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THE SEARCHLIGHT MESSENGER
THE SEARCHLIGHT MESSENGER
|Posted on October 2, 2011 at 2:28 PM|
I have to tell you, one of the occupational hazards of being a physician, is the formal dinner table. This is the traditional “non-doctor place” where doctors are hit-up by guests for medical advice. I'm not sure how conversations drift to "headaches". I mean, a lot of people get them. So when you're a doctor, people are going to ask.
So, one question will lead to another because somebody had a stressful day, and they're glad to be winding the day down with a pleasant dinner, and wondering, "Why am I getting a headache now?"
I am often asked by family, and friends, “What is a migraine headache, and are my headaches migraines?” This is sometimes difficult to answer when brought up as dinner conversation. So you ask why? Because we're talking about pain. Yeah, food and pain are just not good partners. I've been to a lot of dinners.
Understand, many things can cause headaches. From brain tumors to eye fatigue, many conditions can present with severe to mild headaches. Besides, this subject gets so deep, unless you’re ready for a long conversation, you don’t dare get started. But that's not going to happen. Many questions come up. So, this is the discussion which usually ensues, and it always gets interesting.
Barring serious conditions such as brain tumors, severe head and neck pathology, trauma, eye and vision disorders, serious metabolic conditions and infectious diseases, this article is meant to discuss non-pathogenic and non traumatic induced headaches, moreover, the difference between muscle tension headaches and migraines.
Yeah the ones we all get. It can't be helped. It's where we are at the paces we run. We process more information in a day, most of which is negative, than my Grandparents did in their entire lifetime. And you wonder why we get headaches.
Generally, the "regular joe" thinks of a migraine as a very severe headache. So, when they get a “bad” headache, they usually refer to it as a “migraine”, but this is not the case at all. There are many types of benign headaches which are severe enough to ruin one’s day or even their week. The classification of headaches, and more importantly, migraines, has been written and rewritten by doctors for centuries.
Although doctors have been practicing neurology since there were doctors, It wasn’t until the twentieth century that the specialty of neurology was well etched in stone, which gave way to modern clinical research protocols, and methods to evaluate headaches scientifically. Interestingly, even during the twentieth century, the classification of different types of migraines has changed substantially.
We live in a fast paced society. We run around dehydrated, drinking coffee, stare at LCD screens whether tiny or large. Drive to work or school, drive back, go do things, watch the news, most of it bad, and don't forget this is the stuff that didn't happen at work. Yeah, we worked today too.
Most of us manifest our stress physically, so we either get upset stomachs, aching necks, or we get headaches, and for some, all three. In America, particularly, two types of headaches are generally seen in this regard, muscle tension types, and vascular migraine types. Here’s “the quick and dirty” on both. and keep in mind that there is no purity in these classifications, and that most headaches are mixed.
Muscle tension headaches tend to come on as the day progresses, while the stressors one is dealing with are ongoing and building. So by the end of the day, your headache progressively worsens, your neck and scalp muscles increase their tone and now you have a full blown “head-knocker” at the end of the day.
Migraines on the other hand are vascular in nature, are brought on by chemical changes reacting to stress loads and dietary triggers. You generally awaken with the headache as they come on after the stress is gone. You guessed it, the following day, after the stressful event or events are over, you’re in pain.
It is the classic euphoric phase of “the general alarm reaction to stress”. So you wake up with a “banger” which is hugely painful and stays with you all day. This is also why a migraineur (pronounced, “mi-gren-yurr”) tends to have his headache on Saturday mornings, or say, the day after that big speech he had been preparing for weeks.
Muscle tension headaches, also known as “tension” headaches or “contraction” headaches, are direct results of increased tone and muscular irritation in the back, shoulders, neck, and scalp. As a result, they usually respond to anti-inflammatory drugs like ibuprofen or aspirin; massage; muscle relaxants; or just lying down for a while.
Migraines are more brittle. Since they involve vascular changes in the coverings and meningeal septa of the brain, anti-inflammatory drugs and muscle relaxation are usually ineffective treatments, moreover, they can even make a headache worse. Increased blood vessel caliber is the problem and needs to be turned off and re-set. This is why caffeine, decongestants, and other vasoconstricting agents help.
A test I have many patients, as well as friends and family try, is the “Beer Test”. It’s not one hundred percent, but fairly reliable, and if you want to know if that headache you have had all day is a migraine or tension headache, when you get home, drink a beer, preferably "a dark".
If the headache goes away, it’s a tension headache, if it gets worse, it’s a migraine. The practice of medicine, as cutting edge as it is, we seasoned craftsmen, can still shoot from the hip.
So, tension headaches are a direct result of stress insult, like someone turning up the volume on your neck muscles throughout the day. This type of headache is obviously exacerbated by posture, compensatory changes after an injury, arthritis, chronic musculoskeletal conditions, and of course, stress load.
