Headache Frequently Asked Questions (FAQs)

Migraine rescue refers to treatments aimed at breaking up a headache that is already present. This is different from prophylaxis which aims to prevent or at least decrease the frequency and severity of headaches. Usually, rescue is accomplished with medication, although there are some non-pharmacologic treatments available for people who do not want or cannot tolerate medications.

Abortive is another term for rescue medications. They are used to help stop a headache that is already present. They are most effective when taken early on in the headache. Some abortives can be bought over the counter, but the more potent and effective are usually obtained by prescription. Choice of abortive agents depends on a number of factors, including other medications you are taking, the frequency, severity and duration of your headaches, finances, and other variables. There are many options and these should be discussed with your headache doctor or health professional.

Preventative medications are used when headaches occur often enough or are disabling enough to disrupt your life. Generally, there are four categories of preventatives used in Migraine: neuromodulatory drugs, such as topiramate and valproic acid, neurotransmitter modulators such as amitryptilene or olanzepine, vascular agents such as propranolol or verapamil, and homeopathic agents such as butterbur or feverfew. Preventative medications should be one part of a treatment plan and are generally not intended to “cure” or completely prevent headaches on their own.

There are many aspects to treating headaches, and while medications can be very useful, they are just one aspect of headache care. Lifestyle changes such as regular sleep schedule, regular mealtimes and exercise are very important as are recognition of triggers and other medical issues such as sleep apnea, jaw clenching, etc. There is a variety of "non-traditional" therapies that are used in headache treatment, including biofeedback, yoga, and acupuncture. In addition there are non-medicine, traditional modalities such as physical therapy and nutritional analysis and counseling. Developing a treatment plan is a very individualized process and requires close, ongoing collaboration between the patient and healthcare providers.

There are several types of biofeedback. The most common kind measures muscle tension and the amount of electrical activity in the muscle is displayed either visually or aurally in a way that allows patients to learn to relax their muscles. Another form uses the amount of moisture on the skin surface as the feedback source. Two newer technologies allow for the feedback source to be cardiac activity and brainwave (alpha) activity to be monitored. There have been several quality studies that show a benefit for muscle biofeedback, particularly in tension headache. The other modalities are being used with good effect in selected patients but there are no definitive studies comparing this approach with pharmacologic or other approaches. Certainly from an intuitive viewpoint, it makes sense that biofeedback would benefit certain headache sufferers.

For people whose headaches are mild to moderate and relatively infrequent, this class of medicines (aspirin, acetoaminophen, ibuprofen or naproxen, sometimes combined with caffeine) can be very effective. The danger comes with overuse. When these medications are taken too often or in excess dosing, they result in a chronic, daily headache syndrome known as Medication Overuse Headache (MOH). Overuse can also lead to cardiac, liver and kidney problems. A good rule of thumb for over the counter medicines is "no more than two days per week." If you need treatment more often than this, it is probably time to consult your doctor.

Most headache specialists will tell you they are at least as important as the medications. Very often it is the little things we do that set us up for headaches. In general, migraine sufferers do best when they have a routine. Regular meal times, regular sleep patterns, regular menstrual cycle and regular exercise schedule. Again, there is a lot of variability from person to person, and it is best to discuss your daily and weekly activities with a medical professional skilled in headache management. Very often, modest "tweaking" of lifestyle can result in huge decreases in the frequency and severity of headache.

The most important factor in stopping a headache is early recognition. The earlier you treat a headache, the more likely the treatment will work. It is important to have a treatment plan in place. That means working out, in advance, what you are going to do when a headache starts. It is hard to think clearly when your head hurts so it should be a simple plan. Next, if it involves medication, be sure you have the medication on hand and available. This means having medication in the glove compartment, in your desk at work, in your briefcase, medicine cabinet, etc. It is also important to have a place you can go when you get a headache and to educate those around you as to the accommodations you may require. Finally, it is important to have a plan B if you need it. This should all be worked out with your headache specialist, neurologist or primary care doctor at a time when you are headache-free.

In most cases, the short answer is yes. It is very unusual to find migraine headaches in someone without any family history of migraine. One very rare form of migraine, called Familial Hemiplegic Migraine has actually be traced to a specific gene, but as yet no gene has been identified for the more common forms of migraine. There is a group of people who develop migraine-like headaches after significant head trauma, and they may or may not have a family history. Knowing your family history for headaches (not just whether there is one, but what different family member do for their headaches) is one of the most useful pieces of information you can bring to your physician.

A migraine trigger is anything that consistently results in a headache. Common triggers include, alcohol, lack of sleep, and skipped meals. Many people have food triggers and smell triggers. But everyone is different. One migraineur can eat chocolate until they are three hundred pounds and not get a headache while the next person with the same headache type can't walk by a candy counter without getting a headache. Rather the listing all the things that ever gave anybody a headache, it is better to be observant about the events that surround your headaches and when you see a pattern, act accordingly.

