profile of cluster headache in words which may be reproduced in full: “The pain is one of the worst known, causes extreme restlessness. The patient rack and clutch the affected side of the head… bizarre behavioral responses bordering onto insanity… early morning uniocular pain which reaches its severity in 10-15 minutes. He cannot remain in bed; he paces around for 45-60 minutes holding one hand over the affected eye which reddens and waters; the other hand is placed on the adjacent temple or the ipsilateral neck. The ipsilateral nostril feels blocked and discharges a clear fluid. At the end of the episode he returns to bed, exhausted. Such attacks occur nightly for 6-8 weeks until the cluster period is over.”
A cluster headache differs from migraine headache, as explained in the Lancet article refereed to in the preceding para, in yet another way - “the inability of cluster headache patient to remain still during the attack, in contrast with migraine headaches where the slightest head movement tends to increase pain.” Restlessness is the major diagnostic criterion of cluster headache. But, perhaps one good point about cluster headaches is that, such headache are of short duration that rarely exceeds two hours.
For some reasons unknown to this day, cluster headaches are more common among men than in women. This is another point of departure from migraine headaches which are more common in women. Again, it is hypothesized that cluster headaches occur in families. A study reported in the Journal of Neurology, Neurosurgery and Psychiatry (1995) concluded 18that first degree relatives of someone with cluster headache have a 14-fold risk of having these headaches themselves.
Cluster headaches are not common in any particular part of the world. A report in the British Medical Journal (1993) stated that in a sample of 100 cases of headaches referred to two neurologists, there were only 3 cases of cluster headaches vs 53 cases of migraine alone. In India it is still rarer and in any case it is much less than migraine headaches.
Alcohol ingestion has sometime been blamed as being partly responsible for cluster headaches. “At the end of the first beer” is the typical response of a patient with cluster headache. But another strand of opinion regards alcohol as only a precipitating factor in attacks during the cluster period between attacks, but does not blame alcohol as a cause of the malady.
Exact cause of cluster headaches remains unknown, except the precipitating causes. Indirect evidence suggests that its nocturnal origin may be due to hypoxemia (insufficient oxygen in the blood) caused by sleep apnea. This also happens when one sleeps buried under a blanket and wakes up with headache because of poor intake of oxygen and a high level of carbon dioxide that builds up in the human system resulting in headache. Based on this assumption, a preferred mode of treatment of cluster headache is 5 − 8 liters of oxygen inhalation per minute for 10 minutes at the onset of an attack; the procedure to be repeated if the attack recurs.
Analgesics, singly or in combinations, have not been of much help in cluster headache. Two drugs which are used to treat cluster headaches are ergotamine tartrate (a crystalline alkaloid derived from ergot which is a fungus growing on rhy) and sumatriptan are of some help. It apparently works by narrowing the blood vessels to the brain and retains its effectiveness when used over a long period. Corticosteroids have also been tried with mixed results. 19However, the most effective measure to treat cluster headaches is a combination of two drugs, verapamil (mainly used for treating hypertension) and lithium (generally used in manic-depressive illness) under strict medical supervision. Those failing to respond to pharmacological intervention may have to seek advice of a neurosurgeon who may suggest a procedure which involves incision of a simple ganglion (a mass of nervous tissues lying outside the brain or spinal cord) as a remedial measure. Various prescription medications, including antidepressants, steroids, ergotlike compounds or drugs for heart do help as prophylactics under certain conditions.
 
