headache/migraine general information
what types and how common? The International Headache Society recognises thirteen
major categories of headache1 (e.g. migraine, tension-type, cluster, head trauma and so on)
and over a hundred different sub-categories. A recent major survey2 found that the percentages of adults who had suffered from any category of headache, migraine or tension-type
headache at some stage in their lives were 99, 25 and 88% for women and 93, 8 and 69% for
men. In the previous year 15% of women and 6% of men had suffered from migraine, while
86% of women and 63% of men had suffered from tension-type headache. About 1 in 3 adults
suffered from more than a headache a month and 1 in 30 a headache at least every other day.
The survey concluded "Headache disorders are extremely prevalent and represent a major
health problem."
what causes headache and migraine? All the major categories of disease may need to
be considered when coming to a diagnosis in a headache sufferer. Examples of possible causes
include head trauma, vascular disorders, non-vascular intracranial disorders, disorders of the
neck, eyes, ears, nose, sinuses & teeth, viral & bacterial infections, and metabolic problems.
This handout however will focus mainly on the most common forms of head pain - tension-type
headaches and migraine. Stress3, menstruation, alcohol, smoking, weather changes, food4,
genetic predisposition5, psychological state6, housing7, physical & sexual abuse8 and overuse of
medication9 are some of the factors that may at times contribute to these headache disorders.
the bath-tub model: It can be very confusing when trying to understand what causes
someone's headaches to find that a particular factor sometimes triggers a headache and
sometimes doesn't. To explain this I use what I call a bath-tub model. The different factors
that contribute to the headache all add to the level of water in the bath-tub. However it is only
when the water level gets so high that it overflows from the bath-tub that one develops obvious
symptoms of headache. So having an argument might or might not trigger a headache. This
depends firstly on whether arguments are one of the factors that are relevant to my headaches
- one of the factors that add water to my bath-tub of vulnerability. Secondly even if arguments
are relevant triggers, this particular argument will only trigger a headache on this particular
occasion if the water level in the tub is so close to the top that the addition of the argument's
"water load" pushes the water level high enough to spill over into obvious symptoms.
mood and personality: There are strong associations between depression5 & anxiety10
and migraine & tension-type headaches. For example6, when patients presenting to a family
practice with headaches recurring almost every day were assessed psychologically, 74% were
found to have a clinically significant depression. Similarly in a random sample of 500 young
adults10, migraine sufferers rated significantly more highly than non-sufferers on test scores
for anxiety, panic, depression, obsessive/compulsive and somatization. The association with
anxiety was particularly strong. It seems very likely from the research that this connection
between mood and headache disorders is due to both a shared genetic vulnerability and also
a mutual aggravation where mood disorder worsens headache and vice-versa. However the
belief that there is a particular migraine personality type - for example characterized by
ambition, orderliness and rigidity - is probably a myth11.
stress and trauma: Stress seems to be of particular importance as a precipitating factor
for headaches. In a recent major study3 stress & mental tension was reported as a trigger for
both migraine and tension-type headaches more than twice as often as any other factor. The
frequency and perceived unpleasantness of daily hassles, particularly hassles related to health,
parallels the frequency and intensity of headaches in chronic sufferers12. As with mood
disorders the cause-effect relationship is probably two way. A sudden increase in stressful 1.
major life events13, especially losses and illness, may well herald the start of a headache
problem. A history of sexual or physical abuse - particularly wife battering - may at times be
relevant14, though usually the association with the onset of a headache problem is not
recognised by either sufferer or therapist.
treatment overview: James Lance, former president of the International Headache
Society, has a useful flow-chart15 where he suggests that for many who only suffer headaches
monthly or less frequently, it may be enough firstly to detect and where appropriate avoid
personal trigger factors (possibilities include excessive light/noise/smells, smoking, stress/
relaxation post stress, certain foods or lack of food, alcohol) and secondly to use relief
medication or other "first aid" methods. The recently introduced sumatriptan16 (Imigran) is a
useful step forward in relief medication, though orally it seems only modestly more effective
than established forms of treatment. For those who suffer from frequent headaches, it is more
obviously relevant to consider counselling, relaxation methods, physical exercise and regular
prophylactic medication. It may be sensible to check for depression, high blood pressure and
excessive use of medication especially if the headaches are increasing in frequency.
relaxation, biofeedback and stress management: Relaxation orientated therapies
produce 45 to 65% improvement in migraine17 - similar to the benefits achieved by medication.
