Head Aches & Migraines There are several types of headaches, with as many ways of treating them. Taking an aspirin or tranquilizer may provide temporary relief but it does not remove the cause. The frequent use of pain-relievers causes nervous debility, weakens the heart and brings on other complications. The common causes of headaches are allergy, emotional reasons, eyestrain, high blood pressure, hangover, infection, low blood sugar, nutritional deficiency, tension, the presence of poisons and toxins in the body, and migraine. Allergies, an often unsuspected cause of headache, vary in different individuals. The foods to which some people are allergic and which can trigger headaches are milk and milk products, chocolates, chicken liver, alcohol and strong cheese. Sneezing and diarrhea are further indications of an allergy. Intense emotions often cause headaches. Many people who outwardly appear to have a pleasant disposition may actually be simmering about a job, or may bear resentment towards a person or something. This hidden hostility may manifest itself as headache. It is important, that negative feelings should not be bottled up but should find some safe means of expressions. Eye-strain is a common cause of headache. In such cases, an eye specialist should be consulted and proper treatment taken. Simple eye exercises such as moving the eyes up and down and from side to side, palming, rotating the head, with neck outstretched, forward and backward three times, then clockwise and anti-clockwise can relieve eye-strain. High blood pressure can cause pounding headaches. The headache usually starts at the back of the head on getting up in the morning. A safe method of treatment for this is to immerse your legs to calf-level in a tub of hot water for 15 to 20 minutes. This draws the blood away from the head and down to the feet, giving relief from the headache. Many people get a severe headache after consuming alcohol in excess. Alcohol causes the blood vessels to swell, resulting in a painful headache. The best treatment for this is to avoid excessive consumption of alcohol. A hangover headache can be avoided by taking a vitamin B-1 (thiamine) tablet with the drink. Headaches may occur if there is an infection, such as a cold, virus and fever. Vitamin C therapy is the best all round method. For a cold, high doses of vitamin C should be taken at hourly intervals with the appearance of the first symptoms like a sore throat, runny nose, etc. Vitamin C has worked miracles, and is considered a natural antibiotic. Low blood sugar is one of the causes of irritability and headache. Sugar is not a cure for low blood sugar, though it may raise the blood sugar temporarily and make one feel better for a while. Low blood sugar is the result of an abused pancreas which over stimulates the production of insulin in the body. It can be controlled by eating smaller meals at short intervals rather than the standard three large meals daily. The intake of carbohydrates should be cut down to the minimum and coffee should be eliminated as it over stimulates the pancreas. A lack of iron, resulting in anemia, is a common cause of headache. The headache sometimes appears before the onset of anemia, due to a chronic iron deficiency. Brewer’s yeast is an excellent source of iron and anemia can easily be prevented by taking a few teaspoons daily. Headache can also be brought on due to the deficiency of B vitamins, namely pantothenic acid, B-1 (thiamine), B-12 and B-6 (pyridoxine) and can be cured by taking these vitamins. When taking any of the B-vitamin factors separately, it is absolutely essential to add the entire B-complex range to one’s diet in some form such as Brewer’s yeast, liver, wheat germ, etc., otherwise too much of one factor can throw the other factors into imbalance, resulting in other problems. Actually, the entire B complex group itself serves as protection against headaches, including migraine. Tension headaches are probably the most common of all, and are caused by emotional conflicts which result in stress. Stress causes the muscles of the shoulder, neck and scalp to tense unconsciously. Persons who are irritable, tense and lose their temper quickly usually get this type of headache. It increases gradually and passes off with the release of tension. One should try to relieve the stress which produces the headache. Poisons and toxins admitted into the body through food, beverages and water, as well as through breathing, polluted air, can cause any number of disturbances. A headache may be the first warning that a poison has entered the body. Additives in foods and in many cases, cosmetics, skin and hair products are also serious offenders in bringing on headaches. In addition, there are toxic air contaminants which are too numerous to mention. Migraine Headaches: Afflict about 10% of the world’s population and can be defined as a paroxysmal affection, accompanied by severe headache, generally on one side of the head and associated with disorders of the digestion, the liver and the vision. It usually occurs when a person is under great mental tension or has suddenly got over that state. Migraine is also known as "sick headache" because nausea and vomiting occasionally accompany the excruciating pain which lasts for as long as three days. Migraine usually gives warning before it strikes: black spots or a brilliant zigzag line appears before the eyes or the patient has blurring of vision or has part of his vision blanked out. When the headache occurs, the patient may feel tingling, numbness, or weakness in an arm or leg. Migraine sufferers have what is known as a "migraines personality". They are compulsive workers and perfectionists, who feel that they have to do everything right away. When they complete a task, they are suddenly laid down from a state of temporary tension to a feeling of utmost relief then the migraine. It is a purely physiological process. The head and neck muscles, reacting to continuous stress, become overworked. The tightened muscles squeeze the arteries and reduce blood flow. When a person relaxes suddenly, the constricted muscles expand, stretching the walls of the blood-vessel. With every heart beat, the blood being pushed through this vessels expands them further and causes incredible pain. When a headache strikes, one should stay on one’s feet in the daytime and do simple chores which do not require too much concentration or walk, move around and get some fresh air. The best remedy to prevent headaches is to build up physical resistance through proper nutrition, exercise and constructive thinking. As a first step undertake a short fast. During the fast, citrus fruit juices, diluted with water may be taken six times daily. By taking the load of digestion will at once save nervous energy which can be utilized for more important purposes. The blood and lymph will also be relieved of a great burden. After a short fast, the diet should be fixed in such a way as to put the least possible strain on the digestion. Breakfast should consist of fruits, both fresh and dried. Lunch should consist largely of protein foods. Starchy foods such as whole wheat bread, cereals, rice or potatoes should be taken at dinner along with raw salads. Spices, tomatoes, sour buttermilk and oily foods should be avoided. Drinking a glass of water (warm water in winter and cool water in summer) mixed with a teaspoonful of honey the first thing in the morning, is also a good remedy. Water Treatment There are certain water applications which help relieve headaches. Copious drinking of water can help as do the cleansing enema with water temperature at 98.6oF, the hot foot bath, a cold throat pack, frequent applications of towels wrung out from very hot water to the back of the neck, a cold compress at 40oF to 60oF applied to the head and face or an alternate spinal compress. Hot fomentations over the abdominal region just before retiring relieve headaches due to stomach and liver upsets. Index Botox for Migraines: Looking Good, Feeling Good? Distinguishing a Severe Headache from the Warning Signs of Stroke A Textbook Case of Sinus Headaches? Don't Be So Sure Fair Weather Headaches The Fruit Fix: Will It Prevent Hangover? Avoiding Hangover Hell Headaches: An Overview Under Pressure: Understanding Sinusitis Alternative Treatments for Headaches Headache, Hypnosis, and Stress: A Case History What is Migraine?: Causes, Symptoms and Treatment Spectrum of a Migraine Botox for Migraines: Looking Good, Feeling Good? By: Eric Sabo A common procedure that reduces wrinkles may also help prevent frequent headaches, new findings suggest. Researchers found that giving a series of injections with Botox, already used by millions concerned about looking their best, could cut the incidence of severe migraines by more than half. Those who used Botox also had less need for over-the-counter pain medications when they did suffer a headache. The results, which were presented at the American Headache Society meeting last week, have been criticized by some migraine experts. "There is no proof that Botox works," said Michael Welch, MD, a neurologist with the Rosalind Franklin University of Medicine and Science in Chicago. He complained that the new results were based on a review of a previous trial that failed to show Botox could help prevent migraines overall. Finding that it works on a smaller group of patients in the same study is not considered reliable, he said. "We have to be very cautious." Still, the latest news is bound to add to the strange fortunes of botulism toxin A, a purified food poison that has now become a runaway cosmetic hit as the main ingredient in Botox. The anti-wrinkle treatment was first approved for use against eye muscle disorders, and it has since been found to relieve everything from nerve problems to excess underarm sweat. The toxin quickly gained popularity with so-called "Botox parties," where plastic surgeons injected wrinkled volunteers in front of small gatherings of people who were considering the procedure. Dual-Purpose Botox? So far, Botox is not approved by the Food and Drug Administration (FDA) for migraines. Yet Stephen Silberstein, MD, director of the Headache Center at Thomas Jefferson University Hospital in Philadelphia said that the treatment could prove tempting for migraine sufferers who want to feel better and look younger. "It's icing on the cake," he said. Silberstein was part of the research group that reexamined 228 people who suffered from severe migraines. About half of the patients received a series of 10 to 25 Botox injections in their head, neck or shoulders every three months. The other half received saline injections. After six months, Botox failed to show a reduction in migraine headaches compared to a placebo. But looking at patients who suffered more frequent attacks, Botox was linked to a 20 percent greater reduction in migraines, according to results presented at the headache meeting by David Dodick, MD, of the Mayo Clinic in Arizona. The Botox group suffered an average of 14 migraines a month before the study. After receiving treatment, headaches dropped to six a month. In the saline group, patients went from nearly 13 migraines a month to about eight. Another analysis, led by Frederick Freitag, DO, of the Diamond Headache Clinic in Chicago, found that Botox could reduce the need for pain medication. Patients who took Botox reduced their use of ibuprofen and other pain relievers by 60 percent compared to 35 percent with saline injections. Botox in Practice Freitag, who has treated his migraine patients with Botox for more than a decade, said that people who have four to eight headaches a month generally don't respond to this therapy, but those with more challenging headaches might. There are several treatments that are used to prevent migraines, including anticonvulsants, blood pressure medications and anti-depressants. The newest treatment is Topamax, which was specifically approved by the FDA for migraine prevention. Freitag said that Botox seems to have the same effect as antidepressants in relieving headache frequency. "About one third of patients will show some benefit," he said. Botox, however, can also make your face feel frozen, and those who hope to have fewer age lines in addition to fewer headaches may come away disappointed. The areas of the body that doctors need to inject Botox is often different for migraines than for cosmetic reasons. "They rarely overlap," Freitag said. "Patients will look the same." Distinguishing a Severe Headache from the Warning Signs of Stroke By: Eric Sabo A rapid, severe headache has long been considered an early warning sign of stroke. Along with other clues, such as a sudden numbness on one side of your face or body, an extremely painful headache that seems to come out of nowhere may require an immediate trip to the emergency room. Strokes are more common as you get older, but these so-called "brain attacks" can strike at any age. The faster you get to the hospital, the better your chances of preventing serious damage to the brain. But new research suggests that migraines and other headaches are not just an early sign of stroke, they may even put you at risk for one. Looking at some 12,700 men and women who were involved in the Atherosclerosis Risk in Communities Study, published in May in Neurology, investigators found that people who have a history of severe migraines were more likely to suffer an ischemic attack, the type of stroke that is caused by blocked blood vessels. Compared to those who reported few serious headaches over their lifetime, migraine sufferers also showed greater symptoms of having a stroke or mini-stroke, known as a transient ischemic attack. This connection appeared strongest in men and women who suffer from aural migraines, which are associated with blurry vision and strange smells, in addition to pain. Intuitively, a link between migraines and stroke would seem to make sense. Severe headaches are believed to cause a disturbance in blood vessels, and there is an unusually high prevalence of strokes in younger migraine sufferers. How to Tell the Difference But these recent findings also cause some confusion. For those who frequently get serious headaches, how can one tell regular pain from a possible stroke? "There is a great overlap in symptoms between migraine and stroke," says Philip Stang, MD, lead author of the study and an associate of the department of epidemiology at the University of North Carolina. "And there are types of migraine that include stroke features and vice-versa." Keeping that in mind, experts say there are some potential