Physicians now know better ways to diagnose and treat the victims of sever head pain
By David R. Coddon, M.D.
“Daddy, please make the pain go away,” my son Johnny cried one day when he was 12 years old. I had been called home from my office on an October afternoon to find him writhing on the floor in agony. He was sweating profusely and holding his head. His face and lips were white as a sheet, and his hands were ice cold. He later became nauseous and vomited uncontrollably.
I was terrified that Johnny had suffered a brain hemorrhage. Unlike most parents, however, as a neurologist I was able to put my fears to rest. Johnny was severely ill, to be sure, but he was not having a stroke. He was having a migraine headache attack. I carried him upstairs to his bedroom where he eventually fell asleep. When he woke up the next morning the severe pain was gone. Only a dull headache and a washed-out feeling remained to remind him of the terrible ordeal he had gone through.
Johnny is unusual in that his father is a headache specialist, but he is not a victim of some rare disorder. More than 20 million Americans suffer the throbbing pain of migraine headache. Sever as it is, migraine is only one of several types of chronic and recurrent disabling headaches that afflict more than 10 per cent of the people in the world. In the United States, as many as 40 million persons seek medical help each year for relief of severe head pain; more than half of all visits to doctors are due to headaches. Americans spend billions of dollars annually on over-the-counter remedies and prescription drugs for headache relief. More work time is lost to headache than to cancer, heart disease, stroke, and psychiatric illness combined.
As director for the Headache Clinic at the Mount Sinai Medical Center in New York City and in my private practice, I see thousands of headache sufferers each year. I have learned that headaches respect no age, race, sex, geographic, or other differences. Headache victims are found in all parts of the world, and they live in noisy big cities and on quiet farms.
Headaches have plagued people throughout recorded medical history and probably existed long before. For centuries, the malady was surrounded by myth and misunderstanding. Primitive cultures viewed severe headache much as they did fits or seizures. Victims of severe headaches were believed to be possessed by evil spirits and were sometimes tortured or physically abused. In more modern times, some people have been unwilling to tell others that headache causes their distress, fearing that they will not be taken seriously. Yet many have achieved success in spite of severe, recurrent headaches. Julius Caesar, Thomas Jefferson, Ulysses S. Grant, Frederic Chopin , Lewis Carroll, Sigmund Freud, Virginia Woolf, Princess Margaret Rose, and Kareem Abdul-Jabbar are just a few among those who have been tormented by headaches.
Those of us who specialize in diagnosing and treating headaches have learned a great deal about them through research in recent years. We have developed elaborate classification schemes for quickly and precisely diagnosing headaches, and treatments ranging from drugs to biofeedback techniques are now widely available. But we are only beginning to understand the underlying cause of headache, in part because headache is a uniquely human condition. Rats, baboons, and other animals that have been valuable as test subjects in other forms of medical research may have headache, but they cannot communicate this condition to researchers.
Many specialist s now believe that a change in the rate of blood flow through part of the intricate maze of blood vessels in and leading to the head causes headache. The head contains the body’s largest network of blood vessels and pain-sensitive nerves, the neurovascular bed. Headache occurs when the blood flows slows down too much.
This can happen when the blood vessels dilate (enlarge), when the blood thickens, or when the blood is rerouted unevenly through the intricate channels. In fact, as many as 90 per cent of the headaches I encounter involve these vessels and blood flow, even through they are given different medial names.
Knowing that headaches result from changes in blood flow helps us to understand why they are triggered in so many , and often contradictory, ways. For example, many adults get headaches while they are resting on weekends, while others get them after strenuous activity. Many children get them after a busy day at school. Physical activity ensures a steady, even flow of blood to all parts of the body thus assuring a rich supply of oxygen to all the body’s cells. But when the activity stops, the blood flow slows down and becomes uneven in the head and other parts of the body. Pain may then strike in the head because there are so many pain receptors in the vessel walls and in the tissue surrounding the vessels in the head. These oxygen-sensitive pain receptors send distress signals to the brain.
