Migraine, cluster and tension: Headache misery may yield to proper treatment

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"My headaches started when I was taking birth control pills. The pain was intense, first right above my eyes, then spreading below the eyes. It might start on one side and the next day switch to the other side. Nearly every week I'd be sick two or three days like I had the flu-vomiting, aching, and yawning all the time. All I wanted to do was sleep.

"After I went off the pill, the headaches were sporadic. I'd go for years with very little trouble. Surprisingly, during my pregnancies, they disappeared. But they returned with a vengeance at menopause, and I was sick more than I wasn't sick. I could hardly stand it. "

Janice Bailey, of Tucson, Ariz., describes her decades-long battle with "sick headaches," the most common symptom of a disabling condition called migraine. Attacks often follow exposure to a trigger-such as birth control pills.

Migraine is only one of 12 headache types (with more than 60 sub-types) classified in 1988 by the international Headache Society for use in diagnosis. Migraine, cluster, and tension-type headaches are the main varieties. Numerous physical disorders underlie the nine other types.

Chronic headaches plague more than 45 million Americans, reports the National Headache Foundation, of Chicago.

Still, the vast majority of headaches are temporary, "requiring no more than an over-the-counter analgesic," says Russell Katz, M.D., deputy director of the Food and Drug Administration's division of neuropharmacological drugs, which reviews anti-migraine drugs. "Headaches from life-threatening conditions such as tumors are uncommon," he says.

An important tool in diagnosing headache is the patient's medical history, says Stuart Stark, M.D., director of the Headache Program for The Neurology Center in Alexandria, Va.

"The history usually is sufficient to determine the specific type of headache," he says. "But when headaches are debilitating, a diagnostic workup is warranted."

Workups often include taking pictures of the brain with a radiological procedure such as computed tomography or magnetic resonance imaging. To rule out certain causes, further procedures may be needed-blood tests, for instance. "We particularly look at the blood count," Stark says, "to see whether the blood is too thick or too thin. Blood that clots abnormally can be caused by disease, such as lupus [a rheumatic disease]."

Migraine
Migraine headaches affect 16 million to 18 million Americans, of whom nearly two-thirds are women, the National Headache Foundation says. Since migraine is believed to be mostly an inherited condition, children, even babies, may be "migraineurs," as victims of this headache are called.

"Abdominal colic could be a form of migraine," Stark says. "If the mother or father has had migraines, it's worth considering the colic as a possible prelude to a migraine condition. About all you can treat a baby with is liquid Tylenol, but the colic could alert you to watch for symptoms as the child grows."

The two main migraine sub-types are "migraine with aura" (formerly called "classic migraine") and "migraine without aura" (formerly called "common migraine"). Attacks can last from several hours to several days.

About 10 percent of migraine patients have auras-certain neurological (nerverelated) symptoms that precede the headache by 5 to 30 minutes but sometimes persist into the headache phase. Aura symptoms include visual disturbances such as flashing lights or zigzag lines or even temporary vision loss. Others are a pins-and-needles feeling on one side of the face or body followed by numbness, or numbness without the tingling. Less frequent signs are speech problems, confusion, and weakness on one side.

Migraines without auras may be accompanied by vague warning signs, including mood swings, mental fuzziness, and fluid retention.

Bailey says she often was very tired before an attack. "I'd yawn and yawn," she says. "But mainly it was just an overall feeling. I'd know I'd better not eat much if I had that feeling."

Patients describe their pain with words such as intense, throbbing, pounding. They feel it in the forehead, temple, ear, jaw, or, like Bailey, around the eye. Most migraines are one-sided. Some start on one side but spread to the other.

Besides headache, symptoms include nausea, vomiting, appetite loss, diarrea, sensitivity to light and noise, fever, chills, flu-like achiness, and sweats. Attacks range in frequency from several times a week to once every few years.

About 5 percent of migraineurs don't have headaches. "They may have vomiting, dizziness, or ringing in the ears," Stark says. "Since migraine is a condition of the brain, literally any neurologic symptom can occur."

But where does a migraine come from?

A longstanding theory holds that blood vessels in the scalp and on the brain's surface constrict. This reduces the brain's oxygen supply to produce the aura some patients have. The same vessels, reacting to the brain's need for oxygen, open up, or dilate, releasing pain-causing chemicals called prostaglandins, other chemicals that increase sensitivity to pain, and still others that induce painful inflammation and swelling.