differences as well. For one, most migraines will clear up relatively quickly, whereas stroke symptoms are constant. The presence of certain risk factors may also make one more suspicious that a headache could be a sign of stroke. For example, younger women with migraines, especially if they smoke or take oral contraceptives, are more likely to suffer a stroke than others, says Stang. In older patients, hypertension is a more serious risk factor for stroke than severe headaches. It may turn out that the link between migraines and stroke risk is not a serious concern. In an editorial that accompanied the study, the authors argue that there are more questions than answers at this point. Stang is cautious as well. "Since there is no laboratory test to confirm migraine, it is difficult to be so precise and assured," he says. Still, there is little question about the importance of seeking medical help at the first signs of a stroke, including severe headaches. Specially trained hospital staff can determine if you are having a stroke and initiate treatment, which can prevent significant harm if started early. Experts recommend that you seek help immediately if you experience the following, sudden symptoms: Numbness or weakness of the face, arm or leg, especially on one side of the body Confusion, trouble speaking or understanding Trouble seeing in one or both eyes Problems walking, dizziness, loss of balance or coordination Severe headache with no known cause A Textbook Case of Sinus Headaches? Don't Be So Sure. By: Christine Haran You've probably heard friends or family members complaining of recurring sinus headaches. Maybe you yourself feel that pressure over your sinuses on a regular basis. If you or others you know experience these types of headaches routinely, new research suggests that what you may actually have is migraine headaches. "There is a great under-recognition of migraine," says Curtis Schreiber, MD, associate director of the Headache Care Center in Springfield, Missouri, who led a study published in the September 13th issue of the Archives of Internal Medicine. In the study, Dr. Schreiber and his colleagues screened almost 3,000 people who had a self-described or physician-diagnosed "sinus" headache, specifically people who complained of intermittent headaches marked by sinus pressure, pain and nasal congestion. They excluded patients with obvious signs of sinus infection, such as fever or colored nasal discharge. The researchers found that 88 percent of participants who thought they were suffering from sinus headaches actually had a type of migraine headache. Below, Dr. Schreiber discusses why there is so much confusion between sinus and migraine headaches. When do sinuses cause headache? Headache can occur as part of an acute sinus infection. Infections of the sinuses are commonly caused by viruses and bacteria. Typically, when people have sinus infections, they develop a fever and colored nasal discharge. Sinus infections are identified by these symptoms and sometimes CT scans of the sinuses and laboratory tests. The kind of "sinus" headaches that neurologists and headache doctors are skeptical about are those that are episodic and recurrent. Although pain may start over the sinus areas, other symptoms occur as the headache progresses. A typical patient might say, "I get sinus headaches once every month or every couple of weeks. I don't have fever with it. I really don't get much discharge or drainage with it, but it starts over my sinuses and it gets to be severe." In what way does a migraine look like sinus headache? If you look at a headache textbook and read how migraine headache is defined, you'll see a relatively small number of symptoms included in that diagnostic definition. Those features include moderate to severe intensity, throbbing pain, light sensitivity, sound sensitivity, nausea or vomiting, and pain that worsens with routine physical activity. That's the mental checklist that clinicians are trained with, and it doesn't include "sinus" symptoms. However, there is a group of migraine patients who start with sinus-area symptoms. People might have nasal congestion or watery eyes. They might have pressure over their cheek area or forehead. As the headache progresses, it develops symptoms more typical of migraine, such as light sensitivity or nausea. If you look at the study that we did, it showed that 88 percent of people with a history of "sinus" headache, without obvious symptoms of infection, fulfilled a migraine-type diagnosis. What are other reasons why a person might think their headache is a sinus headache? It's not uncommon for patients to say, "Sinus headaches run in my family." But usually, we don't think of infectious processes as having a genetic link. And for women who say, "It seems like I get sinus headaches and they're worse around my menstrual cycle," we think about migraine, not infections. If you look the patients with these self-described or previously clinician-diagnosed sinus headaches that turned out to be migraines, the triggers often included things such as weather changes, which can lead many sufferers to presume that the attack was sinus related. In fact, weather changes are a frequently encountered trigger for migraine headaches. Many headache sufferers notice headaches seem to be worse in the spring and the fall, during the time typical of seasonal allergies. This association also leads many to presume that their headaches are sinus related. What message can be taken from this study? I think the message here is not that every person with sinus headache has migraine. There are people who do have infections and other less common sinus problems that need to be appropriately diagnosed and treated. However, there are probably a lot of headache sufferers who have this sinus presentation of migraine who limp along with it for a day or longer and miss work, family and social activities on a regular basis. Sufferers of this type of headache, and their healthcare providers, should consider the possibility that this headache is a migraine. There may be as much as a 9 out of 10 chance that it is migraine, and if so, a migraine-focused treatment approach may provide more effective relief. What advice do you have for people who suffer from these types of headaches? When people see their healthcare provider with headaches, they need to be prepared to describe all of the symptoms that occur during the attack. How it starts is important, but they should also be able to relate all of the symptoms that occur with the headache. Be sure to relate the total duration, from start until all of the symptoms are gone. Let your healthcare provider know about the impact of the headache, the things that you normally do, but can't do when the headache is there. Patients need to be explicit about how well their treatment plan is working. All too often, if a patient is asked, "How is your treatment working?" they say, "Well, OK, I guess." Many healthcare providers may presume that they are doing really well when, in fact, the patient means, "I'm getting partial relief." For patients with migraine, the modern goal for treatment is to become pain-free and back to normal function within two hours of treating. For many sufferers partially effective treatments reduce the symptoms but a return to normal function is hours or days away. What Kind of Headache Do You Have? Some people say the pain is like a band slowly tightening around their head. Others describe pain that worsens when someone turns on a light. Both are descriptions of headaches, but they are symptoms of very different types of headaches that are generally treated quite differently. While nearly everyone gets an occasional headache, people with chronic headaches live in fear of when the next headache will strike, and they suffer when it does. Headache specialists say the key in treating a headache successfully is uncovering what kind of headache you have. And you don't have to be a neurologist to begin classifying your headache. Below, Richard Lipton, MD, a professor of neurology, epidemiology and social medicine at Albert Einstein College of Medicine in Bronx, describes the symptoms of the most common types of headaches to help you distinguish the type of headache you tend to get. How common are headaches? Headache is a nearly universal human experience. In any given year, 90 percent of Americans say they've had at least one headache not caused by a cold, the flu, a hangover or a head injury. But even though headache is a nearly universal human experience, there are headache-prone individuals who have frequent attacks, where headache becomes a significant medical symptom and not just a problem of everyday life. What are the main types of headaches? There are two categories of headaches, primary headaches, where the headache problem is the disorder, and secondary headaches, where the headache is a symptom of an underlying condition like a stroke, a brain tumor or an infection. If we look at the primary headaches, there are four major kinds, migraine, tension-type headache, cluster headache and then the fourth group is a miscellaneous group of other, usually uncommon headache types. How can the type of pain you have help doctors make a diagnosis? One issue is the quality of the pain. Is it throbbing? Is it a steady ache? Another feature is the location of the pain. Is it in the eye? On one side of the head? On both sides of the head? Another feature of the pain is the frequency and duration. Do attacks last 10 minutes? Do they last 10 days? Do they occur every day? Do they occur only occasionally? What is a cluster headache? Cluster headache derives its name from the fact that the attacks tend to occur in clusters. So a person with cluster will have a long period where they don't have any headaches at all, and then they'll have what what's called cluster phase; where they will begin having attacks on a daily or near-daily basis for weeks or months. The cluster attacks tend to be short, they last 15 to 90 minutes. Cluster headaches are always one-sided. The pain is usually in or around one eye, and it is accompanied by redness or tearing of the eye, drooping of the lid, nasal stuffiness and features of that kind. But the hallmark of cluster headache is the fact that the attacks cluster in time. How common are cluster headaches? Cluster headache is quite rare. Cluster affects perhaps 2 in every 100,000 people. Given the severity of cluster attacks, that's a good thing. Of the primary headache disorders that we're discussing, the one that is predominant in men is cluster headache. The other disorders are more common in women. What are features of tension and migraine headaches? Migraine headaches and tension-type headaches are the two most common forms of primary headache and, interestingly, they're defined in opposition, both by features of pain and by the features that accompany pain. Where tension headache pain tends to be on both sides of the head, migraine pain tends to be just on one side of the head. Where tension-type headache pain tends to be mild or moderate, migraine pain tends to be moderate to severe. Where tension-type headache pain is a steady ache or a pressure, or some people describe a hat-band of pain, migraine pain is typically described as throbbing or pulsing. And where tension headache is not influenced by routine physical activity, migraine sufferers usually find, if they move around, if they bend over, if they cough, that makes their pain worse. Similarly, the disorders are defined in opposition in terms of associated symptoms. Migraine is characterized usually by nausea and vomiting and/or sensitivity to light and sound, or an aura, which involves visual displays that usually precede or accompany a headache. Tension-type headache is defined by the absence of those very same features. How long do tension headaches usually last? Tension-type headaches typically will begin at the end of a stressful day, at three or four or five in the afternoon, and they typically last from one hour to six hours, though they may last even longer. How common are migraine headaches? Roughly 12 percent of the population gets migraine. That's 18 percent of American women and 6 percent of American men. So projecting to the U.S. population, we estimate that there are 28 million Americans who have migraine. How long do the migraine headaches last and how often do they occur? Migraine headaches last four to 72 hours. On average, untreated, they last 24 hours. Treated, it depends how good your treatment is, but they could last as little as one minute. On average, migraine attacks occur once or twice a month, although patients who go to see headache specialists often have more frequent headaches, which is why they go to see a specialist. What can trigger a migraine? Migraine has many triggers and, in fact, one of the simplest and most useful things that a person with migraine can do is to learn to identify their headache triggers so they can avoid them if they're avoidable or plan to manage them if they're the sorts of triggers that are unavoidable. It's important to know that triggers vary enormously from person to person and there's a very long list of triggers, including dietary triggers and sometimes people get the advice, "Well, if you have migraine, you should avoid soft cheese, red wine, all alcohol, anything fermented, anything with preservatives, anything with nitrates, anything with chocolate, anything with NutraSweet and so forth." My view is that, although all of those factors are migraine triggers for some people, for any individual person, the triggers are individual. In addition to those dietary triggers, hormonal factors are an important trigger, so many women find that they get headaches the day before menstrual flow begins or the day that flow actually begins. That effect, we believe, is an effect of estrogen withdrawal. For that reason, menopause is a difficult time for many women because the estrogen levels bounce around and, when they decline, that can initiate headache. There are a number of other triggers for migraine. Some people find that travel and shifts in time schedules, too much sleep, too little sleep trigger migraines. Falling barometric pressure, which is something that happens in anticipation of a rainstorm, is a migraine trigger. Interestingly, people don't tell their doctors a lot of the things that they notice, because they're afraid their doctors will think that they're making foolish or crazy connections. But the reality is that learning to recognize your triggers gives you an opportunity to intervene to prevent your