Hystory of headache triggers and causes from Young and Silberste2004. by AAN Press

History of

Headache

HEADACHE IS INDELIBLY LINKED with the stress and speed of modern life,

but it is by no means a modern phenomenon. People have suffered

from headaches since the dawn of civilization and, for as long as headaches

have existed, so have headache treatments. Well-known migraine sufferers—

or migraineurs—include Julius Caesar, Napoleon, Ulysses S. Grant,

Thomas Jefferson, Robert E. Lee, Charles Darwin, Sigmund Freud, Vincent

van Gogh, Pablo Picasso, and Lewis Carroll. A comprehensive list of famous

historical headache sufferers—and their sometimes unique treatments—

would fill more space than this book allows. What is surprising is that modern

medicine still resorts to similar treatments.

Trepanation is a procedure that has been performed since 7000 B.C.,

in which the skull is perforated with an instrument. Trepanation may

have been done to release the demons and evil spirits that were believed

to cause headaches, madness, and epilepsy, but it may also have been

done for medical reasons. Some African tribes continued to practice

trepanation today—without anesthesia—primarily for relief of headache

or removal of a fracture line after head injury. Surprisingly, it is also used

in Western society. There are still modern trepanation practitioners (see

www.trepanation.com) .

People have suffered from headaches since

the dawn of civilization and, for as long as

headaches have existed, so have headache

treatments.

For thousands of years, the medical and popular literature has

described headache triggers, relieving factors, and the signs and symptoms

of migraine, including headache, aura, nausea and/or vomiting,

and familial tendency. References to headache are found as far back as

3000 B.C. The earliest published reference is a Sumerian epic poem,

which gives an early description of the sick headache:

The sick-eyed says not

“I am sick-eyed”

The sick-headed not

“I am sick-headed.”

This could be interpreted in two ways: headache sufferers 5,000

years ago were either searching for an explanation other than headache

for what afflicted them, or they preferred to hide their affliction from

others. Both these situations are still common today.

The Ebers Papyrus, an ancient Egyptian prescription for headache,

dates from about 1200 B.C., and is said to be based on medical documents

from 2500 B.C. It describes migraine, neuralgia, and shooting head

pains. Like other ancients, the Egyptians believed that the gods could

cure their ailments if they followed divine instructions (Figure 2-2A). A

clay crocodile holding grain in its mouth was firmly bound to the

SECTION I • History, Philosophy, and General Concepts


drilled in his skull—and

survived!


Headache treatment in

ancient Egypt.

patient’s head by a strip of linen inscribed with the names of the gods

This may have produced headache relief by compressing

and cooling the scalp.

Hippocrates described both the visual aura that can precede a

migraine headache and its relief by vomiting in 400 B.C. He believed that

headache could be triggered by exercise or sexual intercourse; that

migraine resulted from vapors rising from the stomach to the head; and

that vomiting could partially relieve the pain of headache. Plato believed

that preoccupation with the body triggered headaches:

“Yes, indeed,” he said, “this excessive care for the body that goes beyond simple

gymnastics is about the greatest of all obstacles.… It is troublesome in household

affairs and military service and … it puts difficulties in the way of any kind of

instruction, thinking, or private meditation—forever imagining headaches and

dizziness and attributing their origins to philosophy.… It makes the man always

fancy himself sick and never cease from anguishing about his body.”

Headache was believed to be inflicted by divine decree as a punishment

for sins, and curable by repentance and good deeds. Celsius (215 to

300 A.D.) believed “drinking wine, or crudity [upset stomach], or cold, or

heat of a fire or the sun” could trigger migraine. Aretaeus of Cappodocia

(200 A.D.) is credited with first describing migraine headache.

The term migraine, derived from the Greek word hemicrania, meaning

“half of the head,” was introduced by Galen in approximately 200

A.D. He mistakenly believed it was caused by the ascent of vapors that

were excessive, too hot, or too cold. Popular names that evolved over

the years for this uncomfortable and often disabling disorder include sick

headache, blind headache, and bilious headache.

A solution of opium and vinegar applied to the skin was widely used

as a headache remedy in Europe during the thirteenth century. The

vinegar probably allowed the opium to be absorbed more quickly

through the skin. Vinegar compresses have also been used alone as a

headache treatment. Shakespeare discusses headache treatment:

Desdemona binds her husband’s head with the handkerchief—a remedy

still used by many migraine sufferers—that will later be her undoing:

OTHELLO: I have a pain upon my forehead here.
DESDEMONA: Faith, that is with watching; twill away again. Let me

but bind it hard, within this hour. It will be well.

