Headaches

Definition

A headache is head pain above the eyes or ears, affecting either the whole head or one side, top or back of the head, and sometimes extending into the neck.

Description

Everyone gets headaches. A primary headache is one with no specific underlying cause, developing most often as a result of general tension or muscle tension. Other primary headaches include cluster headaches and migraines; neither is common in senior adults. Second in frequency to tension headaches, migraine headaches are more serious than other primary headaches and usually require clinical evaluation and treatment. They are often accompanied by nervous system symptoms such as nausea and exaggerated sensitivity to light, sounds, or odors. They can begin in childhood and continue through middle age when they often diminish.

Secondary headaches develop because of a specific underlying condition that in some way affects blood circulation or nerves of the head; secondary causes range from harmless to life-threatening. The simplest types of secondary headache are caused by eye strain, allergies and hay fever, food additives, inhaled irritants, stomach upsets, indigestion, constipation , use of alcohol or caffeine, smoking cigarettes, and bumping the head, and can usually be treated successfully by correcting the underlying condition. Sometimes primary headaches are confused with tension headaches, including those caused by sinusitis or sinus infection, allergic reactions, a misaligned jaw (temporomandibular joint syndrome or TMJ), high blood pressure (hypertension ), and low blood sugar (hypoglycemia). Older adults are most often affected by hypertension headaches, caused by high blood pressure, and temporal headaches, caused by inflammation of arteries that pass through the temples on either side of the head. Because some underlying causes of headache can be life threatening, persistent headaches, headaches with fever or vomiting, sudden severe headaches, and those following a fall or accident should always be reported to a healthcare practitioner so that a possible underlying condition can be identified and treated without delay.

Common Forms of Headaches

• Tension headache: most common form, a constant pain or pressure in one area or around entire head, feeling like a tight band, with most acute pain over eyebrows, sometimes accompanied by aching neck and shoulders.
• Cluster headache: rare but severe with throbbing pain on one side several times a day for minutes or hours, with flushed face, tearing eyes, and congested nose.
• Common migraine: second most common primary headache with severe throbbing typically on one side, nausea, possible vomiting, light and noise sensitivity, and sometimes dizziness.
• Eyestrain headache: frequent pain in front on both sides of the head.
• Hunger headache: top of head or all over, occurs before mealtimes because of low blood sugar (hypoglycemia).
• Bilious headache: dull pain in the forehead with possible throbbing in temples after eating too much or with indigestion, can also occur with immediate sitting or lying down after eating.
• Sinus headache: persistent pain over nose and cheeks, one or both sides, may start upon waking and continue all day, accompanied by heavy mucus drainage.
• High blood pressure (hypertension) headache: dull pain over entire head becoming worse with physical activity.
• Temporal headache: stabbing or consistent pain in temples on both sides or around the ear.
• Temporal mandibular joint headache: pain above the ears and in temples with muscle contraction along the jaw and clicking of jaw on movement, simultaneous shoulder and neck pain.
• Exertion headache: overall headache occurring only after physical exertion, sneezing, or coughing.

Demographics

Researchers report that 90% of headaches are tension headaches, which occur in men and women alike, with no differences based on age or race. Cluster headaches are rare (1% of population) and occur primarily in men between ages 28 and 30. Migraine headaches represent 6% of headaches, occurring in 6% of all men and 18% of all women but usually diminishing in mid-life and occurring less often in senior adults. Temporal headaches occur primarily in individuals over age 50. Headaches caused by an underlying condition occur with the same frequency as the condition and within the population affected by the condition. (See specific condition for details.)

Causes and symptoms

A wide range of factors and underlying conditions are responsible for causing primary headaches in senior adults. Tension headaches are caused by stress and tenseness or muscle tension, occurring daily in some individuals. Although cluster headaches are believed to be triggered by drinking alcohol or smoking cigarettes, they do not typically affect older adults.

Older adults who had migraine headaches when younger may find that symptoms diminish with age.