Of course, not everyone gets a headache after strenuous activity. In fact, many people rarely get them. The important point to remember is that people who suffer sever, recurrent headaches differ somehow in the part of th brain that controls blood flow from those who do not get headaches. We have not yet precisely identified this difference, but we hope to find it soon so we can develop more effective ways to prevent and treat severe headaches.
Nevertheless, we do know a great deal about the causes and cures of vascular-flow headaches, chief of which is migraine headache. For example, most migraine sufferers are unable to drink read wine without bringing on a headache. Red wine contains histamine, a substance known for its powerful ability to dilate blood vessels and thus slow blood flow. On the other hand, many drugs that are used to treat headache successfully constrict blood vessels and thus increase blood flow. A well-known cola-based soft drink was originally sold as a headache remedy. It contained cocaine, a pain-killing drug that also constricts blood vessels.
Aspirin is effective for many headaches because it increases blood flow by breaking up clumps of platelets- blood cells that cause blood to thicken. It also helps reduce inflammation of the affected vessels and nerves of the neurovascular bed and provides pain-killing action throughout the nervous system.
Migraine headaches, the kind that my son Johnny gets, occur in all races throughout the world. They usually begin in childhood, and can be recognized in children as young 2 years old. Migraine attacks tend to occur more often and with greater severity in boys until the middle or late teens. Thereafter, males tend to have fewer migraines, but the attacks usually become more frequent and more severe in females with the onset of menstruation. Adult female migraine sufferers outnumber male victims about 4 to 1. The attacks usually last only a few hours n small children and adolescents, but they typically last from one to three days in adult females, and they sometimes las as long as two weeks.
Female hormones play a basic, but still unknown, role in migraine headaches. This is true not only in females, but also in teen-age boys during puberty. A woman’s migraine attacks generally disappear during pregnancy, and they become ess frequent and severe with advancing age until they disappear at the time of menopause. Migraine attacks are likely to occur more often and be more severe in women who use oral contraceptives than in those who do not take the pill. Taking oral contraceptives can bring on vascular-flow headaches in women who never had them before.
As many as 80 per cent of those who get migraine headaches have a parent, brother, or sister who also suffers attacks. Many migraine victims have allergic reactions to food and to many medications, particularly penicillin. Most of them suffered from carsickness when the were children.
During the 1920s and 1930s, many physicians believed that migraine headache sufferers shared common psychological traits. For example, migraine victims were thought to be intelligent, hard-working, and overconscientious. Physicians soon spoke of the “migraine personality” – for example, the woman who suffered migraine headaches and arranged all the magazines in the doctor’s waiting room into neat stacks. Today we know that no such migraine personality exists. Anyone can develop migraine hadaches.
We still do not know the exact cause and mechanism of migraine headaches, but experiments have demonstrated that a change in blood flow within the vessels carrying blood to the structures in the head is involved. Computerized axial tomography, a highly specialized X-ray photographic technique that enables us to see inside the head during a migraine attack, has shown some areas of lucency (lightness) that represent decreased blood flow. The blood vessels constrict; then they dilate and release certain chemicals that cause inflammation in the affected area. Some headache specialists believe that the pain of the migraine headache is associated with dilation of the blood vessels in the area. Others regard the dilation merely as a result of whatever triggers the migraine attack and not the cause of the migraine attack and its pain.
Because most migraine headaches strike with little warning, a migraine sufferer or parent must act quickly to reduce the attack’s severity. If taken soon enough, simple aspirin can prevent or greatly decrease the severity of a child’s migraine attack. Adult sufferers can get relief by taking prescription drugs derived from ergot, a substance made by a fungus that grows on rye plants. Ergot preparation must also be taken in the early stages of a migraine attack to be effective.
Ergot medications constrict blood vessels greatly and must be used with care. Too much taken too often can produce unpleasant tingling in hands, feet, legs, and chest, seriously damage blood vessels, and even cause gangrene in the limbs. Ergot preparations produce nausea and vomiting and tend to be addicting. Paradoxically, a patient who takes large amounts of them or one who discontinues taking the medications may get a headache.
… to be continued