Migraineurs suffer as they do because the headache waits, then sneaks up on them when they’re resting. The other important thing to remember is that in all these headache types, physical examination, metabolic workups, and imaging, are always negative for “lesion” or organic pathology. What I’m saying is that, “migraine”, is a diagnosis of exclusion. Other organic conditions must be ruled out first.
“Migraine” is a very old term derived from the Greek, meaning “semi-cranium” or “half skull”. Yes, generally a migraine headache is usually, but not always, unilateral, affecting one side of the head. The problem is they come in so many different manifestations that it has been difficult to classify them, even in modern medicine.
Several versions have been published since the early 1920s, however, after World War II, neurologists in America started to find some consistencies which allowed at least for neurologists, an ability to observe, diagnose, and treat with a standard of care. It also allowed doctors to communicate the type of headache a patient was experiencing.
This so-called classification remained in place for nearly sixty years, but in 1995, The National Headache Foundation along with The American Academy of Neurology, published straight forward guidelines that have allowed all physicians to more easily navigate the presentation of headache patients, diagnosis them accurately, and treat them appropriately and effectively.
The older “traditional classification” which is still used by many older doctors, uses excellent descriptors and relies on 5 major presentations, and thus, the patient is labeled as such.
They are: Classical Migraine; Common Migraine; Complex Migraine; Mixed Headache; and Migraine Equivalent (also known as Retinal Migraine). I don’t need to remind you that there are many variations on each one of these.
Classical Migraines are the brittle ones you hear about, and the type that causes a great many to present to the emergency department of their local hospital.
Here’s a typical presentation. Usually a woman, as 75% of migraineurs are women; she awoke with a one sided throbbing headache that wouldn’t respond to any medication. It started with a visual aura of sparkles in the upper left visual field (what we call a stratified visual scotoma). She can’t stand to have any light in the room, noises make the pain worse, and she’s nauseous and vomiting, in addition, just moving around makes it much worse.
It should be noted that auras can present in many fashions, including ringing in the ears, a tingling sensation anywhere, a deja vu, or a lot of yawning during the day. Yeah! I know!
The patient generally requires narcotic pain management, and neurovascular control with a triptan drug (see below) and an-anti emetic like phenergan.
It is this sufferer, the U.S. Department of Labor has stated, “costs our nation nearly 33 billion dollars in lost man hours a year"! That’s not including the tab to her health insurance company. Oh, and don't forget, if she’s on Medicaid insurance, your tax dollars.
Common Migraines, are much less intense and disabling, they still throb, are usually one sided, the patient can have nausea, but generally no vomiting. The lights and sounds are still bothersome but not as overwhelming. Most apparent in their history, is no aura or scotoma. These are self limited, usually responding to aspirin, Tylenol and caffeine in combination, and of course, rest.
Complex Migraines can be terrifying. Also referred to as Hemiplegic Migraines, they will generally have features of either a classical or common type, but in addition, present with neurologic deficit. Many are mistaken for Cerebral Vascular Accidents (stroke), or Transient Ischemic Attack, and require hospital observation and treatment. Ancillary studies are usually negative, and the event resolves spontaneously. Obviously, this patient requires an exhaustive evaluation before being given this diagnosis.
Mixed Type are just that. They are also the most common headache generally seen. They are more migraine than muscle tension, however, they are usually a common migraine with muscle tension overlay or muscle tension headache with migraine overlay. Again, aspirin, Tylenol, and caffeine are helpful; also mild muscle relaxants are effective. Usually if one component is treated, the other falls away. Interestingly, these respond very nicely to Botox injection which can keep the patient headache free for months.
Migraine Equivalent types are very interesting. Generally seen in college aged “type A” personalities, their hallmark is the scintillating visual scotoma, but there is no pain. That’s right! There is no headache. These patients are obviously afraid they have something serious when they first see their doctors, but after a negative work up and reassurance they do fine.
Also interesting is the phenomenon of "dissipation" with this migraine. The scotoma starts generally as a “dot”, slowly enlarges, becomes a "crescent" with a large visual field cut known as a bilateral superior, left or right, lateral homonymous quadrantanopsia, (say that 3 times, real fast), sweeps laterally, then vanishes.
These types of migraine usually resolve as a condition by the time the individual reaches their thirties.
The newer guidelines have made diagnosis more accurate and streamlined for therapy using two sets: “Migraine with Aura”, and “Migraine without Aura”. Both have their specific subsets, criteria, and recommended therapies for each. Understand that The National Headache Foundation also endorses guidelines for other types of headaches that are not classified as “migraine”.
What we really know about migraines now, started in the 1980s, subsequently producing new knowledge and new therapies. When sumatriptan hit the medicine cabinet as migraine weaponry in 1991, much changed in the approach to headaches, including migraine classing. Since its introduction, our understanding of the migraine condition and the migraineur’s display of symptoms has been revolutionary, and produced a paradigm shift in treatment. We now know that the “migraine” is actually a cascade of events.
