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Help for Headache – Part 2:
Getting the care you need

June 2009 – Vol. 13, No. 6

Editor: Janet M. Pollard, MPH

One of the first steps to managing headache pain is to get the right diagnosis, which is often not as simple as it sounds. Since there can be underlying causes of headache, it is important to first rule out these causes. Once secondary causes are ruled out and you have gotten a specific, primary headache diagnosis, you and your doctor can begin to work to manage the pain.

Getting Correct Diagnosis: The first step to managing your paid

Here are some steps you can take to help in the diagnosis process:

• Make an appointment specifically to talk about your headaches. When you call, confirm that your physician evaluates and treats patients with headache. If you need help finding a physician, you can try the American Headache Society’s Find a Healthcare Professional site.
• Keep a headache diary. A headache diary consists of tracking when your headache occurred (frequency), how intense it was, anything that might have triggered or relieved it (including medications taken), and when it ended (if it ended).¹ If immediate help is not required, try to keep this diary for about one month prior to your doctor’s visit.
• Organize the details of your headache history. For example, be prepared with your family history of headaches (headaches often run in families), past relief efforts you have tried including drug and non-drug efforts, any previous tests you have had (e.g., CT Scan, MRI, spinal tap, blood tests, urine tests, x-rays) and their results, when your headaches first began, as well as the information from your headache diary.
• Consider taking a headache disability assessment quiz, such as MIDAS or the HIT-6² or another headache management tool.
• Educate yourself as much as possible ahead of time. The more you know about your headaches, the better equipped you will be to answer questions and help in your treatment and management plan.
• Before you leave the physician’s office, make sure you have all of your questions answered. Ask for the following information in writing, or write it down during your visit:
  
  
  • “What is my specific headache diagnosis?
  • What is the treatment plan, including a list of specific medications and lifestyle changes?
  • How often should these medications or treatments be taken (daily or weekly)?
  • How do the medications work, and what should be the expected outcome after taking them?
  • When should I come back for the next office visit?
  • What should I do if the medication is not working or I do not like the medications?
  • What are some signs or symptoms that the medications are not helping?
  • What level of success can I expect from the medications?

By working with your physician and developing an organized strategy to treat your headaches, you can significantly improve your headache pattern and decrease the impact headaches have on your family and work life. By being prepared for your headacherelated office visits, you can make your time spent with your provider much more efficient and increase the chance of success. The time that you invest will reap rich rewards in your overall quality of life.”²

Headache Hygiene: Self-care for headache relief

“Headache hygiene is the practice of taking care of yourself in a way that will reduce the likelihood, frequency, intensity, and severity of headaches.”³ “Many lifestyle factors influence migraine and other headache conditions. Therefore, taking care of these lifestyle factors may reduce the risk of severe attacks.^3”“…Migraine [in particular] loves change. So changing the wake-sleep cycle, missing meals, being exposed to stress, even following stress – which has sometimes been called a let-down headache – all of these things may perturb the inner steady state in a person who is prone to have migraines. A particular perturbation might mean a lot for one individual and not much for another, but there are patterns.”⁴ The following lifestyle modifications from the American Headache Society^3,5 may significantly impact the frequency of headaches for some individuals.

