_______________________________
Note 1 - Headache "triggers" may be certain foods, environmental conditions (like heat, cold, noise, etc.), bright lights, head trauma, motion (as on a car or roller coaster ride, for example), fatigue; almost anything.
_______________________________

I once had a wife who had migraines, and I have to admit that I thought they were psychological phenomena. Now I understand more about the genetic reality of migraines, but, regardless of the cause, it has always been clear that the pain involved could be debilitating. My own experiences with headaches have been few and easily cured by aspirin, so it took me awhile to understand the enormity of chronic headaches, including migraines.

Headaches are a little like arthritis in the sense that there are many types, but we will focus mainly on three common chronic types: migraine, stress, and cluster headaches.

Migraine headaches are normally a product of one's genetic inheritance, and occur more often in women than men. Symptoms are usually throbbing or aching pain, often on one side of the head, and often accompanied by nausea, maybe throwing up, and maybe visual abnormalities or dizziness. Some sufferers get an "aura." An aura is a shimmering light, or colors; or some other visual oddities. With an aura, you have a "classic" migraine; without one, you just get credit for a "common" migraine. [Now everyone who gets a headache will see an aura. Who wants to be common?]

Tension headaches are the most common type. This type of headache results from contraction of the muscles in one's head and neck, which causes the blood vessels in the head to expand, often resulting in a feeling of pain on each side of the head - like it's being squeezed in a vice. If chronic, it is now thought that these headaches, like migraines, are genetically influenced. As with migraines, tension headaches can be intensified by overuse of over-the-counter (OTC) drugs.

Cluster headaches occur most often in men, and are characterized by excruciating pain (some say the worst imaginable, but maybe that's just a man thing) in an eye or a temple, and last from 15 minutes to an hour or more. They occur in waves lasting weeks to months, and occurring once or twice a year.

Let's be a bit more specific about how a headache happens. When a headache hits, it can be triggered (see footnote 1, page 1) by a number of factors. These triggers act upon people with a genetic disposition toward irregular serotonin control. It is thought that a trigger causes a wave of electrical activity to spread through the brain. Then the serotonin level surges (kind of a wave action). A result is that decreases in seratonin (at the ebb) cause blood vessels to become irritated, and maybe the trigeminal nerve (a major nerve in the brain/face) as well. The result is PAIN.

This leads us to the next step, which is how to ease or prevent the pain.

First, a word of warning. Many sufferers of chronic headaches increase their susceptibility by over-medicating, which can lead to rebound headaches. Rebound headaches are more frequent headaches which are the result of too much pain relief medication; where "too much" can be the amount of caffeine contained in three or four cups of coffee per day, or in more than twice-weekly doses of pain relievers or decongestants; or even two aspirins a day and some caffeine. The trick is to use medications sparingly (i.e., tolerate as much pain as you can). It is ironic that a person may find that something like Aleve, Advil, aspirin, or Tylenol may effectively reduce headache pain, which can lead to more frequent use, which may then cause more frequent headaches. And, for whatever reason, the medication of choice tends to become less effective, causing one to increase the frequency of its use - kind of an endless circle. This just isn't fair!

A reasonable beginning approach to fighting a headache is be to try one of the following (actually, maybe all of them):

• Try a relaxation technique, like deep breathing, or Yoga (you may have to consult Lilias for that);

• Try something with caffeine in it - coffee, soft drink, caffeine tablet, or ??

• Try aspirin, ibuprofen (like Advil, for instance), or acetaminophen - but not more than twice a week (avoid the rebound).

• Use ice packs wherever you are hurting; ice can be very effective.

• Try to rest or sleep in a dark, quiet room.

More about caffeine. Sometimes taking a little caffeine will help fight off a migraine before it reaches full force. This strategy tends to work especially for someone who does not consume caffeine-containing products on days that are headache-free. Caffeine may help because it constricts dilated blood vessels, which might cause the pain. It is essential to heed the warning that excessive caffeine consumption can exacerbate a headache problem; a double-edged sword, as it were.

Now let's address OTC pain relievers. If none of the previous strategies have worked, an OTC medication may help; again, it's more likely to be effective if taken early in the development of pain. The list of the most effective OTC products includes:

• Excedrin Extra-Strength is an effective choice, but contains enough caffeine that it can cause rebound headaches.