headache, so it's well worth paying attention to. What are the signs that a headache might be due to an underlying medical problem? Although the overwhelming majority of people with recurrent headaches have primary headaches, sometimes headache is symptomatic of a serious underlying disorder. There are a series of red flags that suggest that might be the case. One red flag is new onset of headache after the age of 55, and that may imply either inflammation of the arteries of the head or, on rare occasions, a brain tumor. Headaches associated with a fever or a stiff neck may reflect an infection, such as meningitis, that requires medical attention. Headaches that are associated with neurologic symptoms, other than typical aura, are alarming. While tingling or numbness that occurs for 5 or 10 minutes prior to the onset of headache is not alarming, weakness, difficulty moving one side of the body and double vision are good reasons to go to the doctor. In addition, a headache that begins very suddenly is a red flag. So if you go from having no pain at all to having very severe pain, that may be a first manifestation of stroke and, if that happens, that's a good reason to seek medical care. What's the biggest myth about headaches? The reality is that, if people are living with pain, with anxiety, with limitations on their ability to either do the things they want to do or make the plans they want to make because of headaches, that's a very good reason to seek medical care. Headache is not a problem that you need to learn to live with. It's a problem that you need to learn to manage and live without. Fair Weather Headaches By Christine Haran You may have an elderly relative who says that she can predict the weather based on the pain in her arthritic knee. Or maybe you find that you get headaches on damp days. While many people believe there are links between weather and certain medical conditions, there has been little evidence to prove it. But a study recently published in the June issue of the journal Headache suggests that weather can be a trigger for migraine headaches. Approximately 18 percent of women and 7 percent of men suffer from migraine headaches, which are a result of changes in the brain and surrounding blood vessels that cause pain and sometimes nausea, vomiting and light or sound sensitivity. While known triggers include wine, chocolate, sleep deprivation and stress, many people with migraine say that weather also sets off their headaches. This study, conducted by researchers at the New England Center for Headache in Stamford, Conn., assessed 77 migraine sufferers who tracked their headaches on calendars for two to 24 months. Participants filled out a questionnaire about if they believed the weather affected their headaches, and if so, how strongly it influenced headaches. Researchers also obtained weather data from reporting station near the participants from the National Weather Service. They then assessed the relationship between weather and the participants' headaches based on absolute temperature and humidity, barometric pressure and changing weather patterns. The study found that about 51 percent of the participants did have a weather trigger, though about 62 percent thought that they were sensitive to weather. The most common weather trigger was extremely hot or cold weather, the second was an extreme of atmospheric pressure such as humidity or dryness, and the third factor was any major change in the weather over a two-day period. Almost 40 percent of all participants were found to be sensitive to one weather factor, while about 12 percent were sensitive to two factors. Study author Alan Rapoport, MD, director of the New England Center for Headache and a clinical professor of neurology at Columbia University College of Physicians and Surgeons in New York City suggests that people who think they might have weather-triggered migraines track their headaches. "Any good headache specialist should have a patient tracking their headache on a calendar," he says. "It's difficult for patients to do as careful a study as we did, but they can try to correlate the weather with the degree of headache they have." Those who determine that they are prone to headaches when the weather pattern is changing, for example, could carry their acute medications with them at that time, or take their preventative medication before the weather change to avoid a migraine. It's not yet understood why weather cause migraines. "We know that migraineurs have an inflammation in the meninges, or the covering of the brain, as well as dilation of the blood vessels in the meninges," Dr. Rapoport says. "Exactly how weather patterns trigger the abnormalities that start the migraine process is not yet known." The next step, he says, is to figure out exactly how weather triggers a headache attack, so that these headaches can be more successfully prevented or treated. The Fruit Fix: Will It Prevent Hangover? By Christine Haran The best way to avoid a hangover is to not drink. But since many of us do find ourselves "over-served" at times, we're always seeking more creative ways to prevent a hangover. Still, chances are no one has recomended eating the fruit of a prickly pear cactus before hitting the bar. But that's more or less what researchers at Tulane University in New Orleans offered study participants to reduce hangover symptoms; the results were recently published in the Archives of Internal Medicine. Before hangovers can be effectively treated, you have to first know what is causing the headache, dry mouth, nausea and other symptoms that people suffer from after a night of overindulgence. According to lead researcher Jeff Wiese, MD, an associate professor of medicine at Tulane, there are probably three causes of hangover: dehydration; disrupted sleep because the brain is stimulated due to alcohol withdrawal; and inflammation, which is caused by the congeners in alcohol, which are the impurities that give spirits their flavor, color and aroma. Dr. Wiese and his colleagues chose to focus on the inflammatory component of hangover, which is why they evaluated extracts of a type of prickly pear fruit called Opuntia ficus indica in their 55-person study. When the body is under stress, it produces heat shock proteins to repair cellular damage as soon as it starts. The prickly pear fruit has been shown to accelerate the creation of these proteins and reduce inflammation. "If the plant repaired those cells that were inflamed, there would be less inflammation and fewer hangover symptoms," Dr. Wiese explained. In the study, researchers divided participants into two groups. While one group received the extract five hours before consuming a meal and enough alcohol to induce a hangover, the other group took a placebo. The next morning, nine hangover symptoms and overall well-being was evaluated, and the study was repeated two weeks later with the placebo and extract groups swapped. The researchers found that the extract reduced three of the nine symptoms—nausea, dry mouth and loss of appetite—and was associated with a higher score for well-being. Additionally, levels of C-reactive protein, a blood marker of inflammation, were higher in people with more severe hangovers. While the study authors are not yet recommending that you grow prickly pear cacti in your backyard, they say the study offers scientific validity to the idea that there is an inflammatory component to hangover from congeners. "So if an individual decides to imbibe, they should choose their alcohol wisely, drinking those low in congeners," Dr. Wiese said. "This includes the clear spirits such as vodka, gin and rum, particularly those that have been highly distilled, which are the more top-shelf liquors." In the meantime, a better understanding of the physiology of hangover may, at some point, lead to hangover medications. But, Dr. Wiese warns, because of the many causes of hangover "there will never be one drug that will cure it." Avoiding Hangover Hell By Christine Haran "I'll never drink again." It's a claim many of us have made the morning after a debauched night while struggling to face the daylight with a pounding headache, a parched tongue and a distinctly queasy feeling in the pit of the stomach. For many, this promise is short-lived and is particularly hard to maintain during the holiday season. As Robert Swift, MD, a professor of psychiatry at Brown University Medical School and associate chief of research at the Providence VA Medical Center in Rhode Island, points out, people tend to increase their alcohol consumption during the holidays when there are more parties and people have more leisure time. So if you've overindulged at the office holiday party, you might find yourself not only deeply embarrassed but also seeking a quick hangover cure. Hangover remedies abound and include such treats as anchovies, tea made from rabbit droppings and, of course, another stiff drink. But do any of them work? Below, Dr. Swift talks about what exactly causes a hangover, how best to cope—and how to avoid such misery in the first place. What is hangover? Hangover is a "collection" of symptoms that occur after a bout of alcohol drinking. It's that simple. What predisposes some people to hangover? There are some studies that suggest that there may be some genetic predispositions to hangover, although that's not clear. Obviously, larger quantities of alcohol are more likely to produce more severe hangovers. And there are a lot of other factors that may go into it as well. There is some evidence that the type of alcohol consumed may relate to hangover, the time of day that the alcohol's consumed, whether one is drinking instead of sleeping, whether you eat while you're drinking, and how well hydrated you are. Can you give a sense of how many drinks are needed over what period of time for an average person to end up with a hangover? That's hard to know because it depends on a lot of factors, and it's an individual sort of thing. There are people who are drink very, very heavily—who are alcoholics—and never get a hangover and there are some who drink very heavily and they do get hangovers What the worse time of day to drink in terms of hangover? It's interesting. On the one hand, alcohol consumed in the morning tends to be more intoxicating, believe it or not. But by and large, most people drink in the evening and late at night, and that means that they may be drinking instead of sleeping and alcohol influences the quality of sleep as well. As a result, one ends up sleep deprived, and that can certainly exacerbate hangover symptoms. Does body weight play a role? Body weight will play a role in that it affects the concentration of alcohol and other substances that ultimately get into your body. The concentration is actually affected by the amount of water in your body, which is partially dependent upon your weight but not entirely. When people do calculations of alcohol—how much alcohol will it take to achieve to a certain blood alcohol level—they look at what's called "lean body weight" because the alcohol doesn't go into the fat. So a fat person isn't necessarily more resistant to the effect of alcohol because they may have the same amount of body water as somebody who's very skinny. Men have more body water than women do, so if a man and a woman who weigh the same drink the same quantity, the man will have a lower blood alcohol than the woman will, because the woman has less body water to dissolve the alcohol. What are some of the symptoms of hangover? I think the predominant symptom of hangover is headache. Most people experience a headache, and many experience some gastrointestinal symptoms, predominantly nausea and sometimes vomiting. There's a sense of general malaise, of just not feeling well, feeling like you're fatigued, can't concentrate. People's mouths feel very dry because they're dehydrated. What is happening in the body to cause these symptoms? That's still not entirely known. There are two major theories about the causes of hangover. The first theory is the withdrawal theory, which suggests that hangover is really a type of mild alcohol withdrawal. If you look at people's brains in a brain wave machine, even though people may be feeling fatigued and tired, their brain is actually stimulated. And that's what alcohol withdrawal is: It's a hyperstimulatory state. Chronic alcoholics, if they stop drinking, get anxious, they get excited, they can't sleep, they get the shakes. They may even hallucinate. It's thought that even one bout of heavy drinking may induce a state of kind of mild central nervous system excitation and people perceive that as a hangover. The second theory is that the hangover is due not to the alcohol per se but other things in the alcohol, the so-called congeners. A beverage alcohol is usually not 100 percent pure. For example, whiskey may be distilled, but then it's stored in charred-oak barrels for years and years, so you get all of these compounds that leach out of the barrels and then get degraded over time. There are hundreds of biological compounds in alcohol beverages. Of course, with wine and beer, you actually add yeast to the grapes or the malted barley or whatever, so there are lots of chemicals in it. The other thing is that the yeast also makes other kinds of alcohols. When yeast ferments sugar and alcohol, the vast majority of what it makes is ethyl alcohol, which is the alcohol we drink. But the yeast can also produce other alcohols, such as smaller alcohols like methanol (or wood alcohol), and methanol's pretty toxic. It can cause blindness, in fact, if you drink it pure. When methanol is metabolized in the liver, it's converted to formaldehyde, which is embalming fluid. So when you drink alcohol that contains some methanol, your body first gets rid of the ethyl alcohol but the methanol stays in your blood. It doesn't get degraded, and it actually builds up over time. Then when you've burned up all the ethanol, you start to metabolize the methanol and produce formaldehyde as a byproduct of that, and some people feel that produces the symptoms. Do certain types of alcohol beverages have more methanol than others? Yes. There appears to be a relationship between the likelihood of getting a hangover and how dark the alcohol is. The color means that the alcohol has more junk in it. The darker color is somehow reflecting the level of congeners. So more clear-colored alcohols, like vodka and gin, are less likely to give you a hangover than a darker-colored alcohol, like a whiskey or a scotch, bourbon or brandy. Likewise, among wines, people often find they're more