Stark is among the neurologists who subscribe to a newer theory that migraine stems from a chemical change deep within the brain, where the body uses the neurotransmitter serotonin abnormally. (Neurotransmitters are chemical messengers that nerve cells use to tell each other what to do.)

Working with other chemicals, serotonin regulates blood vessel constriction and dilation. It can both sharpen and deaden pain. While serotonin's role in migraine isn't completely understood, areas of the brain responsive to serotonin are often involved in migraine. The hypothalamus, for instance-which regulates involuntary bodily functions such as menstruation, sleep and hunger-has cells sensitive to serotonin. Such cells also appear in large amounts in the stomach and intestinal walls. Certain serotonin cells stop "firing" during sleep, which often ends a migraine attack.

"Serotonin acts on the electrical impulses sent out by nerve cells in and around the blood vessels in the brain," Stark explains. "We believe that in a migraine attack, the serotonin isn't properly used for some reason, so that the electrical wave of impulses becomes diminished, or depressed. The wave, called 'spreading depression,' reduces blood flow through the vessels leading to the back of the brain.

"This is when the aura occurs. The symptoms depend on which areas of the brain are included in the wave. Spreading depression is believed present in all migraine attacks, even in people who don't have auras.

"After the spreading depression subsides, the blood vessels start leaking fluid, inflaming the outside of the vessels. The inflammation causes the pain, which can extend to all the nerve cells supplying the blood vessels, not just those in the area of the spreading depression."

The spreading depression correlates with the aura, but not the headache, Stark says. In other words, a depressed wave limited to one side of the head can lead to pain on both sides.

Also, some scientists believe a disturbance in the brain's trigeminal nerve contributes to migraine headache by causing the release of "substance P," which causes inflammation.

If these theories are correct, changes in the head's blood vessels, impulses deep within the brain, and the pain pathway in the trigeminal nerve may all play a part in migraine pain.

Given the theory that most migraineurs are predisposed to their condition, migraine has been described as a cocked gun waiting to go off-except that this gun has many triggers.

A trigger for Bailey was cigarette smoke. "At a party where lots of people were smoking and there wasn't good air flow, I'd nearly always get sick," she says. "Once I was sick, smells such as glue, pesticides or perfume egged it on."

Reaction to stress is a common trigger. Others include fatigue, lack of sleep, glaring lights, excessive noise, weather, certain drugs that cause blood vessels to swell, and hormonal fluctuation-as happens around menstruation, at menopause, and during use of birth control pills.

Foods trigger migraines, too. Keeping a food diary can help identify sensitivities.

As for headache prevention and treatment, FDA has approved a number of anti-migraine drugs. Their benefits vary from person to person and must be weighed against the risks, some of which are serious.

"One preventive drug is Inderal [propranolol]," says FDA's Katz. "It was initially approved to treat high blood pressure and heart problems, and only accidentally found to prevent migraine. It's not useful after the headache begins." FDA approved Inderal, a beta blocker, for preventing migraine in 1979. It's the only beta blocker with this indication. Inderal's effect in migraine is not well-understood.

The other drug approved for preventing migraine is Sansert (methysergide), one of several ergot drugs, which constrict blood vessels. Sansert can't be given continuously for more than six months, so its use is limited.

"Effective drugs to stop a particular attack of migraine once it has started," Katz says, "include analgesics and ergotamines. Whichever is used, it must be taken early in the attack to be most effective." For occasional mild migraines, he says, over-the-counter pain relievers or prescription drugs with a low dose of codeine are usually adequate.

"Isometheptene combined with dichloralphenazone and acetaminophen--Midrin or Isocom--may also be helpful early in an attack," Katz says. "Antiemetics can relieve the associated nausea .and vomiting in migraine."

OTC analgesics for headache include aspirin, Tylenol (and other brands of acetaminophen), and Advil, Motrin IB, and Nuprin (and other brands of ibuprofen). Ergot drugs include Ergomar, Ergostat, Cafergot, Wigraine, and D.H.E. 45.

Cluster Headache
"This piercing pain," the man cries to his wife. His hand goes to his right eye, which is teary and red with irritation.

