Understanding Headaches and Migraines

John Wiley & Sons

Chapter One

Most of the time, it is possible to work out whether someone has a headache or a migraine. There are usually clear differences between the two, as you will see from this chapter.

Headaches differ in both intensity and in type, or quantity and quality if you like, which means that two headaches of similar type but differing in intensity can end up in two different categories. However, as with many things in life, there can be confusions in the grey areas where one category meets another. (Could anyone say exactly when they stop liking someone and start loving them, or exactly when day becomes night?) To confuse the issue further, within the category of 'headache' there are many sub-types. In addition, how long you have them for can influence whether a doctor perceives you to be a victim to either acute or chronic headaches.

Some people will often say they have a migraine when actually they do not. Similarly, some people with a migraine think that they simply have a 'bad headache'. Hopefully, reading this book will help a few of these people to get a clearer picture. Sometimes, knowing what is wrong is half the way to a solution.

It is not possible to divide up headaches clearly into different categories without any overlap or blurring. The nature of the subject matter precludes this. There are even a number of interchangeablewords for ordinary headache - cephalodynia, cephalalgia and encephalalgia - and if you ever look at your medical notes, you might find that some of these terms have been used. Don't be worried if you become a little confused by the fact that descriptions of apparently different headache types seem similar at times. This is unavoidable, since they do genuinely overlap. Imagine if someone asked you to describe yourself in a few words. Whatever words you chose would also be reasonably accurate words to describe millions of other people, and so it is with headaches. They differ in type as well as intensity, but trying to condense the complicated experiences of individuals into some type of common description means that some of the accuracy is lost. Headaches differ so much from person to person that there are bound to be problems when we try to outline what makes a 'typical' tension headache, for example. However, there is some common ground, as you will see. Another thing to consider is that someone can occasionally have more than one type of headache at the same time. Doctors are accustomed to seeing patients who have both migraines and tension-type headaches.

Primary or secondary?

If you read about headaches and migraines, there is a good chance that you will come across the terms 'primary' or 'secondary'. In fact, your doctor might even use these terms. Most people - that is, around 90 per cent - have primary headaches. These are headaches which exist entirely on their own and are not related to any other medical condition. Quite simply, they are headaches that are not really a sign of any other underlying disease or illness. Secondary headaches, on the other hand, are related to other conditions, and they are known as 'secondary' because they are a 'secondary symptom'. These types of headache occur precisely because you have some other physical problem. For example, your headache may be the result of high blood pressure (hypertension) and people with diabetes can get headaches for the same reason. At first, a doctor might be unsure whether your headaches or migraines are caused by some other factor, and this is why he or she might do other tests to eliminate certain possibilities. Different people accept the diagnosis of primary or secondary headaches in different ways. For some people, there is a relief associated with knowing that their headaches are primary. They are happy to know that there is no underlying cause, no illness lurking in the background. For other people, this is too vague, and they would actually rather be told that their headaches are secondary because at least they then know what is wrong. They find it difficult to live with pain when the doctor cannot identify a clear reason for it. You might like to think about which type of person you are, especially if you are about to see your doctor to get your headaches checked out. Spend some time dwelling on your likely reactions to being told that your headaches are either primary or secondary. It's not self-indulgent to think about yourself now and then: it can help you to see who you are and what you are.

Headache or migraine?

Strictly speaking, a migraine is a form of headache (it is even referred to as a 'migraine headache'). However, because it is rather a special form, it is usually seen as separate, is given its own name, and people study it specifically. It is probably easier to begin with defining a migraine first, since headaches tend to be defined as anything other than a migraine.

Migraines tend to be on one side of the head only (they are unilateral). Many people know that a migraine is going to occur because they might feel irritable, unduly tired, crave certain foods or even yawn excessively for hours or even days before it begins. This period is called the 'prodrome'. Some people then experience an aura which tends to begin just before the migraine itself. This aura is often in the form of a visual disturbance. We can divide migraineurs into two types based upon the aura, and these two different kinds of migraine were previously known as 'common' or 'classic'. Although some doctors will still use these terms, they have now been officially abandoned in favour of 'migraine without aura' and 'migraine with aura'. Most migraines are not accompanied by an aura. A migraine aura can come in a number of forms, which can include a strange taste in the mouth, or smelling something that is not there, or even a sense of feeling detached from reality. Most commonly, there is some visual disturbance, often a rainbow-like arc which moves across the visual field (a term we use to describe what you can see when your eyes are open). Sometimes it is in the form of flashing lights before your eyes, called phosphenes. (Don't confuse this with what can happen when you suddenly stand up after having been bending down for some time, although it can appear to be the same.)

Although the aura can last for some time, it is usually something that develops gradually over about 5 to 20 minutes and usually lasts up to an hour. As it can overlap with the migraine itself, it is not always something that comes before, and only before, the migraine. For those people who have an aura, it can be a useful warning to enable them to can take a painkiller or seek out a quiet place before the migraine starts properly.

Migraines tend to be pulsating: they throb. The pain is very strong, and you will commonly feel sick, or perhaps even vomit. You are likely to be unable to withstand strong light, often just normal dim daylight, and you are possibly equally averse to sound. In addition, moving around, especially moving the head, can make migraines much worse. So, a person with a migraine is typically someone who feels the need to go to bed, seeking quiet, darkness, and inactivity. Some people can go to sleep with a migraine and wake up fine, whereas others can wake up still in pain. Generally, a migraine lasts from about 4 to 72 hours. If you go to sleep with a migraine and wake up with it, you would count your time asleep in its duration.