Erasmus Darwin, grandfather of Charles Darwin, suggested treating

headache by centrifugation in the late 1700s. He believed headaches were

caused by vasodilation and suggested placing the patient in a centrifuge to

force the blood from the head to the feet. Fothergill introduced the term

fortification spectra in 1778 to describe the typical visual aura or disturbance

of migraine. Fothergill used the word fortification because the visual aura

resembled a fortified town surrounded by bastions (Figure 2-3).

Liveing wrote the first book on migraine in 1873: On Megrim, Sickheadache,

and Some Allied Disorders: A Contribution to the Pathology of Nervestorms.

This book originated the neural theory of migraine. He ascribed

the problem to “… disturbances of the autonomic nervous system,”

which he called nerve storms.

William Gowers published an influential neurology textbook in

1888: A Manual of Disease of the Nervous System. Gowers emphasized the

importance of a healthy lifestyle, a concept to which we have holistically

returned, and he advocated treating headaches with a solution of

nitroglycerin, 1 percent in alcohol combined with other agents. The

remedy later became known as the Gowers mixture. Gowers was also

famous for recommending Indian hemp (marijuana) for heada
Stephen King, the “horror” novelist, vividly describes the pain, sensory

hyper-responsiveness, and feeling of prostration associated with

headadche :“…The headache would get worse until it was a smashing weight, sending red

pain through his head and neck with every pulsebeat. Bright lights would make

his eyes water helplessly and send darts of agony into the flesh just behind his

eyes. Small noises magnified, ordinary noises as loud as jackhammers, loud

noises insupportable. The headache would worsen until it felt as if his head were

being crushed inside an inquisitor’s lovecap. Then it would even off at that level

for six hours. He would be next to helpless.”

Firestarter, by Stephen King

Lewis Carroll described migrainous phenomena in Alice in

Wonderland and Through the Looking Glass, depicting instances of central

scotoma (blindness), tunnel vision, phonophobia (sensitivity to sound),

vertigo, distortions in body image, dementia, and visual hallucinations



Alice in Wonderland.

Joan Didion describes a situation with which most headache sufferers

can probably identify:

“We have reached a certain understanding my migraine and I. It never comes

when I am in real trouble. Tell me that my house is burned down, my husband

has left me, that there is gunfighting in the streets and panic in the banks, and

I will not respond by getting a headache. It comes when I am fighting not an

open but a guerilla war with my own life, during weeks of small household confusions,

lost laundry, unhappy help, canceled appointments, on days when the

telephone rings too much and I get no work done and the wind is coming up. On

days like that my friend comes uninvited.”

In Bed, by Joan Didion

Emotional well-being can produce a dramatic change in headache

intensity. One dramatic example is found in the Personal Memoirs of

Ulysses S. Grant. The general describes a sick headache he suffered on

August 9, 1865. He attempts to cure it by “bathing [his] feet in hot water

and mustard and putting mustard plasters on [his] wrists and the back

of [his] neck.” However, he gets complete relief only when he receives

word that Robert E. Lee has agreed to discuss terms of surrender; “… the

instant I saw the contents of the note I was cured.”

In defining the elements of the migraine personality, Joan Didion’s

physician focuses on two areas that are usually considered to be areas of

feminine concern—personal appearance and housework:

“You don’t look like a migraine personality.… Your hair’s messy. But I suppose

you’re a compulsive housekeeper.

Actually my house is kept even more negligently than my hair, but the doctor

was right nonetheless; perfectionism can also take the form of spending most of

a week writing and rewriting a paragraph.”

In Bed, by Joan Didion

However, not all perfectionists have migraines, and not all

migraineurs have perfectionistic personalities.

Migraine treatment advanced significantly in 1938 when John

Graham and Harold Wolff demonstrated that the drug ergotamine

worked by constricting blood vessels and used this as proof of the vascu-

lar theory of migraine. Ergotamine is produced from ergot, a fungus

found on wheat and bread. Ancient Greek and Roman writings include

references to “blighted grains” and “blackened bread,” and to the use of

concoctions of powdered barley flower to hasten childbirth. Written

accounts of ergot poisoning first appeared during the Middle Ages

. Epidemics were described in which the characteristic

symptom was gangrene of the feet, legs, hands, and arms, often associated

with burning sensations in the extremities—symptoms now recognized

as ergot poisoning. The disease was known as Ignis Sacer or Holy

Fire and, later, as St. Anthony’s Fire, in honor of the saint at whose shrine

relief was obtained. This relief may have resulted from the use of grain

that was not contaminated during the pilgrimage to the shrine.