likely to get a headache from red wine rather than white wine. Sulfites in red wine may contribute to hangover in people who are sensitive to them. How can people treat a hangover? Prevention is best. Avoid alcohol and you won't get a hangover. Drinking in moderation will also help. Mixing alcohol with other beverages, drinking slowly. Drinking alcohol with food will reduce the concentration of alcohol in your stomach. It will dilute it and be less irritating to the stomach. Also when people drink and eat at the same time, less alcohol is absorbed into their blood because the alcohol's absorbed more slowly and therefore more of it gets metabolized by the liver and the stomach before it gets into the blood stream. Why do some people argue that a drink in the morning cures hangover? The "hair of the dog that bit you"—a drink in the morning—might make you feel better because you stop the metabolism of methanol and the formation of formaldehyde because you've got alcohol in your system again. That could help the withdrawal theory, too. If you are withdrawing from alcohol, so to speak, you give yourself a little bit of alcohol to "detox" yourself. If you have overindulged, are there any options? If you have overindulged, remedies abound. I think for thousands of years probably there have been reported remedies for hangover. But there really is very little that has been scientifically proven to improve a hangover. In fact, I don't know of anything. So people should just treat their symptoms? People should treat their symptoms, but even treating the symptoms can have side effects. For example, if you have a headache, you can take an antiinflammatory medication like aspirin or ibuprofen. But, those can be irritating to the stomach, which has already been irritated from the night before. And after you've been drinking a lot of alcohol, you should not take acetaminophen (Tylenol) because it has some toxicity to the liver, which is actually magnified by drinking alcohol. In fact, there have been questions about whether there ought to be a warning on the label. Rehydrating will help, though people aren't as dehydrated as much as they feel dry. But actually drinking fluids, having some carbohydrate in case your blood sugar's down, having something mild in the stomach if there's some stomach irritation, is a good idea. Is there anything good about a hangover? The question that one could argue philosophically is that a hangover might be good for you because it deters you from drinking too much the next time. Headaches: An Overview By: Stephen Emond, MD, FACEP Headaches are a common cause of suffering, but all headaches are not created equal. The main challenge to affording relief from various forms of "cephalgia," or "head pain," is categorizing a headache by type, and then proceeding with the therapy most likely to help. The International Headache Society's landmark work on headache classification has allowed important advances in headache study, but is somewhat awkward to use in clinical practice. One practical approach is to first distinguish "urgent" headaches (those that may be life-threatening) from others that may be less urgent, if no less distressing. Identifying "special" headaches (those that may only benefit from specific therapy) is the next step. Finally, if neither of these classifications fit, treatment of tension or migraine headache (the most common) is in order. Urgent Headaches: Urgent headaches may be immediately life-threatening, and should be treated promptly. Subarachnoid hemorrhage ("aneurysm") Patients typically describe a headache related to a leaking aneurysm as a sudden, "thunderclap" headache, often the "worst headache of my life" (an "aneurysm" is a swelling of a blood vessel in the brain). After this sudden onset, the pain may persist at a high or low intensity for days. Abnormal neurological symptoms may occur, including brief loss of consciousness at the onset of the headache, a stiff neck, or eye movement abnormalities. Such a headache mandates prompt evaluation by a physician, since a missed aneurysmal leak can result in a catastrophic stroke or death. Evaluation typically takes place in an emergency department, and includes a brain computed tomography (CT) scan. A spinal tap (looking for leaked red blood cells) may be necessary to completely rule out the diagnosis. An MRI may be useful, but typically requires neurology or neurosurgery consultation. The definitive treatment for subarachnoid bleeding is surgery, although calcium channel blocking drugs (tioclodipine) may limit damage. Temporal (giant cell) arteritis: Patients with temporal arteritis (TA, an inflammatory process involving the walls of medium-sized arteries) are usually over age 50. Its symptoms are newly experienced localized headache, scalp tenderness and diminished pulse over the temple area , fevers, and aches. An unusual symptom highly suggestive of TA is "jaw claudication," or cramping of the jaws while chewing. Blindness (due to involvement of the ophthalmic artery) is a frequent complication, and may be prevented with prompt therapy. Blood tests reveal intense inflammation (with a high "ESR" test), and definitive diagnosis is made by finding inflammation on a biopsy specimen taken from the temporal artery. Treatment consists of prompt therapy with high-dose corticosteroids (such as prednisone), which should be instituted if the syndrome is suspected (even before definitive biopsy results return. Bacterial meningitis: Acute bacterial meningitis is a virulent infection, and is typically manifest by an ill-appearance, fever, headache, stiff neck, and photophobia (avoidance of bright light). A rash may be present some forms. Diagnosis consists of a spinal tap showing white blood cells, chemical tests, and bacteriology studies. Treatment requires prompt antibiotic therapy. CT scans and MRIs While a "negative" CT of the brain is reassuring, the cost of imaging every person with headache is prohibitive (up to $3 billion/year in the US). Moreover, a CT scan will find a identifiable cause of headache (blood, tumor) in no more than 0.5 to 2.5% of patients, and most of these patients have abnormal clinical findings. The Table lists indications for CT scan or MRI for headache. Findings Suggesting Need For Neuroimaging "Worst headache of my life" Headache onset after exertion Decreased alertness Stiff neck Abnormal neurological findings Decline during observation New headache lasting > 2 months in patient 40-60 years old Brain Tumor: Though a fear for many headache sufferers, brain tumors are uncommon. Indeed, fewer than 20% of patients with brain tumors experience only headache as a symptom (the most frequent symptom is seizure and/or neurological abnormality on exam). Waking with a headache is said to be an important sign of a tumor-related headache, although this occurs frequently in chronic headaches Diagnosis is based on brain imaging and biopsy. Treatment is determined by an oncologist in consultation with a neurosurgeon. Cluster Headache: Cluster headache commonly affects young- to middle-aged men. It is of short duration (30-90 minutes) and causes headache behind one eye, with eye redness, tearing, and nasal stuffiness on the involved side. Headaches are clustered over time (often separated by weeks to months); in times of headache activity, headaches may occur up to 6 times a day, often causing insomnia. Diagnosis is based on its classic presentation. Treatment includes high-dose anti-inflammatory medications (ibuprofen, others). For unknown reasons, over half get relief from breathing 100% oxygen by face mask. Coital headache occurs around the time of intercourse, and lasts from minutes to hours, and may be indistinguishable from subarachnoid hemorrhage. Diagnosis may require CT and spinal tap to rule out subarachnoid hemorrhage. Sinus Headache: Typically occurring in conjunction with upper respiratory tract infection or allergic rhinitis/sinusitis, sinus headache is usually dull and constant, worse when bending forward, and may be associated with colored nasal discharge. Diagnosis may be made clinically, by x-rays, or on CT. Treatment is based on cause (antibiotics if bacterial, antihistamines/decongestants/intranasal steroids if allergic), and are supplemented by interventions to promote drainage (brief course of nasal spray, intranasal saline mist). Eye Strain Headache: This headaches is associated with prolonged reading or staring at a computer screen (but not with astigmatism or refractive errors). Hormonal Headache: While temporally related to menstrual cycle, menopausal flushing, or hormone use (oral contraceptives), this headache has no distinguishing features otherwise. Pain tends to diminish cyclically, or after menopause is completed (but only in 1/3 who develop menopausal headaches), or after hormone discontinuation. Benign Intracranial Hypertension: Also known as "pseudotumor cerebri," this syndrome typically affects young, overweight women on certain medications (oral contraceptives, tetracycline, certain steroids, or vitamin A). The headache itself is nondescript, but exam findings include swelling of the optic nerve, which usually raises the specter of brain tumor. CT scan looks essentially normal, and a spinal tap reveals high pressure. Therapy includes corticosteroids. Post-Traumatic Headache (Concussion): "Concussion" is defined as loss of consciousness associated with head injury. Symptoms include headache, dizziness, and confusion; long-term symptoms are headache, irritability, fatigue, anxiety, insomnia, memory disturbance, and impaired concentration may persist for up to 18 months. A CT scan is typically normal. Treatment involves support with mild analgesia and reassurance. Migraine With Aura (Classic Migraine): A typical headache is heralded by an aura (blinking lights with partial vision loss, then sight restoration) followed in 25 to 60 minutes by a throbbing, unilateral headache associated with nausea, vomiting, and photophobia lasting 6-8 hours. Abortive treatment includes non-steroidal anti-inflammatory medications, anti-nausea medications, ergot derivatives, and other agents; preventive treatment involves various agents (see article on Migraine). Common Headaches: While these headaches may have somewhat different causes, their manifestations (and treatment) are similar. Both may be triggered by stress. Migraine Without Aura (Common Migraine): Migraine headache tends to be throbbing and one-sided (typically over the temporal area), and precipitated by certain foods, strong smells, or the menstrual cycle (the ratio of female to male sufferers is 3 to 1). The time of day of onset varies. Diagnosis is based on symptoms and lack of neurological abnormalities. Treatment is the same as above. Tension Headache: Often located in a both-sided "hatband" and neck distribution, tension headache is constant, precipitated by stress, has no associated symptoms, and usually occurs later in the day; female to male ratio is 1 to 1. Diagnosis is by clinical characteristics. Treatment involves a step-wise approach, beginning with over-the-counter non-steroidal medications or acetaminophen, followed by prescription-strength doses when necessary. Worse headaches may require migraine-type medications, such as Midrin (isometheptene, dichloralphenazone, and acetaminophen). Medications containing caffeine or butalbital are sometimes used (though risk of rebound headache increases). Prophylactic treatments similar to those used for migraine may be useful. Brain Hemorrhage: When an aneurysm (outpouching of a blood vessel) ruptures, hemorrhage occurs. In the brain, this can lead to blood accumulating in the space surrounding the brain (subarachnoid hemorrhage) or in the brain itself (intracerebral hemorrhage). Either of these potentially life-threatening events can produce headache, sometimes of very high intensity. Usually this headache is sudden, and often there are other symptoms such as weakness, sensory loss, speech difficulty, etc. Headache Due to Infection: Infections of the brain are rare, but when present must be treated immediately. Meningitis, an infection of the membranes surrounding the brain (meninges), usually presents with headache, fever, and neck stiffness. Bacterial meningitis is potentially fatal, and early diagnosis, accomplished by performing a lumbar puncture (spinal tap), is essential. Infections elsewhere in the head can of course cause headache, the most notable being sinusitis. Active infections can certainly cause awful head pain, but a controversy exists among headache experts regarding chronic sinus inflammation. Some feel headache can be the result of ongoing sinus allergy, congestion, or other processes. However, if there is no active sinus infection, recurring headache is probably not directly due to sinus problems. When my patients ask about this possibility, I take a close look at the tissues around their sinuses and consider further evaluation including CT or MRI scanning, and referral to an ENT physician. Headache Due to Brain Tumor: Here we are, back to the most feared cause of headache. I probably find an unsuspected brain tumor once every two years – and I am involved in the care of about 2,000 headache patients. Some tumors can be cured, others can be controlled. And luckily, in addition to being an unusual cause of headache, they almost always produce other symptoms and signs that are easy to spot by most medical practitioners and all neurologists. These symptoms include localized weakness (for example in one limb or one side of the body), sensation changes, visual changes, speech or behavior changes, and gait difficulty. Tumors can arise in the brain, such as astrocytoma and meningioma, or be the result of spread of a primary tumor elsewhere in the body. Drug-Induced Headache There are several ways substances of all sorts can lead to headaches. Alcohol, and caffeine, in excess are famous headache instigators. (Interestingly, small amounts of caffeine can relieve a headache, as those of you with migraine probably discovered long ago). Drugs like cocaine, stimulants, and marijuana can also induce headache. Analgesic (pain-killer) medications can lead to chronic headache if taken too frequently via the mechanism termed analgesic rebound, a poorly understood, but highly frustrating condition. As one of my new patients remarked once “I can't believe the one thing that helps my pain, is actually causing it!” (In fact, she did not believe me, and continued to take her 20 Excedrin tablets daily until I was finally able to convince her to stop—she is now doing great using pain medication only occasionally.) HA