Real, persistent pain of headaches - There are many different types of headache, each with its own triggers

Real, persistent pain of headaches
By WONG LI ZA
wongliza@thestar.com.my

There are many different types of headache, each with its own triggers. DERRICK Chen thought nothing of having two roti canai for supper a few weeks ago. He went to bed not long after, but in the morning, what greeted him was a sharp pain on the right side of his head.

This was a pattern he noticed lately: a heavy supper preceding a pounding headache the next day.

Chen, 41, has been suffering from headaches for the past 10 years. He describes his pain as “pin prick” in nature that occurs on his left or right temple. Sometimes he experiences a dull, pulsating pain at the back of his neck.

“If I take two (paracetamols) at the start of a headache, I will be fine the entire day. However, the following morning, the headache returns and I will need to take two more painkillers,” said Chen, a businessman and father of three.

His longest spell lasts seven days; his shortest, one day. On average, Chen, a smoker, experiences two to three headaches a month, usually migraines.

So far, he has seen two neurologists and undergone a magnetic resonance imaging (MRI) test, but doctors found nothing.

“They told me it’s stress, to take it easy and continue taking paracetamol. One doctor said it could be my eyesight but I had that checked and it was fine.”

Chen has also consulted a traditional Chinese sinseh who prescribed him dried cockroaches boiled with herbs to drink.

“I’ve tried that three times but the headaches are still there,” he said.

Sakeenah (not her real name), started getting migraines when she first returned to Malaysia from Britain 20 years ago.

“It was most probably due to the heat,” recalled Sakeenah, who was in her mid-30s then.

She suffered from migraines once a month, especially on the first day of her period. She would also get a migraine if she missed a meal or when travelling overseas.

“I would get this throbbing pain on the right side of my head, but the pain was not so bad then,” said Sakeenah, now in her mid-50s.

Her migraines worsened when she went into menopause in her early 50s.

“I would get it once every two weeks and the pain was much more intense. Work stress added to the intensity and late nights did not help, either,” said Sakeenah, whose symptoms included vomiting, sometimes throughout the day, and sensitivity to light.

Sakeenah, whose mother and son also suffer from migraines, has consulted a neurologist and undergone an MRI, with results coming back negative. In addition to Western medication, she has tried acupuncture and ayurvedic treatments but she admitted that she did not follow up with her sessions.

“I just want fast relief because it’s so debilitating and I want it to go away, especially when I need to work,” she said, adding that stress is a main trigger for her.

Many possible causes

Another word for headache is cephalalgia, which originates from an ancient Greek word meaning “head pain”.

A headache is not a disease per se, but a medical problem that is often a life-long condition. Among the most common disorders of the nervous system, headaches occur due to many possible causes.

Some people are more prone to headaches because of their genetic make-up, brain chemistry and also hereditary reasons. Lifestyle is another factor, with stress, lack of sleep and missing meals among the causes.

Understanding headaches starts with knowing that there are many different types of headache disorders.

Each experience differs in terms of nature of pain (dull, sharp, throbbing and so on), severity, pain location, frequency and duration of attacks, and presence of other symptoms, such as nausea.

The most severe form of headache is a cluster headache, which is almost exclusive to middle-aged men.

Studies also show that over 80% of women in their reproductive age have headaches, usually more severe than men. Women also suffer more from migraines and tension-type headaches than men. Fluctuating hormone levels as women go through menstruation, pregnancy and menopause may play a role, but it does not apply to all women.

According to the World Health Organisation (WHO), the most common headache disorders are tension-type headache (TTH), migraine, cluster headache and “chronic daily headache” syndromes.

Studies show that headaches disrupt family and quality of life, and productivity, more than many other chronic disorders.

According to WHO, in developed countries, TTH alone affects two-thirds of adult males and over 80% of females. In Malaysia, no major studies have been done on the prevalence of headaches.

“However, headache is the most common complaint in our neurology outpatient clinic and we see about 12 new patients a week,” said Prof Datuk Dr Raymond Azman Ali, senior consultant neurologist at Hospital Universiti Kebangsaan Malaysia’s Department of Medicine.

The most common form of headache the clinic encounters, he added, is migraine, although many medical books list tension headache as most common.