• Aleve - previously discussed in the September 1995, issue of the MAF FITNESS NEWSLETTER, on page 12.

• Ibuprofen (e.g., Advil, Motrin, Nuprin, _ _ _), an inexpensive nonsteroidal, anti-inflammatory category of drugs known as NSAIDs. These drugs can be fairly effective against tension and migraine headaches, and are reasonably well tolerated, but gastrointestinal upset is not uncommon. This class of drugs may be more effective when caffeine is taken at the same time.

• Aspirin-Free Excedrin is less effective than Excedrin Extra-Strength, but it might be a good choice for those who don't tolerate aspirin very well.

• Aspirin can be a good choice, but one has to be aware of the possible side-effects. It should be avoided for those who are pregnant, or have gastritis or ulcers. There are other side effects as well; like its blood thinning properties (which you may or may not want), it can cause liver damage, and, in high doses, kidney irritation.

• Anacin is less effective than Excedrin Extra-Strength, but it is less likely to cause sideeffects or rebound headaches (that is a side-effect, isn't it?).

• Acetaminophen is less effective than aspirin-containing products, but may be useful for minor headaches, and without aspirin's side-effects.

More on Migraines

Stopping a Migraine

• Midrin is relatively safe and effective. So much so that it may be given to children as young as 5 years old. It can cause fatigue, and those with high blood pressure should avoid it.

• Norgesic Forte is a fairly potent non-addictive drug for stopping a migraine. But it has a high aspirin content, so it may cause stomach problems for some people.

• Butalbital compounds are all potentially addictive, but are considered safe when not overused.

• Sumatriptan (Imtrex), which is very effective, but also expensive ($34 a shot - literally, it must be taken by injection). But, at least the side effects seem pretty benign - sometimes nausea. The medication comes packaged for easy self-injection. This med also comes in pill form, which is less effective than the injection version (wouldn't you know it?). In addition to being more effective, the injection version also works faster - as little as 10 minutes, as opposed to an hour for the pill form. Unfortunately, use of this drug can cause rebound headaches. Also, it is not a good choice for children; pregnant or nursing women; people with liver, kidney or heart disease; or those over age 60.

• DHE, or Dihydroergotamine, if you prefer. This is another of those injection meds, but you have to use a regular syringe, and load it yourself. It does not come in an easy applicator like Sumatriptan. It is, however, well-tolerated, and effective, but not as effective as Sumatriptan. But it lasts longer and does not cause rebound headaches. It should not be taken by those who are pregnant, have uncontrolled hypertension, poor circulation of the hands or feet, or are over age 60.

• Ergotamines can be effective, but they can cause several side-effects. Among them: nausea and anxiety. They can cause serious rebound headaches; and people over 40 probably shouldn't use them - they can cause heart attacks.

• Corticosteroids come in either pill or injection form, and is particularly effective with severe migraines and menstrual migraines, but must be taken only in small doses and for short periods of time. Extended use can cause several severe side-effects, like: liver failure, weight gain, adrenal gland suppression, and predisposition to fractures.

• Narcotics and sedatives are more-or-less a last resort if nothing else has worked. Doctors may wish to avoid prescribing drugs from this group because of the obvious possible addiction problem.

Preventing a Migraine

If all else has failed, one may decide to turn to a preventive medication, with a physician's assistance, of course. That is almost a superfluous statement since the drugs can only be obtained through a prescription. Under the following circumstances, you may choose to follow this path:

• You get moderate to severe migraines more than three times per month, or:

• Migraine relief has so far failed, or:

• The frequency/intensity of your migraines is adversely affecting your quality of life, or:

• You are willing to play "human guinea pig" by taking daily doses of medications, suffer the possible side-effects, and change drugs often in a search for "the right stuff."

• Antidepressants are used not for their psychological affect, but because they affect serotonin. Because many of them affect the heart, they may be inappropriate for the elderly.

