“You worry at first that the pain will kill you, and then you wish it would,” says Elizabeth McKim, an assistant professor of English at St. Thomas University in Fredericton. McKim’s voice is cheerful, but her office is dim and her eyes are shuttered behind sunglasses. The pain she speaks of is a migraine headache. For McKim, something as simple as a glimpse of the sun’s bright light glinting off the Saint John River can trigger an agonizing headache. The sunglasses, subdued office lighting and avoidance of sunny-day activities help, but when a migraine hits, her only option is to cloister herself in a dark quiet room and wait – sometimes for up to 12 hours – for the pain to abate.
All of us have felt the pounding pain of a headache. But for the millions of North Americans who are flattened by migraines (more than half of migraineurs, as they are called, are women), cluster and tension headaches, that pain can change the way they live their lives. For some, like McKim, it means days off work and less time spent with family and friends. There is good news, though. Specialists in pain management now have a much better understanding of how a headache takes hold, and that’s opening up new ways to overcome the pain.
What’s new? Headaches are no longer understood simply as a vascular problem, in which blood vessels become inflamed and then expand to cause that familiar throbbing pain. Instead, new research indicates that they result from a complicated series of interactions between nerves, body chemistry and blood vessels. And new information suggests that headaches can literally be a pain in the neck, with the headache response being triggered by the irritation of specific nerves based in the neck. “We now know that there is a clear-cut biologically based change that goes on during an attack,” says Dr. Marek Gawel, a neurologist at Sunnybrook Health Science Centre in Toronto and president of the North American Headache Society. “Using image scans, we have seen an area in the brain stem [in the neck] actually light up.”
But when it comes to diagnosis, old habits die hard. Headaches are such a generalized complaint that doctors often suggest over-the-counter medications and send patients on their way. “Headaches are extremely poorly treated,” says Dr. Gary Shapero, who runs a pain clinic in Markham, Ont. “Most doctors do not recognize that injury or damage to the musculoskeletal structures in the neck can play an important role in causing headaches.” Dr. Shapero takes his patients through a complete medical exam. “We look at lifestyle and stress levels, and all of my patients keep a daily log to find out what they are actually doing at the time their headaches occur.”
Those headaches can range from the simply annoying to the absolutely debilitating. While some scientists believe that tension, cluster and migraine headaches are distinctly different afflictions, other researchers believe that they are in fact the same phenomenon, differing only in intensity of pain. Whether distinct or related, though, they all share common triggers and some similar treatments.
“Mine are definitely tied to hormones,” says Judy Huddart, an executive assistant in Toronto. Now in her 40s, she has been coping with migraines since she was 13 years old. Her first came with her first period. Now, they occur both at ovulation and two days before menstruation. Huddart describes the onset as an ominous sensation that builds to a throbbing pain behind her eye. Her eye swells and begins tearing; her nose runs. Then, her hand starts to tingle and becomes numb. Sometimes nausea hits.
Like Huddart, most headache sufferers can pinpoint the trigger for their pain: hormones, eyestrain, excess stress, bright lights or deafening sounds. Other less common causes include strenuous sex, ripe cheese, red wine or chocolate. Exactly why one person suffers while another doesn’t remains a mystery, but scientists do believe that genetics play a role. While some might argue facetiously that their families give them a headache, the tendency to suffer from headaches does tend to run in a family. One explanation: your family may have a lower physical threshold for internal triggers such as hormones and external triggers such as food, leaving you more vulnerable to attack.
Women tend to be more headache-prone than men, and female sex hormones may be to blame. If you endure the symptoms of premenstrual syndrome, then you know that headaches can be set off by fluctuating estrogen levels, especially just before and during menstruation. The hormones released during pregnancy can also cause – or relieve – headaches. Some migraineurs, for example, find that their headaches are worse during the first trimester and then lessen or disappear altogether during the latter two. After pregnancy, though, they can become temporarily worse. Menopause can also bring relief or new pain. In the few years before menopause, when hormone levels ebb and flow from month to month, some women who have never had headaches begin experiencing them. But for some migraine sufferers, menopause can spell relief, with a reduction in the number and severity of attacks. Huddart is looking forward to that possibility. “I keep praying they’ll stop with menopause, but there’s no guarantee.”
Two cautions: hormone replacement drugs for menopausal women with migraines may need special adjustment. A low-dose synthetic estrogen is often recommended, since it doesn’t appear to trigger migraines as much as naturally derived estrogen. And for women on the birth control pill, estrogen may make headaches worse. (If your headaches are worse while on the Pill, consult your doctor.) Women who have migraines with aura – a kind of distorted vision – face a sixfold increase in their risk of stroke.
“The headaches were constant and nothing could really take the pain away for any length of time,” says Beverly Hann, who suffered for 13 years with chronic tension headaches after a series of car accidents damaged her neck. Hann, a nurse who brings her personal experience as a headache sufferer to her work in the Toronto pain clinic of Dr. Peter Rothbart, was at one point downing Tylenol with codeine every three to four hours on an almost daily basis.
