Friday, April 17, 2009

Migrane (I)

About 95% of recurrent headaches are either migraine or tension headaches. Some people have both kinds. Some medical texts refer to this as “mixedheadache disorder.” For many years, these two headache types were thought to be independent disorders, but now many neurologists feel the mechanisms that cause both of them are similar and treatments for them overlap. Like two flavors of ice cream, migraine and tension headache lie on the same spectrum of headache. There are other notable forms of “primary” headache such as cluster headaches. These are fortunately uncommon and will not be discussed here. Most headaches can be diagnosed by your health care provider through a history of symptoms and a physical exam. Rarely, there may be a secondary cause of headache such as a tumor or blood vessel problem. In the event a rarer cause of headache is suspected, blood work, neurology referral, or even imaging by CT or MRI may be needed. Typically, no scanning is warranted for uncomplicated migraine and tension headaches, as they are usually normal and are costly to the patient.

Characteristics of Common Headaches Migraine Headaches:
Usually have a pulsing or throbbing quality, but may be continual dull ache, or pressure. Some describe stabbing or sharp pains.
  • Are felt on one or both sides of the head, in regions of the cheeks, behind eyes, forehead, temples, crown, sides or back of the head
  • May be first experienced in childhood, but most have their first in late teens or 20’s
  • May be mistaken for recurrent “sinus infections” or “sinus headaches” as they can occur with nasal congestion and result in pressure under and behind the eyes
  • May have neck tension at the beginning or throughout - mistaken as a tension headache lasts several hours to several days
  • Usually occur abruptly; often a patient feels fine at bedtime, and wakes with the pain; pain may develop in a short time of several minutes to hours; pain may quickly rise to moderate or severe intensity
  • May be debilitating or just severe enough to impair daily function or performance
  • May have nausea or vomiting along with pain
  • May be improved or relieved by sleep, often a person seeks a darkened room and bed for Relief
  • May be worsened with activity, exercise, bright lights or noise
  • May be preceded by visual changes, such as an aura of zigzagging lines or blind-spots
  • May occur as infrequently as once a year or several times a week
  • Often there is a family history of one or more family members with migraine, tension headaches, “sick headaches”, or “sinus headaches”
  • Over-the-counter pain medications may completely relieve, blunt, or not help pain
Tension Headaches:
  • May present as a constant dull ache, often progressively worsening over several hours
  • May be felt on both sides of the head, the frontal area, or at the base of the head and neck
  • Usually felt as a squeezing, tightness or band like constriction around the head
  • Severity is usually not disabling as migraine can be, but may impair performance or function precursor of neck and shoulder stiffness common
  • May be experienced on an infrequent basis, or become a daily occurrence with time are noted at the end of work or class days or at times of “stress-let-down,” after exams or on vacation
  • Over-the-counter pain medications frequently help, but with time not be as effective exercise, sleep, massage may help but seldom worsens it
  • With time can go from an occasional or episodic to a chronic or near daily headache; through the course of the day may intensifyand take on more qualities of migraine
What Causes Headaches?
Estimates are that over 28 million Americans suffer from headache and meet criteria for migraine on history alone. Only 14 million are currently diagnosed. So many still go through life self-treating them as “regular” or “plain-old headaches,” thinking they are “sinus” headaches or sinus infections, or simply don’t feel they are “bad enough to be a migraine.” Perhaps 3% of these are tension headache. We all have the ability to experience headache but some people have a higher headache threshold or point which the headache process is triggered and pain begins. Others have low thresholds and get more frequent headaches. Migraine (and it is theorized tension headache) is a complicated process that begins with exposure to a trigger or group of triggers. This subsequently causes the propagation of an aberrant neurochemical process in the brainstem structure (nucleus caudalis) outward along one or both cranial nerves (trigeminal nerves) to the cheeks, eyes, forehead and temples. The cervical nerves (cervical roots C2,C3,C4) may also be activated affecting the base of the skull and upper neck. Affected nerves and blood vessels along the way experience swelling and release pain generating chemicals (called neurogenic vasoinflammation). The process eventually spreads like a forest fire to the furthest extents of neurons in the brain and surrounding structures (called central sensitization). It causes pain over a portion of or the entire head. Neck stiffness and pain can erroneously be thought of as a tension or muscle-contraction headache. Sudden onset mask-like pain in the cheeks, eyes or forehead can wrongly be thought to be sinusitis. Headaches are easier to trigger in some people than others. Some common triggers of migraine are:
  • Acute or chronic emotional and/or physical stress
  • Weather changes such as barometric pressure drops with storm fronts, changes in altitude or depth such as with flying or scuba diving
  • Odors like perfumes or colognes
  • Irregular sleep; too much, too little (less than or greater than 7–8 hours a night)
  • Low blood sugar from skipping meals
  • Caffeine use or withdrawal from it if regular daily intake has been high
  • Menstrual cycles, typically drops in estrogen just prior to beginning menstruation
  • Ingestion of MSG (monosodium glutamate) and its many hidden forms found in an abundance of packaged and frozen foods, restaurant foods, chips and spice mixes
  • Ingestion of foods with nitrates, found in most processed meats
  • Ingestion of instant soups (bouillon), cheeses, and gravies found in All-You-Can-Eat bars
  • Ingestion of alcohols like wine (from sulfites), and beer (from yeasts)
  • Ingestion of NutraSweet, especially multiple servings through the day (Splenda is OK!)
  • Ingestion of chocolate, onions, aged cheeses, smoked or pickled foods, nuts, bananas, pineapples, and even citrus fruits and juices
  • Lengthy exposure to flickering lights, fluorescent lights, even bright sunlight, and computer screens Remember that any one trigger or the combined effects of several triggers may spawn a migraine. Due to similar mechanisms, tension headache may result from these too. The effects of triggers are cumulative each day or mount over time from regular exposure. Small doses of triggers are sometimes all it takes to cause a headache.
continued (part 2)

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