Headache Help (34 page)

Nevertheless, many people with post-traumatic headaches often do not receive much sympathy from physicians, coworkers, friends, or family members, with the result that the situation can spiral into a vicious cycle of psychological stress. You may already feel disabled because of frequent headaches after an accident and then feel the additional stress of difficulty at home or work due to your headaches, anxiety, insomnia, and attention or concentration difficulties. Most people at this point admit that they don’t care much about the insurance, litigation, or worker’s compensation, saying, “All I want to do is get back to normal.” To make matters worse, objective testing does not reveal problems in the vast majority of these injured people, and they are often not fairly compensated by legal and insurance processes. Although most people with post-traumatic headaches improve within weeks, a small but important percentage of them continue to suffer for months, years, or a lifetime.

If you’ve been in an accident or endured some other kind of head injury that is now causing headaches (or some of the other symptoms we’ve listed), you should definitely consult a doctor to assess the physical injury. The doctor may suggest physical therapy, psychological counseling, relaxation training or biofeedback, medication, or a combination of these treatments.

R
ELIEVING
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OST
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RAUMATIC
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EADACHES WITH
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EDICATION

In the first few weeks of headaches, anti-inflammatories (aspirin, ibuprofen, and naproxen) are usually recommended because they not only help with the head pain but can also help relieve any accompanying neck or back pain. If these drugs are ineffective, the doctor may next recommend a choice from the list of medications used for tension headaches and migraines, depending on which type the pain most closely resembles. Muscle relaxants like cyclobenzaprine (Flexeril) or methocarbamol (Robaxin) may also be helpful if spasms occur in the neck, but these medications may cause fatigue.

Most people with post-traumatic migraines need only abortive medications because the headaches resolve themselves over time. However, if the headaches are migraines, occur frequently, or cause you to use excessive amounts of abortive medication, a preventive strategy may be recommended.

The antidepressants, particularly amitriptyline (Elavil) or nortriptyline (Pamelor), Depakote, and the beta-blockers (Inderal, Corgard) are the most commonly prescribed preventives used for post-traumatic headaches. The sedating antidepressants, particularly amitriptyline, often help relieve daily headaches, migraines, and any associated insomnia. In severe cases, a combination of these may be recommended. The anti-inflammatories may also be used as a preventive.

If the headaches are migraines, your doctor may recommend calcium blockers (verapamil) as a first-line therapy. SSRIs (Prozac, Paxil, Zoloft, Celexa) may help, particularly if you also have anxiety or depression or both. Intravenous DHE, given repetitively in the office or in the hospital, is very useful with severe cases and is used along with a daily preventive medication. “As-needed” medications need to be limited, following the steps outlined in previous chapters. The triptans (Imitrex, Amerge, Maxalt, Zomig, Relpax) are particularly useful for migraines.

EXERCISE AND SEXUAL HEADACHES

Exertional headaches are divided into three main categories:

1. Benign exertional headache
   
2. Headache associated with sexual activity
   
3. Benign cough headache
   

If physical exercise triggers headaches, and serious problems, such as brain tumors, have been excluded, then you are experiencing benign exertional headaches. Typically, this type of headache is felt on both sides of the head and usually throbs, occasionally occurring with nausea. These headaches usually last from minutes to twenty-four hours, and are not linked with serious problems, such as brain tumors. Hot weather and high altitude may make these exertional headaches more likely to occur. Keeping well hydrated can help. “Smoother” exercises such as walking and biking are less likely to trigger exertional headaches.

If you’ve never had exertional headaches and you suddenly get them, you should call your doctor or go to the emergency room immediately. As with all headaches, new-onset exertional headaches are more worrisome than those of long-standing origin. Headaches that begin extremely explosively and rise to a ere scendo within one minute are particularly potentially serious. Your doctor will need to first check that you have no serious problems in the brain that are causing them, such as a brain tumor, an aneurysm that can cause bleeding, or other similar problems. Your doctor may need to do an MRI (magnetic resonance imaging), MRA, plain x-ray of the skull, blood tests, or even a lumbar puncture (spinal tap) to rule out more severe causes. Fortunately, however, the vast majority of these exertional headaches are benign and are not associated with serious problems in the brain.