In 1853, Louis René Tulasne of Paris established that ergot was not a

hypertrophied rye seed, but a fungus, Claviceps purpurea. Once infected by

the fungus, the rye seed was transformed into a spur-shaped mass, purple-

brown in color—the resting stage of the fungus known as the sclerotium

(derived from the Greek skleros, meaning hard). The term ergot is

Ergot: fungus growth on rye.

derived from the French word argot, meaning rooster’s spur, which

describes the small, banana-shaped sclerotium of the fungus (Figure 2-6).

The use of ergot was romanticized by Alfred, Lord Tennyson (1809-

97):

He gently prevails on his patients to try

The magic effects of the ergot rye.

The first pure ergot alkaloid, ergotamine, was isolated and used primarily

in obstetrics and gynecology until 1925, when Rothlin successfully

treated a case of severe and intractable migraine with a subcutaneous

injection of ergotamine tartrate. This indication was pursued vigorously by

various researchers over the following decades and was reinforced by the

belief in a vascular origin for migraine and the concept that ergotamine

tartrate acted as a vasoconstrictor. Dihydroergotamine (DHE®)* was synthesized

by Stoll and Hofmann in 1943 and was used to treat migraine by

Horton, Peters, and Blumenthal at the Mayo Clinic.

The modern approach to treating migraine began with the development

of sumatriptan (Imitrex®) by Pat Humphrey and his colleagues.

Ergot, the French

word for rooster’s

spur

*The brand names of medicines are in parentheses, throughout.

Based on the concept that serotonin can relieve headache, they designed

a chemical that was similar to serotonin, although more stable and with

fewer side effects. This development led to modern acute migraine treatment

and to the elucidation of the mechanism of action of what are now

called the triptans, seven of which are now available in the United States.

We are at the threshold of an explosion in the understanding, diagnosis,

and treatment of migraine and other headaches. Many new treatments

have been developed, and many more are in various stages of

development. Concomitant with this is the renewed dedication of clinicians

to headache treatment and teaching. Let us hope that future

headache sufferers will not relate to this refrain from Iolanthe, by W.S.

Gilbert and Sir Arthur Sullivan (Love, unrequited, robs me of my rest

[the nightmare song] 1882):

When you’re lying awake with a dismal headache

And repose is taboo’d by anxiety,

I conceive you may use any language you choose

To indulge in without impropriety.


We are at the threshold of an explosion in the

understanding, diagnosis, and treatment of

migraine and other headaches.

1

The Causes

of Headache

CAUSES VERSUS TRIGGERS

IT IS IMPORTANT TO REALIZE the difference between a headache cause and

a headache trigger. Among other things, stress and weather changes

can trigger a headache. Knowing what causes a headache is crucial to

treating the headache successfully. A brain tumor, a high fever, or head

trauma can cause a headache (Figure 3-1).

Many people are convinced that their headaches are caused by certain

foods. However, although many foods are recognized headache

triggers, very few, if any, can directly cause a headache. One exception,

of course, is the dreaded “ice-cream headache,” in which ice cream or

another cold stimulus to the back of the mouth produces a brief, severe

headache.

TRIGGERS

Marie Alvarez suffered from two severe migraines a month for much of her life.

They were severe and responded moderately well to treatment. In her 40s, she

developed pain in the right front of her head that moved to the left and back of

the head. She had a mild, chronic, nagging, left-sided headache, and then devel-

It is important to realize the difference

between a headache cause and a headache

trigger.

oped neck pain. These migraines were much more frequent and difficult to treat.

Eventually she was found to have a herniated disc in the upper part of her neck

that was pushing on the nerve on the left side. She eventually had surgery, her

headaches returned to their original location, and once again they became simple

to treat.

This story illustrates an important concept. While all of Maria’s

headaches were migraine, a significant inciter or trigger made her new

headache very hard to treat until it was located and corrected. A huge

number of triggers exist (Table 3-1). Almost any kind of physical prob-


20

TABLE 3-1 Migraine Triggers

Diet

Hunger Additives

Alcohol Certain foods

Chronobiologic

Sleep (too much Schedule change

or too little)

Hormonal changes

Menstruation

Environmental factors

Light glare Altitude

Odors Weather change

Head or neck pain

Of another cause

Physical exertion

Exercise Sex

Stress and anxiety

Letdown

Head trauma

Migraine biology

Hormones

Diet

Changes

Sensory stimuli

FIGURE 3-1

Migraine triggers.

lem in the neck or head, including the jaw joint (temporomandibular joint

disorder), eyes, teeth, and neck, can be a trigger. Sometimes a worsening

of migraine and, to a lesser extent, tension-type headache can be caused

by physical illness, such as mononucleosis, thyroid disease, or sleep

apnea; a chronic environmental factor, such as smells at work or chronic

sleep deprivation; or a psychological condition, such as chronic stress

or major depression. Unlike migraine, and perhaps tension-type

headache, psychological conditions and other triggers play only a small

role in making cluster headache worse.

