HEADACHES - Full extract 

Graham works for a large department store. He is in charge of men's fashions and does a lot of travelling. I've always been astonished at how he tears off to places like Singapore and Taiwan and then bounces back fresh for another week. His friend Paul also attends our practice. 

One Saturday afternoon Paul gave me a call to say that he had come home to find Graham vomiting and very distressed with a bad headache. He had suffered a similar headache a few months earlier. When I arrived Graham was laying across his bed in a darkened room, a towel and bucket next to him. 

Apparently he awoke feeling vaguely unwell and then the outer part of his vision went zig-zaggy. The right side of his face went numb for a while and then he developed a throbbing pain on the right side of his head. He vomited a couple of times in the toilet and then laid down on his bed. 

By the time I saw him the visual symptoms had gone. His main concern was the headache and nausea. While I was there he vomited again. I examined him carefully to make sure that he did not have a fever or signs of any other illness such as meningitis or a stroke. Everything seemed fine. I concluded that he had a severe migraine. 

I gave Graham an injection for the migraine as well as something for the vomiting. I asked Paul to give me call later that day to let me know how Graham was getting on. He slept a little after the injection and over several hours the headache gradually subsided.

I have since reviewed him at the surgery for a full physical examination and he appeared in very good health. It was a good opportunity to discuss migraine in detail, including ways of reducing the likelihood of further attacks. 

Graham has since made a few changes to his lifestyle. In particular, he makes sure that he doesn't get too exhausted. He also has some medication to take at the first sign of another attack. 

Which ever way you look at it, headaches are a real pain. In fact, headaches are probably the commonest pain that people see their doctor about. And if you happen to have a severe headache, it is only natural to wonder whether there could be some sinister cause. 

With headaches it is not the brain that hurts but the structures around it. The large blood vessels and the lining of the skull contain pain-sensitive fibres...as do the scalp, spine, eyes and sinuses. We frequently see headaches in people with viral infections and minor febrile illnesses. 

However, there are two main types of recurrent headaches... 

• Tension headaches are often described as being like a tight band around the head, or a tightness at the back of the neck. They are frequently worse at the end of the day and tend to improve with a rest. It seems that spasm of the scalp and neck muscles causes the actual pain, with stress and overtiredness playing a role in some people. Neck problems and dental conditions like malocclusion can also cause tension headaches. 
  
• Migraine is a more specific type of headache. It affects between 10 to 20% people and is more common in women. Often there is a family history. Sometimes there will be an aura or warning that a migraine is about to occur; there might be visual symptoms like shimmering or tunnel vision, or perhaps numbness of one side of the face. The headache that follows is usually throbbing in quality and there may be some associated nausea and vomiting. Some migraines are triggered by red wine, chocolate or glarey lights. The important feature about migraine is that it is episodic; between each attack the person feels well. 

The distinction between tension headaches and migraine is useful because the treatment of each condition can be quite different. Just to complicate matters, some people have features of both types of headache. 

When the doctor is seeing a person with recurrent headaches, a careful history and physical examination is required to rule out any serious cause. Then lifestyle factors are looked at. Advice might be given about diet, resting, and reducing stress where possible. Alternative therapies like acupuncture and meditation may also be discussed. 

Simple analgesics like paracetamol or aspirin might be necessary to relieve the symptoms of milder headaches. Anti-emetic medications to relieve nausea may also help. Ergotamine preparations in either tablet or suppository form have long been used for migraine treatment and often prove quite effective. However, they should not be used by people who have high blood pressure or vascular problems. Several preventive medications are also available for people with recurrent migraine. 

In the last couple of years a drug called Sumatriptan has become available for the treatment of acute migraine. It mimics the action of a central nervous system neurotransmitter and reverses the dilatation of the cranial blood vessels that is associated with migraine headache. It is available by tablet, injection or nasal spray and has been very widely researched in Australia and overseas. It has been shown to be both safe and effective but the main limiting factor is its cost. The nasal spray is particularly useful when the person is vomiting. Unlike the tablets, the medication is at least known to have been kept down.

Although conditions like strokes and brain tumours are very uncommon causes of headache, they still need to be kept in mind. In patients of any age, a sudden-onset very severe headache always needs a thorough check, in case a cerebral haemorrhage is responsible. 

Likewise, persistent headaches that are not relieved by rest and analgesics also require careful assessment, especially if there are other symptoms like blurred vision. Further investigations or referral to a neurologist may be necessary. 

Fortunately, the vast majority of headaches have no serious underlying cause, and most can be relieved or improved with treatment. 

Health tips: 
* Even if you have had headaches for years, see your doctor for review. There may be a new approach that can be tried to relieve them.

* Recurrent migraine sufferers should have a clear treatment plan so that they know exactly what to do with all grades of headache.

* A sudden or unexpected very severe headache always needs an urgent medical check.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: December 11, 2004