Adull ache started behind my right eye one afternoon six months ago. By the evening it had morphed into a throb the size of a golf ball. It got so bad that after 3 hours of braving the pain I had to take a paracetamol and lie down. The painkiller didn’t help and I spent the evening feeling maddeningly alert given the throbbing in my head and the pangs of nausea that accompanied the pain. The headache came in waves till it finally subsided. The headache came again around the same time next month and the months thereafter. There was a pattern, the headaches preceded my monthly period by exactly two days.
I consulted S. Murali, consultant neurologist at Manipal Hospital, Bangalore. He took a detailed patient history and advised that I get a magnetic resonance imaging (MRI) scan done to check for any structural abnormalities in the brain. The scan was normal and Dr Murali said what I was experiencing was a run-of-the-mill migraine headache.
Common though they may be, migraines can be extremely painful and debilitating. I was losing two-three days every month because there wasn’t much I could do except lie down once the headache started.
A head start: Supplement medicines with relaxation techniques like meditation for quick relief.
Once diagnosed, the doctor recommended that I take a paracetamol as soon as the headache began and keep a diary to identify my migraine headache trigger. It could be anything from skipping a meal to environmental changes like too much humidity that ends up “triggering” a migraine episode (see “Common migraine triggers”). I found that taking a paracetamol right at the onset of the headache made the throbbing golf ball in my head bearable. Also, I discovered my trigger—in an effort to lose weight I had been on a low-carbohydrate diet the last few months.
I switched to eating more carbs and that helped. Dr Murali called me a “mild migraineur”.
Primary or secondary
K. Ravishankar, consultant-in-charge of the headache and migraine clinics, Jaslok Hospital and Research Centre and Lilavati Hospital and Research Centre, Mumbai, says that regardless of the symptoms, a sufferer must find out if the headache is primary or secondary. A primary headache is one where there is nothing structurally wrong in the brain—migraines, tension headaches and cluster headaches all fall in this category.
A secondary headache is one where there is an identifiable cause like a brain tumour or a meningitis infection. A sinus-related headache is also a secondary headache, but one that is easy to treat. He adds, “90% of all headaches are primary headaches.” Praveen Gupta, head of neurology at Artemis Health Institute, Gurgaon, says a headache that is accompanied by the following symptoms is likely to be a secondary headache: fever, vomiting, visual disturbances, feeling numb in the feet and hands or feeling weak in one side of the body.
The migraine factor
“Migraines are the most common headaches and occur three times more often in women than in men and can be far more painful in women,” says Dr Murali.
In a research paper “Men, Women and Migraine: The Role of Sex, Hormones, Obesity and PTSD”, published in The Journal of Family Practice in April, B. Lee Peterlin— director, headache research, Johns Hopkins Headache Center, Johns Hopkins University, Baltimore, US—and his colleagues concluded that the disproportionate number of women suffering from migraines was because the female hormones progesterone and estrogen play a role in the occurrence and severity of migraines. It is said that 14% of women migraineurs only get menstrual migraines and since these women, like me, suffer from migraines at a specific time in their hormonal cycle, it is likely that the monthly dip in estrogen levels is responsible for this tendency.
Migraine treatment depends upon the severity. I was lucky and only needed paracetamol and trigger management. In severe migraine, defined as the number of attacks being more than four a month, preventive medicines need to be taken every day. Also, medication that specifically works to fight migraine pain is prescribed for such a patient, says Dr Ravishankar. He says a common myth he finds among patients is that headaches are caused by gastric problems. “Acidity does not cause headache, the headache that coexists with acidity is a migraine and needs to be treated as such.” Another common myth he finds among patients is that headaches are caused by eye problems. When he first started the headache and migraine clinic in 1995 at the Jaslok Hospital and Research Centre, many of the referrals were from ophthalmologists. “The eye is not the commonest cause of headaches; the most often seen causes of headaches are migraines, tension-type and cluster headaches,” says Dr Ravishankar.
The pain in a tension-type headache is a dull, generalized ache around the head and neck and can feel like someone has put a thick band around your head. The tightness of the muscles can extend to the neck and the base of the head and can last for a few hours in an acute scenario, or extend to a few days or weeks in a chronic one. “This is a featureless (not accompanied by other symptoms like an intolerance to light or vomiting) headache that will respond to simple painkillers or mild sedatives,” says Dr Ravishankar. Like migraine headaches, tension-type headaches have triggers too and it helps to identify them and then learn to avoid them.
Cluster headaches are less common than migraines or tension headaches and occur mostly in men in the 40-60 age group. A cluster headache is an explosive pain that is usually in the forehead area or around an eye. It is also accompanied by other symptoms, including teary eyes, nasal congestion and sweating. It manifests at the same time every day and comes in a cluster of weeks and then disappears for a couple of years, only to reappear, says Dr Gupta.
He describes a recent patient, a 55-year-old man who came to his clinic complaining of piercing pain in the left side of the head. The pain appeared at exactly 3 in the afternoon every day and lasted for 2 hours. The pain started a month before he sought medical help and he had no history of any previous illness.
This kind of headache is often called a “suicidal headache”. Dr Gupta, for instance, quoted the patient as saying “dying would be better than anticipating and bearing this pain every day”. Dr Gupta gave him a prescription for a specific set of medicines that reliably treat cluster headaches and the man got relief.
The medicines used for all headaches should be supplemented with relaxation techniques like yoga and meditation as these can help reduce the severity of attacks.
Sujata Kelkar Shetty, PhD, writes on public health issues and is a research scientist trained at the National Institutes of Health in Bethesda, US.
Common migraine triggers
• Getting too much or too little sleep
• Suffering from acute emotional stress
• Going overboard with an exercise regime
• Dieting and/or skipping breakfast
• Increased humidity in the atmosphere
• Drinking too much caffeine (tea, coffee, Coke)
• Eating Chinese food (containing MSG, or monosodium glutamate)
• Eating processed and fast food
• Spending too much time inthe sun, particularly without sunglasses
• The fan or AC being on too high a setting
• Long hours in front of thecomputer or television.
• Drinking alcohol
• Cigarette smoking
• High altitudes experienced during air travel or hiking in the mountains
• Bright light of all kinds, including sunlight
• Going overboard with an exercise regime
• Excessively hot weather.
Common tension- headache triggers
• Drinking alcohol
• Cigarette smoking
• Caffeine overuse or withdrawal
• Teeth grinding or jaw-clenching
• Eat well-balanced, regular meals
•Exercise on a regular basis, at least five times a week
• Take the prescribed pain medication but don’t overuse it
• Maintain good posture at all times, particularly when at the desk
• Find hobbies that you enjoy and that relax you and incorporate them into your daily/weekly schedule
• Use relaxation techniques like yoga or meditation
• For migraine and cluster headaches, keep a headache diary that lists what you ate, how much you slept and the activities you engaged in before a headache-attack
• Once you identify your headache triggers, find ways of avoiding them
• The better you get at avoiding triggers, the less medicine you will need to combat the pain.
Source: Dr K. Ravishankar, Dr Praveen Gupta and Dr S. Murali.
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