Chapter 4
Living with Headaches

People with headaches face a number of challenges. Clearly, the threat of a severe headache occurring at any time causes stress and anxiety. And when a headache does strike, it disturbs people's daily lives. Drew, a young headache sufferer, describes his experience: "I got two bad migraines this summer. The first was right before a big golf tournament. It was real important, but the headache threw me out of the tournament. The second was before an all-star game. I worked hard to make it to the all-stars. But I couldn't play."³⁹

In an effort to avoid such disruptions and the accompanying anxiety and stress, many headache patients take steps to manage and thus control their headaches. In so doing, they lessen the severity and frequency of their headaches, which makes living with their condition easier.

Identifying Triggers

One of the first steps people with headaches take is identifying their personal headache triggers. This is often accomplished by keeping a headache diary. Such a diary is kept for about eight weeks. It is used to track headache attacks in order to determine what triggered them.

In a typical headache diary, patients record the date, time and duration, preceding symptoms, and intensity of headaches, the medicine they took and the dosage, and whether the medicine provided complete, moderate, or poor relief. In addition, patients list everything they ate and drank for twelve hours preceding the headache. They also track what activities they participated in, what their sleep schedule was like, what their stress level was, what environmental pollutants they came in contact with—including noises, odors, and bright lights—and for women, the date of their last menstrual period. After about eight weeks, patients and their doctors review the diaries, looking for any patterns. For example, if a patient notices that he or she often gets a headache after a stressful day at work or school, it becomes clear that stress is one of this individual's headache triggers. Similarly, if attacks coincide with the consumption of hot cocoa or fudge, the patient can deduce that chocolate is a trigger. Kathleen, who keeps a headache diary, explains what she hopes to gain:

I'm not sure what causes my headaches. My doctor asked me to keep a headache log. Whenever I get a headache, I have to write down what I've done activities-wise, and what I've eaten and drank for twelve hours before. Then I check the log after every headache to see if maybe I ate the same thing each time. I haven't found anything yet. But eventually, with the log, I think I'll be able to identify what's causing them.⁴⁰

By keeping a headache diary and acting as a medical detective, patients can gain better control of their headaches. Once a pattern is identified and triggers are determined, patients can take steps to avoid or lessen their contact with their personal triggers. In some cases, this helps prevent headaches from occurring. Even if a person's triggers turn out to be unavoidable—such as air pollution, for example—by identifying specific triggers, patients can prepare to have abortive medicine handy when they must come in contact with these triggers. This will help to lessen the severity of a headache. In addition, keeping a headache diary can also help patients keep track of whether their headache medicine is working effectively. If it is not, they can tell their doctor, and a new medication, which may provide more relief, can be prescribed. Moreover, keeping track of medicine dosages can help patients to avoid overuse of medication and the rebound headaches that often result.

Indeed, keeping a headache diary is so useful that interested groups such as The Migraine Trust, a British headache information and support group, and Excedrin, an analgesic manufacturer, offer free copies of headache diaries on their websites. Headache patients are encouraged to print these headache diaries and use them to manage their headaches more effectively. Peterson explains:

Keeping a migraine diary will help you take control of your life and better cope with your predisposition towards these menacing headaches. If you're not aware of your personal migraine triggers, this tool will help you—and your doctor—become more attuned. I recommend that all my patients keep one. Your migraine diary will enable you to track your own patterns and be your own detective in determining what your headache triggers may be.⁴¹

Elimination Diet

For some people, keeping a headache diary is not enough, especially when it comes to identifying dietary headache triggers. In these people, rather than an individual food such as chocolate triggering their headaches, a combination of foods are responsible. Since food combinations can be endless, it is hard to determine these triggers through a headache diary alone. Some individuals may react to specific foods or food combinations only in certain quantities. Identifying what these combinations and quantities are can be tricky. Therefore, some patients combine the use of a headache diary with a headache trigger elimination diet.