• Maintain regular sleep patterns.
  • Go to sleep and wake at the same time each day.
  • Don’t sleep excessively on the weekends or too little on the weekdays.
  • Strive for 7–9 hours of sleep each night (or during the day if you do shift work). See HealthHints: Sleep – Your health & performance depends upon it, Part 1 (PDF) & Part 2 (PDF), for more information.
• Eat regular meals.
  • Low blood sugar can trigger a headache.
  • Too much sugar may lead to a rapid increase in blood sugar followed by a rapid decline in blood sugar, which can trigger a headache.
  • Do not skip meals. Eat a good, healthy breakfast. Eat regular meals each day including proteins, fruits, vegetables, and carbohydrates.
• Drink plenty of water.
  • Dehydration may cause headache.
  • A normal adult should drink plenty of water throughout the day.
• Exercise regularly.
  • Aerobic exercise for at least 30 minutes three times a week can help reduce the frequency or severity of migraines.
  • Moderate exercise 3–5 times each week will help reduce stress (the most common trigger for migraine attacks identified by individuals with migraine⁴) and keep you physically fit.
  • Too much exercise or inconsistent patterns of exercise may trigger headache.
• Reduce stress.
  • Stress may lead to an increase in headache and has been identified by individuals with migraine as the most common trigger.⁴
  • Limit stress by avoiding conflict or stressful situations when possible/appropriate.
  • Try to resolve disputes calmly.
  • Take a daily “stress break” to do something you enjoy, or just relax for a few minutes with soft relaxing lights or sounds, music, deep breathing (PDF), etc.
  • Stress management through relaxation techniques or biofeedback training may be helpful for headache relief. See HealthHints: Stress – Changing the way we react (PDF).
• Limit caffeine and alcohol.
  • Caffeine is a stimulant, and caffeine withdrawal may cause headaches when blood levels of caffeine taper. “It’s clearly a two-edged sword because a number of prescription and over-the-counter medications for treating acute migraine contain caffeine. So caffeine can play a positive role in some individuals…. Limit…caffeine since overuse may aggravate headaches. If [you] typically do get caffeine at a fairly early time in the morning, as many of us do, usually via coffee or some other drink, then try to keep it on the same schedule each day. That might be helpful in reducing the likelihood of a headache.”⁴
  • Alcohol may also be a trigger for headache, while alcohol in moderation may reduce the number of headaches.

Trigger Avoidance: Avoiding factors that increase your risk for headache

Triggers are specific factors that may increase your risk of having a headache, particularly migraines. “Triggers do not ‘cause’ migraine. Instead, they are thought to activate processes that cause migraine in people who are prone to the condition. A certain trigger will not induce a migraine in every person; in a single migraine sufferer, a trigger may not cause a migraine every time.”³ This can also be true for other types of headache. By keeping a headache diary, you will be able to identify some triggers for your particular headaches. Once you have identified triggers, it will be easier for you to avoid them and reduce your chances of having a headache attack.³

Potential Headache Triggers^{3, 4, 5, 6, 7, 8, 9, 10}

Categories	Triggers	Examples
Dietary	Food Items	Alcohol (especially beer & red wine) Aspartame Caffeine (too little or too much) Monosodium glutamate (MSG, a flavor enhancer found in a many Asian foods as well as a wide variety of processed foods) Nitrates (preservatives found in many processed meats like bacon, hot dogs, pepperoni, and salami) Salty foods Tyramine (found in aged cheese, some beans, chicken livers, chocolate, figs, sour cream, smoked fi sh, soy sauce, vinegar, and yogurt) Other foods: avocado, banana, citrus, dairy products, fermented or pickled foods, nuts, onions, peanut butter
	Skipping meals/fasting
	Dehydration
Physiological/ Physical	Injuries	Head trauma
	Overexertion/intense physical exertion	Exercising when out of shape or in heat Excessive exercise Sexual activity
	Change in sleep patterns	Napping Oversleeping Too little sleep/fatigue/sleep deprivation
	Hormonal changes (estrogen level changes, rapid changes in estrogen levels)	Menstruation Hormone replacement therapies Birth control pills Menopause
	Eyestrain or other visual triggers	Reading in dim light Extended reading or driving sessions Needed or outdated presecription for contacts or glasses
Environmental	Weather and other environmental changes	Extreme heat or cold; change in season, altitude level, or barometric pressure
	Bright or changing lights	Sun without eye shades/sun glare Flashing lights or screens
	Loud noises
	Odors/pollution	Perfumes, flowers, chemicals, smog, smoking or exposure to smoke
Stress	Work	Unrealistic timelines
	Home	Financial issues
	Family	Job-career changes/moving Marriage/childbirth Death/loss/divorce
	Everyday irritants	Sitting in traffic, searching for lost papers, tolerating annoyances at work
Stress Let-down	Discontinuation of work	Weekends Vacation Ending a project or stressful task (such as a presentation)
Medication	Drugs	Nitroglycerine
	Missed dose(s) or overuse	Missed medication Medication overuse (rebound headache)

 

Treatment with Medication: What are the options?