The cause of migraine is believed to be abnormal nervous system processing of signals in the brain (neurovascular pain syndrome) combined with inflammation of veins in the head and facial area (trigeminal vascular system). Migraine headaches are triggered by lifestyle and environmental causes, including skipped meals, red wine, changes in weather, lack of sleep, stress, fluctuating estrogen levels in women, and flashing lights or strong odors. The outstanding symptom is severe headache with vision problems and nauseas and, less often, speech disturbances or numbness in face and arms. Tension headaches can also trigger migraines in some people. Food cravings and feelings of sleepiness, irritability, or depression may precede a migraine headache by hours or days.

Many underlying conditions cause secondary headaches, including sinus infections, eyestrain, physical exertion, hunger, indigestion, overeating, caffeine consumption and withdrawal, and overuse of pain medications. More serious causes include:

• Temporal mandibular joint syndrome, a malformation of the jaw
• Brain tumors
• Pooling of blood beneath outer covering of brain (subdural hematoma) or blood from rupture of arteries inside the skull (epidural hematoma)
• Bacterial infections such as meningitis, tuberculosis , or Lyme disease
• Stroke due to blood clots or rupture of blood vessels in the brain
• Hemorrhage between the brain and its outer lining (subarachnoid hemorrhage or aneurysm)
• Severe high blood pressure
• Inflammation of temporal arteries (temporal arteritis) on each side of the head at the temples
• Glaucoma with sudden increase in pressure inside the eye
• Parkinson 's disease
• Under-active thyroid (hypothyroidism)
• Lack of blood supply to heart muscles (cardiac ischemia)

Certain medications also cause headaches, including estrogen, progestin, antidepressants (selective serotonin reuptake inhibitors) and blood pressure medications (calcium channel blockers ).

Symptoms of headaches range from feeling a band of tightness around the head to stabbing pain.

Diagnosis

Tension headaches do not always require physician diagnosis and treatment; however, it is important to differentiate suspected tension headaches from secondary forms so that an underlying illness can be identified as a possible cause. An accurate diagnosis of the underlying illness that is causing secondary headaches is essential because more serious causes of headache can also affect the brain, causing significant damage and possibly death . Doctors will take a history, particularly about typical onset of the headaches and type and location of pain, as well as age at onset, history of head trauma, prior and current illness, and medications. Routine physical examination may be followed by laboratory tests to determine blood, heart, and thyroid status and possible presence of infection. Cultures may be done to identify bacteria causing suspected infection. Diagnostic imaging of the head such as computed tomography (CT) and magnetic resonance imaging (MRI) may be done to identify the presence of tumors, bleeding, blood clots , or aneurysm . A spinal tap may be necessary to rule out meningitis .

Treatment

Treatment for tension headaches or even minor migraine headaches is typically an over-the-counter pain medication (analgesic) recommended by the primary care physician. A wide range of analgesics are available (aspirin, acetaminophen , naprosin sodium , and other non-steroidal anti-inflammatory drugs [NSAIDs]). Because each works in a different way, the doctor should be consulted about choosing the best one for a particular type of headache.

Migraine headaches that are moderate to severe may require migraine-specific-abortive medications such as sumatriptan or ergotomine. These medications counteract the cause of the headache, dilated temporal arteries, rather than just relieving pain. They are available by prescription only and have side-effects that may aggravate other conditions such as high blood pressure, kidney disease, glaucoma , liver disease, or atherosclerosis . They may also interfere with other types of medications. Narcotics, antidepressants, and blood pressure medications are also sometimes prescribed for migraine headaches.

Individuals who have an underlying condition that causes secondary headaches should be treated by the physician treating that condition. The simplest causes of secondary headache can be treated successfully by correcting the underlying condition. When a secondary headache is a sign of a more serious underlying condition, type and severity of the condition determine treatment.

Nutrition/Dietetic concerns

Deficiencies in certain vitamins and nutrients, as well as overeating and indigestion, can cause headaches. Following Food Pyramid recommendations with a diet rich in whole grains, fruits and vegetables, and healthy sources of protein (lean meat, fish, eggs, nuts and beans) can provide essential nutrients, helping to avoid headaches. Meal portions should be just enough, without over-eating. Remaining somewhat active up to two hours after meals encourages digestion of food. Water and juice should be the principle beverages, avoiding excess caffeine or alcohol. Chocolate also contains caffeine and may trigger a headache. The colon can be kept clean and constipation avoided by regularly consuming sufficient whole grains, fruits, and leafy greens. Eating yogurt or taking probiotic supplements can help maintain normal bacteria in the intestines to aid digestion.

