Headaches are common. They can range from mild to simply annoying to severe and debilitating. Many people call all moderate to severe headaches “migraines,” but these are, in fact, the least common headaches.
More often the head pain people describe are either tension headaches or sinus headaches. Cluster headaches, chronic daily headaches, or medication induced headaches are less common, but also need to be considered.
It is important to distinguish between these different types of headaches, because each has different causes and requires specific treatment.
Tension headaches cause a dull aching pain spreading over the entire head, sometimes worse in the back of the head, where they can radiate into the back of the neck, to the shoulders, and the forehead. Patients sometimes describe the sensation of a tight band around their head, and the areas of worst pain can be very sensitive to touch or pressure. Because muscle relaxants sometimes help, muscle tension and spasms are often blamed for these headaches, but many clinicians feel that it is STRESS which causes increased pain sensitivity and triggers these headaches.
The best approach to managing these headaches is therefore trying to identify the stress trigger and learn to diminish its intensity. This could be done with relaxation techniques, biofeedback training, counseling, and other stress management techniques (see below).
Medications for acute tension headaches include NSAIDs (non-steroidal anti-inflammatory drugs) such as Ibuprofen (Advil), Fenoprofen (Aleve, Naprosyn) and others. A new class of drugs called TRYPTANS (Imitrex, Relpax, Zomig, Axert) are also effective, but expensive, the reason why many insurances will only pay for a certain number (often nine) per month.
Medications which, when taken regularly, can prevent tension headaches include tricyclic antidepressants (such as Amitryptelene) or venlafaxine (Effexor) or mritazapine (Remeron). Low dose anticonvulsants such as Topiramate (Topamax) and muscle relaxants such Cyclobenzaprine (Flexeril) also help some people.
Cluster headaches are less frequent, but quite distinctive. In contrast to other headaches, they occur in men two to four times as often as in women. They often start during sleep and affect the area around and behind the eye, radiating into the forehead, the cheek and jaw, and even the teeth on the same side. Redness and tearing as well as swelling of the eye and eyelid and a runny nose make people assume that cluster headaches are caused by allergies. But they are thought to originate from irritation of the first branch of the trigeminal nerve. Histamines, nitroglycerin, and stress can trigger irritation of that nerve. Cluster headaches can be short but tend to occur several times during one episode. Current treatment is with 100% oxygen, and/or steroid drugs.
Chronic daily headaches refers to a broad range of headache disorders which occur on more than fifteen days every month. Different causes include eye strain, allergies, sinus issues, hangover, hunger, caffeine withdrawal, high blood pressure, fever, TMJ (temporomandibular joint) dysfunction, and post-traumatic headaches. They can also be a side effects of medications, particularly overused headache medications such as NSAIDs, tryptans and aspirin.
Migraine headaches are caused by spasms in the walls of the blood vessels in and around the brain. They occur in people with an as yet unidentified genetic predisposition but can also be triggered by trauma and stress. Some people have warning signs, such as visual changes or numbness in the face, in an arm or a leg, called “aura.” Women sometimes experience migraines shortly before or during menstruation or at mid-cycle when estrogen levels can change abruptly. Other migraine triggers are certain foods, changes in weather or altitude, lights, dehydration, stress, and sleep deprivation Severe migraines can last for days and are often combined with light sensitivity, nausea and vomiting. For many patients sleep in a dark and quiet room will end the migraine attack. Others require medication such as ergot preparations and tryptan drugs, such as Imitrex, Axert and others. Antiemetics such as Ondansetron (Zofran) as well as hydration are used to stop nausea and vomiting. Although all of these treatments can be taken by mouth or by nasal spray, severe cases sometimes require intravenous administration of fluids and drugs. Prevention is sometimes useful with beta blockers (Timolol, Propanolol) or calcium channel blockers (Verapamil) or anti-convulsants (Topomax) or barbiturates (phenobarbital). Most recently, a monoclonal antibody (TEV-48125) has been shown to decrease migraine symptoms significantly.