On the other hand, triggers bring on headaches one at a time. For

example, a person drinks a glass of red wine and a few hours later develops

a migraine. The wine brought on a single headache, but it is not

responsible for an overall worsening of the headache problem.

Types of Headache

Headache can be divided into two broad groups: primary headache disorders

and secondary headache disorders. A primary headache disorder is one in

which the headache itself is the problem. In other words, there is no

deeper underlying cause. The most common primary headache disorder

is tension-type headache; the second most common is migraine headache.

The International Headache Society has classified the primary headache

disorders, as shown in Table 3-2.

A secondary headache may be a symptom of an underlying condition,

such as a brain tumor, stroke, or fasting. Secondary headache disorders

can be ruled out by a thorough history and physical examination.

Diagnostic testing may be necessary if suspicious features are present

(see Table 4-1, Warning Signs—“Headache Alarms”).

Most people who have headaches have a normal physical examination.

Therefore, the history is the most important diagnostic tool the

physician has at his disposal. Important diagnostic clues include when

and under what circumstances the headaches began. For example,

migraine and tension-type headaches usually begin in childhood or

early adult life. The onset of a new headache after the age of 55 years is

worrisome and could indicate a more serious disorder. Fever in associa-

CHAPTER 3 • The Causes of Headache

21

SECTION I • History, Philosophy, and General Concepts

22

TABLE 3-2 Primary Headaches

Classification

1. Migraine

Migraine without aura

Probable migraine without aura

Migraine with aura

Typical aura with migraine headache

Typical aura with nonmigraine headache

Typical aura without headache

Familial hemiplegic migraine

Sporadic hemiplegic migraine

Basilar-type migraine

Probable migraine with aura

Childhood periodic syndromes that may be precursors to or associated with migraine

Cyclical vomiting

Abdominal migraine

Benign paroxysmal vertigo of childhood

Retinal migraine

Complications of migraine

Chronic migraine

Status migrainosus

Persistent aura without infarction

Migrainous infarction

Migraine-triggered seizures

Migrainous disorder not fulfilling above criteria

2. Tension-type headache

Infrequent episodic tension-type headache

Infrequent episodic tension-type headache associated with pericranial tenderness

Infrequent episodic tension-type headache not associated with pericranial tenderness

Frequent episodic tension-type headache

Frequent episodic tension-type headache associated with pericranial tenderness

Frequent episodic tension-type headache not associated with pericranial tenderness

Chronic tension-type headache

Chronic tension-type headache associated with pericranial tenderness

Chronic tension-type headache not associated with pericranial tenderness

Probable tension-type headache

3. Cluster headache and other trigeminal autonomic cephalalgias

Cluster headache

Episodic cluster headache

Chronic cluster headache

Paroxysmal hemicrania

Episodic paroxysmal hemicrania

Chronic paroxysmal hemicrania

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and

tearing (SUNCT)

(continued on next page)

tion with the onset of headache suggests an infection. Vigorous exercise

or exertion, such as weight lifting, may trigger migraine. A person can

have more than one type of headache, and the pattern may change over

time. The most important headache is the one that causes the most pain

or the greatest worry to the sufferer. Many doctors use questionnaires to

help focus on symptoms and improve the reliability and efficiency of the

history. In this way, the doctor will have more time for discussion, treatment,

and teaching, and also to be sure that nothing of importance has

been missed. While most headaches are not symptoms of a serious medical

problem, some are. This is discussed in detail in Chapter 4.

LOCATION AND DURATION OF PAIN

A unilateral (one-sided) headache suggests migraine or cluster headache,

or one of a few unusual types of headache. Migraine pain can change

sides from one attack to the next or can involve both sides of the head.