TENSION HEADACHE
By far the most common type of headache accounting for 60 to 70 percent of all headaches is Tension Headache. Experienced as a dull sensation or heaviness this is a vice-like squeezing pain around the back of the neck, scalp or forehead which aggravates by poor posture or prolonged sitting in one position (as it happens with computer workers sitting before their terminals far too long) which stiffens musculature around the neck, strains eye muscles and causes emotional strain. Other causes of tension headaches are poor postures with the neck craned forward, excessive frowning or jaw clenching, TMJ(temporomandibular joint) dysfunction, sinus infection, nasal congestion, strenuous exercise on a hot day resulting in dehydration or some form of physical and mental fatigue. Typically an individual with this type of problem explains “a band around my head as if I am wearing a hat” or “a pressure like a weight on the top of my head” may also be described as a “dull constricting pain in the hat band region.”
As one wakes up in the morning one feels fresh, relaxed and pain-free, but as the day progresses tension builds up in severity so that by the late afternoon one is completely worn 20out by pain. Physical sign of tension headache are “wrinkled forehead, taut looks, muscle contraction at the jaws and temple, while the patient restlessly clenches and unclenches fingers.” There may be a local tenderness or muscle spasm adjacent to a painful site—for example, cervical spondylosis which gets worse by the movement of the muscle, and often relieved by hot or cold pads or analgesics. Unlike migraine, tension headache is not associated with visual or gastric disorders.
The pain arising out of tension headache lasts for weeks or even months. Nature of pain is continuous with very little changes in severity throughout the working period. The pain rarely interferes with day-to-day routine activities, is responsive to common analgesics but more responsive to sedatives alone or in combination with analgesics. In majority of cases one's first encounter with tension headache is during early adulthood, though a few may have it at an earlier age. For some unknown reasons tension headache is more common among women than in men-may be men can better absorb emotional trauma than women in similar situations. As explained in the foregoing review, according to American Medical Association more women (76%) than men (57%) experience recurring headaches.
Tension headache is not the same type of headache which one experiences after a strenuous physical activity. Such cases of exertional headaches are fatigue-related innocent transitory events which are easily helped by simple analgesics like simple aspirin or paracetamol or by simply changing to less strenuous job.
Newer investigative techniques to better understand the nature of tension headache through electromyography (EMG) which measures muscle contraction and assess manual palpitation by a pressure algometer, bring out that muscular tension, though an important factor, is not by itself enough 21to explain tension headache in majority of the cases-in fact, some research has recently established that there is no direct casual link between contraction of scalp muscle and tension headache; though it may influence the severity and duration of such headaches. Recent understanding of serotonergic pathways involved in neural mechanism in sleep and sensory perception shows that all types of pain results from some defect in the brain's pain control system that affects both opiate receptors, serotonergic transmission and biochemical balance which show through headache. This mechanist concept of pain should, however, not undermine the role emotional factors play in all types of headache in general and tension headache in particular in modulating the nervous system responsible for all sort of sensations including those of pain.
Relief measures for tension headaches are many. Common analgesics combined with sedatives, as said earlier, do help at least temporarily. Relaxation exercises like (say) meditation, massage and gently stretching of the neck and shoulder, yogic exercises do help. A method most often used to relieve tension headache recommends: “Try moving eyes clockwise circle several times, then counter-clockwise.” Give rest to the eyes in every few hours by cupping them lightly with the palms of hands or looking into natural greenery for a few minutes as a break from strenuous work—physical as well as mental. Avoid extreme environment—too much hot, too much cold, too noisy and very bright light.
Another method to stop tension headaches described by Mira Kanaster, a US-based massaged therapist and author of Discovering the Body's Wisdom explains a simple pain control technique common among practitioners of acupressure: “With your right thumb, apply firmly pressure to the web between the thumb and the index finger on your left hand. Press inward, slightly under the bone. Hold the 22position for one minute, then switch to the other hand.” But a word of caution is given on this practice. “Using this technique during pregnancy may cause contractions.”
The relief effect of other therapies on headaches have been mixed. Results of acupuncture have been extremely poor. Hypnosis too appears to be of no help. Psychotherapy does help. Most of the patients would have tried all sort of remedies, including routine analgesics, but without much help, when they seek medical advice. As such they would expect an in-depth investigation like CT scan or MRI to build their confidence rather than to be handed over yet another routine prescription slip by the attending doctor. Such diagnostic measures are for those with chronic and disabling headaches who have not been helped by routine treatment and their headache persists and interferes with their routine activities.
 
HANGOVER HEADACHES
Discussion on tension headache will not be complete without some reference to hangovers so common amongst the drinking populations. Tension headache should not be confused with “hangover”—a malaise accompanied by headache “day after” following the night of over-indulgence with alcohol. Hangover generally follows after a stuporous sleep as a direct outcome of consuming alcohol faster than the body can absorb it. Excess of alcohol dilates blood vessels in the head which shows up through headache; the pain stops when blood vessels return to normal. Normal accompaniments of hangovers are thirst, nausea, exhaustion, depression and irritability, though symptoms and severity vary.
Therapy for hangovers is nonspecific. But choosing alcohol that combines with fruit juice, avoiding such alcohol as champagne, red wine, a 12-year-old scotch and fancy liqueurs that contain a high level of headache triggers do help prevent hangover headaches.23
 
THE WAY AHEAD
Recent pharmaceutical advances show that more than 80% of headaches respond well to treatment. Some drugs that are prescribed for other medical conditions can also cure headaches (a case in point is nitroglycerine to treat angina). They do so by stabilizing and regulating brain centers and brain chemicals which are involved in headache mechanism. By doing so they reduce both the frequency and severity of headache attack. These medicines include certain anticonvulsants, some of the antidepressants, beta blockers, calcium channel blockers and ergot derivatives. Researchers around the world are also zeroing onto a new preventive immunization against headache and new drugs that are not habit forming and without side effects.
Many people try to live with their headaches far too long before they go to a doctor. But if a severe headache persists for more than a day, or if the headache is of such intensity as to interfere with his activities, one should not delay seeking medical intervention. In particular, this should be the right course if a headache persists, grows worse, changes its nature, is a new kind never experienced before, or is associated with other symptoms. If a child complains of headache which is not relieved by routine analgesics, has fever or not doing well in school-in short, “if he just isn't himself—it would be wise to have him examined,” for persistent, disabling headaches in children are more ominous than in adults.
A cardinal rule for headache avoidance is to shun potentially addictive medication and eliminate possible trigger factors. Apply a cold pack where the pain is centered on the heads or upper back neck as soon as possible. This provides some relief in as many as 70 percent of headache cases. Running cold water over the head may have a similar effect.
Skipping meals or meals at irregular hours result in drop of blood sugar which presage headaches. Regular meals to 24prevent low blood sugar. Unless one is diabetic, take a small snack the last thing at night to keep blood sugar at optimum level and again on waking up in the morning before a full breakfast to store enough “fuel” for the body to function well the whole day. Drink plenty of water to replace lost fluids, particularly in hot weather or following physical exertion or excessive alcohol consumption to prevent headache. To avoid being dehydrated, it is a good practice to sip water off and on during the course of the day as a health ritual rather than drinking water only when thirsty.
The way ahead is to understand the basic mechanism of origin, conduction and perception of headache, the role of contributing factors and the relief measures which can be undertaken to soften pain in the head. Headache laboratories are involved in research on artificial induction of headache to explore the possibility if on some future date some antiserum can be developed to immunise people against headache. As more information becomes available on such modes and modalities of headache, we shall be able to prevent and treat headache more effectively. This is the chief goal and fond hope of headache researchers in the days ahead.