Managing Headaches



Headaches and migraines can impact your quality of life and be immobilizing - but they don't have to be.



Types and Causes of Headaches

Headaches can stem from a large variety of reasons. Those suffering from regular headaches are often aware of the cause of their headache, however in many cases, the cause of a headache may go unknown. There are two basic categories of headaches, namely primary and secondary. Primary headaches are those headaches that are caused by no specific underlying reason. They are not the result of any specific disease or process and are commonly thought of as being a result of a problem in function rather than a problem with the brain’s basic structure itself. The most common types of primary headaches include migraine & cluster headaches as well as tension-type headaches. Since there is no underlying brain structural problem with primary headaches, it is important to note that there are no investigative tests such as magnetic resonance imaging tests (MRIs) or computed tomography (CT) scans that can be done to determine an exact reason for the headache. If you suffer from primary headaches, however, some investigative tests may still be used to rule out more serious causes of your headaches. Secondary headaches result from another problem, which has headache as a symptom of the underlying initial problem. Secondary headaches can result from head and neck injuries, inflammatory processes within the body, hormonal issues, as well as more serious causes such as brain tumours or aneurysms. The main types of primary headaches and common secondary types of headaches are described in detail below:

Migraines Migraines are often described as a severe (and often unbearable) throbbing or pulsating pain in one or both sides of the head, often around the temples, front of the head or behind an eye.

Auras, nausea, vomiting, double vision and an extreme sensitivity to light, sound or smells often accompany migraines. Migraines can also be accompanied by a loss in memory, altered thinking capacity, and altered speech. Migraines can last anywhere from an hour to, in extreme cases, several days. Most migraines are severe enough that they cannot be ‘worked through’ and once the headache has passed, a ‘headache hangover’ is often felt. This 'headache hangover' is a feeling of extreme fatigue, dizziness and difficulty concentrating. Neck pain may or may not be present during or after a migraine headache. Migraine headache triggers are not always known. You may have heard of people keeping a headache journal to try and find commonalities amongst the onset of migraines so that they can avoid these triggers in the future. One of the most common migraine triggers are certain food and drinks, including red wines, cheeses, chocolate, excessive caffeine, pickled foods, foods containing monosodium glutatmate (MSG), citrus fruits and sourdough bread. Other common non-food related triggers include flickering lights, intense exercise, intense smells (such as perfume), weather changes (barometric changes), and menstruation cycles. Stress is also an extremely common trigger of migraine headaches in many sufferers. We suggest making note of the above common triggers and see if they might relate to the onset of your migraines!


Check out Shannon Rogers' (our Functional Rehabilitation Therapist) presentation on "How to Use Exercise to Manage Migraine and Improve Neck Health"



Cluster Headaches Cluster headaches are an extremely painful type of headache, which comes on rapidly and occurs in a cyclic time frame, hence the name. Headaches occur over a specific time frame, usually a two to twelve week period and this is often related to a particular season of the year. During the cluster period, headaches generally occur every day (often more than once in a day) and often occur at the same time during the day. Time between headaches is pain-free. Cluster headaches often occur at night, generally within a couple of hours of going to sleep. Most cluster headaches are 30-90 minutes in duration. Sufferers often describe the pain as burning and sharp like a red-hot stick poking through the eye. Cluster headaches occur on one side (and do not switch sides within a cluster period) and they are usually located around an eye but may extend to other areas of the head and neck. Other symptoms can include redness, swelling or tearing of the affected eye, droopiness of the affected eye, sweating of the face, and stuffy or runny nasal passages on the affected side. Sufferers of cluster headaches often also describe restlessness as a symptom of the headache; due to pain, the headache sufferer just can’t sit still. Fortunately in most cases, cluster headaches usually dissipate as quickly as they began.

Triggers for cluster headaches can be strong smells, high altitudes, bright lights, heavy exercising or becoming overheated. Alcohol is also a well-known cluster headache trigger. An aura may occur with a cluster headache but it is uncommon.