due to metabolic or systemic disorders I can't list in detail all of the illnesses that seem to bring recurrent headaches with them in addition to their other symptoms, but to name a few: hypothyroidism, lupus, hypertension, heart disease, pulmonary disease, sleep disorders, arthritis, and AIDS. Most of these become obvious after careful evaluation, but persistent headaches which do not respond to treatment warrant a detailed examination and diagnostic testing. Evaluation of the headache patient The assessment of a headache sufferer should start with careful listening on the part of the physician. I teach medical students and post-graduate physicians in training, and one of my goals is to help them to become better listeners (and I am working on my own listening skills as well). Nearly all my diagnoses are made by analyzing what my patient has to say about his/her headaches: where they occur, how often, what symptoms accompany them, what measures help them, which symptoms hurt, etc. I also make sure to do a VERY thorough neurological exam and a detailed examination of the head, and neck. There are numerous structures in and around the head that feel pain including scalp, blood vessels, eyes, ears, teeth, sinuses, and muscles and bony elements of the neck. All of these can be examined to some extent in the office with simple tools. Food and Beaverage Triggers For Headaches Food and beverage triggers: Rarely do we connect our eating habits with headaches, but there is a strong relationship that often goes unnoticed. Some foods are commonly related to headaches. Some of the most common trigger foods are: hard cheese hot dogs chocolate nuts Less common food triggers are: smoked fish vinegar fermented food (cream, yogurt) freshly baked yeast products peanuts (and peanut butter) monosodium glutamate (commonly found in Chinese food) soybean onion canned figs citric food bananas pork caffeinated beverages avocado liver In my practice, I have noticed that a few of the above-mentioned triggers are more common than others. Bananas, pork, and Chinese food seem to be high on the list. You have to take into account that certain foods may serve as intermittent triggers, but once a food has affected you once, it becomes a risk factor. In addition, almost any alcohol drink may trigger a headache, but red wine is the most common culprit. How Can You Recognize Your Triggers? One of the most important aspects of headache treatment is your own control over your headache, and control starts with identifying your own triggers, and learning to avoid them. I recommend writing down your triggers in a trigger diary. Each time you have a headache, try to relate it to one or more of the triggers that are listed above. At the end of the month you can sit down and analyze your results to see which are the most common triggers in your case. This is a sample of your trigger diary:Date Emotional Stress Environmental Chemical Food and Beverages October 25 Fight with family x x x x November 3 x x x Didn't eat breakfast x November 10 x 2 hours exercise x x x Decemeber 13 x x x x Had a beer Using a trigger diary allows you to track your headaches, and become more aware of what your personal headache triggers may be. How Can You Use This New Knowledge? When you review your triggers, you will notice that some of them occur only once, while others have a tendency to repeat themselves. By studying these patterns you can determine which are your important triggers. For example, if every single time you eat chocolate you get a headache, then you know that one way to avoid an attack is to avoid chocolate. If you get a headache after you arrive home from your daily jog, you may want to consult your doctor because there is some medication you can take before doing exercise that will prevent the attack. This way you will gain more and more knowledge and as a result, control over your headaches. Remember I said before that triggers might change, so if you haven't noticed a known trigger actually inducing an attack, you might want to expose yourself to that trigger to see what happens. The important thing is that now you are aware of its existence and you have the control. Summary If you are a headache sufferer, you know that certain situations or things you do or foods you eat, will cause an attack to start. There are different kinds of triggers and they work differently in each person. The trick is to recognize your own triggers so you can avoid them and by doing that, diminish the number of headache attacks. When you feel pain, there is a feeling of helplessness—you feel the pain is bigger than you and that you have no control over it—just the thought of it makes you shiver. Getting to know and manage your triggers will give you a sense of power over your headaches, you will very soon see a decrease in the frequency, which you can obtain just by avoiding your personal triggers. It doesn't take much work—just some discipline and awareness, and then you will be on the road to improve your quality of life. Under Pressure: Understanding Sinusitis By Christine Haran We've all had cold symptoms that linger on for weeks, leaving us wondering if we'll ever feel healthy again. Most of the time it's just a bad cold caused by a virus, or allergies. But nasal congestion that prevents the sinuses from draining properly can create a perfect environment for a bacterial infection and the development of sinusitis. More than 31 million Americans have at least one case of acute sinusitis each year, and a small portion of those people will go to develop chronic sinusitis, with symptoms lasting at least 12 weeks. Below, Dr. Jerry Schreibstein, president of the Massachusetts Society of Otolaryngology and a practicing ear, nose and throat physician in Springfield, Massachusetts, reviews the different kinds of sinusitis and how each type can be prevented and treated. What are the sinuses? The sinuses are air-containing spaces in the face that act as cushions for the brain in the event of trauma and also act to aerate and humidify the air that we breathe. The sinuses produce mucus that drains through the nose back down the back of the throat, and we typically swallow that mucus. What is sinusitis? Sinusitis is an infection or inflammation of the sinuses. It typically occurs a week or 10 days following an upper respiratory tract infection. The common cold is a viral infection that causes an inflammation of the nasal membranes. Those membranes, in turn, cause inflammation of the sinus openings. If the viral inflammation doesn't clear, the mucus that's produced in the sinuses backs up, the sinus gets obstructed and bacteria can infect those areas, and you get what we call a bacterial sinusitis or a bacterial rhinosinusitis, meaning that the nose and the sinuses are both involved. Chronic sinusitis is sinusitis with symptoms lasting longer than 12 weeks. Imaging tests such as CT scans are helpful for diagnosis in this situation. And the patient who gets repeat episodes of acute sinusitis would be labeled as having recurrent sinusitis or recurrent acute sinusitis. What are some of the symptoms of acute and chronic sinusitis? Acute sinusitis is manifested by pain, pressure, congestion, colored nasal discharge and pain in the upper molars. Headache, in and of itself, is not a sign of an acute sinus infection. There are many different reasons why people get headaches and nasal congestion. Migraines, tension headaches, trigeminal neuralgia, which is an inflammation of the nerve that innervates the cheeks, can all cause pain in the sinus area, but not necessarily be due to an infectious cause. Chronic sinusitis is the condition where there's a chronic congestion. There's often postnasal drip, altered sense of taste or smell and a chronic discharge. And by definition, those are symptoms that are lasting more than about 90 days. They may be associated more with pressure symptoms than true severe pain. What are risk factors for sinusitis other than an upper respiratory infection? Untreated allergy can lead to an infection. When someone has allergic rhinitis, the nasal membranes get swollen, the nose and sinuses produce more mucus and the small openings of the sinus get swollen shut, whether it be from allergy or from a viral upper respiratory tract infection. If the secretions in the sinus back up, you get secondary bacterial infection. Other things that can precipitate infections are anything that can cause nasal inflammation. This includes pollutants, secondhand smoke, and in children, chronic adenoid infections. Nasal polyps can cause obstruction of the outflow track of the sinus. If you have nasal polyps and you get an acute viral infection, it compromises the drainage of the sinus and then potentially causes an infection. How can people prevent sinusitis? There are ways that people can prevent the development of an acute sinus infection. You want to do things that help promote drainage of the sinuses. So you want to use a clean humidifier with a nice, warm steam mist. Over-the-counter saline sprays that are non-medicated are very helpful to promote secretions. Topical nasal decongestions, when used for two or three days, can promote drainage and improve the nasal obstruction. But when used for more than three days, they can be addicting and you can get a rebound effect. The other things that are useful to prevent an acute sinus infection are oral decongestants. I also recommend avoidance of some of the common over-the-counter cold preparations that contain antihistamines, which dry the secretions and prevent the sinuses from draining. I prefer to use antihistamines only when people have underlying allergy. For the patient with chronic sinusitis, non-allergic rhinitis due to environmental irritants such as secondhand smoke and topical nasal steroids can prevent swelling of the sinuses and the sinus membranes. And there have been some studies to suggest that using intranasal steroids is useful for acute sinusitis. But that has to be done under a physician's supervision. How is acute sinusitis diagnosed? The most important thing is always listening to the patient and taking a good history. The doctor should make sure the patient has had an upper respiratory tract infection that's lasted for seven to 10 days or has been worsening after seven days, or that they've had allergy. When doctors examine the patient, they look for colored nasal discharge in the nose; pain in their teeth; pain or tenderness in their cheeks; and pain between the eyes or tenderness on the frontal sinuses over the eyes. I typically do not recommend X-rays to make the diagnosis of acute, uncomplicated sinusitis. Nasal endoscopy, which involves a fiber optic instrument that enables the doctor to examine the nose and sinuses, is very helpful to make the diagnosis for a patient if you cannot find nasal discharge on exam. It's also useful for someone who has had chronic sinusitis where you want to look at the openings of the sinus and get a culture to see what is the cause of that infection for someone who's already been on several antibiotics. How is sinusitis treated? Typically, 10- to 14-day course of antibiotics would be given for an uncomplicated, acute bacterial sinusitis. The most important thing in treating chronic sinusitis is to try and identify and eliminate the underlying cause such as an underlying allergy to pets or mold. Do they have anatomic problems in their nose that might predispose to chronic sinusitis? These could include nasal polyps, septal deviation and, in children, adenoid inflammation. The mainstay of treatment for chronic sinusitis is using saline washes to flush the nose out, using intranasal steroids when appropriate and, oftentimes, prolonged courses of antibiotics are indicated prior to considering surgical intervention. For patients who have been treated with appropriate medical therapy and are still having symptoms, endoscopic sinus surgery should be considered. What are saline washes? There are several ways to deliver the saline, but I typically have a patient mix up one to two tablespoons of kosher salt, which is a little bit purer, a teaspoon of baking soda and eight ounces of warm water. People can use a little teapot, a syringe or other devices to instill that saline solution in the nose. What that does is it helps wash out the thickened mucus, the bacteria and any debris that might be in the nasal passages, and it helps decongest the sinus openings to allow the sinuses to drain better. What is the goal of sinus surgery? The goal of endoscopic sinus surgery is to reestablish drainage of the sinuses and to promote natural function of the cilia, which are the sweepers for the sinuses, so that they drain properly and that they're open and aerated. So if there is an underlying inflammation, whether it be allergy or a viral infection, the sinuses will not become obstructed. It's important to note, though, that endoscopic sinus surgery does not cure all patients. It is very successful when a properly trained specialist performs the surgery. However, appropriate medical management and identification of the underlying risk factors, like allergy, pollutants and secondhand smoke, is very important in the long-term management of sinus disease. Will untreated sinusitis resolve on its own? There have been some studies to suggest that mild cases of sinusitis can be treated with decongestants, antiinflammatories and topical nasal washes. The problem is, is if you have a true bacterial infection, there is the potential for serious and life-threatening infections. They are not common, but they do occur. So the main reason to treat acute sinusitis is to prevent the symptoms of chronic sinusitis and those acute bacterial complications. How can sinusitis be different in children? In children, there are several issues that affect sinusitis. Adenoid enlargement can be a predisposing factor to sinusitis. Children with Down syndrome or what they call the craniofacial syndromes such as Treacher-Collins Syndrome or other conditions where the structure of the sinuses is affected, are predisposed to sinus infection. The main risk factor for children is that they get more viral infections than adults. The average preschool child has six to eight upper respiratory tract infections a year. But I think the biggest risk factor for children is secondhand smoke. Secondhand smoke has been shown to delay the clearance of mucus in the nose, because it affects the cilia, the natural sweepers for the sinuses, from doing their job. What is the biggest misconception people have about sinusitis? I think the biggest myth is that people think they