Know your headache

Different types require different treatment

Consumer Reports on Health: February 2012

Almost everyone has a headache now and then, but each year about 1 in 10 adults in the U.S. experiences at least one so painful that he or she sees a doctor. Eighteen percent of women and 6 percent of men have migraines in a given year, which can be severe and a challenge to treat.

In a study of migraine sufferers, more than 40 percent incorrectly thought the pain was caused by sinus problems. About as many said they received that incorrect diagnosis from a doctor. Many people with chronic headaches have tried antibiotics or decongestants, which haven't helped, and some even undergo unnecessary sinus surgery.

Studies have also found that more than half of migraine sufferers treat their headaches without discussing the problem with a doctor. That might be a reason only one in five people with persistent and severe migraines takes medication to prevent them.

At the other extreme, many people get caught in a cycle of medication overuse, in which the increasing use of pain drugs causes the headaches to strike more frequently, making the drugs less effective. In a 2010 survey, nearly one in four people with chronic daily headaches said they took pain drugs every day. Medication overuse might account for half the cases of that kind of headache.

Defining the type and cause of a headache is key to determining how to treat or prevent it. About 90 percent of the diagnosed cases are primary headaches, which occur in the brain's sensory and pain-signaling systems.

Headaches can also be a sign of an underlying problem, including stress, poor eating habits, or getting too little sleep. Sometimes they can signal more serious concerns, such as depression, high blood pressure, an acute sinus infection, a sleep disorder or, in rare cases, a brain infection, tumor, or stroke. If headaches strike 10 or more days a month, are associated with other neurological symptoms, or worsen, consult a doctor. Note the danger signs. Seek immediate medical help if your headache:

  • Strikes suddenly and is severe.
  • Is a new-onset headache that lasts longer than 24 hours.
  • Follows a head injury or other trauma.
  • Is brought on by exertion.
  • Hurts much more than any previous headache.
  • Comes with a fever, stiff neck, vomiting, loss of balance, change in vision or speech, or one-sided numbness or weakness.

Thwarting headaches

Keep a record of each episode, noting possible links to food or beverages, sleep patterns, or certain events. (A free template for a headache diary is available from the American Headache Society.) Here are other steps to prevent or cope with headache pain:

Manage unavoidable triggers. Tinted glasses help minimize the effects of bright light. Some women who get migraine attacks related to menstruation might benefit from taking preventive medication just before and during their period. Good choices include ibuprofen (Advil, Motrin IB, and generic) or the prescription drug sumatriptan (Imitrex and generic).

Make simple changes. Cutting down on alcohol, eating less, and controlling stress with meditation, relaxation, or other means can help prevent headaches. If the problem stems from a lack of sleep, take steps to get 6 to 8 hours each night. Go to bed and wake up around the same time, and don't watch TV or use a computer in bed. If you snore, ask your doctor whether you should be evaluated for sleep apnea.

Consider nondrug therapies.
In a September 2011 study, researchers in Sweden randomly assigned 91 migraine sufferers to one of three programs. One group exercised on stationary bicycles for 40 minutes three times a week for three months. Another practiced relaxation in a weekly class and at home every day. The third group took daily doses of topiramate (Topamax and generic), an antiepileptic medication that's used at lower doses to prevent migraines. Researchers found that exercise and relaxation reduced the frequency of migraines and the need for painkillers as effectively as topiramate, but without side effects.

Acupuncture is another option, but research has found mixed results. A 2009 review of 22 studies concluded that it might work slightly better at preventing migraines than medicines such as betablockers. But traditional acupuncture worked no better than "sham" acupuncture, where needles were inserted at random sites or weren't inserted at all.

Preventive drugs

Beta-blockers such as propranolol (Inderal and generic) and timolol (Blocadren and generic) are often the best first choice because they're inexpensive and have a long safety record. Side effects can include fatigue and fainting caused by low blood pressure.

Tricyclic antidepressants such as amitriptyline (Elavil and generic) are also an option. Common side effects include dry mouth, sedation, and weight gain.

The anti-epileptic drugs topiramate (Topamax and generic) and valproate (Depakote and generic) are another choice. But there's no evidence that they're more effective than beta-blockers or tricyclics, and the drugs can cause side effects including hair loss, nausea, tremors, and vertigo, and even in some instances, organ damage, suicidal thoughts, and tongue-swelling.

The Food and Drug Administration recently approved Botox injections for migraine prevention in adults experiencing 15 or more headaches a month for three months or more. The costly treatment requires about 30 to 40 injections into the forehead, temples, and neck every three months. But some clinical trials have found that the injections work no better than a placebo. And one small study suggested that injections might work better for certain types of migraines, those centered behind an eye or that cause gripping pain rather than those with an explosive type of pain.