Medication treatment options fall into two broad categories:

• Pain-relieving medications (also known as acute or abortive treatment) are taken to stop the pain as soon as possible after a headache begins.¹¹
• Preventive medications are taken regularly, often on a daily basis, to reduce the severity and frequency of headaches.⁹

Choosing a drug strategy to manage your headaches depends on the frequency and severity of your headaches. For those who need medication no more than 10 days a month, pain-relieving drugs may be effective; while, for those who experience headache more often or with great severity, preventive drugs may be a better choice.^9,11,12 Other medical conditions will also be taken into account as well as medications that have or have not worked for you in the past.¹¹

Over-the-counter (OTC) pain medications, such as acetaminophen, ibuprophen, naproxen, or aspirin taken at the first sign of headache may be helpful. (Note: Never give aspirin to children because of the risk for a condition known as Reye’s Syndrome.) These pain relievers are classified as nonsteroidal anti-inflammatory drugs (NSAIDs) and help by blocking the action of chemical messengers that cause pain.¹¹ Read the label on OTC products to be sure you are making the best choice for your particular headache. Understanding the active ingredient, form (e.g., tablet, liquigel, suspension, etc.), and other terminology (e.g. extra-strength, time-released, etc.) can help you make a wise choice.

If OTC products do not control pain, other pain-relieving medications may be prescribed, including drugs known as triptans, ergots, butalbital combinations, opiates, corticosteroids, and antinausea drugs.¹¹ See some of the options here, along with their pros and cons here.

Specific prevention strategies vary, depending on which type of headache you have. If preventive drug therapy is prescribed, your doctor may recommend antidepressants, beta blockers, anti-seizure medications, injection methods, or others.¹² See a description of some of the options for preventive treatment here, along with their pros and cons here.

For more on specific medications, you can read the medications topic sheets from the National Headache Foundation.

Medications combined with healthy lifestyle and trigger avoidance strategies can be a positive treatment plan for primary headache pain. For more ideas on easing the pain, see What else can I do to ease the pain of primary headache?

 

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This document is meant for educational purposes only and is not intended to replace the advice of your doctor or other health care provider.

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References:

1. National Headache Foundation (2009). Headache diary [on-line]. Retrieved April 6, 2009. From http://www.headaches.org/For_Professionals/Headache_Diary.
2. Bain, P. (2008). How to talk to your practitioner about your headaches [on-line].
   Retrieved March 5, 2009. From http://www.achenet.org/education/patients/HowtoTalktoYour
   PractitioneraboutYourHeadaches.asp.
3. American Headache Society (2007). Headache hygiene – what is it? Retrieved March 5, 2009.
   From http://www.achenet.org/education/patients/headacheHygiene.asp.
4. Swanson, J. (2008). Migraine FAQs: An interview with a Mayo Clinic specialist [on-line].
   Retrieved February 10, 2009. From http://www.mayoclinic.com/health/
   migraine-headache/MI00026.
5. American Headache Society (2007). Trigger avoidance information [on-line].
   Retrieved March 5, 2009. From http://www.achenet.org/tools/
   TriggerAvoidanceInformation.asp.
6. Cleveland Clinic (2006). Migraine headaches [on-line]. Retrieved March 27, 2009.
   From http://my.clevelandclinic.org/disorders/migraine_headache/
   hic_migraine_headaches.aspx.
7. George, C. (2008). So many ways to treat so many types of headache [on-line].
   Retrieved March 4, 2009. From http://blog.livehealthcom.net/2008/12/
   so-many-ways-to-treat-so-many-types-of-headache/.
8. Mayo Clinic (2008). Headaches: Reduce stress to prevent pain [on-line].
   Retrieved February 10, 2009. From http://www.mayoclinic.com/health/
   headaches/HE00002.
9. Mayo Clinic (2007). Migraine [on-line]. Retrieved February 10, 2009. From http://www.mayoclinic.com/health/migraine-headache/DS00120.
10. U.S. National Library of Medicine (2006). Migraine [on-line]. Retrieved
    February 10, 2009. From http://www.nlm.nih.gov/medlineplus/ency/article/000709.htm.
11. Mayo Clinic (2008). Migraine guide [on-line]. Retrieved February 10, 2009.
    From http://www.mayoclinic.com/health/migraine-headache/MI99999.
12. Mayo Clinic (2008). Chronic daily headaches [on-line]. Retrieved
    February 10, 2009. From http://www.mayoclinic.com/health/
    chronic-daily-headaches/ds00646.