have a sinus infection when they're sick for two days and they have colored nasal discharge. Just because you have colored nasal discharge and sinus pressure, doesn't mean that it's a bacterial infection that requires antibiotics. Often with a viral infection, you can still get colored nasal discharge. As specialists, we like to try to prevent the overuse of antibiotics because that just leads to more resistant infections. Is there any new research that looks promising? I think there's a lot of interest in determining what role fungi plays in the development of chronic sinusitis. Also, I think there's a lot of immune system research to see why patients who have had what looks like technically good sinus surgery still can continue to get infections. Alternative Treatments for Headaches By: Alex Mauskop, M.D. The successful treatment of conditions ranging from the common cold to many cancers remains beyond the reach of modern medicine, despite its tremendous advances. It is not surprising, then, that patients seek a variety of alternative or complimentary therapies. Complementary techniques are those that lack definitive proof of efficacy and are not accepted by the medical mainstream. While many treatments widely used in modern medicine also lack scientific proof, they are not considered complementary or alternative because of their wide acceptance by the medical establishment. While the experience of an occasional headache may be universal and usually is tolerable, chronic headache is an important cause of distress and disability. The vast majority of people who suffer from headaches have either tension-type or migraine headaches. Headache only recently began to receive attention from the pharmaceutical industry and organized medicine. Selective serotonin-agonist drugs like sumatriptan have revolutionized treatment of migraines and dramatically changed the lives of millions of people. However, even these "designer" drugs do not work for at least 30% of patients. Unpleasant side effects may occur, and a very small proportion of patients can suffer serious side effects. These concerns encourage many patients who have tried conventional therapy for migraines to explore complementary therapies. Most headache sufferers, however, have never seen a physician for their headaches and may turn directly to complementary treatments, which seem cheaper, safer (though this may not always be the case), and more holistic. In numerous double-blind treatment trials, a large proportion (30-40%) of headache patients respond favorably to placebo. This "placebo effect" can account for completely useless therapies being effective in some patients. If a particular therapy appears to be clearly ineffective, but at the same time is harmless and inexpensive, I would not discourage an interested patient from trying such an approach, in hopes of a favorable placebo response. Acupuncture: This ancient method has recently received a boost in popularity because of the consensus statement by a panel convened by the National Institutes of Health. This statement strongly suggests that acupuncture is a legitimate therapy proven to be effective for some conditions and deserving additional studies for others. The panel concluded that nausea and acute dental pain clearly respond to acupuncture, while many painful conditions, including headaches, may respond to acupuncture but require additional studies. Acupuncture treatment is done using very thin disposable needles, which cause very little discomfort or pain. In patients with chronic headaches treatment involves ten or more weekly 20-minute sessions. Electrical stimulation of the needles is frequently used instead of the traditional twirling of the needles. Double-blind study of acupuncture is very difficult because blinding for insertion of a needle is impossible, and inserting needles into non-acupuncture points has been shown to relieve pain. A large number of animal studies indicate that different mechanisms of action (involving different chemical substances) may be involved in pain relief from acupuncture. Only about 70% of humans and animals respond to acupuncture. Patients with chronic headaches who did not respond to acupuncture were shown to have low endorphin levels. Despite the lack of definitive proof of its efficacy, acupuncture has a significant potential to help some patients with headaches. Issues of cost, convenience and patient preferences should be taken into the account when deciding on this treatment. Mind-body Techniques: Biofeedback is another therapy where definitive proof will be hard to obtain. Most specialty headache clinics offer biofeed back,which strongly suggests that a large number of patients benefit from it(but does not prove its efficacy). Biofeedback is only one of many relaxation and stress management techniques which can be equally effective if strictly adhered to. This is a big "if." Biofeedback is a preferred technique because it gives the patient a structure and a therapist, who acts as a coach. The essence of biofeedback, which is often combined with behavior modification, is to teach a patient how to encounter stress without adverse physiological effects. A typical course of biofeedback consists of 8-10 weekly 30-45 minute sessions. Learning to control body functions such as temperature can be achieved only by first learning to relax the skeletal muscles. This is achieved through progressive relaxation, visualization and breathing techniques. Most important though is the daily practice of these techniques. The practice sessions can be only a few seconds or minutes long, but have to be very frequent. A conscious effort is required in the first few weeks of training, but gradually self-monitoring and very brief relaxation techniques become a subconscious habit. This appears to allow many patients to lower tension throughout the day and this results in fewer headaches. Children are especially adept at biofeedback. They can often learn not only how to prevent their headaches in 4 to 5 sessions, but at times can learn how to stop their headache once it begins. Nutritional Therapies: Dietary approaches to the treatment of migraines are widely advocated, but have very little scientific basis, which places them in the category of complementary methods. Dietary avoidance is a widely-advocated strategy. Migraine can be triggered in susceptible individuals by tyramine-containing foods, some food additives and sugar substitutes, as well as by skipping meals. Some patients report that their headaches get better with elimination of wheat, sugar, or milk products from their diets. While we do not have scientific proof, it is possible to speculate on why these dietary changes may work. If the patient is so inclined there is no reason to discourage her from trying these dietary changes, which are usually safe and in expensive. Strict vegetarian and other unusual diets, on the other hand, can lead to vitamin B12 and other deficiencies, which can make headaches worse and cause other health problems. Magnesium is a vital element which plays an important role in the pathogenesis of migraines. Many studies have found low magnesium levels in the serum and tissues of migraine patients. In one study, an intravenous infusion of 1 gram of magnesium sulfate was given to 40 consecutive patients with acute migraine. Twenty-one (53%) had very good and sustained relief of their headache. Of the responders, 86% had low serum ionized magnesium levels, while of the non-responders only 16% had low values. A study of intravenous magnesium in the treatment of cluster headaches suggests a possible 40% success rate in this difficult-to-treat disorder. Oral magnesium supplementation was attempted as preventive therapy of migraines in three double-blind trials. Two of the three trials were positive, while one was negative. The negative study might have used a more poorly absorbed salt of magnesium. The absorption of various salts of magnesium has not been studied, so it is difficult to recommend a specific product to patients interested in trying magnesium for their headaches. Magnesium oxide, magnesium diglycinate and slow-release magnesium chloride seem to work for some patients when used in 400-600 mg daily dose. Wider availability of serum ionized magnesium testing may enable us to identify patients who have low ionized magnesium levels and who are most likely to benefit from magnesium supplementation. In order to remove magnesium from the list of complementary therapies and move it into the mainstream we need large trials unequivocally proving its efficacy. Riboflavin or vitamin B2 has been reported to relieve migraine headaches better than placebo. The maximum effect was achieved after three months of daily intake of 400 mg of riboflavin. The study involved only 55 patients, but the treatment is very benign and potentially very effective, which makes riboflavin a good candidate for further extensive trials. Feverfew is the only herbal remedy studied in double-blind fashion. In a trial of 24 patients, a daily dose of feverfew was found to be better than placebo as prophylactic therapy for migraines, though the difference was not dramatic. Because feverfew is fairly safe and may help some patients, this is the herb to recommend to patients interested in herbal remedies. Migra-Lieve is a product made by Natural Science Corporation of America which contains magnesium, riboflavin and feverfew in one tablet. Having these three ingredients in one tablet greatly improves compliance and has been effective for many of my patients. To be fair, I must disclose that I have a financial interest in the success of this product. However, my involvement started only after I became convinced that it helps my patients. Guarana is a relatively recent import from Brazil, which is being used for headache relief. It may very well have some analgesic properties because of its high caffeine content. However, daily caffeine consumption is one of the leading causes of rebound headaches (see articleon Rebound Headaches). Guarana and all other caffeine-containing foods, drinks and medications should be avoided in patients with frequent headaches. Anecdotal reports suggest that ingestion of ginger, gingkoor valerian root, all of which are well tolerated, may help some patients with headaches. Aromatherapy: Aromatherapy may not appear as far fetched if we consider how much of our brain is devoted to olfaction and that strong odors can almost instantly induce a migraine. A double-blind study of healthy volunteers showed that an external application of peppermint extract raises pain threshold and has strong relaxing effects, while eucalyptus has calming and relaxing effects and improves cognitive performance without analgesic effect. Another study which used peppermint oil for tension headaches showed positive results. This gives some scientific support to a variety of topical products being promoted for the treatment of headaches. Homeopathy: Homeopathy is based on an unproved concept of using extremely small amounts of substances (usually herbal), which in large amounts can induce a symptoms which are being treated. Since the treatment is extremely benign and relatively inexpensive it can be tried by patients who believe that it may help. Physical Approaches: Regular and frequent aerobic exercise as a treatment for headaches is impossible to study in a double-blind trial and would require a very large comparative trial to confirm efficacy. However, there is little doubt that it offers effective relief for many stress-provoked conditions, including headaches. Other unsubstantiated but anecdotally effective modalities include application of heat and cold, massage and many other similar techniques. As long as they are safe and affordable, patients should not be discouraged from trying them. Chiropractic manipulation has several potential benefits, which must be weighed against possible complications. Controlled trials in tension headache have yielded mixed results, while small trials looking at migraine prevention have been encouraging. More than 100 cases of serious complications of this approach have been reported. The number of unreported complications must be certainly much larger. Most of the complications involve neck manipulation resulting in a stroke. Because there is no proof that this treatment works, and in view of the potential for very serious complications it seems prudent to strongly discourage headache patients from trying chiropractic treatment. Headache, Hypnosis, and Stress: A Case History By: Larry Deutsch, MD Now, more than ever, concerned physicians are beginning to ask about and understand the role of non-drug therapies to assist patients with headache. These therapies, alone or in combination with medications, can significantly impact headache treatment. This pleases me. As a family physician and clinical hypnotist with 30 years experience in the field, I applaud this trend. Certainly, a capable and compassionate physician will struggle to assist his or her patient to find headache relief by whatever methods; complimentary, traditional, or both. Much can be gained if we look at hypnosis as a helpful tool in the battle for headache relief. Training your brain As our understanding of how the brain works and which compounds (or neurotransmitters) control our pain response expands, we begin to suspect that relaxation therapies, including hypnosis, may alter in a positive and fundamental way our brain chemistry such that pain relief is more likely. An interesting study was performed with patients who learned relaxation skills. The researchers checked the subjects' monoamine oxidase levels—since monoamine oxidase is what metabolizes serotonin, a pain relief chemical, and found changes in those levels consistent with what you would expect with preventive drug therapy. The study suggests that it is not just a matter of feeling relaxed that's important, but actually learning via these relaxation therapies to turn on and off certain pain pathways in the nervous system by changing monoamine oxidase levels and, consequently, serotonin levels. In this article, I would like to introduce you to hypnosis and self-hypnosis as a modality of pain relief for patients who suffer from headache. Hypnosis is fun, effective, relaxing, and has no side effects. What is this thing they call hypnosis? No, Virginia, it is NOT clucking like a chicken, barking like a dog or being “put under,” helpless and at the control of the master. Rather, for most people most of the time, it is a focused state of attention or harmony. It is easily achieved by visiting