For a half hour, the man has been pacing, unable to keep still. Pausing to stub out his cigarette, he clenches and unclenches his fists, then wipes sweat from his right brow with a tissue. He blows his nose.

Finally, the pain is over. He collapses in a chair to wait, fearing the pain will return yet a fourth time today.

The patient is a fictitious composite of symptoms and behavior typical of cluster headache sufferers.

Cluster headache is so-named because it recurs in clusters, several times a day, for several weeks or months. A cluster may start at a certain time of year, perhaps with a change of season. Each headache lasts from 15 minutes up to 4 hours, but the cluster attack-repeated headaches-can go on for weeks or months. When the cluster series is over, in 90 percent of patients, it won't recur for months or years. The cause is unknown.

Nearly a million Americans have cluster headaches, the National Headache Foundation reports. Most cluster patients are men, usually smokers. Cluster has been called the "suicide headache," "demon of headaches," and, because it often wakens the person, "alarm clock headache."

Nearly always, only the blood vessels of one carotid artery are affected, making the intense, steady pain one-sided-usually centered behind the eye and in the temple.

Also, the pupil on the pain side may constrict, the eyelid may droop, and the brow may sweat. Nasal congestion may lead the person to suspect a sinus infection, but sinus headaches don't start and stop several times a day. Unlike migraineurs, who want to curl up in bed, cluster victims can't sit still.

Why these symptoms accompany cluster headache has not been established. One theory suggests involvement of the nerves supplying that area, according to Seymour Diamond, M.D., executive director of the National Headache Foundation and head of the Diamond Headache Clinic in Chicago.

One hundred percent oxygen inhaled through a mask for 8 to 15 minutes often stops an attack, Stark says. Painkillers tend not to work, he says. Drugs such as Cafergot lessen some acute attacks. Sansert is sometimes prescribed for prevention.

"We aren't certain how drugs work in cluster," Stark says.

Tension-Type Headache
The tension-type headache usually involves increased tension in the scalp and neck muscles. It has also been called "muscle contraction headache," " psychogenic headache," "stress headache," "ordinary headache," and "tension headache."

As some of those names suggest, tension-type headaches are the commonest, accounting for 90 percent of headaches not due to disease, and are most often caused by anxiety and stress-for instance, a mile-long traffic tie-up, work deadlines, standing sixth in a grocery check-out line, money worries.

Others susceptible to tension-type headache, Katz says, are people with poor posture, beauticians and others who move their neck and shoulders a lot, and people who work at stationary, repetitive tasks, as on an assembly line.

The pain often involves most of the head, from the forehead to the nape of the neck, and feels like a dull ache, as though the head were being pressed in a vise. Neck and shoulder muscles may be tense. The pain may go away after an hour. it may last several days.

"Usually, OTC pain relievers, hot packs, and relaxation will relieve occasional tension headaches," Katz says.

Patients with chronic tension-type headaches often are depressed. The depression may result from the pain itself, wrote Stephen Silberstein, M.D., and Marsha Silberstein, M.D., in recent articles in Pain Management. For these patients, some doctors prescribe antidepressants.

Other headaches are associated with physical problems, including dysfunction of the temporomandibular joint (which connects the jaw to the skull), brain disease, a blow to the head, arthritis, whiplash, metabolic disorders such as an overactive thyroid gland, and dental, sinus or ear infection. Treatment is based on the underlying cause.

Thanks to increasing knowledge about headaches, most headaches can be prevented or treated, if not cured. Bailey, for instance, has been treated with Inderal since 1983. Does she still have sick headaches?

"I don't know," she says. "I haven't quit taking my medicine long enough to find out."

DIAGRAM: Migraine Aura and 'Spreading Depression'

Tingling on one side of the face or body and visual sensations such as flashing lights and zigzag lines are the most common symptoms of the migraine aura, a pre-headache phenomenon in about 10 percent of migraine sufferers. Many scientists believe the aura correlates with a brain wave of depressed electrical impulses called spreading depression. According to this theory, spreading depression occurs in all migraine attacks, even those without auras.

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By Dixie Farley

Dixie Farley is a staff writer for FDA Consumer.