A headache, on the other hand, can be any pain in the head which is not a migraine. However, certain head-pains are not headaches. Toothache, for instance, is an obvious example, but sometimes toothache can cause pain in the head which is actually felt on the skull. This kind of confusing pain is known to doctors as referred pain (because it is being 'referred' from one part of the body to another). One useful way to tell whether you have a headache that is actually toothache is by tapping your teeth, one by one, with your finger. You have to be brave, because when you find the right tooth you will get a lot of pain. In fact, anything going wrong with the head area, such as an ear infection, can create a pain that is quite indistinguishable from a headache.

The most common true headache is the tension-type, which might be called a 'stress headache' by your doctor. Stress headaches are the ordinary everyday headaches that most people have every now and then, and they are usually brought on by some kind of muscular stress in the neck or shoulders. This type of headache can be the result of psychological stress, because stressed people hunch up and tense their back and neck muscles even if they are not aware of it. Tension-type headaches can last for days but are often relieved quite quickly if the person takes some aspirin or other painkiller. They tend to be all over the head, commonly feeling as if someone has put a tight band around the head. They do not tend to be associated with other symptoms, unlike migraine, although some sickness can occur. When people get other symptoms, they are usually individuals who also suffer from migraines.

Cluster headaches are rarer than migraines or tension-type headaches, but are still the third most common. If you have a cluster headache, you will probably be in intense pain in your eye socket, and the eye might be red and weeping. The terrible pain will last up to a few hours and go away again only to return later. This can sometimes be mistaken for trigeminal neuralgia, where you experience shooting pain up one side of the face, and the skin of the cheek is often highly sensitive to touch. Cluster headaches are very distressing for their sufferers, and the pain is so strong that they can do nothing during an attack other than try to cope with it. Getting on with household chores or watching TV are generally not options. The pain is too intense to allow you to do everyday things, and sufferers often dance or pace around to try to relieve the agony.

Elsewhere in this book you will learn about many other types of headaches, indeed doctors have identified as many as 150 different types based upon their many causes. Although it is a large number, it is because there are so many reasons why a headache can develop. In many ways, your head is the most important part of your body. Most of the things you do are controlled by the brain directly or indirectly, and so it is not surprising that there are so many ways in which the head can 'go wrong'. If you break your ankle, you get pain in the ankle. When something related to the head goes wrong, you can get a headache. Since the head is in charge of most things, including the way your ankle functions, something wrong in any part of your body can, in theory, give rise to a headache. Perhaps you can see why doctors have such a difficult job to do when working out why you have a headache.

Acute (episodic) or chronic?

This is a tricky question for doctors. The first time anyone has a headache (probably as a baby) it is obviously an acute headache, because there is no history attached to it. Most of us go through life having occasional headaches and they are generally seen as individual acute episodes (you will also find that doctors talk of 'episodic' versus 'chronic' headaches and migraines). Similarly, if someone has an outburst of eczema once every 10 years we would also regard this as acute. As you can see, therefore, the acute/chronic distinction is really about the frequency of occurrence of something, not its strength, and not even that it recurs. Our difficulties arise when we try to pin down exactly some borderline between acute and chronic headaches, or indeed other conditions, because that is very difficult to do. We all know how much people argue about the age of consent, for instance. In the UK, for some things, you are an adult at 18; for other things you are considered able to make your own decisions at 16; and you can drive a car at 17. In other countries, the ages for the same 'abilities' are different. Furthermore, there will always be people who are more mature at 15 than others are at 18. Similarly, with headaches, you will find that what one doctor calls a series of acute episodes, another will believe to be a chronic condition. The general guidelines on defining headaches come from the International Headache Society. They specify that a chronic tension-type headache is one that occurs for 15 or more days each month for at least six months. Of course, here is our problem. If a headache occurs for 14 days each month for six months, it does not meet the criterion. While such guidelines are helpful, they do not always cover every possibility, and so the doctor rightly has room for discretion and judgement.

There is no equivalent specification of time for the diagnosis of chronic migraines produced by the International Headache Society. Usually, people who have migraines tend to have them regularly over a long period of time, and so, in a sense, almost all are chronic migraine sufferers.

Points to note

Headaches are complicated things. Sometimes the signs and symptoms of different kinds of headache overlap, but generally it is possible to diagnose particular headaches if care is taken.

Primary headaches are those which are themselves the main medical problem. Secondary headaches occur as a symptom of some other medical condition.

Migraines tend to be on one side of the head and are usually throbbing. They make people hypersensitive to light and/or sound. Sometimes they are associated with an aura.

Tension-type headaches are relatively steady, rather than throbbing, and are frequently based around the temples or feel like a tight band around the head. They are chronic if they occur for half of the days in a month for six months or more.

Toothache, eye strain, or tension in the shoulders or neck can sometimes be confused for a headache.

Box 1. Myths about headaches and migraines.

People commonly get the wrong idea about headaches and migraines. Lots of myths contain a grain of truth which is why they can sometimes flourish; but a grain of truth is not the same as a fact.

Headaches and migraines are excuses for people who don't want to work. It is true that people sometimes take days off work because they claim to have a headache or migraine, and sometimes they are lying. However, some people also say that they have food poisoning when they have no such thing. The vast majority of people who have severe headaches or migraine are genuine and are in considerable pain.

Headaches and migraines are all in the mind; they are just psychological. There is a psychological component to headaches, and it is true that people can think themselves into a headache.

Continues...

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Excerpted from Understanding Headaches and Migraines by Mark Forshaw Excerpted by permission.
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