a professional skilled in hypnosis. This pleasant state has two fascinating and useful properties: 1) It is profoundly relaxing. In our stressful lives what person would not enjoy a few minutes of deep relaxation in the middle of the day from hell! 2) The mind becomes open to positive and therapeutic suggestions. Only suggestions given with your permission and for your own benefit are accepted. No one can be forced or coerced into doing something they do not wish to do. Hence, when I help patients use hypnosis for headache and stress, I offer them headache-specific suggestions as well as relaxation and stress reduction instructions. I find this process fun and creative. I get to know my patient not just as Mr. Jones with a headache, but also as a real person in a stressful situation. This stressor in combination with his or her biological predisposition to headache is creating more pain. Case History of Mr. X Let's take a look at a case history and see how it all fits together. Mr. X, a hard-driving chief financial officer of a high-tech company is known as the “firing man,” and is responsible for downsizing a company whose expenses exceed its revenues, and whose market share is declining. His neurologist has referred him to me for help with his chronic daily headache that has not responded well to numerous medications. His executive decisions in the short run will result in layoffs and suffering for many. However, with his expertise, talent, intelligence, and hard work, he may “turn the company around” and in the long run, his efforts will benefit far more people than those who will suffer in the short term. He is not well liked by his coworkers and worries a lot about his health and finances. He is a pleasant man, but rather intense and self confident to the point of arrogance. At this time, he is willing to consider non-drug therapies to diminish the pain and discomfort of his daily headaches. Motivation As I got to know him, I developed for him the three elements essential to our success. First, in order to benefit from the therapy he must be motivated. He must be motivated to want to use hypnosis for his purposes, not mine, and motivated to put aside ten minutes each day to develop via hypnosis relaxation sufficient to impact on the pain chemicals in his brain. Rapport Second, I established with him a positive and supportive rapport. Trust is an essential element of the hypnotic process. For this gentleman who is used to firing people and always being in control in a “one up, one down” situation, I must simply be his assistant. Without this rapport, hypnosis will not be effective. Hypnotizability Third, I made sure he had sufficient hypnotizability. Most of us can experience hypnosis without difficulty. Maybe only about ten percent of us will not be able to enjoy the hypnotic process. I have little to worry about with this patient. Most high-functioning individuals in our society have good hypnotic skills, as hypnotizability is associated with creativity, intelligence, and imagination. Hypnosis After a brief explanation of hypnosis and after gaining his permission, Mr. X was hypnotized to enjoy some deep relaxation. Of course, like many patients he had expected to be “put under” as he had seen on the stage. Prior to his hypnosis, he was informed that this would not happen and that he could maintain whatever level of awareness that he desired. Regardless of the depth of his experience, his relaxation and his ability to accept therapeutic suggestions would please him. With this mixture of motivation, trust, and hypnotizability, I was not at all surprised that Mr. X achieved some initial success at relaxation using hypnosis and self-hypnosis. Contrary to what some might expect, I do not use a gold watch or have my patients stare at a fixed point or command people to relax. Rather, I use my voice and music to develop a relaxation situation that guides a patient via a series of permissive and open-ended suggestions into a hypnotic state. Mr. X was pleased and agreed to return for further sessions. Not surprisingly, he canceled most of them because he was too busy at work! Nonetheless, he was very positive about the hypnosis that we did. He reported that the relaxation lessened the pain from his headaches. Practice and Repetition It is a principal of hypnosis that all suggestions require reinforcement. Additionally, practice and repetition are required to develop these skills so they can produce both a biologically medicated pain relief (via altered brain chemicals) and a psychological harmony that helps the patient deal more easily with daily stress. As with most of my patients, I asked Mr. X to set aside ten minutes daily (preferably at work and without interruption) to listen to a CD that I created for him to recapture the relaxed feeling and increased suggestibility that he experienced in my office. With some practice on his part, I was confident that these daily and pleasant practice sessions would reinforce positive suggestions relating to his particular headache and attitude toward work. Results have been very satisfactory so far. Mr. X has not returned for further work. When last I inquired, he reported an improvement in the severity of his daily headache. Once again, he said he had little time for therapy, but he was enjoying the ten minute practice sessions via his personalized CD. This particular case history illustrates the value of using non-drug therapies to assist in pain control. Human beings are complex creatures who may have many different triggers for headache. Some of these triggers are stress and psychologically mediated. By dealing effectively with these triggers we may assist in pain control with fewer or no drugs. Summary Hypnosis is effective and fun and provides a powerful complimentary or stand-alone therapy to those who suffer from headache. Stress reduction and relaxation techniques have an important role to play in the treatment in one of the more vexing problems physicians face in practice, the patient with headache. A recent paper titled “New Treatment Options in Migraine” by neurologists Drs. Brandes, Edvinson, Marcus, and Rapoport rates relaxation therapies as “effective” as a non-drug therapy for migraine. What is Migraine?: Causes, Symptoms and Treatment By: Mitchell S.V. Elkind, MD Headaches are one of the most common reasons people seek medical help. Almost everyone has had a headache at one point in his or her life. Although some headaches are a signal of a serious underlying illness—such as a tumor, aneurysm (ballooning of a blood vessel), or other illness—recurrent headaches more often occur without any underlying disease present. Crucial to the appropriate treatment of headache is the proper diagnosis of its type, and migraine headache is a particularly common form of recurring headache. This article provides an overview of migraine and its treatment, but it should not substitute for a thorough discussion with your physician. Sometimes a separate visit to your doctor to discuss your headaches specifically may be necessary. In some cases, especially if there are unusual features of your headache or if medicines don't appear to be helping, your doctor may choose to refer you to a headache specialist. The Causes and Symptoms of Migraine Approximately 25% of women and 8% of men suffer from migraine at some time in their lives. The precise cause of migraine is unknown, but it is probably related to chemical changes in the blood vessels supplying the brain and its coverings. These changes may involve constriction (narrowing) and dilatation (widening) in some brain blood vessels. Migraine headaches are usually described as a one-sided, throbbing pain of the temple, forehead, or eye. The headache usually, but not always, comes on over several minutes; on some occasions it may occur suddenly, like a thunderbolt. Other symptoms (Table 1) may accompany the headache, including nausea, vomiting, or the feeling that light bothers the eyes (photophobia) or sound bothers the ears (phonophobia). The headache may last for minutes, hours, or even days. Pain may be mild or severe, and it may vary in intensity between different episodes in a single person. Migraine is characterized as an episodic headache problem because sufferers generally feel well between attacks. Some people may have more constant or daily headaches in between full-blown, severe attacks. The headaches may occur as infrequently as once every few years or as frequently as daily. Migraine headaches can be so severe that they temporarily disable people. Some people need to leave work or school, or they may be unable to socialize normally or take care of home activities. If the headaches occur frequently enough, they can lead to a more constant inability to carry out one's regular activities or routine. The disability caused by migraine is undoubtedly vastly underestimated. People with so-called "classic migraine" may experience an "aura" before the onset of the headache. This aura most often consists of painless visual phenomena appearing off to one side of the visual field. Many different kinds of visual symptoms have been described, including flashing lights, jagged lines, sharp-edged shapes, or quivering or scintillating forms. Sometimes there is also an area of lost vision (a "scotoma"), typically located off to one side and moving slowly toward the center of vision over several minutes. This hole in the vision will gradually become larger as it moves. The headache may then begin as the visual symptoms diminish. The aura may serve as a warning to some people that a headache will come. Sometimes other symptoms constitute the aura, including tingling about the lips and fingertips, dizziness, difficulty speaking, or a feeling of weakness of one side of the body. Because these symptoms are similar to those of a stroke, their occurrence should prompt medical attention when they occur for the first time, before a clear diagnosis of migraine is made. Migraine attacks often strike without warning, but there are some common, often avoidable triggers. Different people have different triggers for their migraines. Common triggers include specific foods, changes in sleeping patterns, hormonal changes, stress, or sexual activity. Some of the foods that can precipitate migraine in susceptible individuals are listed in Table 2. The most common food triggers are chocolate, cheeses (particularly aged cheeses), aged meats, nuts, bananas, and avocados. Alcohol, particularly red wine, may also be a trigger. It may be useful to experiment to see if eliminating specific foods helps decrease the frequency of headaches. Many people find that headaches actually tend to come on during periods of relative freedom from stress and sleeplessness, such as the weekend or on vacations. Menstruation is a common trigger in many women, some of whom may get migraines only at the time of their periods. Certain environmental triggers may also bring on headaches, including allergens, fluorescent lighting, or changes in temperature. A headache diary in which one keeps track of headaches and possible environmental or other triggers may help one determine factors that precipitate headache, and thus help one learn to avoid these triggers. Table 2. Foods and drinks that may cause migraine Chocolate Alcohol (especially red wines) Aged cheeses Buttermilk Nuts Aged, canned, cured or processed meats Bananas Yeast and yeast extracts Raisins Avocados Red plums Figs Fava beans Broad beans Canned soups Sauerkraut Monosodium glutamate (MSG) Soy sauce Spectrum of a Migraine By: Harvey Blumenthal, MD Recent astonishing basic science discoveries are altering our concepts of migraine at a breathtaking pace. Migraine is now considered a genetic disorder influenced by other internal and external factors. The neurologic disorder we call migraine results from altered neurochemical, electrical, and vascular changes in the nervous system. While headache is the most common and usually the most dramatic manifestation, remember, there is more to migraine than headache. Occasionally, the visual symptoms, nausea, vomiting, or frightening focal neurological symptoms, such as blurred vision and weakness, are more distressing to the patient than the headache itself. Little wonder that the clinical manifestations of migraine can be so variable across a broad spectrum of symptom presentations. At one end of this spectrum is the most common clinical syndrome called migraine without aura, and at the other end are rare and complex disorders like familial hemiplegic migraine and basilar migraine, which are discussed later in the article. Even migraine without aura presents with a range of variable symptoms, frequency, and duration of attacks—not only between patients but between different attacks in the same patient—a spectrum within the larger spectrum. Migraine With and Without Aura The two most common patterns of migraine are migraine with aura, formerly called classic migraine, and migraine without aura, or common migraine. Approximately 18 percent of women and six percent of men in the USA are plagued by migraine, and 15 to 30 percent will experience an aura, described below, with some of their migraine attacks. Five phases of migraine There are five phases of migraine that are not universally present, and may variably occur during different attacks in the same individual, underscoring the concept of a clinical spectrum of migraine. The first phase, or prodrome, occurs in 40 to 60 percent of migraineurs. This consists of altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food like chocolate, all of which suggest origin of these symptoms in the hypothalamus of the brain. These symptoms usually precede the headache phase of the migraine attack by several hours or even days, and experience teaches the patient or observant family that the migraine attack has begun. The second phase of migraine is called the aura. The two most common aura symptoms are visual or sensory phenomena. Less common symptoms are weakness, lack of coordination, or speech problems such as word finding difficulty. The aura symptoms usually precede the headache phase of the migraine attack, but occasionally will occur simultaneously. Sometimes, two aura symptoms will occur in the attack, usually visual and sensory symptoms. These may occur simultaneously but more likely consecutively. The aura symptoms appear gradually over five to 20 minutes and usually subside just before the headache begins. When confronted by a patient who has recently experienced only one or two such attacks for the first time, the doctor must differentiate whether