MOST COMMON HEADACHE TYPES
Migraine headaches usually throb and affect one or both sides of the head. Physical activity tends to worsen the pain. Patients also may have nausea, vomiting, light and noise sensitivity, or other symptoms. Some sufferers have warnings, such as visual disturbances. Attacks last from a few hours to days, recurring from several times a week to once every few years. Women get migraines more frequently than men.
Cluster headaches occur as a series of one-sided headaches that are sudden and excruciating and continue for 15 minutes to 4 hours. Cluster attacks last 4 to 12 weeks, followed by remission as long as months or years. Other symptoms on the painful side include nasal congestion, drooping eyelid, and irritated, teary eye. Most cluster patients are men.
Tension-type headaches may last a few hours, a few days, or be chronic. The pain is described as a tight band around the head, but it can affect any scalp, face, neck, and shoulder muscles. Some patients, especially those with chronic tension headaches, also suffer from stress, anxiety or depression.
PHOTO: Man with a headache

HELP FOR HEADACHE SUFFERERS
In addition to over-the-counter products, a number of prescription drugs are available to treat headaches. Some migraine preparations also are approved to treat cluster headaches. One labeled as only "possibly" effective for migraine is approved for tension headache.

Anti-migraine drugs should be taken under medical supervision. Though they provide benefits, they can cause side effects, some of which are serious. Scientists don't know exactly how they work. The drugs' names, approved formulations and uses, and probable ways they achieve their effects are:

Ergotamine tartrate (Ergomar, Ergostat) tablets, dissolved under the tongue, are used short-term to prevent cluster headaches in some patients and to treat migraine and cluster. This drug constricts blood vessels and inhibits pain-causing fluid leakage from vessels in the brain's outer membrane. It interacts with brain "receptors" for serotonin (a chemical messenger that nerve cells use to tell each other what to do).
Ergotamine tartratelcaffeine (Cafergot, Cafermine, Ercaf, Ercatab, Ergo-Caff, Gotamine, Lanatrate, Migergot, Wigraine) tablets and/or suppositories are used to treat the same headaches as ergotamine alone. Caffeine increases ergotamine's effect, reducing the amount of ergotamine needed.
Dihydroergotamine mesylate injection (D.H.E. 45), an ergotamine derivative, is used like ergotamine. However, it can be injected in a muscle or given intravenously and may be more effective for a given attack.
Methysergide maleate (Sansert) tablets are used to prevent vascular headaches that occur once or more a week or are uncontrollable by other treatments. Thus, it is not used once an attack begins. It should not be taken continuously longer than six months. Sansert blocks serotonin transmission.
Isometheptene mucate/dichloralphenazone/acetaminophen (Amidrin, I.D.A., Iso-Acetazone, Isocom, Midrin, Migratine, Migrazone, Migrex, Mitride) capsules are used to treat tension headache and, the labeling says, "possibly" migraine. (FDA recognizes a potential benefit in migraine but requires more research to prove it is fully effective.) Isometheptene constricts vessels, dichloralphenazone mildly sedates, and acetaminophen relieves pain.
Propranolol hydrochloride (Inderal) tablets are used to prevent migraine. This drug may block communication between certain nerve cells.
FDA is reviewing data to support marketing of a migraine preparation called Imitrex (sumatriptan succinate), formulated as an injection patients can administer. The drug acts on serotonin receptors.

Last fall, an advisory panel to FDA on nervous system drugs recommended unanimously that Imitrex be considered approvable for treating migraine headaches. The panel concluded that more evidence was needed to prove safety and efficacy for use in cluster headaches.

DANGER SIGNALS
Sometimes a headache can signal a serious condition requiring prompt medical attention. According to the National Institute of Neurological Disorders and Stroke in Bethesda, Md., a doctor should be consulted if a headache:

is accompanied by confusion, unconsciousness or convulsions
involves pain in the eye or ear
is accompanied by fever
is accompanied by nausea
occurs after a blow to the head
is persistent in someone previously free of headaches
is recurrent, especially in children
interferes with normal life.
For more information, contact the Neurology Institute, P.O. Box 5801, Bethesda, MD 20824; telephone (1-800) 352-9424; or the National Headache Foundation, 5252 N. Western Ave., Chicago, IL 60625; telephone (1-800) 8432256. (NHF offers a list of headache clinics and a state list of National Headache Foundation physician members interested in treating headache.)

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