Cluster headaches are almost always one-sided, with the pain centered

in or around the eye, temple, cheek, or adjacent areas. Tension-type

headache typically involves both sides of the head. Trigeminal neuralgia

is a disorder evidenced by jabs of brief, one-sided, severe pain (similar to

CHAPTER 3 • The Causes of Headache

23

TABLE 3-2 Primary Headaches (continued)

Probable trigeminal autonomic cephalalgia

Probable cluster headache

Probable paroxysmal hemicrania

Probable SUNCT

4. Other primary headaches

Primary stabbing headache

Primary cough headache

Primary exertional headache

Primary headache associated with sexual activity

Preorgasmic headache

Orgasmic headache

Hypnic headache

Primary thunderclap headache

Hemicrania continua

New daily persistent headache

an electric shock) on or near the upper or lower jaw or cheek that is triggered

by light touch to a trigger zone. They may occur many times a day

and last only a few seconds. Headaches caused by disease in the neck

usually radiate from the neck to the back of the head on the side of the

disorder. In general, the location of pain in primary headache is not very

revealing. Establishing the headache profile is a critical factor in accurately

diagnosing and appropriately treating headache. Comments such

as, “It hurts real bad for a long time” are not very helpful in finding the

correct diagnosis.

FREQUENCY AND TIMING OF ATTACKS

Migraine attacks occur at various times—for example, in association

with the menstrual cycle, on weekends, on vacation, when relaxing

after stress, or at random. Cluster headaches usually occur in a regular

pattern, typically one to three times a day during a cluster period, which

usually lasts between two weeks and six months. The attacks occur at

similar times of the day or night, often awakening the sufferer from

sleep. Some brief-duration headaches occur dozens, and occasionally

hundreds of times a day.

SECTION I • History, Philosophy, and General Concepts

24

TABLE 3-3 How Long Does the Headache Last?

Headache Type Typical Duration

Migraine 4 to 72 hours

Status migrainosus Migraine lasting more than 72 hours

Cluster 15 to 120 minutes

Episodic tension-type 30 minutes to 7 days

Trigeminal neuralgia Seconds

Establishing the headache profile is a critical

factor in accurately diagnosing and

appropriately treating headache.

It is important for people with headaches to convey to their doctor

how often their headaches occur. Sometimes they may only communicate

the frequency and timing of their severe attacks, ignoring the more

frequent or daily headache. This can lead to misdiagnosis and inappropriate

treatment.

PAIN SEVERITY AND QUALITY

The severity of the pain and the speed of its onset and resolution are also

important diagnostic clues. Headaches of sudden onset are worrisome.

Doctors often use a 1 to 10 scale, with 1 representing minimal discomfort

and 10 the most excruciating pain the person has ever experienced.

Migraine pain and cluster pain are often rated as 10/10. The absolute

number used is not particularly important, although people who often

say that their headache is “15/10” tend to damage their credibility. What

is most helpful is consistency, so that both the patient and the physician

can tell if progress is being made in treatment.

Migraine pain is characteristically pulsating or throbbing, but it can

begin as a dull, steady ache that slowly evolves. It may not acquire a

throbbing quality until the pain becomes more severe. Cluster headache

pain is deep, boring, or piercing—described as feeling as though a redhot

poker were being thrust into the eye. Generally, tension-type

headaches are dull, band-like, or vise-like.

Associated Features

Nausea, vomiting, and even diarrhea can occur during a migraine attack.

Photophobia, an unusual or heightened sensitivity to light, and phonophobia,

a heightened sensitivity to sound, can also be associated with migraine.

Eye-tearing, redness, congestion of the nose on the side of the headache,

and swelling of the face are seen predominantly in cluster headache.

Aggravating and Relieving Factors

As noted above, headaches often have triggers, and many people confuse

triggers with causes. For example, you might get pain after pulling

CHAPTER 3 • The Causes of Headache

25

a muscle in your shoulder or neck and then get a migraine-like

headache. The neck pain would be the trigger of the migraine. There

may be other migraine triggers, but when the neck problem is serious,

the migraine will be much more severe. Removing the trigger is important,

but it is also important not to get confused and say that the problem

is strictly in the neck. Persons with trigeminal neuralgia have trigger

points on the face and the mucous membranes of the mouth. Slight

stimulation of these trigger points by eating, speaking, exposure to cold

air, brushing the teeth, or stroking, shaving, or washing the face may

provoke an attack. Menstruation is a regular trigger of migraine in many

women. Wine can be a migraine trigger—strangely white wine triggers

migraine in France and red wine is a trigger in England. In Italy, everything

seems to trigger a headache.

Sleep problems may be a cause or a trigger of headaches. Sleep

apnea, a condition in which an individual stops breathing while asleep

and then partially awakens, is a common problem, especially in the

overweight individual. It may cause morning headache. Some psychological

disorders, such as depression, may make it difficult to fall asleep

or stay asleep.