these focal neurological symptoms represent migrainous aura or manifestations of impending stroke (TIA) or even a focal sensory seizure. Passage of time with repeated identical self-limited attacks and diagnostic testing may be required to be sure, but there are certain features more typical of migraine aura. First, visual and sensory TIA symptoms and seizures usually develop more rapidly than the gradual progression of an aura over five to 20 minutes. Second, migraine aura is often characterized by a combination of negative and positive symptoms—the migraineur may experience a hole in the vision (negative symptoms) and dazzling, glimmering, scintillating lights (positive phenomena). TIA usually presents as a black or blank negative visual loss only. Sometimes, especially in the elderly, the visual aura occurs repeatedly without any headache. These are called late life migraine accompaniments. Sometimes these patients experienced more typical migraine in youth, the migraine subsiding for many years, only to recur as migraine aura without headache in later life. In this setting, the doctor may be more secure in the diagnosis. However, late life migraine accompaniments often develop with no previous history of migraine. These patients with new late life migraine symptoms must be carefully evaluated to rule out cerebrovascular disease, tumor, or even retinal detachments. The sensory auras of migraine usually consist of numbness (negative sensory symptoms) and positive symptoms of tingling. Numbness would be considered a negative sensory symptom because it is the absences of feeling. Tingling is a positive sensory symptom because a new sensation presents itself. Again, these sensory symptoms usually progress over five to 20 minutes and are followed by the headache phase, which is the third phase of the migraine attack, and usually the most dramatic. It is the headache phase of migraine for which most patients consult doctors. The fourth phase of migraine is the headache termination. Sleep, even a brief nap of one or two hours, is the most common natural method of headache resolution, but biofeedback and relaxation exercises may also be helpful. Biofeedback is a behavioral approach to reducing and managing pain. Patients are taught to control certain functions such as muscle contraction and release and corrected breathing to enhance blood flow to peripheral blood vessels. Today, pharmacologic treatment is the most common medical intervention to terminate an acute migraine attack. The fifth phase of migraine, the postdrome, is reported by 94 percent of patients, but these symptoms have not been widely studied. The postdrome symptoms may last about 24 hours and range from feeling drained or washed-out to an unusual sense of elation or euphoria. Some patients experience either a low-grade, background headache for 24 to 48 hours or a recurrent migraine attack, and they may still be sensitive to light, sound, and movement. In 1988, the International Headache Society (IHS) published an extensive classification and diagnostic criteria for headache disorders; although widely acclaimed and almost universally accepted by headache specialists, the IHS classification may be too complex and unwieldy and various simplified modifications of the IHS criteria have been suggested. The experienced doctor uses the IHS criteria as a guide, but must not be rigidly hide-bound by them. Furthermore, both migraine and tension-type headache are very common and when patients report symptoms of both, there may be overlapping features which make it difficult to tell where one ends and the other begins. In fact, the IHS system of classification is being revised and should be more accurate and complete when available by 2002. There is no diagnostic test for migraine and the diagnosis is made on the basis of the history and a normal examination. Therefore, the more thorough the history, the more certain the diagnosis. Diagnosing Migraine Often, the patient does not initially describe the headache characteristics well, and the skillful doctor must take the time to extract important subtle historical points. For example, some patients spontaneously report only pressure-type pain in the back of the head, but by digging a little deeper, the examiner will help the patient recall that the worst headaches, occurring infrequently, build up with an intense throbbing quality and radiate to one eye or temple. Often these patients report that being unsure at the outset if this headache will build to severe intensity, they fail to take acute care medication early enough and obtain less effective relief than if they had treated the migraine earlier in the attack. The headache of migraine is one-sided in 60 percent of cases and usually alternates sides from one attack to the next. Often, the patient will insist the headache is always on one side, but when pressed will recall that rarely, perhaps 10 percent of the time, the headache will occur on the opposite side. This alternating hemicrania, however infrequent, makes the doctor more secure in the diagnosis of migraine. Some migraineurs at first insist the headache is on both sides, but, if asked, will admit it is worse on one side. The headache usually builds up over a period of 30 minutes to several hours, but may occur with more rapid intensity. Although the pain of migraine is usually moderate to severe, many patients will report milder headaches, which they refer to as "sinus headaches," or "regular headaches," which in reality are milder migraine attacks. Benign headaches that recur episodically are much more likely to be migraine or tension-type headache than sinusitis. Sometimes radiography is needed to settle the issue, and CT of the sinuses is superior to sinus x-rays in diagnosing acute sinusitis. Many patients are very test-oriented and, already knowing full well of the radiologist's normal report, anxiously ask, "what did the x-ray show?" and fail to appreciate the knowledgeable opinion of an experienced doctor in making a diagnosis based on a thorough history and examination. Differential Diagnosis and Investigation To be sure, we must always be aware of migraine mimics, episodic headaches caused by congenital vascular malformations, repeated exposure to carbon monoxide, transient increased spinal fluid pressure resulting from a cyst in the brain, or other structural brain disease. In the elderly, temporal arteritis, an inflammation of the cranial blood vessels, must always be considered. Other brain inflammations may present with frequent headaches before other symptoms as mental changes, seizures or strokes result from the blood vessel inflammation. Even headache resulting from brain tumor may mimic migraine or tension-type headache. Certain danger signals usually warn the doctor this headache may be more serious than migraine. The young healthy patient with a textbook history for migraine and a normal examination seldom requires diagnostic investigation. If, however, the patient fails to respond as expected to treatment efforts, diagnostic testing may be wise. Unsuspected inflammations, malignancy, or infections such as Lyme disease sometimes can be diagnosed only by spinal fluid (CSF) examination. For structural brain lesions, MRI (short for magnetic resonance imaging, which uses magnetic fields to image soft tissues such as muscle, brain, and nerves) is usually more sensitive than CT scanning, but CT is more sensitive for demonstrating intracranial bleeding from a ruptured aneurysm in the first 24 hours while MRI becomes more sensitive after 48 hours. Recently we have learned there is a high familial incidence of aneurysms; unsuspected asymptomatic intracranial aneurysms were found in nine percent of 396 persons having a first degree relative with an aneurysm. A careful family history is therefore important if a warning leak is suspected. Diagnostic techniques for determining migraine CT of the sinuses is more sensitive than sinus x-rays or MRI. We must never forget dental disease or jaw dysfunction as a cause of head or facial pain, or localized eye disease such as glaucoma, which can cause one-sided orbital pain. Cervical spine disease or lesions at the base of the skull may cause pain at the back of the head and plain x-rays or imaging should be considered. Certain prescription medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), estrogen, other hormones, or certain calcium-channel blockers may cause or worsen headache. Since these drugs are often used to treat headaches, sorting out the diagnosis may be difficult. Overuse of OTC and prescription analgesics, ergots, and caffeine can cause rebound headaches. Distinguishing Migraine Without Aura From Tension-Type Headache Tension-type headache (TTH) is the most common kind of headache, experienced by almost everyone some time in their lifetime. Most people take an aspirin or acetaminophen and never even think about consulting a doctor for these occasional mild headaches. TTHs are less intense than migraine and rarely disabling; these are nonthrobbing, pressure or tight band-like global headaches that seldom have associated symptoms like nausea or light sensitivity. When TTH occurs for more than 15 days per month for over six months it is termed chronic tension-type headache (CTTH), distinguishing it from episodic tension-type headache (ETTH,) which occurs fewer than 15 days per month. Before publication of the IHS system of headache classification in 1988, TTH was called tension headache or muscle contraction headache. We commonly see patients who begin with tightness in the back of the head or upper neck pressure and these mild headaches can often be relieved with simple analgesics, physical therapy, and/or biofeedback. If not treated early, however, this TTH may progress and assume characteristics of migraine with a severe throbbing quality and radiate to become localized over one orbital region, accompanied by nausea or light sensitivity. Modern headache investigators increasingly speculate that migraine and TTH may have a common origin resulting from "neurogenic inflammation," altered pain regulating chemical transmitters in the brain stem, and changes in cranial blood vessels. In support of this view are recent reports about episodic TTH responding to sumatriptan in patients who also have migraine. In any case, patients with TTH seldom consult doctors, and when they do, treatment is usually easy with reassurance, simple analgesics, biofeedback, medicine to combat anxiety, or certain antidepressants. Most patients respond to over-the-counter preparations but some will require prescription medication. Occasional use of simple or combination pain medicines, butalbital combinations or opioids, which are common ingredients in powerful pain medications, may afford good rapid relief; these can be used safely up to two times a week, but the patient must be cautioned against dose escalation and increased frequency of use, which can lead to analgesic rebound headache. Transformed Migraine and Chronic Tension-Type Headache Dr. Ninan Mathew coined the term "transformed migraine," describing the phenomenon of patients with infrequent or episodic migraine in their teens who develop frequent milder headaches in their 30s and 40s. They often take increasing doses of medications, both prescription and OTC preparations, which usually contain caffeine, barbiturates, aspirin or acetaminophen. People with a predisposition to headaches will often develop a pharmacologic tolerance to these drugs, and as the medicine is metabolized, a rebound headache occurs, usually in the early morning, several hours after the last dose. The patient then takes more of the offending medicine resulting in a vicious cycle in which the drug is perpetuating and worsening the headache condition and the episodic migraine is "transformed" into a chronic daily headache. Over 90 percent of patients with transformed migraine have a history of migraine without aura and 80 percent take excessive amounts of medication. Other factors promoting transformation include trauma or meningitis, but in many cases a precipitating factor cannot be identified. Migraine Triggers There is also a spectrum of variable migraine triggers reported by patients. These include altered sleep patterns, sleep deprivation, or sleeping longer than usual. Some migraineurs can predict their attacks with barometric pressure changes that precede weather fronts. Migraine can develop in response to motion sickness, especially in childhood. Menstruation is a very common trigger, and some women may suffer attacks of pure menstrual migraine only when they have their periods. More often, women recognize that their migraine attacks are more predictable and more severe around menstruation, underscoring the influence of hormonal changes on migraine. It is not surprising that birth control pills or other hormonal manipulation may increase the frequency and severity of migraine attacks. Falling levels of estrogen seem to trigger headache by affecting pain receptors and blood vessels in the brain. Certain forms of alcohol such as beer, red wine or champagne commonly trigger migraine. Other substances like caffeine, cured meats, MSG, Nutrasweet, strong cheeses, yogurt, pickled foods and others are common precipitants. Often, these triggers may not be recognized until the patient keeps a headache diary and records what foods and beverages were taken in the 24 hours before the migraine attack. External sensory stimuli are among the most common migraine triggers. Certain smell stimuli such as cigar smoke, particular bath oils, perfumes, or other stimuli, such as scents wafting in a candle shop, may precipitate migraine. The most intensively and scientifically studied migraine trigger is the spectrum of visual sensory stimuli, ranging from bright light to specific striped and other geometric patterns. A Typical Migraine The IHS classification includes migrainous headache disorder. This diagnosis designates patients whose headache characteristics are typical of migraine, but at least one criterion is lacking. While these patients would be excluded from entry into a migraine drug study protocol, almost all clinicians would make a provisional diagnosis of migraine and treat these patients for migraine accordingly. Summary We have reviewed the variable clinical features of migraine and some relationships of migraine with other headache disorders. While we contend these views are generally shared by most headache specialists, we must also acknowledge that some very respected headache investigators reject the concept of a spectrum of migraine. Treatment |