Headaches including migraine headaches

Janet D. Pearl, MD, MSc

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Headaches including migraine headaches

Headaches can vary from the most common tension  headaches which are usually well treated with over the counter pain medications to cluster headaches, a rare neurological condition involving an excruciatingly severe unilateral headache pain without known cause, or cure.

Tension headaches

Tension-type headache affects 1 in 5 people.  The pain is often described as a constant pressure, or vice like pain that is felt on both sides of the head and can radiate to the neck and also to the eyes. It usually results in mild to moderate intensity, but can be severe.  Tension-type headaches can last from minutes to days, months or even years, though a typical tension headache lasts 4–6 hours. Tension-type headaches account for nearly 90% of all headaches. In a small percentage of cases, tension type headaches can become chronic occurring 15 days or more a month for at least 6 months.  One half of patients with tension-type headaches identify stress or hunger as a precipitating factor.  Sleep deprivation or eyestrain or other possible causes.

Tension type headaches often improve with over the counter pain medications such as ibuprofen, aspirin or Acetaminophen.  Frequent use of pain medications in patients with tension-type headache may lead to the development of medication overuse headache or rebound headache. Certain antidepressants and anti-seizure medications are used to treat chronic tension headaches.  Acupuncture, manual therapy and trigger point injections can also be helpful when tension headaches become chronic.

Rebound headaches

Rebound headaches also known as Medication overuse headache (MOH), usually occur when acute headache relief medications are taken excessively to relieve episodic headaches. People suffering from MOH say that their intermittent headaches change to a new type of headache that is persistent.  They typically awaken with headaches and note relief when they take their usual headache medications (ibuprofen, acetaminophen, or fioricet/fiorinal).  The best treatment for this problem is to stop the analgesic medications.  The headaches will get worse before they get better.

Migraine headaches

A Migraine headache is diagnosed by signs and symptoms.  It is chronic headache disorder characterized by recurrent usually one sided,  moderate to severe, pulsating headache lasting 2 to 72 hours. Migraine headaches are often accompanied by nauseavomiting, or sensitivity to light or sound.  They are often worsened with physical activity.  In about one third of migraine sufferers, a migraine headaches  may start with an aura,  an altered sensation often a visual one, numbness, or weakness, that means a migraine is coming. This aura can occur hours to minutes before the migraine strikes.  Some migraine suffers notice changes in mood, energy level or sensitivity to smell or hearing, called a prodrome, a couple of days before a migraine starts.  After a migraine headache, one can feel tired or “hung over” with gastrointestinal symptoms, mood changes, and weakness.

For migraines, the causative factors are genetic or environmental. Migraine headaches frequently run in families.  Women who are still menstruating are at risk for these headaches because of the hormonal changes in the body.  However, other triggers, such as food additives, stress, and some medications mean that anyone can potentially have migraines. If you have sensitivity to a particular trigger, then migraines could plague you.  15% of the population experiences a migraine headache at some point in their life.  As in tension headaches, stress, hunger and fatigue can trigger a migraine headache. Your physician may diagnose your headache by history alone, but may wish to order other tests to rule out life threatening problems, such as aneurysms, bleeds, infection, inflammation, and tumors.


The first line of treatment for headaches are medications.  Initial recommended management is with simple analgesics such as ibuprofen and acetaminophen for the headache, an antiemetic for the nausea, and the avoidance of triggers. Specific medications such as triptans or ergotamines may be used to stop the headaches (abortive treatment) if the more simple headache medications are not effective.  For chronic, persistent headaches, medications may be started to prevent headaches, such as Beta blockers, anti-seizure medications, or certain antidepressants.

Neurologists are usually the specialists that diagnose migraine headaches and manage the medications used to prevent and treat them.  Analgesic medications including opioid medications are not considered to be appropriate treatment for chronic migraine headaches. For headaches that do not respond well to preventive or abortive treatment we can help with certain specialized procedures.  Occipital nerve blocks can help with chronic headaches and migraines by blocking the signals from this nerve in the back of the head. Some headaches arise from problems with the facet joints in the neck, and certain injections into these joints can relieve headache pain from this source.  Finally, Botox injections are quite effective against migraine pain and can be done for persistent migraine headaches that last 15 or more days per month. Botox injections often allow migraine patients to live relatively normal lives.

botox for migraines

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