HEADACHE PREVENTION THROUGH STRESS MANAGEMENT
An important part of preventing many types of headaches is incorporating stress management practices into a healthy life style including enough sleep, a nutrient dense diet, avoidance of food triggers and exposure to environmental disease factors, such as mold, tobacco smoke, fragrances, pesticides and others. Headaches are often caused by a combination of different factors, with chronic stress topping the list. Today’s culture of fast paced, rapid changes, and “always on” attitude can be stressful. Internal factors such as living with chronic pain as well as internal patterns of self-criticism and disapproval (1) can also contribute to chronic stress.
Over time, exposure to these stressors can lead to significant health problems including inflammation, high blood pressure, and different types of headaches. Daily stress management exercises can reduce the frequency and severity of headaches and also benefit overall health.
Ecotherapy and “Forest Bathing” are terms for spending time outdoors, in nature, with full attention paid to the sights, sounds, and smells of the environment as they occur moment by moment. This experience on a regular basis is felt to improve wellbeing, reduce stress and decrease frequency of headaches and other chronic health issues. One study published in 2011 (2) compared the effects of walking in the city to taking a forest walk. The same amount of physical activity in the forest led to more significant reductions in blood pressure and stress substances in the blood.
Breathing Practices, done on a regular basis, can also reduce blood pressure and tension and increase concentration. Since breathing often mirrors emotional state, regulating and slowing down the breath can improve mood and relax the mind. There are many breathing practices to try. “4-7-8” breathing is one example. Here is how:
- Put one hand on your belly and the other on your chest.
- Take a deep slow breath and silently count from 1 to 7
- Breathe out completely as you silently count from 1 to 8.
- Repeat three to seven times or until feeling calmer.
- Notice how you feel at the end of the exercise.
Diaphragmatic breathing is sometimes called “belly breathing,” meaning the abdominal muscles assist the diaphragm, a large dome shaped muscle beneath the lungs, in emptying the lungs. This breathing exercise can be done while standing, sitting, or lying down.
- Place one hand on the chest and the other just below the rib cage. This will allow you to feel the motion of the diaphragm
- Breathe in slowly through the nose so that the stomach moves out against the hand. The chest should not move much.
- Breathe out through pursed lips as though whistling. Feel the hand and your stomach move in as you exhale.
Focused breathing is another type of breath practice that can be done throughout the day to reduce tension and stress.
- Breathe normally and try to register all the different sensations flowing through the body as long as possible
- It is normal for the mind to wander away from the awareness of breathing. Notice when this happens and bring the attention back to the breathing sensation. Continue as long and as often as possible throughout the day.
Mindfulness has been shown to be an effective practice to reduce stress, manage difficult emotions and mental habits, and improve health. Mindful Self Compassion and Mindful Eating has been shown to helpful in bringing awareness to unconscious habit patterns of body and mind which can contribute to headaches. Jon Kabat-Zinn, founding Executive Director of the Center for Mindfulness in Medicine, Health Care and Society, has many free guided practices in print and online. (3) The Insight Timer Meditation App is another popular way to explore mindfulness practices as you meditate with an online community.
Exercise and Movement increase serotonin, dopamine, and endorphins which improve mood, reduce insomnia, and increase stress resilience. The beneficial effect of these neurotransmitters and hormones make regular exercise an especially effective method to manage stress and prevent headaches.
Incorporating one or more of these practices into your daily life are steps you can take now to become more stress resilient and benefit your health. Over time, you may notice fewer and less severe headaches as you practice these exercises. There are many other complementary and alternative treatments to prevent headaches that you can discuss with your health care provider to see what is safe and appropriate for you.
(1) Neff, Kristin and Christopher Germer: The Mindful Path to Self-Compassion NY 2011
(2) “The Power of Nature Psychology” www.psychologytoday.com Aug 8, 2012
(3) Kabat-Zinn, Jon: Full Catastrophe Living NY 2013