Life-style stresses abound. These include marital and family status,

education, occupation, outside interests, friendships, and major life

changes, such as marriage, divorce, separation, a new job, retirement, or

a birth or death in the family. Employment provides many stressors. Is

the person’s work satisfying or merely drudgery? Is there conflict in the

workplace? Exposure to drugs or toxins in the workplace may trigger

headaches. Workers in munitions factories may develop nitroglycerin

headaches, and carbon monoxide exposure due to poor ventilation can

trigger headache.

Behavior during the Headache

Many people find that sleep will clear their attacks and migraineurs

often retire to a dark, quiet room and lie motionless to obtain relief.

Relief can sometimes be obtained by applying hot or cold compresses

or pressing on the arteries of the scalp, but only during the period of

SECTION I • History, Philosophy, and General Concepts

26

compression. Migraine frequency and severity often decrease during

the last two trimesters of pregnancy or with the onset of menopause.

Tension-type headache sufferers may seek to distract themselves and

remain active, or they may seek relaxation or rest. People with cluster

headache find that sitting upright, rocking in a chair, pacing to and fro,

or engaging in vigorous movement lessens the pain.

FAMILY HISTORY

Some headache disorders run in families. Approximately 50 to 60 percent

of migraineurs have a parent with the disorder, and as many as 80

percent have at least one first-degree relative with migraine disorder.

Cluster headaches rarely occur within the same family. Nearly half of

those with tension-type headaches have family members with similar

headaches.

Familial headaches do not necessarily imply a genetic factor,

although this often seems to be the case with migraines. Shared environmental

exposures may also cause familial headaches. For example, a

malfunctioning furnace may cause carbon monoxide-induced

headaches in an entire family.

Past Headache History

Past response to a particular treatment may support a particular

headache diagnosis, although a specific headache treatment can mask a

serious neurologic disease. Treatment failure may be the result of the

wrong dose or not allowing enough time for a potential benefit to

accrue, such as stopping or discontinuing a preventive headache medication

after only a one-week trial. The successes and failures of past

treatment may improve future treatments, helping the doctor to better

select subsequent therapies. Medication-induced or rebound headaches

can result from the excessive use of nonprescription pain relievers, such

as aspirin or acetaminophen, as well as narcotics, barbiturates, ergots,

and triptans.

CHAPTER 3 • The Causes of Headache

27

Individual Impact of Headache

Diagnosis alone does not provide enough information. Headaches differ

in severity and affect an individual’s ability to function. The Migraine

Disability Assessment (MIDAS) questionnaire assesses the impact of

headache on work and school, chores, and household work, as well as

social, family, and leisure activities. It measures actual days of missed

activity—for example, work absenteeism and the number of days with

high levels of activity limitation. It can help both doctors and patients

focus on how headaches affect a person’s life. Migraine is the likely diagnosis

when there is a high level of disability due to a primary headache

that is recurrent (comes and goes). A MIDAS score greater than 10 indicates

significant disability. Another impact test is called the Headache

Impact Test (HIT)-6. It is a little different in that it assesses emotional

impact as well as physical disability.

PHYSICAL AND NEUROLOGIC EXAMINATIONS

After obtaining a thorough history, a physical examination is performed.

It should include the taking of vital signs, including pulse, blood pressure,

and a baseline weight, examination of the heart and lungs, and listening

to the blood vessels in the neck, such as the carotid and, perhaps,

vertebral arteries, for turbulent blood flow. The head and neck should be

examined for growths, bruises, thickened blood vessels, trigger points, or

other tender areas. The jaw should be examined for tenderness,

decreased movement, asymmetry, or severe “clicking.” Neck rigidity

may be due to irritation of the lining of the brain and might suggest

meningitis, masses in the skull, or hemorrhages.

When performing the neurologic examination, the doctor may look

for swelling of the nerves in the back of the eyes (papilledema), which

SECTION I • History, Philosophy, and General Concepts

28

Headaches differ in severity and affect an

individual’s ability to function.

suggests increased pressure around the brain that warrants a test to rule

out a mass lesion, such as a brain tumor. Arm or leg weakness, or facial

paralysis (known as focal neurologic deficits) may indicate brain disease. A

thickened or nodular scalp artery, diminished or absent artery pulsations,

reddened, tender scalp nodules, or necrotic lesions of the scalp or

tongue suggest giant cell arteritis (also called temporal arteritis), a cause of

headache and sudden blindness in the elderly.

Sometimes a diagnosis cannot be made on the first visit, and sometimes

the initial diagnosis is incorrect. A headache diary can be

extremely helpful in uncovering unrecognized patterns and providing

clues to diagnosis. The diary can be used to log headache frequency,

severity, and duration, the medications that were used, and possible

headache triggers.