Such a diet can be highly restricted. It involves the elimination of all likely headache triggers. For people who suspect they are sensitive to a wide variety of items, this includes caffeine, processed meats, chocolate, beans, aged cheeses, nuts, and alcoholic beverages. For other people, it may involve the elimination of only a few suspected triggers. Patients replace these foods with safe substitutes that are not commonly headache triggers, such as brown rice, chicken, fish, and vegetables. Then, in the course of one or two months, possible headache triggers are reintroduced into the patient's diet one at a time, in varying quantities and in different combinations, while patients carefully record their reactions in their headache diaries. In this manner, people learn how much of a possible trigger they can tolerate and whether or not the food affects them when eaten alone or only when combined with other possible triggers. Sharon, who thinks her son's headaches may be triggered by caffeine, talks about how she is using an elimination diet to identify his triggers:

He loves soda, and that's what we think is causing his headaches. What else can it be? He has a simple life. He doesn't seem stressed, no big exams, no girlfriends yet. But he drinks a lot of soda. We're trying to see if it might be the caffeine in the sodas. We made him stop drinking soda, and anything else with caffeine, like iced tea, and lattes; and we're gradually reintroducing it and seeing what happens. He's up to one cola a day. We'll keep increasing the amount and see what happens.⁴²

Avoiding Food Triggers

Whether through the use of a headache diary alone or through the use of a headache diary combined with an elimination diet, once dietary and other headache triggers are identified, in order to lessen the frequency and severity of headaches, patients try to avoid these triggers. This is often easier said than done. Although avoiding dietary triggers, for instance, does not sound difficult, giving up a favorite food or drink is never easy. In order to compensate for the loss of a favorite food, headache patients find that substituting a safe alternative food in its place helps them to cope. For instance, many patients substitute cottage cheese for aged cheeses; and lamb, chicken, and fish for hot dogs and other processed meats. Similarly, they may opt for decaffeinated soda and coffee and fruit juice instead of wine, beer, and caffeinated beverages. Hard candy, cake, cookies, and Jell-O often are substituted for chocolate.

Although making these changes can be difficult, avoiding dietary triggers can really pay off. Paulino explains how avoiding red wine helped one of his patients:

Jennifer… began experiencing recurrent headaches at the beginning of the summer following her twenty-third birthday. During that summer, she began dating a French exchange student from a well-to-do background. During their dates at high-priced French restaurants, Jennifer would drink red wine with her meals. Once the exact triggers were identified, Jennifer set about developing a plan for avoiding red wine.… Four months later, Jennifer's chronic headaches were reduced to an occasional, mild, nondescript head pain that occurred every three months on average.⁴³

Changing Sleep Patterns

Like dietary triggers, irregular sleep patterns that trigger headaches can often be avoided. Such patterns include getting too much or not enough sleep as well as experiencing nonrestorative sleep.

People may not get enough sleep because they stay up late to study, finish a project, or socialize. They may sleep late on the weekends in order to compensate for their lack of sleep. Unfortunately, this type of irregular sleep schedule appears to affect serotonin levels, triggering headaches in sensitive people. So, too, does having nonrestorative sleep. Such sleep is characterized by difficulty falling asleep or staying asleep. It is often interrupted by any number of things, such as a crying baby, street noises, or insomnia. Even though people who get nonrestorative sleep may spend six to eight hours in bed, as a result of sleep interruptions they report waking up feeling tired.

No matter what causes irregular sleep patterns, in order to combat and better control headaches, sensitive people must avoid them. According to headache experts Stafford and Jennifer Shoquist: "Dysfunctional [irregular] sleep looms as a pivotal lifestyle factor that you can change to get your body back into a positive groove and help avoid migraines."⁴⁴

This is done by following a set sleep schedule that involves going to bed and waking up at the same time each day, no matter whether it is a weekday or weekend. Such a sleep schedule helps regulate an individual's sleep patterns, keeping sleep-triggered headaches at bay. In addition, patients plagued by nonrestorative sleep find that taking steps to make their sleep more restorative can help reduce their headaches. These steps include using tools to block out annoying sounds such as earplugs, soft background music, or a white-noise machine that produces a droning sound like the hum of an air conditioner. Patients also avoid activities right before bedtime that are known to keep people awake, such as exercising vigorously, drinking caffeinated beverages, or eating a large meal. Patients who make these changes report that they feel more refreshed upon awakening and experience fewer headaches.