Not directly. There are several rare migraine variants that do have a greater risk of stroke, and there have been cases of people having a stroke during a complicated migraine. Statistically, stroke may be more common in people with a history of classic migraine, but this is not a risk factor we have any control over. People who have migraine should take extra care not to increase their risk by smoking, leaving high blood pressure and high cholesterol untreated, not exercising, and so forth. There are lots of reasons to treat migraines, and lots of reasons to practice a "stroke-smart" life-style.

There are three ways to look at this question: What causes humans to get migraine?, What causes an individual migraine attack?, and What causes your head to hurt when you get a migraine? The first question is fascinating to headache specialist because there is no definite answer. For the vast majority of people, migraine is a genetic disease – it runs in families. It probably represents an overly sensitive response by the brain to changes in the environment (internal or external). The second question – what causes an individual attack is better understood. When a noxious stimulus reaches the trigeminal nerve (one of the cranial nerves that mediates sensation in the head), it triggers the release of chemicals called vasoactive peptides that create changes in the diameter of blood vessels in the membrane that lines the brain. It also causes changes in the ability of nerves within particular parts of the brain to fire properly. Finally, it causes the brain to become overly sensitive to sensory input. The third question is an individual one and we don't know why one person's headache is triggered by red wine and the next person will have an apparently identical headache from strong perfume but never from red wine. This is an area of intense interest among scientists studying headache.

At least with respect to migraines, it is a chronic disease. That means it is a condition to be managed. Unfortunately, we have no complete cure. The goal of headache treatment is to make headaches an infrequent and relatively painless event rather than a constant, disabling focus of one's life. Prevention means paying attention to the things that seem to bring on or worsen headaches and modifying your lifestyle to avoid or minimize them. Often, prevention will include medication or other modalities such as biofeedback or physical therapy to help control the headaches. There is no secret formula that works for everyone, but everyone can positively affect (that means reduce the frequency and severity) their headaches by working with their doctors to develop a treatment plan.

Migraine is the most common form of headache, but not all headaches are migraines. The term "migraine" refers to a headache which is usually (but not always) on one side of the head. It is a headache that lasts from two to seventy-two hours, typically, and it is often associated with nausea and/or vomiting, sensitivity to light and/or sound. The character of the pain is typically a throbbing pain.

There are several categories of migraine: migraines that are preceded by a warning symptom, called an aura, are known as Classic Migraine or Migraine with aura. Migraines that begin with pain and no warning are known as Common Migraine or Migraine without aura. Other less common forms include Complicated Migraine, Hemiplegic Migraine, Basilar Migrainre, Ocular Migraine, Opthalmic Migraine, and Acephalgic Migraine. Migraine can also be part of a mixed headache pattern in which the patient has more than one type of headache (e.g. Migraine + Tension-type). It is important to know what type of headache you have because management varies greatly for different headache types.

Contrary to popular belief, a cluster headache is not simple a collection of headaches that come in a bunch together. A cluster headache is a type of headache which is relatively short-lived (compared with migraine) lasting usually between 20 minutes and two hours. It is always one-sided and is associated with symptoms such as a stuffy nose on one side, tearing, an enlarged pupil, or a droopy lid. The headaches tend to occur several to many times a day for a period of days to weeks, and then disappear for a variable amount of time, usually weeks to months. Treatments for cluster differ significantly from treatments for other headache types. Clusters are, by reputation, some of the most painful headaches imaginable. It is important to have a treatment plan in place before a cluster begins.

An aura is a phenomenon (called a sign or symptom) that occurs in advance of the onset of pain. Typically aura precedes headache by twenty or thirty minutes, but this varies quite a bit. The most common aura type is visual. The visual aura can take the form of squiggly lines or a blind spot or flashing lights, often off to one side or the other. Visual changes, in which there is a complete loss of vision, is not a typical aura and should warrant a call to your doctor or a trip to the ER, unless they are typical for your headaches. Other auras can include nausea, excessive yawning, weakness on one side, numbness or tingling on one side or virtually any other sensory or motor phenomenon. It is always best to discuss the way you feel before a headache with your doctor.

A complicated migraine is a migraine episode during which there are non-pain-related neurologic signs. The most common of these are weakness or sensory changes (usually numbness or tingling) on one side of the body. But speech arrest (difficulty speaking or understanding), vertigo, and visual changes have also been described. The main difference between a complicated migraine symptom and an aura is that in complicated migraine, the changes are concurrent with the headache while in aura, they precede it. Complicated migraines have some other implications for your health which make it a good idea to seek neurologic advice regarding prevention of these episodes.

These are visual disturbances, usually seen in people in their fifties or later, in which visual aura occur but no headache follows. They are usually short-lived, lasting only minutes, and can occur off to one side of the visual field or another. They are not dangerous, but it is important to make sure that any visual change, especially when they first start, be evaluated by your ophthalmologist.