Tension-Type Headaches Tension-type headaches are the most common type of headache and many people experience them regularly, particularly when under stress. For this reason, these headaches are also sometimes referred to as ‘stress headaches’. Aside from stress, tension-type headaches are reported to be commonly triggered by a number of other factors including hunger, fatigue, poor posture and eye strain. Tension-type headaches can last anywhere from 30 minutes up to even a week! The pain of a tension-type headache is generally described as a mild to moderate dull but constant and diffuse pain, and usually occurs on both sides of your head. Tension-type headaches are not associated with any visual disturbances or auras and often the pain of a tension-type headache can be tolerated such that sufferers are able to ‘work through them’. For some people, however, the pain is more severe, can last a long time, and is unable to be ‘worked through’. Women are more than twice as likely to suffer from tension-type headaches than men. The underlying cause of tension-type headaches used to be thought of as increased tension in the muscles of the neck and face which then causes the headache pain. More recently, however, tension-type headaches have been thought to be linked to sufferers being hypersensitive to pain and stress, which then causes the headache.

Tension-type headaches can also be described as episodic or chronic. Episodic tension-type headaches occur once to twice a month whereas chronic tension-type headaches occur more than 15 days in a month.

Cervicogenic Headaches Cervical is the medical term meaning ‘relating to the neck’ and ‘genic’ means originating or coming from. Cervicogenic headaches are headaches that are associated with neck pain and stiffness; the cause of the headache comes from structures in the neck. Cervicogenic headaches are most commonly felt on one side of the head but occasionally a cervicogenic headache can cause pain on both sides. These types of headaches typically occur due to excessive strain on the structures of the upper neck, which can occur from a traumatic event such as whiplash. More often than a traumatic event, however, cervicogenic headaches occur as the result of prolonged stress on the upper neck structures such as when sitting at a computer for prolonged periods, especially when sitting with poor posture. Sinus Headaches The sinuses of the face lie in the cheeks, behind the bridge of your nose, as well as in the forehead/brow area. The sinuses help to humidify air and secrete mucus to assist air filtration. Those suffering from a sinus headache often complain of the area ‘feeling full’. Pressure and fullness felt may even extend into the upper teeth area. Sinus headaches most often occur after an upper respiratory infection or cold. The upper respiratory infection or cold causes inflammation of the lining of the sinuses (sinusitis), which prevents draining of the mucus in the sinuses and then causes the build-up of pressure in the area. Inflammation may also occur as a result of an allergy. Often the pain of a sinus headache worsens when the sufferer bends forward, lies down, makes sudden movements, or when they first get out of bed due to the added pressure that the change in position causes. Sudden temperature changes, such as going from a warm house into the cold outdoors, can also increase the pain of a sinus headache. The face overlying the inflamed sinus may be tender to touch. Frequent colds, climbing or flying to high altitudes, frequent diving or swimming, or having a history of allergies such as hay fever increases your risk of suffering from a sinus headache. In addition, having any type of issue with your nasal passages such as polyps or a deviated septum, or can also put you at a higher risk of developing this type of headache. Sinus headaches are often confused with migraines or tension-type headaches. Many people who seek medical attention due to what they believe are sinus headaches are actually diagnosed as having migraines or tension-type headaches.

Temporomandibular Joint (TMJ)-Related Headaches TMJ disorders can commonly cause headaches. In many cases it is obvious that one has a TMJ disorder because there will be pain around the jaw or ear as well as clicking in the joint or problems opening or closing the jaw itself. Headaches may develop related to these symptoms. In some TMJ cases, however, local TMJ pain may not be present and headaches may be the only symptom one feels so the TMJ joint gets overlooked as the culprit. TMJ-related headaches can also closely mimic tension-type headaches, cervicogenic headaches, migraines, and sinus-related headaches therefore a thorough examination of the TMJ should be included in any physical examination for headaches to either rule the TMJ joint in or out. Other causes Other secondary type headaches can come on as a result of a number of other causes including:

  • poor posture or work biomechanics

  • skipped meals

  • dehydration

  • food sensitivities

  • lack of sleep

  • head injury/concussion

  • inner-ear problems

  • excessive noise

  • hormones (menstrual-related, pregnancy-related, or other),

  • glare from sunlight, computer screens or other screens

  • anxiety

  • alcohol, particularly from red wine or excessive drinking

  • medication

  • ice cream or eating/drinking extremely cold items (brain freeze)

  • excessive exercise

  • brain aneurysm

  • brain tumour



Diagnosis

Your healthcare professional will need to ask a variety of questions to determine the cause of your headache(s). Firstly, when determining the reason for a headache it should be noted that any sudden and severe headache is indicative of a serious problem and should be treated as a medical emergency, which needs to be investigated immediately.

