Headache
 

by Dr. Dave Horsfall, MBChB


t is estimated that three quarters of the population will suffer from a headache in any one year and it is one of the commonest complaints to a family doctor. Fortunately most headaches are not serious and only a very few will turn out to be life threatening. Despite these facts the doctor must to rule out any serious cause of headache during the course of his consultation

Although the commonest causes of headache are tension headache and migraine, there are other less common causes that your doctor needs to check for, as the treatment is different. Neck pain or cervical spondylosis is thought to cause headache by referring pain from the neck over to the top of the head. Dental disorders, refractory eye errors and sinusitis can also cause pain referred to the head.

It is important that a doctor rules out the rare serious causes of headache. The worrying conditions patients need reassurance over are bleeding in the head (sub arachnoid haemorrhage and haematomas), strokes, tumours in the head, usually derived from spread from lung cancer, infections in the head such as meningitis, and temporal arteritis a condition mainly found in the elderly where the arteries in the head are inflamed and if not treated can lead to blindness

Headaches can be an interesting problem for a doctor as patients presenting with headaches may in fact have an unrelated illness. The patient may be suffering from depression, sugar diabetes, anaemia, thyroid disease or he may be taking other medications that can cause headaches. A patient presenting with headache may be using a headache as an excuse for other problems unrelated to a headache. There are also some patients who present to a family practitioner with severe headache, trying to "feed" an opiate or other pain drug addiction.

What headache a patient suffers from depends almost entirely on an accurate history. The physical examination and laboratory investigations are usually unhelpful and are used primarily to rule out the rare serious disorders, so most doctors will advise some investigations for this reason.

The main non-serious headaches, which will be discussed, are tension-type headache and migraine.

Tension-Type Headache is the most common headache presenting to a doctor, with women suffering from these headaches slightly more often than men. (F : M = 1.4 : 1). These headaches, which are recurrent, can either be episodic or chronic.

Episodic tension-type headache is characterized by recurrent episodes of headache that last for a few minutes to several days. The patient experiences a mild to moderate pressing or tightening pain around the head. The headache is not worsened with routine physical activity and the patient does not suffer from any nausea. There are no visual or aural (photophobia or phonophobia) experiences with this headache.

In chronic tension-type headache, the pain is similar to episodic tension-type headaches except that they come on more frequently. The patient suffers with the headache for at least 15 days of the month for at least 6 months and the patient may also suffer from some nausea, photophobia, or phonophobia.

The treatment of episodic tension-type headache is by simple analgesics (aspirin, paracetemol, or ibuprofen.). These are not effective for chronic headaches as they do not alleviate the pain well and contribute to analgesic-abuse headache. Chronic tension-type headaches are treated with preventative medication when the headache disturbs the patients daily activity. Drugs commonly used are the tricyclic antidepressants (e.g. Amitriptyline).

Migraine headaches are severe throbbing headaches occurring on one side of the head, usually over one eye. They are recurrent, occurring at least 5 times a year. People suffering from these headaches may also have some nausea and vomiting. They are not as common as tension-type headache but are more frequent in women than men. They occur at any age but usually between the ages of 10 and 30. Many migraine sufferers have a history of migraine in their family. The cause of these headaches is unknown but stress, some drugs such as oral contraceptive medication, and some foods such as chocolate and red wine may bring them on. The headache may be aggravated by routine physical activity like walking up a flight of stairs. The patient may also experience some feeling of nausea and may be intolerant of light and noise.

The classic migraine is accompanied by an aura, which is an unpleasant sensory experience occurring before the headache. Visual auras are the most common and may appear in one eye as a moving, bright, curved, saw-tooth line with obscured vision. Some of these figures are strikingly colourful, whereas others are dull and monochromatic. Spreading numbness, in one side of the face or upper limb, or both, is the next most common aura. These auras develop over about 5 to 20 minutes and last for less than an hour. They are followed by the headache. Fortunately, most people who suffer from migraine headaches do not experience an aura.

The management of migraine headaches is initially centered on preventing them occurring. Avoidance of stress situations with accompanied exercise, discontinuation of oral contraceptive medication and avoidance of foods that precipitate attacks. Medication for migraines are used to either treat a migraine that is in progress or to prevent the onset of headaches in patients with disabling recurrent migraine. Fortunately most migraines are mild and can be managed with non prescriptive analgesic such as aspirin, paracetemol and ibuprofen. Severe headaches however can be aborted with sumatriptan or ergotamine. In some cases opiod medication may be required.

Although there are a lot of other benign headaches that people can suffer from, they are unusual and cannot be discussed here. Any headache that is unusually severe, presenting for the first time, comes on suddenly or associated with other problems such as nausea, vomiting or change in mental status probably needs to be assessed by a doctor to ensure that there is no serious problems. But it is important to realize that most headaches are no more than tension-type or migraine headaches.