Headaches that come on with sexual activity usually begin on both sides of the head; often, stopping the sexual activity immediately can halt the headache. One type of sexual headache causes a dull ache about the head or neck that increases as sexual excitement escalates. A second more explosive type is very severe and occurs with orgasm. Benign cough headache is usually very sudden, lasting less than one minute, and is on both sides of the head.

Typically, benign exertional headaches occur in people who are in their twenties and thirties, sexual headache occurs more in middle age (at approximately age forty), and a cough headache typically comes in the sixties. More men than women have these exertional headaches.

Obviously, to prevent exertional headaches, you can avoid the exercise or the sex that tends to trigger them, though many people are not willing or able to do this. The usual preventive treatment is an anti-inflammatory medication, such as indomethacin (Indocin) or naproxen (Aleve). Ibuprofen (Motrin) or flurbiprofen (Ansaid) may also be effective. These medications are usually given one half to two hours prior to the activity. The effective dose varies widely, but the usual doses are: indomethacin, 50 mg to 75 mg; Aleve, two tablets; ibuprofen, 600 mg; flurbiprofen, one or two of the 100-mg tablets. While triptans may be effective, doctors do not usually encourage the taking of a triptan (Imitrex, Maxalt, Amerge, Zomig) prior to exercise.

If you get an exertional headache, apply ice to your head, lie down in a dark room, and take one of the medications described for migraine and tension headaches. (For a discussion of these “as needed” migraine or tension headache medications, see Chapters 5 and 8.)

SPINAL TAP HEADACHES

About one-third of people who have spinal taps, a diagnostic procedure, get lumbar puncture headaches. Although anyone can get one, women with a history of headaches and younger, underweight people are at highest risk.

The smaller the needle used, the smaller the risk of a subsequent headache. The position you assume after the procedure, the experience of the doctor, or the amount of spinal fluid taken do
not
appear to affect the likelihood of getting such a headache. Psychological factors play a lesser role than was once thought.

Usually the headache comes on within forty-eight hours of the spinal tap, but occasionally it may not occur until two weeks afterward. The pain may be in the front or back of the head, or in the neck and shoulder area. Typically, it hurts to sit or stand, but lying down can help. The pain may be throbbing, pounding, or ache severely.

The symptoms resemble those of migraines—nausea, visual disturbances, sensitivity to light, and dizziness—but in addition, neck pain and spasm often occur. Usually the headaches resolve themselves within days to weeks, occasionally longer. Just what causes the headaches is not known for sure, though some experts believe the mechanism may be similar to that of migraines.

For most people, simply using analgesics, as described in Chapter 2, is all that’s necessary until the headaches decline. Although oral caffeine may help, it’s hard to consume enough to make a significant difference. If the headache persists for more than two days, your doctor may recommend an injection of caffeine. Be warned, however, that it can cause central nervous system side effects such as jitters or tremors, as well as a rapid heartbeat. Drinking at least six glasses of liquid each day may also help.

If the headache is severe and unimproving, an epidural blood patch—an injection of your own blood in the lower back, where the spinal tap was done—can be extremely effective. This is an easy procedure for an experienced physician. And if this treatment doesn’t work, then standard tension headache prevention medications may be recommended, as well as a saline solution injection near the spinal tap puncture.

SINUS HEADACHES

Although many people think they suffer from chronic sinus headaches, chances are they are experiencing mild migraines. Very few chronic headaches—less than 2 percent of all headaches and less than 30 percent of recurring headaches believed to be sinus headaches—actually fit into this category.

It can be exceedingly difficult to determine the cause of a frontal, or facial, headache associated with nasal congestion or stuffiness. In certain seasons or during weather changes, many people with migraines do experience a stuffy frontal headache, which they mistake for a sinus headache. A combined approach, treating both the migraines and nasal congestion, may be necessary.