In his suburban office, Dr. Rothbart uses a modal of the human skull to explain how neurologists now believe headaches originate. Like both sufferers and practitioners in this field, Dr. Rothbart uses the language of war to describe the buildup to a headache’s attack. Tracing the route with a pen, he points out the control centre for the pain: the trigeminal nerve system, which lies just below the skull. The trigeminal is surrounded by a bunker of muscles, ligaments, tendons, blood vessels, discs and vertebrae. The nerve branches up the neck and out on both sides of the head to the eye, cheek and jaw.
Normally, the trigeminal receives information from the head and makes minute chemical adjustments in response to light, sound or tension. But if the trigeminal becomes overwhelmed by fatigue or stress, or if you are simply born with a hypersensitive nerve, relatively minor triggers can cause the nerve to launch an all-out response: like sending in the air force to blow out a match.
This overreaction sets off a cascade of biochemical and vascular responses in your head. The first is an upset in the balance of several chemicals in the brain, including the neurotransmitter called serotonin. Among its many functions, serotonin is responsible for sending the message to constrict your blood vessels. Another chemical messenger called substance P is also released, causing irritation of the surrounding nerves and blood vessels. That irritation in turn is believed to cause an inflammation of the meninges, the sheaths that cover the brain. It’s at this point that you may start to feel that familiar pounding in the back of your head, or in your neck, scalp or forehead (or, if you’re especially unlucky, all over your head). Although scientists still aren’t sure exactly why, this reaction will result in a tension headache in some people. In others, it means a migraine.
Some medical researchers believe that the trigeminal itself can trigger the pain, without a trigger from another source. And Dr. Rothbart believes that neck trauma is the root of the pain for many of his patients: he says some 80 percent of them have neck problems or have experienced some trauma, such as whiplash. He’s been following developments in this field for the last decade, just when researchers finally started to put the pieces together. “It’s like the Agatha Christie mysteries,” he says. “The clues over the years have helped us see that what appears to be a tension or a migraine headache is really a problem that usually originates in the neck.” This discovery, he says, holds enormous promise, offering the prospect of eliminating the cause of the headache rather than simply dealing with the symptoms.
One treatment to grow out of this new understanding is a series of injections with a local anesthetic called nerve blocks. “Patients receive an enormous variety of relief from the pain by blocking the [C.sub.2] nerve which feeds into the trigeminal,” says Dr. Rothbart. Hann, the nurse in his clinic, is living – and now pain-free – proof of that relief. For a year, she received a series of nerve blocks that alleviated her pain. Then, in 1992, she opted for surgery that permanently deadened those same damaged nerves in her neck, so that they could no longer transmit their pain-triggering messages. “Now,” she says, “I get the odd headache if it rains, but that’s about it.”
“Biofeedback, massage, acupuncture. . . .” Judy Huddart runs through the list of things she tried in her efforts to head off the pain. “I was a vegetarian for a year, and my headaches still came back.” For some time, she used a prescription medication called Cafergot (ergotamine), but it never worked completely. “I always ended up with a fullblown migraine.”
For some sufferers, medication designed to halt the headaches can end up causing them. It’s called rebounding, and while researchers still aren’t certain how it happens, the headaches typically occur after three to six months of daily painkiller use. When it happened to Huddart, she had to be hospitalized for a week to clear her body of the medications. “Then, I had to start all over,” she says. Others build up a tolerance to their medication, which eventually renders the drag ineffective.
But in the headache field, new drugs are always being developed. One of the latest is Imitrex, touted as one of the most effective so-called “abortive” headache medications available. (In painkilling lingo, an abortive is a drug that stops a headache after it has started.) It’s not cheap: each tablet costs about $18 and each self-administered injection sells for about $35 per syringe. Stadol NS, a nasal spray, also offers hope for migraineurs. Many headache sufferers experience nausea during an attack and as a result have difficulty swallowing pills or keeping them down. The nasal spray offers an alternative way to deliver the drug into the sufferer’s system. There’s also an emergency-only injectable treatment called DHE (dihydroergotamine). It has good relief response with minimal side effects. And one old herbal favorite – feverfew – is now available in an over-the-counter medication called Tanacet 125. (It’s also available in its traditional form in health food stores.)
Since Huddart is unable to avoid her main trigger, hormones, she relies on Imitrex. “Within 35 minutes [of taking the drug], it’s as if the migraine never was, and I can remain clear of pain for up to eight hours,” she says. “It’s given me a new lease on life.”
But medication isn’t the only answer. Recently, some headache patients have begun using moderate aerobic exercises such as walking or running to stem their attacks. If they can manage to exercise through their pain for 30 minutes or more, the body releases natural pain-relieving endorphins that can help stanch the ache. In fact, people who get migraines typically have lower resting levels of endorphins than non-sufferers. Exercise has other significant benefits too: it relieves stress and tones your blood vessels, making them more able to cope with the pressure that might once have resulted in a headache.
Like Huddart, it has taken Fredericton’s Elizabeth McKim most of her life to find the fight strategy for dealing with her migraines. Today, she relies heavily on prevention. That means avoiding her most powerful trigger, light, as well as taking a beta-blocker, a drug that acts to regulate blood vessel activity. Instead of disrupting her life and sending her in search of that dark quiet room two or three times a week, her migraines are now milder and come only two or three times a month. “I can almost live normally now,” she says.