“The reason for this discrepancy is, I believe, that the majority of tension headache sufferers prefer to buy analgesics over the counter or dispel their headache as something normal, since they have lived with it for many years.

“Another reason is that a lot of them see a general practitioner or their family doctor and are not referred to us,” said Dr Raymond, who is also Malaysian Society of Neurosciences’ Epilepsy Council chairman.

He said those aged between 12 and 35 form the biggest pool of people who suffer from headaches, and most are female.

One of the biggest myths about headaches is that they are due to brain tumours.

“Our brains do not have pain receptors. You can push a needle through the brain and you will feel nothing. The pain receptors are in the meninges (brain covering), blood vessels and skull.

“Hence, a brain tumour has to be large enough to compress these pain-sensitive structures to cause a headache. But by then, patients would have suffered epileptic seizures, hemiparesis (weakness or paralysis in one side of the body), dysphasia (a communication impairment resulting from brain injury) or a personality change,” explained Dr Raymond.

Some people also wonder if sex causes headaches.

“(That is true). It is well-known that some patients have what is called post-coital headaches,” he said.

However, the myth that hypertension causes headaches is not true.

“If someone with hypertension has headaches, he or she probably has two unrelated problems, a phaechromocytoma (adrenal tumour secreting hormones produced by the adrenal glands, which is rare) or malignant hypertension (very high blood pressure of over 220/140 mmHg). So, don’t wait until you have a headache before checking your blood pressure.”

Knowing the triggers

Tension-type headaches may be triggered by poor posture, working in awkward positions, stress, depression and anxiety.

For migraines, triggers include certain foods, hunger, changes in weather or sleep patterns, exposure to bright lights or unusual odours, skipping a meal, drinking alcohol and having sex.

Dr Raymond said that although certain foods trigger migraines, not everyone experiences the same thing.

“Therefore, we do not ‘ban’ these foods but rather, ask patients to note down in their headache diary what they ate prior to an attack, like durian, chocolate, milk, peanuts, coffee, wine, citrus foods or certain drugs (such as nitrates for heart patients).

“Surprisingly, over-relaxing is also a recognised factor with migraines. Others include sleep deprivation or too much sleep, travelling, heat, unaccustomed exercise, menses and irregular meals, probably related to hypo-glycaemia,” he said.

For women with migraine, the trigger is often linked to a drop in estrogen levels.

According to the book Mayo Clinic On Headache by Jerry W. Swanson, an estimated 50% of migraineurs may have a magnesium deficiency.

For cluster headaches, there are no known triggers. However, measures that may help avoid an attack include having a regular sleep schedule, and avoiding afternoon naps, alcohol, tobacco products, glare and bright lights.

Although most headaches are not life-threatening, they can be debilitating.

“It is not severe in the sense that it can kill you or cause permanent disability. As a neurologist, I want my patients to lead a normal life as much as possible.

“Untreated migraine can lead to depression and about 18% of migraine sufferers have suicidal ideation,” said Dr Raymond, quoting a past study done in Malaysia between Universiti Kebangsaan Malaysia Medical Centre, Universiti Malaya Medical Centre and Hospital Kuala Lumpur,

Dr Raymond cautioned about secondary headaches, which are more dangerous and can lead to death.

“These are headaches due to an underlying disease such as meningitis, temporal arteritis, cervical spondylosis, dental problems, glaucoma or SLE (systemic lupus erythematosus).”

So when should people suffering from headaches seek medical attention?

According to Mayo Clinic On Headache, if you experience a sudden, severe headache that is unlike any you have had before, or a headache that continues to worsen over time, see a doctor promptly.

The same applies to a headache that comes with a high fever or stiff neck.

“I think (you should seek medical advice) all the time, unless it is acute and accompanied by unequivocal flu-like symptoms. A viral upper respiratory tract infection is the most common cause of short-term headache.

“All other headaches should be treated seriously. Let us decide whether to investigate or not. Generally, I don’t do any investigations if the patients have typical features of a primary headache,” said Dr Raymond.

These days, many people are keen to seek other forms of treatments for their headaches besides relying on medication. These treatments are either used as alternative or complementary therapies.

“There is some evidence to support acupuncture’s role in migraine and tension headaches. See a neurologist first and then decide what to do next,” advised Dr Raymond.

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