Restricting Medication

Another common trigger, the overuse of headache medication, can also be managed. But this is not easy. It involves stopping the use of abortive medications for eight to twelve weeks. This can lead to patients' experiencing intense headache pain and, in the case of opiates, withdrawal symptoms. Therefore, most patients make this change under a doctor's supervision. Indeed, some patients check into a hospital or drug treatment facility while breaking the painkiller habit. Here issues of drug abuse are dealt with, and patients are helped to gradually discontinue painkilling medication in a step-by-step approach. This involves the offending drug being administered at smaller and smaller dosages until it is completely stopped. At the same time, other medications, such as preventive medicines, antidepressants, and steroids may be prescribed to help patients cope with rebound headaches until the pain cycle is broken. In addition, alternative treatments, such as biofeedback and relaxation therapy, may be used to help patients cope.

Of course, in order to better manage their headaches, once the symptoms of rebound headaches have ceased, patients must be careful not to overuse headache medication in the future.

Reducing Stress Through Exercise

Since many patients take abortive medication to cope with stress-triggered headaches, one way patients can avoid overusing headache medication is by managing stress. Even though it is impossible for people to eliminate all stress from their lives, people whose headaches are triggered by stress should avoid or lessen stress as much as possible. By doing this, they can reduce the frequency of stress-triggered headaches.

According to many patients and headache experts, one of the best ways to reduce stress is by participating in some form of moderate exercise. Although it is true that strenuous exercise can trigger headaches in some patients, moderate exercise usually does not. Since high-impact exercise appears to trigger headaches, exercise to alleviate stress-triggered headaches is usually low impact. Beneficial low-impact exercise includes walking, dancing, yoga, tai chi, bicycling, golfing, weight training, and swimming, to name just a few. Unlike strenuous exercise, moderate exercise does not affect blood sugar levels or stimulate the production of stress hormones. Instead, moderate exercise stimulates the brain to produce endorphins. Consequently, some people find that exercising at the start of a headache reduces headache pain. Debbie comments: "If I have a headache and I exercise, it helps a lot. Like tonight, I had a headache when I went to my exercise class. But after going and moving around for a half hour the headache got better and the pain was gone."⁴⁵

Exercise also strengthens the body, and improves blood flow and the exerciser's general health. Since healthier people are better equipped to handle any type of pain, exercisers can cope more easily with headaches. Moreover, stronger muscles translate to less strain on the muscles that support the head. This reduces the possibility of muscle tenderness in the neck and shoulders, which can cause muscle contractions that may lead to decreased blood flow and headaches.

In addition, regular exercise is known to improve sleep, a benefit for people who suffer from sleep-triggered headaches. In fact, regular, moderate exercise of at least three times a week for about thirty minutes a session appears to prevent headaches from occurring. Experts theorize this may be the result of improved blood circulation.

Staying Active

Staying active, whether through moderate exercise, by having fun with friends and family, or participating in a hobby, also lessens stress and stress-triggered headaches. Many headache patients find that keeping busy doing things they enjoy takes their mind off stressful thoughts and relaxes them. Hobbies such as reading, painting, music, sewing, quilting, and writing are just a few activities headache patients say help them to relax, as do social activities like scouts, moviegoing, school clubs, and visiting with friends and family. Debbie, who stays active in order to cope with stress and stress-induced headaches, explains: "I have to control stress to control my headaches. I try to keep myself from stressing. I read or go to a movie to mellow out. That way I am in control."⁴⁶

Lifestyle Modifications

Unlike stress, other headache triggers, such as bright lights, noise, certain smells, and air pollutants, are harder to control. However, once they are identified, people with these triggers often make changes in their lifestyles in an effort to limit their exposure to them. For some people, this involves avoiding certain activities. For instance, when loud noise triggers headaches, people may avoid attending concerts in large arenas or sporting events where there is a lot of noise. Instead they may watch sports events on television where they can control the sound and listen to music at home or attend concerts in small, quiet venues where they make sure not to sit close to the speakers. When loud noises cannot be avoided, some headache patients wear earplugs, or earphones connected to a portable CD player playing soft music in order to muffle the noise.