A migraine equivalent refers to a recurring neurologic deficit that lasts about as long as a migraine, but is not associated with pain and is not due to any other medical problem. For example, some people (usually children) get "abdominal migraines." These are episodes of upset stomach, sometimes with nausea and vomiting, that lasts for hours and then goes away for days or weeks or months. They are often relieved with migraine medicines. It is not uncommon for people to undergo elaborate and expensive work-ups looking for obscure causes for this kind of complaint. It is a diagnosis that should be made by a neurologist since there are other things that can present in a similar fashion.

A hypnic headache is a rare headache form that occurs in people between the ages of 40 and 80. It is unique in that it is a headache that occurs exclusively at night, typically lasting between 15 and 60 minutes. The headaches tend to occur at the same time each night tend to be global (not just on one side) and are not associated with runny nose, tearing or other "cluster" features. There are specific treatments for this kind of headache which does not typically respond to the usual headache medications.

This is a chronic headache that is typically one-sided, moderately severe. It tends to be constant with intermittent jolts of increased pain that are very short-lived. This headache is unique in that it will almost always respond to one specific medicine, Indomethacin. It also typically has features such as tearing from the eye on the same side as the headache, a stuffy nose on that side, or a droopy eyelid. Hemicrania Continua shares features with migraine and with cluster headaches and usually requires diagnosis by a neurologist or headache specialist.

Also called Giant Cell Arteritis, this is a syndrome which includes a new headache in someone in their seventh decade of life. Typically, it is a global headache, throbbing in nature, often associated with tenderness over the temples. It can be associated with jaw pain and visual changes but none of these findings must be present for diagnosis. A blood test called an Erythrocyte Sedimentation Rate is a useful test when this diagnosis is suspected. When confirmed, immediate treatment with steroids is indicated. Left untreated, temporal arteritis can threaten your eyesight.

This rare headache form can occur as an episodic or chronic headache. The pain is always on the same side, typically lasting from two to 45 minutes. Usually there are five or more attacks per day. The attacks are typically associated with tearing, nasal fullness, droopy eyelid, red eyes or swollen eyes. These headaches usually respond rapidly and completely to Indomethacin.

Probably one of the rarest headaches, Short-lasting, Unilateral Neuralgiform Headaches with conjunctival injection and Tearing, consists of anywhere from three to 100 very brief stabbing pains, typically lasting less than a minute. The pain is usually around one eye and sometimes triggered by touching certain parts of the face or head. Anyone with SUNCT should be evaluated in a headache specialty clinic.

Many women report that their headaches are worse with their periods. However a true menstrual migraine is a headache that occurs only in association with the menstrual cycle. This may turn out to be an artificial distinction. Fluctuations in estrogen levels remain one of the most consistent triggers for migraine. For this reason, migraineurs often do better when they are on constant hormone replacement. Often, women with regular cycles and predictable headaches will "pulse prophylax" by taking a preventative medication only during the time during which they are at risk for the headache.

Tension-type headache is probably the second most common headache type after migraine. They are often referred to as "hatband" headaches because they typically painful around the back of the head, the temples and forehead, as if a tight hat were in place. They tend to be pressure-like at onset and can last from hours to days. Tension-type headaches can co-exist with migraine, and one can transform or trigger the other. Tension-type headache is often responsive to physical therapy, relaxation therapy and anti-inflammatories or muscle relaxants. It is a myth that tension-type headaches are less painful or less disabling than migraines.

Some of us do. For about one third of women, Migraines disappear or improve dramatically after the menopause. However, for others, the headaches simply change in character or just continue as before. Although less well-studied, men often lose their migraines in their fifties or sixties as well. The reasons for improvement in headaches with aging are not entirely understood, but it most likely has to do with the evening out of fluctuations in hormone levels that come with aging. Whenever there is a change in the character or frequency of headaches, it is a good idea to discuss the changes with you healthcare providers.

By and large, they are not. Certain forms of headache are associated with a slightly higher risk for stroke, specifically, complicated migraine, hemiplegic migraine, basilar migraine, and to a lesser degree, classic migraine. The statistical risk is based on a patients overall likelihood of stroke over a lifetime, not during an individual headache. Migraineurs who have other risk factors for stroke such as smoking, hypertension, hypercholesterolemia, low homocysteine levels, etc. should discuss appropriate changes in lifestyle and medication with their doctors.

For many women, headaches decrease dramatically or disappear completely with menopause. However in the perimenopause, that period leading up to menopause, many women experience a worsening of their headaches or a change in their character, sometimes with increased auras but decreased headaches. All of these phenomena are almost certainly related to changes in estrogen and possibly progesterone that occur during this stage of life. Estrogen levels can be manipulated to minimize these effects. And estrogen as well as other hormones can be measured when perimenopause is suspected as the cause for changes in headache pattern.

Yes. Migraine should be suspected when children (of any age) go through bouts of crying and crankiness, possibly with vomiting or diarrhea, that happen repeatedly, last for several hours, then falls asleep and is fine upon awakening. Be especially suspicious if one or both parents or other siblings or close relatives also experience migraine. Typically these children will have been to many specialists looking for stomach and other problems before anyone thinks to consider migraine.