November - December 2017

Written by Steven Burns
From his column To Your Health

headacheI walked into the exam room to meet a new patient, Kevin. He was in his twenties, thin build and athletic. “What brings you in today?” I asked.

“Doc, I had the weirdest thing happen. I was just sitting in my apartment, and my world turned sideways.”

Early in the practice of family medicine I realized that that, no matter how long you keep working, you will occasionally hear something you never heard before. “How long did the weird vision last?”

“About ten minutes.”

“And how bad was the headache afterwards?”

He gave me a quizzical look. “It wasn’t too bad,” he said. “But I nearly threw up, and I felt really weird for a few hours.”

I explained to Kevin that the symptoms were probably the “aura” (sensory change) associated with a migraine, but his case was strange enough that I was going to talk with a neurologist.

The specialist I consulted suffers from classical migraines, meaning he has visual auras himself. During our call, he reassured me that a 90-degree rotation in vision was a known type of aura. The changes could include inverted image (“upside-down”), wavy lines, loss of vision—either in part or all of the visual field, and even a photographic negative appearance. He said famous artists such as Salvador Dali and Vincent van Gogh may have been inspired by their migraines, as their paintings showed color changes and images that would be likely during an aura. His own auras featured spectacular colors, and might be amusing if he did not know the headache was coming.

Headache disorders are the third highest cause of lost work or disability.

With this information, I reassured Kevin, and, because of the unusual symptoms, I ordered an MRI as the neurologist recommended. It was normal.

The World Health Organization reports that headaches occur in about half of the population in any given year, and that headache disorders are the third highest cause of lost work or disability. Migraine by itself is the sixth highest cause of disability.

The economic impact of headache is high. Estimates of the cost of migraine, including lost work and treatment, run from $13-to-$17 billion per year in the United States, and nearly double that number in the European Union. Most of that cost is from lost work.

Headaches are classified into several types: migraine, tension-type or muscle contraction, medication overuse, and, much less common—cluster headache. Each disorder is complex, but there are defining characteristics.

Migraines typically have a pounding quality and are frequently one-sided. About 25% of migraineurs (people with migraine headaches) have auras, most often visual. Nausea and vomiting are common, and sensitivity to light and sound are usually present. Triggers include stress, sleep problems, weather changes, and certain foods, among many others. Most “sinus headaches” meet the criteria for migraine.

Tension-type or muscle contraction headaches are the most common. They are characterized by a more gradual onset than migraine, described often as a pressure sensation, or “band around the head.” They do not have the auras migraines can have, but they can be severe. Many headaches that arise from neck arthritis or head injuries fit the criteria for tension-type headaches.

Medication overuse headaches are called “secondary headaches,” because they usually arise when people take medication for some sort of pain. Often the pain is that of migraine. Taking pain pills every day, including non-narcotic and over-the-counter medications, can perpetuate this type of headache. Even though most of the medications involved are not narcotics, withdrawing from them can be painful. It is, however, necessary in the treatment of this type of headache.

Cluster headaches are uncommon, affecting only about one person in 1,000. They are the only type of headache that is more common in men, with a male to female ratio of 6:1. The term “cluster” is used because the headaches occur over a period of time, often a month or two, and then cease for months at a time. Unfortunately, over time they can become more chronic and stop clustering. The pain from this headache is extreme. They usually occur at the same time daily and last from 20 minutes to an hour. The pain usually centers around one eye, accompanied by redness and nasal congestion on the same side. During the headache, the person is usually unable to do anything. The pain is so severe that some sufferers have taken their own life. Oddly, inhaling 100% oxygen at the onset of a cluster headache is, for many, the most effective treatment.

So, what are danger signs for headaches? We start with first and worst:

  • The headache is your first, especially after age 50.
  • The headache is your worst, even if you regularly have headaches.
  • There is fever, neck pain, or other symptoms of infection.
  • There are neurological symptoms, such as difficulty speaking or moving.
  • There is a loss of vision, even briefly, with no previous diagnosis of migraine.
  • The headache goes on for more than 24 hours, again, with no headache diagnosis.

Treatment for headaches is beyond the scope of this article, but if you are having severe headaches, you should see your primary care physician right away.

Dr. Steven Burns is board-certified in family medicine and has been in practice for more than 30 years.

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