• Beta Blockers are a group of medications which prevent blood vessel dilation. They can be a good choice for those with hypertension because, as well as fighting a headache, they help lower blood pressure. They may contribute to weight gain (some would consider that worse than the headache), depression, higher cholesterol levels, and other unpleasantries. Inderal may be the most commonly prescribed medication in this group. It is usually not prescribed for those with asthma or congestive heart failure.

• NSAIDs can be very effective at preventing migraines, but frequently cause gastrointestinal problems as well.

• Calcium Blockers are not among the most effective, but have few side-effects; therefore, are a reasonable choice for some.

As a last resort, there is a group of drugs called "MAO inhibitors" (like Nardil). These drugs are helpful for both migraines and simple daily headaches. While these drugs can be very helpful, along with the drugs comes a long list of foods and other drugs to avoid when taking them. It is too long to include here - your doctor will help you. Some of you may want to die before giving up some of the recommended list . This is as far as I am willing to go on migraine prevention. The next step may require hospitalization.

More on Tension Headaches

Try these treatments first:

• Relaxation techniques, such as deep breathing, Yoga, etc.

• Apply ice to the point of pain

• Tolerate the pain as much as you can

• Medication

• Acetaminophen is less effective than aspirin, but easier to tolerate, but can cause rebound headaches.

• Aspirin - see previous description.

• Aleve is a very effective anti-inflammatory, but can cause stomach upset and nausea.

• Aleve is a very effective anti-inflammatory, but can cause stomach upset and nausea.

• Ibuprofen (e.g., Motrin, Advil, Nuprin) - maybe about the same effectiveness as aspirin, and stomach upset can be expected.

• Caffeine - same as for migraine

• Naproxin requires a prescription, but effective as an anti-inflammatory, and may be enhanced with caffeine. Nausea and stomach upset may be expected.

• Midrin (prescription only) is effective and safe, but fatigue and stomach upset are common.

• Norgesic Forte is a strong non-addicting abortive medication for tension and migraine headaches.

• Butalbital Compounds like Esgic are effective, but are addictive - use sparingly.

• Narcotics, like codeine, These are last-resort meds, for obvious reasons.

• Sedatives, like Valium, are habit-forming and often cause sedation. You are in really bad shape if you are using narcotics or sedatives, and must be working closely with a doctor.

Tension Headaches-Prevention

• Antidepressants are the primary choice for daily headaches, not so much for depression, as for impact on serotonin.

• NSAIDs are not as effective as antidepressants, but are without all of their side effects - especially sedation.

• Beta Blockers - previously discussed.

• Muscle Relaxants

• Calcium Blockers

• Take two preventive medications (e.g., a tricyclic antidepressant with an NSAID or a beta blocker; or amitriptyline with propranolol).

• MAO Inhibitors - previously described

• Tranquilizers, Amphetamines, and Narcotic Opioids are lumped together here as a group of dangerous choices that you and your doctor might want to discus as a real last act of desperation.

More on Cluster Headaches

• Oxygen is effective in roughly 80% of cases, the equipment (oxygen tank and mask) can be rented - hospitalization is not required.

• Imitrex - previously described on page 5.

• DHE is also described on page 5.

• Pain Relievers, including OTC meds, and just about everything mentioned so far, including narcotics.

• Lidocaine Nasal Spray may be suggested, in combination with other options.

• Ketorolac Injections are about $10 apiece, but are an effective and a fast-acting anti-inflammatory. It is nonsedating and nonaddictive, and can be obtained in pill form, but which is less effective.

• Antinausea Medications - described on page 6.

Cluster Headaches-Prevention

Your initial choice of medication will likely be selected from the following:

• Cortisone is effective, but side effects are virtually assured. This med may be taken for only a short time during the peak of an episode.

• Verapamil is a calcium blocker with few side effects.

• Lithium can be effective for either episodic or chronic clusters, and is commonly combined with another med.

• Sansert is more effective for episodic, rather than chronic clusters. It does, however, have several side effects, like dizziness, leg cramps, and nausea. Not recommended for those over age 45, or those who are pregnant.

• Depakote may be useful, but it has a number of ugly side effects.

• Ergotamines may be effective, but should only be used in short term situations - as during an episode; otherwise rebound headaches and other side effects can develop.

• Ergonovine is less effective than Sansert, but with fewer side effects.