Diagnostic Testing

Most people with headaches do not need tests to establish their diagnosis.

Diagnostic testing is done to identify serious underlying diseases, such

as stroke, brain tumor, or subdural hematoma. Diagnostic testing can also

establish a baseline for drug treatment, reveal reasons to avoid certain

drug treatments, such as an unexpected illness, and measure drug levels

to determine how much of a drug has been absorbed into the body.

Some features of the headache or characteristics of the sufferer may

suggest a need for diagnostic testing and may indicate the need for emergency

treatment (see Chapter 4).

Some factors suggest that headaches are not due to an underlying

organic cause. When the factors listed in Table 3-4 are present, there is

less of a need to investigate a headache.

CHAPTER 3 • The Causes of Headache

29

TABLE 3-4 Reassuring Headache Factors

• Regular or near-regular hormonal timing of the headache

• Appearance of headache after sustained exertion

• Relief with sleep

• Food, odor, or weather changes provoking headache

Specific Tests

Laboratory tests are not necessary for diagnosis in a typical, healthy

migraineur or someone who is experiencing tension-type or cluster

headache, but they may be helpful prior to treatment. They are used to

rule out more serious disorders, of which headache is occasionally a

symptom. An electrocardiogram (EKG) may be needed when there are

risk factors for heart disease, or to establish a baseline prior to the use of

triptans, ergots, or other vasoconstricting drugs. Physicians often request

liver function tests prior to using drugs that may affect the liver, and a

complete blood count (CBC) and chemistry profile before starting some

types of preventive treatment. A sedimentation rate measures inflammation

in the body and can establish the diagnosis of giant cell arteritis.

Unexpected or overused medications that have a direct effect on

headache and its treatment can be identified by means of drug screening

and toxicology studies. Routine testing for Lyme disease is not recommended.

However, serum antibody testing may be needed if an individual

who has never had a headache develops one, or a headache is

accompanied by other manifestations of Lyme disease.

Electroencephalography

This test measures the electrical activity of the brain and is an excellent

test for epilepsy. The American Academy of Neurology has determined

that an electroencephalogram (EEG) is not useful in the routine evaluation

of people with headache. Migraine aura symptoms and epilepsy

symptoms are sometimes similar, in which case an EEG may be used to

establish the correct diagnosis.

Computed Tomography and Magnetic Resonance Imaging

Computed tomography (CT) uses a computer to analyze multiple X-rays

in order to produce better images. In contrast, magnetic resonance imaging

(MRI) uses a computer, a powerful magnet, and radio waves to analyze

the area of the body in question. CT and MRI are not needed in people

with migraine if there has been no recent change in the headache

pattern, no history of seizures, and no focal neurologic findings. CT and

MRI are useful when headaches are atypical and do not fit into any

SECTION I • History, Philosophy, and General Concepts

30

defined primary group of headaches—for example, they are used to rule

out the possibility of a brain tumor (see Chapter 4).

Magnetic Resonance Angiography and Magnetic Resonance Venography

Magnetic resonance angiography uses the MRI machine to examine

arteries. It is a screening tool for suspected aneurysms (weakened areas

of blood vessel that pouch outward) or arteriovenous malformations

(abnormal tangles of vessels). Magnetic resonance venography looks for

evidence of a blood clot or obscuration in the veins or sinuses that drain

blood from the brain. These sinuses are very different from the sinuses of

the nose (Figure 3-2).

Lumbar Puncture

A lumbar puncture (see Figure 3-3), also called a spinal tap, involves

placing a needle between two vertebrae in the lower back and into a

pocket that contains the cerebrospinal fluid. This test measures the pressure

of the fluid and determines whether or not infection or inflammation

is present. The lumbar puncture is crucial to diagnosis in the five

clinical situations listed in Table 3-5.

CHAPTER 3 • The Causes of Headache

31

FIGURE 3-2

Magnetic resonance

venography: An MRI of the

brain showing cerebral veins

and venous sinuses.

A lumbar puncture may need to be done even if the CT or MRI is

normal, because these tests may miss the presence of blood or infection,

and they cannot diagnose increased spinal fluid pressure. People with

daily headaches of recent onset, particularly those whose immune system

is weakened, may have chronic meningitis, the meningitis of Lyme

disease, or meningitis of cancer cells, all of which require lumbar puncture

for diagnosis.

