Headaches: Sometimes a Migraine is not a Migraine

Headaches: Sometimes a Migraine is not a Migraine

Physicians believe that the proper and specific evaluation and treatment of headaches is a cornerstone to medical practice.  Helping a patient understand what is causing the headache and intervening with a lifestyle or medical change to prevent or treat headaches is rewarding for the patient and the physician.  A headache dramatically impairs the patient's quality of life and ability to work on a daily bases.
Headaches are considered primary and secondary, or due to neuralgia a nerve pain in the head or neck.  The most common type of primary headache is a tension headache. Virtually everyone has had one of these.  It starts in the upper back of the neck or head and spreads out like a tight band around the head just above the eyes.  It can be in the upper back of the neck and in the skin at the back or base of the skull.  It can be quite severe.  Tension is not associated with the visual changes, phobia to bright light, or nausea and vomiting of a migraine.  It is usually a constant pain, not throbbing like a vascular headache, and is not associated with neurological symptoms like weakness or tingling in the extremities. The good news is that the usually respond to rest and an analgesic like acetaminophen, ibuprophen, or something stronger.  It gradually goes away, and the person feels better.  It is most often related to stress and part of the treatment is relieving the stress.
A second type of primary headache is the migraine.  It is caused by the veins in the head that become dilated by some trigger and then constricting.  It may be possibly triggered by muscle fibers on the skull.  It is usually on one side, and is often preceded by shimmering lights called an aura in the visual field of the eye on the affected side, nasal swelling, or nasal congestion.  This aura may be small or a sensation of tingling.  Nausea and vomiting can be severe and dizziness is common.  Sometimes the migraine sufferer can identify things which seen to precipitate a migraine i.e. chocolate, cheese, lunchmeat, msg, wine, sardines.  These things which are known to be triggers have to be avoided.  Migraines usually have pain at a grade of 2 to 7 and they wax and wain and hurt for days.  The migraine traditionally required stronger pain medicine and nausea medicine, but now we have a new drug called tryptans, which can be given very early in the headache process and abort the headache.  There are other medicines such as those which work on the early venous dilation process which the doctor can discuss with you.  Beta blockers may work in these headaches.  There are medicines that stop the migraine from quickly returning.  Migraines often have an aura, nausea, and returns after a few hours again and again as the medication repeatedly wears off.
The third type of primary headache is the cluster.  It primarily affects men, starting in their twenties and thirties.  It is usually one-sided like a migraine, but it is much more intense in its symptoms.  Patients have been known to rub an eye brow off or beat their heads on a wall.  It is a very specific pain and often behind one eye.  It occurs every day for one to two hours, and can return daily for days or weeks.  Then it can abruptly go away for weeks, months, or years and then may strongly return. 
Secondary headaches vary in the seriousness of their presentation, and some can be fatal.  One type of secondary problem is a sinus infection.  It hurts over the facial areas covering the sinuses, and gets better as the infection clears.  These are often treated with an antibiotic, steroid, and an antihistamine.  Another secondary type is that due to fever or to a viral infection.  This improves as the underlying condition clears.  Of course, we have to be sure that the pain is not due to meningitis or encephalitis.  A secondary type might be due to a dental or ear infection.  The secondary problem can be due to high blood pressure which usually needs urgent treatment.  A consequence of this condition might be bleeding inside the head from a ruptured blood vessel or aneurysm.  A person with this severe condition would probably have decreased consciousness and neurological symptoms like weakness or paralysis. A percentage of these people with this type of headache or aneurysm have renal problems as well. Another type of secondary pain could come from trauma to the head, like a concussion.  There could be bleeding on either side of the brain covering called the dura. If these types of pains are present, the physician should order a head CT or MRI to look for the site and extent of the injury.  Another type of brain-related symptoms might be a developing stroke.  This is usually caused by a blood clot including a blood vessel in the brain.  It is important for these to be diagnosed early as certain interventions can be made to prevent more extensive damage.
A tumor or mass within or on the brain can cause severe head pain.  This can develop within the brain itself or spread from other organs.  This type of pain is constant and dull, often awakening one in the morning.  It can cause progressive neurologic symptoms as it grows.  Either free blood or infection of meningitis can cause severe pain.  Sometimes the doctor has to do a lumbar puncture or spinal tap to look for blood in the cerebrospinal fluid.
Vascular symptoms often are pulsating or pounding.  They may be a sign of an aneurysm, intracranial bleed, or the swelling and dilation of a vessel in compensation to something else.  i.e. a tumor compressing the vascular supply.  If you feel pulsations often like your heart beat in your skull quickly get to a physician or the E.R.  Vascular headaches can truly be a life threatening problem; do not ignore them.  Direct trauma can cause a bleed above the dura which is the tough membrane adherent to the skull or subdural underneath the dura.  These may be pulsitile or not, they must be evaluated with a CT and/or MRI and truly can be a life threatening pain symptom.  A skull fracture or skull depression especially a basilar skull fracture with blood bleeding into the middle ear increasing the pressure and bursting the ear drum and blood coming out of one or both ears.  Blood may as well drip down the back of the throat and can be a warning sign.  This is often seen in a motor vehicle accident or motorcycle accident.
Physicians believe that all head pains need a careful evaluation.  The good news is that 80 to 90% of headaches are due to tension.  Helping patients to identify the sources of tension and reassuring these 80% is one vital function we can perform.  The skillful management of migraine and cluster headaches is a priority.  Finally, being aware that a certain number of patients have complex secondary headaches, and being able to evaluate them, is a valuable service in which physicians can perform.

John Drew Laurusonis M.D.
Doctors Medical Center