Similarly, people whose headaches are triggered by bright or flickering lights often avoid driving at night when bright car headlights can trigger a headache. They may also avoid taking a ski or beach vacation, since sunlight reflecting off snow, sand, or water is glaring and can trigger headaches. When bright light cannot be avoided, these people carry sunglasses with them everywhere and use them when exposed to bright light, either outdoors or indoors.

In the same manner, people whose headaches are triggered by certain odors modify their lifestyles to limit their exposure to these odors. For instance, people who are sensitive to certain perfumes avoid buying magazines with perfume samples or going to department stores where perfume is sprayed into the air. They may also ask friends and loved ones not to wear perfume when they are present and often use scent-free beauty products themselves. A woman talks about the changes she made: "I got rid of products that were scented and even changed to detergent and soaps free of perfumes. These things made a big difference—I rarely get a headache anymore."⁴⁷

Likewise, people whose headaches are triggered by the smell of a wood fire report avoiding camping trips and any social event that involves a fireside gathering. At home, these people often use a gas log in place of a traditional fire. When smoke itself is a headache trigger, headache patients try to avoid being around people who smoke. This often involves avoiding smoky places such as bars. In some cases, it may mean avoiding certain friends, coworkers, and family members when they are smoking. Peterson explains: "Passive smoke inhalation can also be a major headache trigger. If you live with a smoker who can't or won't quit set some guidelines to protect your health. Ask that person to smoke outside your home or in closed, designated areas in the house, which you can avoid."⁴⁸ Moreover, since smoking tobacco can constrict blood vessels, which can encourage the development of headaches, patients who smoke are advised to quit.

When indoor pollutants trigger headaches, patients make an effort to limit their exposure to them. If the culprits are strong chemicals in cleaning fluids, many people switch to natural cleaning agents like vinegar and water. When people cannot avoid strong chemicals, they find that opening a window or going outside often helps them to cope, as does wearing a special mask similar to a surgical mask that filters out chemicals in the air. Some people even wear a mask outdoors to limit their exposure to air pollution.

Talking to a Professional

Even when people make lifestyle changes and limit their exposure to headache triggers, many headache patients are still plagued by anxiety over when a headache may strike. Such anxiety stresses the body and can trigger headaches. In order to avoid this, these individuals often find that talking to a counselor, psychologist, or psychiatrist helps them to cope. Through counseling sessions, patients learn how to deal with their fears. Counselors help patients develop a preparedness plan that lessens their dread of a headache striking. Such a plan often includes simple things like being sure to always have abortive medicine handy or taking time out and relaxing when they feel tired or anxious. In addition, counselors often instruct patients in specific coping skills, such as relaxation therapy, that help them deal with their anxiety. Moreover, a psychiatrist may prescribe medication that helps individuals better handle stress. Indeed, many headache patients report that seeing a mental health professional helps them to take a more positive and active role in dealing with their headaches.

Coping with an Attack

Despite the many steps headache sufferers take to better manage their headaches, sometimes a headache will strike. When this occurs, many people have a set procedure that helps them to cope. Since taking abortive medicine at the first sign of a headache seems to provide the most effective relief, headache sufferers carry their medicine with them wherever they go in order to have it handy whenever they need it. Sharon, the mother who thinks her son's headaches may be triggered by caffeine, also has a daughter who gets migraines. Sharon explains, "She keeps Imitrex in her purse with her all the time, and takes it the minute she has symptoms."⁴⁹

Then most headache sufferers try to stop what they are doing and rest until their medicine takes effect. Some people have developed individual strategies that help lessen the intensity of their headaches. For instance, some find that after taking medicine, taking a warm bath or bathing their forehead with warm water helps lessen their headache pain. This is usually followed by lying down in a dark, quiet room. When possible, patients try to sleep. Often when they awaken, their headache is gone. Dina explains her strategy: "I take a warm shower or bath. I think the warm water gets the blood circulating through my body, and reduces the pressure in my head. I also just soak my feet in warm water. I don't know why, but it seems to help."⁵⁰

It is evident that living with headaches can be difficult. But when headache patients take steps to help manage their headaches, they experience less frequent and less painful headaches. And even when headaches do strike, these individuals are better able to deal with them. As a result, headache patients can live active and fulfilling lives.