Headaches
AUTHOR: Judson J. Somerville, M.D., 
The Pain Management Clinic of Laredo

Many of us suffer from occasional tension headaches, especially after a difficult day. Though these can be annoying they are not incapacitating.  Some people, however, suffer from incapacitating headaches, which result in quite a bit of their lives being put on hold due to constant pain.  Though the term migraine headache is familiar to most of us there are many types of headaches many of which are frequently misdiagnosed as migraine headaches, when in fact they are not. Clusters headaches, cervigenic headaches and occipital headaches are just a few of the names of headaches frequently treated in a pain clinic, but which may be misdiagnosed as migraine headaches. The importance of having the correct diagnosis is in determining which treatments are given. If you have the wrong diagnosis you will frequently give the wrong treatment, which is not ideal. Though books have been written on headaches we will narrow our focus and talk about important and the more common severe headaches.  Important headaches are the "worse headaches of your life" and more common severe headaches include "real" migraines and cervigenic headaches. 

The worse headache of your life is a warning sign. Frequently if you have a family history of migraine type headaches and are in your teens or twenties it's just the beginning of these types of headaches. However, even if you have a strong family history of headaches the "worse headaches of your life" needs to be looked at immediately by a medical doctor. Sometimes this is a first sign of a tumor so it's important to see a physician. If in addition you have dizziness or problems with smell, taste, vision, or hearing this is more concerning. Sometimes these types of headaches can occur following an injury to your head or may occur spontaneously.  You must go to the emergency room immediately. With an episode of your " the worse headache of your life" without injury it's still must be looked at, but an emergency room visit is not necessary, unless there is a change in level of consciousness or the person is getting worse. If an acute injury was the cause and it is detected soon enough it is treatable.  Typically the "worse headaches of your life" will either require a CAT Scan or MRI.  The "worse headaches of your life" following an accident usually caused by bleeding into the head. You must not assume it will get better and avoid medical care.

Cervigenic headaches are a frequent type of severe headache, which is often missed diagnosed as "migraines", but in my experience cervigenic headaches are much more common than migraines. Frequently there is a whiplash injury or some other injury to the patient's neck in the past.  No headaches may be experienced for years following the accident however once they start the person has frequently forgotten the old injury. The pain is often to one side of the face and neck or other, frequently alternating sides. True migraines do not do this. These headaches are very persistent and can cause poor sleep. Now poor sleep may not be what you think it is. It is where you lie down and close your eyes for 8 hours, but you wake up more tired than when you went to sleep.  By definition you closed your eyes for 8 hours and did not move, but you did not rest. Other times it can be just tossing and turning all night long. Though some of the medications used for migraines will help with cervigenic headaches, the more common medications used include anti-inflammatories and anti-depressants. However, even with medication pain control usually is minimal during a severe attack. A procedure called a cervical epidural steroid injection is the most useful to help control this type of pain. Usually, before we perform this procedure medications and physical therapy are tried.  Typically physical therapy and medications only help a little bit and the cervical epidural injection is necessary. Ordinarily after having this procedure done the patient's pain improves and I prescribe chiropractic neck exercises. These exercises consist of the patient lying flat on a bed or on the floor and slowly rotating their head from side to side to stretch and strengthen the muscles in their neck. The patient is to do this for one minute a day for the first three days following the procedure. Then the patient will do the exercises one minute every other hour for the next three days and then once in the morning and once in the evening or when the patient is severe for the rest of their life. Certainly, if with these exercises symptoms worsen or cause more pain the patient is instructed to stop the exercises.  Usually the medications injections and exercises are sufficient to control the pain.

True migraines are difficult to treat, but can be treated. These types of headaches have a strong family connection.  This means many relatives in the headache sufferer's family will have experienced the same type of headaches. These headaches may begin at childhood, but almost always arise by the time the patient finishes their 20's. There are more common in women.  Certain type of foods or situations such as change in diet, or sleep habits, tyrosine containing foods, monosodium glutamate containing foods, alcohol, stress or fatigue to name a few can precipitate these headaches.  Often there are four stages to these headaches.  Every migraine sufferer is different and some will have all four stages and some will have different components of the four stages. The prodrom, which is the 1st stage, occurs days or hours before an attack. The migraine sufferer will experience sensitivity to light, sound, mood changes, food cravings or loss of appetite, tiredness, constipation or diarrhea. The 2^nd stage, the aura is an abnormal sensation prior to the headache. The auras occur 5-30 minutes before the headache.  These could be blurred vision, ringing in the ears, or unusual smelling or numbness in an extremity. Migraine sufferers can have very severe auras, but usually they are mild. The  third stage the headaches themselves can last up to hours and weeks with vision problems, depression, pain and nausea and vomiting. The fourth stage of migraines is the postdrome following  the headaches the patient may feel tired and drained. Treatments consistent of medications. In the past the treatment of migraine headaches was poor. Fortunately, there are newer medications such as Imitrex and Zomig, which can help stop the headaches when they first start. There are also medications to help prevent the headaches from  beginning in the first place such as antidepressants and anti-seizure medications.

Although, it seems strange that a medication which helps with depression and seizures could help with headaches, both of these medications do work without the patient having a seizure or having any history of a seizure or experiencing depression. Also, life style changes and diet can help prevent these types of headaches.  There is a national organization called the National Headache Foundation, which has a toll free number 1-800-843-2256, which can assist with, further information.

Overall headaches are challenging medical problems that require a lot of expertise in patients to treat. Though not everyone will be "cured" of his or her headaches, but the headaches can be improved enough so the patient can live essentially a normal life. The "worse headaches of your life" is an emergency and should be examined by a doctor immediately whereas cervigenic and migraine headaches are surely " a pain", but not life threatening. Every day new medications and treatments as well as our understanding of these headaches improve making for safer, faster and easier treatments of these difficult headaches.