Tension-type headaches are likely to respond even better than migraine to such relaxation
based techniques18. For tension-type headaches, relaxation therapies may well be more
effective than pills19. This greater effectiveness of stress management over pills is probably
also true for migraine in adolescents20. Improvements are well maintained or even increased
at follow up21 several years later. Although relaxation skills are in general as helpful as
biofeedback21, in selected cases it may be worth adding this more complex technique18.
Similarly, adding further stress management skills such as problem solving, assertiveness
training and cognitive restructuring may well further increase22 the benefits achieved. At times
it may be important to look for and treat associated depression, grief and abuse. The ways
forward in this area include working to reduce the demands on face-to-face therapist time20 by
making treatments more home-based, adding further skills to a base of well taught relaxation
when appropriate, and clarifying when and what other therapies can be used alongside stress
management for more difficult cases.
acupuncture, massage and trigger points: Acupuncture can produce impressive
results in the treatment of headache. Treating migraine in a well performed, placebo controlled
trial23, Vincent achieved a 44% reduction in overall pain and a 33% reduction in medication at 6
week follow-up after half a dozen weekly acupuncture sessions. Despite no further treatment,
this improvement continued to increase, so that at one year follow-up there was a 69%
reduction in pain and a 63% reduction in medication. The placebo acupuncture group only
achieved minimal improvement even thought they rated their treatment as equally credible.
It seems likely that more traditional acupuncture approaches24 - with less focus on tender
points and more minimal stimulation - are likely to be less effective. In general, tension-type
headache probably responds even better than migraine25. Massage, both generally and working
on specific areas of tenderness, may also be helpful26. Testing trigger areas for tenderness27
can even act as an early warning system for those who suffer from headaches
food and environment: Food allergy, chemical triggers, hypoglycaemia and environmental
factors may all be relevant for headache sufferers. Claimed success rates vary widely. There is
no doubt that very good results can be achieved in certain groups of patients - for example
70%28 to 90%29 response rates in some severe sufferers, particularly children. An elimination
diet followed by the reintroduction of suspected foods is still the gold standard4 for diagnosis.
Other techniques of diagnosis should be approached rather more tentatively - and some are
probably worse than useless. It seems quite likely that in migraine at least 50% of
2.
sufferers will improve on an elimination diet4 so if the headaches are troublesome enough this
approach30 is well worth trying. Sometimes the problem is due to a true allergy; however
probably more commonly chemical components31 of food and other substances may be the real
cause of the headaches. Partial enzyme deficiencies and psychological reactions may also
complicate the picture. Hypoglycaemia may trigger migraines32. Avoiding too much sugar and
refined carbohydrate, eating three well-balanced meals daily and possibly also snacking a little
non-sugary, protein containing food at least once between each main meal may help
considerably. Finally other environmental factors such as smoke, fumes29 and even buildings7
can cause problems.
other treatments: I have already discussed most of the headache treatments that
are better supported by current research. There is also some evidence33 that suggests
homoeopathy may be worth trying. It is clear too that problems in the neck may cause
headache34 so manipulation and other cervical treatment is worth considering in some cases.
Clearly almost any intervention will have its proportion of placebo successes, so a critical
approach to therapists' claims makes good sense. Even so, any general approach such as
physical exercise35 or other efforts to promote general "wellness"36 are likely to boost the
response to more specific treatments and increase overall well-being.
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