Most sinus headaches are caused by infections and fluid buildup in the bony pockets of the upper face. This congestion causes pressure and pain and usually a fever. Symptoms include a runny or stuffy nose, postnasal drip, and tenderness around the sinus regions of the face. X-rays can confirm the diagnosis of sinusitis, though a CAT scan is the best tool for looking at this area. An MRI of the brain also lets doctors “see” the area. Antibiotics are often needed to treat the infection.

Migraines, on the other hand, are far more common than true sinus headaches but are often misidentified because they also can cause pain in the sinuses. Migraine pain is caused by the dilation of blood vessels—which may occur in the face and sinus region—as well as by irritated nerves that misfire the pain signal along the head’s large trigeminal nerve, with branches throughout the face and sinus. Thus, pain in the sinus region may have nothing to do with the sinuses.

If you think you have a sinus headache and decide to take an over-the-counter sinus medication, it may work because it contains caffeine, an analgesic (aspirin or acetaminophen), or a vasoconstrictor—all substances that would help a migraine. Sinus medications with decongestants, however, can make your headache worse if it is not a true sinus headache because they can raise your blood pressure and aggravate the source of your pain. Do not overuse the OTC nasal sprays. Prescription cortisone-based nasal sprays are more effective and do not produce rebound nasal stuffiness. Many people suffer from both migraine and sinus headaches and distinguishing between the two can be a challenge.

ALLERGY HEADACHES

Although allergies and headaches are both very common, allergies usually do not cause headaches. When you experience an allergy attack, you may get a headache, however, because your nasal and sinus blood vessels are more sensitive. When smoke, chocolate, or red wine, for example, cause a headache, it’s probably not because you are allergic to them but because you are sensitive to their effect on blood vessels. Much more commonly, these headaches are a migraine- or a tension-type headache. A true allergy headache, caused by an immune system that misfires, occurs only occasionally and is triggered by pollen, molds, and other common allergens. Its symptoms are very similar to hay fever: a runny nose, sneezing, watery eyes, and sometimes a sore throat, with pain usually in the front, above and below the eyes.

Of course there are food allergies, but they more typically cause nausea, vomiting, hives, wheezing, diarrhea, rashes, and itching rather than headaches. Allergies to dairy foods and wheat products (bread and pasta) are the most common. Keep a headache diary and try to distinguish between a food sensitivity and an allergy; in either case, if you can identify the food that is triggering your headaches, avoid it. Prescription nasal (cortisone-based) sprays and antihistamines occasionally help frontal headaches. However, allergy treatments usually help the allergies themselves much more than they help the related migraines.

TEMPOROMANDIBULAR JOINT (TMJ) HEADACHES, JAW CLENCHING, AND BRUXISM

While disorders of the jaw and teeth are generally overdiagnosed as a cause of headache, TMJ problems, clenching, and bruxism may
add
to a headache patient’s pain. (Bruxism is not only clenching but also grinding the teeth from side to side.) It can be very difficult, however, to assess accurately the extent to which someone’s teeth clenching or TMJ problem is adding to a headache situation.

Some headaches are related to problems with the temporomandibular joint, the hinge attaching the lower jaw to the skull. It is located just in front of each ear, and if you move your jaw you can feel it. When this area is sensitive to touch, especially with a dull or stabbing headache, the headache may be related to a disorder of the joint but may also be a migraine or tension headache. If you have trouble opening or closing your jaw all the way, if your jaw locks, or you are sore in the jaw muscles TMJ may be the problem. Usually these headaches can be relieved with the same strategies used for tension headaches (see Chapters 2 and 8). Check with a doctor or dentist if they persist. Some people clench their teeth and jaw all day or at night, leading to increased headaches. A dentist or TMJ specialist can give you a mouth bite splint to stop you from clenching. Many people suffer from clenching and bruxism
plus
tension or migraine headaches.