Yet another headache

Almost everybody has one now and then, but people tend to dismiss them as a nuisance at best. “All headaches are not the same,” says P.N. Renjen, senior consultant, neurology, Indraprastha Apollo Hospitals, New Delhi. “You need to figure out what sort of headache you are dealing with.”

According to the World Health Organization (WHO), headaches are most prevalent in one’s productive years—from the late teens to the 50s—and have been linked with loss of productivity and absenteeism at work and school.

While migraines are more commonly known now, there are also other types of headaches that can be debilitating in varying degrees. And since there are no definitive tests to clearly identify some headaches, diagnosing them can be tricky.

It’s common for chronic migraine to be diagnosed as chronic tension-type headache (TTH), says Mukul Varma, senior consultant, neurology, Indraprastha Apollo Hospital. “When migraine becomes chronic, the migrainous character (one-sided, throbbing pain) of many of the headaches is lost, and they assume a tension-type character (whole head, dull ache of a non-throbbing kind). The International Headache Classification now says that even if eight of the 15 headaches occurring in a month have a migrainous character, the diagnosis is chronic migraine,” explains Dr Varma, who will be attending the 16th edition of the International Headache Congress starting 27 June in Boston, US, where neurologists and pain specialists will discuss the latest in headache research and medical practice.

Sanjay Kumar Saxena, principal consultant and head of department of neurology at Fortis Hospital, Noida, recalls the case of a woman in her early 40s who had been on migraine medication for seven-eight years. A homemaker living in the Capital, she had had no relief in that long period. But around seven-eight months ago, the doctors re-diagnosed her ailment. She was put on preventive medication to break the cycle of chronic tension- type headache, and has “responded well to the medication”.

The lesson is simple. If you have frequent headaches, don’t ignore them or just pop a painkiller. Find out what kind of headache it is.

Unpacking headaches

Migraines, tension-type headaches (TTH) and chronic daily headaches (CDH) are all types of primary headaches, or headaches that do not trace their source to another ailment such as tumours, bleeding or infections in the brain, or even a previous head or neck injury. For such patients, the MRI and CT scans are normal.

“Globally, the percentages of the adult population with an active headache disorder are 46% for headache in general, 11% for migraine, 42% for TTH and 3% for CDH,” according to a study, The Global Burden of Headache: A Documentation of Headache Prevalence And Disability Worldwide, by L.J. Stovner, K. Hagen, et al, published in the Cephalalgia journal in 2007.

A headache is categorized as CDH if it occurs for 15 or more days a month for at least three months in a row. The Global Burden study adds, “Our calculations indicate that the disability attributable to TTH is larger worldwide than that due to migraine.”

But what is TTH and how is it different from migraine?

Dr Varma says: “TTH is a mild to moderate ache that often feels like a tight band around the head.” Whereas migraine is associated with nausea and vomiting, sensitivity to light and sound, and a throbbing kind of severe pain on one side of the head, TTH is usually a dull, mild to moderate ache that occurs all over the head and is not accompanied by nausea or sensitivity to light and sound.

Adds Dr Renjen: “TTH is a muscular contraction headache. Often, patients are able to pinpoint the particular place where they feel tightness on their scalp.” He adds that of the 10 or so patients who come to him with headache complaints daily, three-four suffer from TTH.

Neurologists the world over agree that headaches are often under-diagnosed and under-treated. In the developing world, this is exacerbated by a crunch of healthcare resources. Accordingly, while there is a wealth of data on prevalence and medical interventions to contain headaches in Europe and North America, few studies have been done on the instance of headaches among Indians.

Even so, a study conducted in Bangalore too found a high occurrence of TTH in the local population. The Burden of Headache Disorders in India: Methodology And Questionnaire Validation For a Community-based Survey in Karnataka State by Girish N. Rao, et al, published in The Journal of Headache And Pain in October, found: “In the validation study, the prevalence of migraine was 22.8%, the prevalence of TTH was 33.3% and the prevalence of headache occurring on…15 (or more) days per month was 2.1%. There were unclassifiable headaches in 3.4%. The proportions were higher in rural areas (migraine: 27.5% in rural and 18.6% in urban; TTH: 34.1% in rural and 32.7% in urban; CDH: 3.3% in rural and 1% in urban).”

How bad is it?

Headaches, especially the chronic kind, can have a debilitating effect on the patient’s quality of life and productivity. A 2004 campaign by the WHO found that “in the UK, for example, some 25 million working—or school—days are lost ever year because of migraine alone. TTH…and chronic daily headache…together cause losses which are almost certainly of at least similar magnitude.”

Patients with migraine or chronic headache disorders are three times more susceptible to depression than healthy individuals, according to the WHO factsheet on headaches.

Despite their differences, there is at least one thing migraines and TTHs have in common: They are both more likely to affect women than men. The WHO factsheet on headaches says TTH often begins during the teenage years, affecting three women to every two men.

The triggers

Besides women, those at risk are people who are by nature anxious, those who are perfectionists and take on stress from work or personal lives, attention seekers, people who are dissatisfied with their jobs or lives, those who are not getting enough sleep and proper nutrition, and even those who have trouble managing work, have the pressure of targets to meet, erratic travel schedules, or poor stress coping strategies.

Dr Saxena says TTH, as the name suggests, “originates from tension in the mind. It can cause an imbalance in the neurotransmitters and lowers the threshold of pain in the muscles around the head”.

Then there’s another kind of headache that also arises from tension in muscles. Cervicogenic headaches occur because the muscles in the head, neck and shoulder tense up. This type of headache, technically a secondary type, is often associated with bad posture—or as Mary Abraham, director and head of the department of anaesthesia and pain medicine at Fortis Hospital, Noida, puts it, “being hunched over the computer for long hours”—or trauma, such as a whiplash injury.

Dr Abraham notes that more patients with this complaint are being referred to her now by neurologists. She remembers a 40-year-old patient who came to her unable to move because of pain in his head, neck and shoulders. The patient, who ran a pharmaceuticals business in the National Capital Region, had been bedridden for a month. Any movement of the head or neck would cause him great distress. Her recommendation: a nerve block injection given in the shoulder to temporarily disable the pain receptors, a mix of acupuncture and physiotherapy and a course of an anti-depressant drug.

Prevention is better than cure

Aspirin, Disprin, Ibuprofen, Crocin, Combiflam, whichever brand name you know them by, these painkillers can help only in cases of infrequent headaches. Painkillers taken almost every day can lead to more pain, says Dr Varma. “You get rebound headaches, also known as medication- overuse headaches, where the pain returns in a more severe form once the effect of the analgesic wears off.”

Since primary headaches cannot be diagnosed through tests, one of the most important tools for analysing them is “headache diaries”, where the patient writes down the triggers, duration and frequency of headaches, etc. These are extremely useful to pin down the headache pattern and triggers, so the patient can be advised to avoid them.

Dr Saxena says a multi-pronged approach is needed to break the cycle of frequent or chronic headaches. “Regular exercise and meals, adequate sleep, waking up early, all these contribute to breaking the cycle of headaches. Also, an antidepressant drug can be given for around six months,” he says. The job of the drug here is to prevent the onset of the headache, not alleviate it once it has set in.

There are also some red flags to look out for. If the “character of headaches” changes in terms of how severe they are or how frequently they recur, then doctors recommend a medical check-up without delay. Also, if someone over the age of 50 suddenly starts getting severe headaches, it is a cause for concern. For these symptoms may indicate something more worrisome.