Do you suffer from headaches? Chances are very good that you might. In fact, headaches are so commonplace that they could be considered part of the human experience. Although headaches are a common problem, many people would argue that the pain that results from them are anything but mundane.
A headache or cephalgia is pain that occurs anywhere on the head or neck. Headaches are caused by a wide range of factors, from everyday experiences like stress to life-threatening conditions like cerebral aneurysms. Headaches caused by referred pain may originate from a strained neck or upper back, or from strained or tired eyes. In addition, headaches are associated with hormonal fluctuations, depression, sinus infections, lack of sleep, and consumption of certain foods.
Given the wide range of etiologies, or causes, of headaches, you may find yourself at a loss to ascertain the reason for your headaches, as well as the best way to control them. Fortunately, the pain doctors at Louisiana Pain Specialists understand that headaches detract from your quality of life and are ready to develop a personalized treatment plan to help you control your pain.
Headaches are generally classified as primary or secondary. Whereas primary headaches are not caused by an underlying pathology or disease, secondary headaches are associated with a pre-existing condition, which may be benign or malignant in origin.
Cluster
Cluster headache is an excruciatingly painful primary headache syndrome, with attacks of unilateral (one-sided) pain and cranial autonomic symptoms (Cohen et al, 2009). The majority of patients have episodic cluster headaches with cluster periods that typically occur in a circannual rhythm, while 10% suffer from the chronic form, with no significant remissions between cluster periods (Ashkenazi et al, 2011).
Tension
Tension headache is the most prevalent type of headache across all age groups worldwide (Crystal et al, 2010). Although it is the most common form of headache, its causes are not well understood (Mayo Clinic, 2011). A tension headache is generally a non-localized, dull, mild to moderate pain described as the sensation of a restrictive band wrapped around the head, or pressure at the forehead, temples, or back of the head. Tension headaches are associated with stress and depression, and may be worsened by aggressive sensory input like bright lights and loud noise.
Migraine
Migraine headache is usually characterized as one-sided, throbbing and pulsating pain, often accompanied by nausea, vomiting and sensitivity to light and noise. It may be preceded by aura, or ominous visual, olfactory, or other sensory experiences that herald the onset of an attack.
According to the National Headache Foundation, migraines affect 29.5 million Americans, and Women are almost three times more likely to suffer from migraines than men (National Headache Foundation, 2011). This may account for 25% of women and 10% of men and, according to a different source, and the condition presents an enormous economic burden for patients, health systems, employers and society (Láinez, 2009).
Central Sensitization
In some individuals who suffer from chronic headaches, eventually the tissues surrounding the head may become painful even with light touch. This phenomenon is known as central sensitization, or overreaction of pain receptors in the central nervous system to normal physical sensations. In this condition, which is thought to be a consequence of prolonged pain from any long-term condition like recurrent headaches, low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord that normally respond only to painful stimuli. Eventually, harmless stimuli provoke feelings of pain, a phenomenon known as allodynia. Some believe aggressive early treatment may help one to avoid central sensitization.
Treatments
There are two types of therapies for headache: abortive and preventive. While abortive treatments aim to thwart a headache that is in progress, preventive treatments focus on discouraging headaches from occurring. For example, certain drugs taken for headaches are designed to halt the pain of an attack, while others are taken to prevent an attack from happening.
At Louisiana Pain Specialists, we offer a broad range of therapeutic options for patients who suffer from headaches. These include:
- Medications
- Diet
- Occipital Nerve Stimulation
- Botox Injections
- Cervical Facet Injections
- Cervical Epidural Steroid Injections
- Occipital Nerve Blocks
- Sphenopalatine Ganglion Blocks
- Supratrochlear Nerve Blocks
- Supra/Infraorbital Nerve Blocks
- Radiofrequency Ablation
Various drugs may be of benefit to individuals who suffer from headaches. Non-steroidal anti-inflammatory drugs (NSAIDs) are a first-line route to relief in many patients. Also commonly prescribed to headache patients are serotonin-binding ergot alkaloids and triptans, which have highly effective vessel-constricting qualities (Baron et al, 2010). New methods of delivering ergots and triptans include orally inhaled and transdermal formulations, both currently under study (Monteith et al, 2011). Unfortunately many medications can cause “rebound headaches” and many believe can make headaches worse if taken regularly.
Other drugs used to control headache include antidepressants, antiepileptics, beta-blockers and calcium channel antagonists. Studies supporting the use of these drugs include a meta-analysis of 37 published studies, which found tricyclic antidepressants effective in preventing migraine and tension-type headaches (Jackson et al, 2010); a review of 70 studies which showed certain antiepileptic drugs may help prevent migraine (Vikelis et al, 2010); a randomized, placebo-controlled, 16-month trial in 232 adult migraine patients that found beta-blockers combined with behavioral management was effective in improving treatment outcomes (Holroyd K, 2010); and a prospective, open-label study that found prophylactic treatment with a calcium-channel blocker was associated with a significant reduction in the number of days with headache, use of acute medications and pain intensity (Vuković et al., 2009).
In addition, anti-emetics are often prescribed to help control the problematic nausea that may accompany headaches.
Although medications help many patients find relief from their headaches, this line of therapy is associated with overuse and dependence. In addition, medications may not always work for all headache patients; for example, Almost 98 percent of migraine sufferers take medications for temporary headache relief, but a large majority report their lives are still significantly affected by the pain and debilitation associated with migraines (National Headache Foundation, 2011).