THE CONCEPT OF PRIMARY HEADACHE

Primary headache disorder is a condition in which the headache is not

caused by another disease or medical condition, but is a disorder unto

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32

The most common primary headache

disorder is tension-type headache; the second

most common is migraine headache.

TABLE 3-5 Situations in which Diagnostic Lumbar

Puncture Is Indicated

• The first or worst headache in a person’s life

• A severe, rapid-onset, recurrent headache

• A progressive headache (over days or weeks)

• An atypical, chronic intractable headache

• A daily headache with symptoms of high spinal fluid pressure

• A new type of headache accompanied by a fever

+

FIGURE 3-3

Patient in position for a lumbar puncture.

itself. The most common primary headache disorder is tension-type

headache; the second most common is migraine headache. Secondary

headaches are caused by another problem or condition. Of the secondary

headache disorders, fasting headache (a headache precipitated by

hunger) is the most common, followed by headache due to nose/sinus

disease or head trauma.

The concept of primary headache is an interesting one. It appears

that the brain can spontaneously produce pain and then take it away.

Some experts have even called primary headache a “reflex.” Migraine

and other primary headaches can be thought of as part of a larger group

of benign, recurrent conditions, including premenstrual syndrome

(PMS), cyclic vomiting in childhood, and some cases of recurrent vertigo

in adults.

Why would nature cause so many people to have recurrent pain

unrelated to injury? Experts have speculated that some primary

headaches may be normal pain reflexes gone awry—a human form of

the fright response to threat that causes animals to become inactive—or

a warning that the environment is too stressful. Nature does not do what

is comfortable for the individual, but what is good for the species.

CHAPTER 3 • The Causes of Headache

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TABLE 3-6 Summary Regarding Diagnostic Tests

1. Diagnostic tests can help to exclude organic headache caused by structural abnormality

of the brain, head, or neck, or by another illness that causes headache. They can

also identify other important conditions that should be considered during treatment.

2. Electroencephalography is not helpful in the evaluation of recurrent headache.

3. Lumbar puncture is crucial in diagnosing people who are experiencing their first or

worst headache and those with severe, sudden-onset headache, progressively worsening

headache, atypical chronic intractable headache, or headache accompanied by

fever and stiff neck.

4. Computed tomography or magnetic resonance imaging is not routinely needed in

adults with migraine or episodic tension-type headache. Neuroimaging should be considered

if headache alarms are present, the headache pattern has significantly

changed, the neurologic examination is abnormal, or seizures occur.

5. Specific testing, such as magnetic resonance imaging, computed tomography, or lumbar

puncture, is appropriate prior to beginning treatment if the person is at risk, the

treatment poses a risk, or worrisome clinical features are present.

6. Consultation and additional testing are often indicated for people with thunderclap

headache, chronic daily headache, headache associated with focal neurologic signs,

fever, severe neck stiffness, or headaches beginning after age 50.

Perhaps there is an advantage to some individuals being highly sensitive

to serve as an early warning system that something is amiss in the environment.

In some people, this “reflex” has simply gotten out of hand

and become dysfunctional for both the individual and society. These are

only speculations at this time, but they may ultimately prove fundamental

to understanding the nature of primary headache.

THE CONCEPT OF SECONDARY HEADACHES

Secondary headaches are due to an acquired injury, an infection, or a

malformation of the brain present since birth. Once the cause is identified,

it is treated, and if the treatment is effective, the headache goes

away completely. This idea is simple and very much the way we like to

view illness: you treat an infection and the symptoms go away, permanently;

you cure the tumor and there is no more headache.

In some cases, a secondary headache is very much like a primary

headache. A person with viral meningitis may have a throbbing

headache with nausea and vomiting and may, in fact, temporarily

respond to a migraine-specific medicine.

Finally, some people have been cured after a secondary headache

disorder, such as meningitis, but continue to have a chronic headache

problem that is very similar in its symptoms to primary headache problems,

including chronic tension-type headache and chronic migraine.

WHEN YOU VISIT YOUR PHYSICIAN

If you are seeing your doctor about your headache—especially if you are

seeing a specialist—bring the following to your appointment:

SECTION I • History, Philosophy, and General Concepts

34

Secondary headaches are due to an acquired

injury, an infection, or a malformation of the

brain present since birth.

1. A headache calendar that covers at least one month, if possible

2. The most recent CT or MRI of your brain or neck, or a copy of the

reports if the test(s) was normal

3. Copies of your most recent blood tests

4. Your last EKG, if you have had one in the last five years

5. A list of your prior acute and preventive headache treatments

6. A list of all your current drugs and food supplements

7. Any prior consultation reports

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