Several dietary supplements reduced the frequency or severity of migraines in small randomized placebo-controlled trials, including butterbur, coenzyme Q10, feverfew, magnesium, and the B vitamin riboflavin. If you'd like to try them, look for the "USP Verified" mark on the container, which indicates that the manufacturer has met the criteria set by the U.S. Pharmacopeia, a nonprofit, standards-setting authority, regarding the quality, purity, and potency of the product and ingredients.

Handling migraines

For mild or moderate attacks, a combination of aspirin, acetaminophen, and caffeine (Excedrin Migraine and generic) works as well as prescription drugs for many people. Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, and generic) or naproxen (Aleve and generic) can also be quite effective.

If those drugs don't work, our consultants suggest trying one of the prescription migraine drugs called triptans. They cause fewer side effects than other prescription drugs, and seven are FDA-approved for certain types of migraines. An analysis by Consumer Reports Best Buy Drugs highlights two with notable benefits:

Sumatriptan (Imitrex and generic) is the only triptan available as a generic. It costs $20 to $24 a tablet compared with $29 to $43 a pill for brand-name triptans. Studies show it's as effective as other triptans for controlling migraine pain. Generic sumatriptan is also available as a nasal spray and in an injectable formulation. Those act faster than pills, and can help if migraines are accompanied by vomiting.

Rizatriptan (Maxalt) delivers pain relief within two hours, faster than most other triptans. At $35 to $38 a pill, it's more expensive than generic sumatriptan, but it's a good alternative if sumatriptan doesn't work for you.

Triptans work best at the earliest sign of a migraine. In about a third of migraine sufferers, triptans don't work reliably. Try several to see which is best for you. They might work better if taken with other NSAIDs. All triptans can cause troubling side effects, including dizziness, fatigue, flushing, numbness, and tingling. And they have been linked to rare cases of heart attacks, lifethreatening disturbances of heart rhythm, strokes, and death. Don't use them if you're obese, you smoke, have coronary artery disease, diabetes, peripheral vascular disease, or a history of heart attack or stroke.

Combination drugs containing butalbital (Fioricet, Fiorinal, and generic) lack clinical trial evidence for effectiveness against migraines and might lead to dependence and overuse. Opioids cause nausea, drowsiness, and constipation, and frequent use can lead to dependence and medication-overuse headaches. If you don't respond to triptans or can't tolerate them, consider opioids.

Too much medication?

To avoid headaches caused by medication overuse, take the smallest effective dose and keep track of how often you take each drug. You're at risk of overuse if you take pain medication for a headache 10 days or more a month. If a pain reliever is no longer as effective as it once was, consider that a red flag.

Some drugs are more likely to cause overuse or "rebound" headaches than others. Butalbital and opioids are among the riskiest, along with triptans and over-the-counter pain relievers. If you suspect that you're using too much medication, cut back gradually. A headache prevention drug might help.

Most people who seek treatment for medication overuse are successful. But close to half relapse within five years, so constant vigilance is needed.

Headache triggers

Tension headaches, migraines, and cluster headaches can be prevented by avoiding things that might cause them. Those can include: stress; lack of sleep; wine or other alcohol; certain foods, such as chocolate and aged cheeses; and exposure to bright artificial light or sunlight.

Which kind of headache is yours?

  Tension Migraine Cluster Medication overuse
Usual location Across the forehead, at the temples, or back of the head One side of the head, most often at the front Behind one eye or one temple Varies, but often includes neck pain
Hallmarks • Mild or moderate pain
• Pressing ache that pulsates
• Moderate or disabling pain
• Pulsating ache
• Worsened by physical activity
• Often associated with nausea and sensitivity to light or noise
• Sometimes accompanied by temporary visual disturbance or
numbness and tingling
• Severe to excruciating
• Burning, pressing, or stabbing
• Runny nose, tearing, drooping
eyelids, facial sweating on the
same side of the face as the
• Worsening headaches despite use of pain medications 10 days or
more per month
• Morning onset
Triggers Fatigue, stress, poor posture, jaw
clenching, smoking
Foods such as chocolate or cheese; alcohol; perfume and other strong
odors; sunlight or bright artificial light; skipping meals; changes in
sleep schedule; hormonal changes including menstruation
Alcohol; nitrate medicines used for chest pain Waking up from sleep
Frequency Occasional to frequent Several times a year to several times
a month
1 to 8 per day during clusters of
weeks or months, then disappears
for months or years
15 or more days per month
Duration 30 minutes to several hours 4 hours to 3 days 15 minutes to 3 or more hours At least 4 hours
Over-the-counter pain relievers Triptans, preferably generic
sumatriptan or rizatriptan
Inhaled oxygen Gradual withdrawal from pain drugs

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