There are a number of non-pharmacological treatment options headache patients may try in order to avoid taking medications. One of these is inhaled oxygen. According to results from the United States Cluster Headache Survey, 70% of 1,134 online survey respondents indicated that they felt oxygen was an effective therapy for headache (Rozen T, 2011). And a five-year double-blind, randomized, placebo-controlled crossover trial published in the prestigious Journal of the American Medical Association (JAMA) found administration of high-flow oxygen to cluster headache patients at symptom onset was more likely than placebo to result in being pain-free at 15 minutes (Cohen et al, 2009).
Another non-pharmacological therapy for headache is diet control. Certain foods are known to trigger headaches in some people; avoiding these foods may prevent headache onset. One randomized, cross-over study in migraine patients showed that diet restriction based on IgG antibodies against food antigens is an effective strategy in reducing the frequency of migraine attacks (Alpay et al, 2010). The patients were randomized to a 6-week diet either excluding or including specific foods with raised IgG antibodies against 266 food antigens, then given the opposite diet. Compared to baseline, there was a statistically significant reduction in the number of headache days in the elimination diet period.
Additional therapies patients may try in lieu of medications and more aggressive treatments include cognitive behavioral therapy and biofeedback. Cognitive behavioral therapy, which can help redefine a person’s perceptions and opinions about illness, and teaches symptom reduction skills, which may help alter an individual’s behavioral response to pain. Biofeedback is a learned skill in which a patient uses self-awareness techniques to reduce pain.
When more conservative treatments fail, your doctor may suggest a mimimally invasive treatment modality for your headaches. One such line of therapy is injections. These may include cervical facet injections, radiofrequency ablation, sphenopalantine ganglion block, peripheral nerve blocks, epidural steroid injections, and Botox injections.
Sometimes, headaches result when nerves are compressed by eroded facet joints of the spine. They can also occur as a result of trauma to the joints as occurs in a whiplash type injury. When this occurs in the facet joints of the neck, headaches may occur. Cervical facet injections (or cervical medial branch blocks) are a minimally invasive procedure. They lower painful inflammation and irritation in the facet joints of the cervical spine. The injected medication includes a combination of local anesthetic and long-lasting steroid. By numbing affected nerves, the injection temporarily halts transmission of pain signals to the brain, and the slow-release steroid combats inflammation.
Cervical Epidural Steroid Injections are most commonly used to treat pain from spinal nerve roots compressed by degenerative disc disease or herniated disc. The pain resulting from compressed spinal nerves is termed radicular pain or radiculitis and refers to pain that radiates along the length of a nerve due to inflammation or other irritation of the nerve root. When radicular pain occurs in the in the neck, it can sometimes radiate to the head, manifesting as headache. Epidudral steroid injections involve injection of a combination of medications – a long-lasting steroid and a local anesthetic – into the epidural space. Upon injection, the medication migrates throughout the vertebral column and related tissues, targeting irritated nerve roots and lowering inflammation throughout the spine. When administered in the neck, an epidural steroid injection can be used to treat head pain.
The use of Botox injections to treat headache is a newer therapy. PREEMPT (Phase III REsearch Evaluating Migraine Prophylaxis Therapy), a pair of studies designed to evaluate the efficacy of botox in the treatment of migraine, suggested botox is indeed effective for this type of headache. In PREEMPT I, a phase 3 study with a 24-week, double-blind, parallel-group, placebo-controlled phase followed by a 32-week, open-label phase, Subjects were randomized to receive injections every 12 weeks of botox or placebo (Aurora et al, 2010). There were significant reductions from baseline in patients who received botox for headache and migraine days, cumulative hours of headache on headache days and frequency of moderate/severe headache days, which the researchers said in turn reduced the burden of illness in adults with disabling chronic migraine. In PREEMPT II, a similarly designed study, botox was found effective for prophylaxis of headache in adults with chronic migraine, and repeated botox treatments were safe and well tolerated (Diener et al, 2010).
Another way of treating headaches is by blocking pain transmission of nerves. This can be accomplished through injection of nerve blocking medication and implantation of stimulation devices. Nerve blocks for headaches may include supratrochlear and supra/infraorbital nerve blocks, as well as sphenopalatine ganglion blocks, and nerve stimulation for headaches may be accomplished through occipital nerve stimulation, or implanting a stimulator at the back of the head.
Supratrochlear, supraorbital and infraorbital nerve blocks are delivered at the supratrochlear nerve (a branch of the frontal nerve, which itself comes from the ophthalmic division of the trigeminal or fifth cranial nerve), the supraorbital nerve (a terminal branch of the frontal nerve that passes through the supraorbital foramen, or opening), and infraorbital nerve (or where the maxillary nerve enters the infraorbital canal), respectively. A nerve block delivered to the sphenopalatine ganglion targets the mass of nerve cell bodies that innervates various structures of the face. Your doctor will choose the appropriate location for a nerve block depending on where your headache occurs and whether it is caused by nerve pain.
In occipital nerve stimulation, a microstimulator that gently modulates the perception of pain is implanted at the rear of the head to control headache. The technique is associated with a very low risk of complications and in one study provided 90% reduction in pain symptoms in a small study conducted at the Mayo Clinic in Scottsdale, Arizona (Trentman et al, 2009). And another small study of 8 patients who received implanted neurostimulators for headache found two patients were pain free after a follow-up of 16 and 22 months, although one of them still had occasional autonomic attacks, three patients had around a 90% reduction in attack frequency, and two patients had improvement of around 40% (Magis et al, 2007).
Although serious causes of headaches are rare, sometimes headaches are a symptom of a more serious disorder. Alert your health care provider know if you have sudden, severe headaches, particularly if they are accompanied by a stiff neck, fever, confusion, loss of consciousness or pain in the eye or ear.
Louisiana Pain Specialists cares about your quality of life and understands the inconvenience of living with headaches. Our caring practitioners will listen to your concerns and work with you to develop a viable treatment plan that will help you manage your condition and regain your health and happiness.
Sources
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