QUESTIONS TO ASK YOUR DOCTOR

• What causes my headaches?
• What is the best medication for my type of headache?
• What can I do to avoid these headaches?
• Can I expect the headaches to stop with treatment?

Therapy

Massage therapy can help relieve muscle tension that may result in headaches. Massage therapists are skilled in treating tension and sinus headaches by relieving tension in various muscle groups, including tense neck, shoulder, and back muscles, and promoting better blood circulation in the head. Massage therapy can also produce deep relaxation , shown to be especially beneficial to individuals who do not engage in regular physical exercise . Acupuncture may also relieve tension headaches by treating the energy pathways (meridians) in the body that may be blocked, causing tensing of muscles.

Prognosis

Tension headaches respond well to analgesics and stress reduction and are not dangerous or known to lead to neurological problems or brain damage. Migraine headaches are slower to respond to treatment and have been linked to stroke , but they diminish in intensity with aging. Secondary headaches are the result of an underlying disease that may be treatable, thereby relieving headaches. However, some underlying diseases can be progressive even with treatment, leading to complications and life-threatening situations, particularly heart disease , stroke, high blood pressure, and kidney and liver disease.

Prevention

Preventing headaches requires staying in good health. Common types of headaches can be avoided by eating a balanced diet with whole grains, fruits and vegetables, and low-fat protein; avoiding stress, not overeating, not smoking; avoiding overuse of alcohol or caffeine, correcting vision problems, managing high blood pressure, and treating sinus infections or fever as soon as they occur. Drinking eight glasses of water each day, getting a good night's sleep, and balancing relaxation and exercise during the day can help relieve stress and prevent tension headaches. Preventing migraines is more complicated, but some of the same preventive methods that work for tension headaches will reduce the threat of migraines as well, including reducing stress, getting good sleep, avoiding caffeine and alcohol, avoiding bright lights and other visual stimuli, getting regular exercise and eating modest amounts of nutritious food. Prevention of secondary headaches is dependent upon preventing the underlying conditions or illnesses that cause them.

KEY TERMS

Analgesic —A medication that modifies neurological stimuli to relieve pain.

Aneurysm —Dilation or ballooning of an artery, stretching artery walls until they become thin and weakened.

Hematoma —A pooling of blood inside an organ or beneath organ tissue, usually becoming clotted into a noticeable configuration and sometimes requiring removal to avoid the pressure on adjacent organs.

Hypoglycemia —An abnormally low level of circulating blood sugar (blood glucose).

Probiotic —The presence of normal or so-called friendly bacteria that are beneficial to their host organism such as normal intestinal bacteria in humans that help digest food.

Temporal —Referring to the area of the temples on either side of the head.

Caregiver concerns

Caregivers should pay attention to onset and symptoms of headaches, asking the individual to describe the headache, and noting time and frequency of headaches. The general practitioner or specialist should be made aware of any unusual symptoms that accompany headaches, particularly if the individual is being treated for another disease or condition and taking medication. Individuals should consult the doctor if a headache is different than usual or is not improving with the usual treatment. The presence of fever, vomiting, stiff neck, or dizziness with head pain could be a sign of something more serious than a headache and should be reported immediately. If the individual loses consciousness, emergency assistance is needed.

Resources

BOOKS

Dietary Guidelines for Americans, 6th ed. U.S. Department of Health and Human Services, U.S. Department of Agriculture. Washington, DC: U.S. Government Printing Office, January, 2005.

“Neurologic Disorders: Migraine.” Merck Manual of Diagnosis and Therapy, Section 16. R. S. Porter, ed. White House Station, NJ: Merck Research Laboratories, 2007.

ORGANIZATIONS

American Academy of Family Physicians, 114 Tomahawk Creek Parkway, Leawood, KS, 66211-2672, (800) 274 2237, (913) 906-6269, [email protected], www.familydoctor.org.

National Headache Foundation, 820 N. Orleans, Suite 217, Chicago, IL, 60610, (888) NHF-5552, www.headaches.org.

L. Lee Culvert