We always knew that there was an underlying driver and that migraines were vascular, hence, the pre-triptan therapies, which were designed to do two things; lyse an acute headache with narcotics and get the patient to sleep so as to break the vascular pain cycle and throbbing. The other, was to approach chronically, preventing the migraine from evolving.
We assumed that migraine headaches were vascular from the beginning, as our known therapies, mostly vaso-constricting agents, were very efficacious, right out of the bucket.
Subsequent research revealed that these headaches occurred in 2 phases. First the blood vessels of the brain would constrict during stress or dietary trigger. Then, rather than come back to their original caliber, the vessels would overshoot, engorge, ultimately causing the painful phase.
So, our therapies in the 1980s and 1990s were designed to keep the constricting phase from manifesting, and therefore there would be no overshoot and no pain.
This is why to this day, we continue to see migraineurs treated with blood pressure lowering medications like verapamil and propranolol, which prevent tightening of vessels. In addition to these agents, antidepressants with chronic neurovascular threshold activity like amitriptyline are added which help control chronic pain. For many patients these drugs work. That’s why they are still used in many migraineurs who suffer severe and ongoing disabling attacks.
Sumatriptan led to more compounds in the “triptan class”, and a host of “me too drugs” which are the mainstay for acute therapy today. This is because the research which produced these drugs revealed that deep inside the brain of a migraineur is a “migraine motor”. It is tied to an area in the midbrain called the Trigeminal Nucleus Caudalis.
When stimulated by neurotransmitters from stress loads, lack of sleep, too much sleep, medications, or food triggers, it sends pain signals along the Trigeminal Nerve (The Fifth Cranial Nerve), and the vascular bed which surrounds it.
The two Trigeminal Nerves (left and right) are sensory nerves innervating the scalp, forehead, face and periosteal bone of the skull. When the migraine motor is stimulated, blood vessels along these nerves are irritated, inflamed, and dilate, causing severe painful migraines.
This should not be confused with its very famous cousin, Trigeminal Neuralgia which is also extremely painful and responds to similar medical treatments.
Sumatriptan is structurally similar to serotonin (5HT), and is a 5-HT_agonist. The specific receptor subtypes it activates are present on the cranial arteries and veins. Acting as an agonist at these receptors, sumatriptan reduces the vascular inflammation and dilatation associated with migraine, countering this cascade at its source.
Even in a disabling attack, sumatriptan injection can lyse the pain of migraine within minutes, without the side effects and sedation of narcotics and anti-emetics.
Now we know more about migraines and tension headaches. We know what causes them, how they are different, and how we can treat them. But you’ve probably been asking yourself, what are these food triggers and how do they stimulate the “migraine motor”? Migraine triggers are all over the web. A good place to start for a thorough list is at The National Headache Foundation .
The real mechanism of migraine motor stimulation is not fully understood, but may involve the neurotransmitter levels of dopamine, serotonin, and nor-epinephrine, in addition, the hormones 2-hydroxy-estradiol, progesterone, and thyroxin, as well as IgG antibodies from different food antigens. However, the triggers are well known and they themselves give us a clue.
Certainly there are known direct vasodilator foods such as Monosodium Glutamate (MSG), caffeine, kava based, and ephedra based herbs, and chocolate. Of course MSG is in all of our salted snacks and most of our “prepared” foods in the freezer section.
Not surprisingly, many of my migraine patients when asked to keep a food diary, find they consumed large amounts of MSG the night before an attack, usually a potato chip, Doritos, or Frito binge. Citrus such as orange juice; wine, particularly the reds; hard aged cheeses; meats cured in nitrates; pickles; peanuts; and mint, to name only a few, are well known culprits. Don't forget about the beer, partcularly, "the darks".
The non-food triggers are classic: too much or not enough sleep; the computer screen you’re looking at right now; stressful life styles, including the classic "workaholic"; drugs of all kinds, including aspirin and acetaminophen; and lastly, medicinal hormones such as progesterone, yeah, your birth control pills. This is one of the reasons why women are more prone to migraine.
Yes, a huge connection with progesterones and vascular engorgement in the turbinates of the nose as well as migraine is well documented. This is also why many women suffer during their menstrual cycles, and even pregnancy.
Because headaches are so prevalent, they can become a huge topic in any casual conversation with any doctor. Perhaps one needs to write a book on the subject to produce a concise literary treatment which the chronic headache sufferer can utilize. But there have been so many. All written by doctors and non-doctors alike. All that folk medicine and traditional medicine out there, it can become easily confusing.
Especially with all those quacks out there with their, "infomercials" and "snake oil" they try to sell you. What does the headache sufferer do? Hopefully this article will help you choose the right book.
In the mean time, watch those foods, try some way to lower your stress, (excuse me, "get off your ass, and find a sport you like to do, and do it"), don’t forget to drink plenty of water. Throw away all of your MSG. Oh, and throw out anything with high fructose corn syrup in it. Do it right now.
If you are a true migraineur, or a chronic headache sufferer, you should see your doctor right away, and don’t forget to check out The National Headache Foundation
Categories: Medical Advise