Most people will only seek professional assistance in determining the cause of a headache once their headache becomes regular, constant, or causes pain that is affecting their ability to function. In order to determine the cause of your headaches your health care professional will want to know when your headaches began, if you feel they are related to any specific event or trigger, how severe they get, how long they last, if they come with an aura, and if they are consistently in one area of your head. They will ask you questions about what aggravates your headache pain and whether or not you can do anything to relieve your headache such as take medication, or massage your muscles. They will also want to know about your general health, any medications you are taking, any history of headaches in your family, and any other symptoms you may be experiencing such as neck, ear, eye or jaw pain. Your Physiotherapist at Fix Physio will determine if there is any related muscular or fascial tension affecting your pain, whether there are any stiff or loose joints in your neck, or if there is any nerve tension in the area that could be related to your headaches. They will specifically assess the upper cervical region (C1-3) but will also need to assess your lower neck and may also assess your thoracic spine area. Your physiotherapist will also assess your TMJ to determine if there is any dysfunction in this joint that could be the direct cause of your headaches or may be contributing to your symptoms. In most cases investigations such as x-rays, MRIs, CTs, or other investigative tests will not show up any structural damage to the brain or neck and therefore in most cases, these tests are not recommended particularly when dealing with primary type headaches. These types of tests (or others) however, may be requested particularly in secondary type headaches in order to rule out specific diseases or processes, which may be related to the ongoing headaches. Investigative tests may be used to look for issues such as hormonal problems, brain aneurysms or brain tumors. It may be recommended that you obtain a professional examination of your eyes and ears as well as a dental exam in order to help determine the cause of your headaches as some disorders of these areas can cause headaches as a symptom.


Medical Treatment

Some headaches are easier to treat than others. Obviously knowing the cause of a headache makes the required treatment much easier to define. For many headache sufferers, medication is the mainstay of treatment. The three most common medications available over the counter are acetaminophen/paracetemol based, acetylsalicylic acid based, or ibuprofen based. Each medication has its own contraindications therefore you should check with your Doctor or Pharmacist before using any to treat your symptoms. For migraines, cluster or tension-type headaches some prescription drugs can be useful and should be discussed with your Doctor. In many cases if an aura occurs and the patient takes the medication during the time of the aura, a full-blown headache can be avoided or the intensity of the impending headache can be decreased. In severe or chronic headache cases, patients and healthcare professionals may choose to resort to more invasive procedures in order to manage symptoms and allow the patient to function. Treatments such as botox injections for migraine headaches or nerve ablations for cervicogenic headaches may be options that can be discussed with your Doctor. Other types of injections or surgeries may also be options depending on your symptoms, severity, and the types of treatments you have already tried. For some types of headaches, Physiotherapy can be a very effective form of treatment. Physiotherapy can be used either on its own or in conjunction with medication.

Rehabilitation

In certain types of headaches, such as tension-type headaches, cervical headaches, or TMJ-related headaches physiotherapy treatment can be very useful to alleviate your symptoms and to help prevent recurrent headaches. Your Physiotherapist will first need to confirm that your headaches and associated symptoms are connected to issues related to your neck, your jaw, or other structures in the head or face which can be assisted by physiotherapy treatment. Your physiotherapist will ask you several questions related to your headaches symptoms in order to confirm the cause of your headache (see Diagnosis above). In addition to asking a wide variety of questions they will need to do a physical assessment to confirm that physiotherapy will be able to assist your headaches. They will examine the posture and alignment of your neck, shoulders, and upper back as well as check your neck and TMJ joint range of motion, and associated muscle flexibility and strength. Your physiotherapist will feel your neck to determine if the joints in your neck are stiff or loose and to determine which areas around your neck, shoulders, face and scalp are tender or painful. They will do the same to your TMJ and its related muscles. Your physiotherapist may also check the overall strength in your upper extremities, as well as check your sensation, reflexes, and the functioning of your cranial nerves. If it is determined that your headaches are indeed from a cause which Physiotherapy treatment can assist, then your therapist will proceed with treatment. Again, depending on your symptoms and the cause of your headaches, a variety of techniques may be used. Manual therapy including massage, as well as joint mobilization or manipulation for the neck, upper back or TMJ commonly improve symptoms. Your therapist may also stretch out any tight muscles contributing to your headaches and will also teach you how to do this yourself. In addition, they will teach you how to strengthen the appropriate muscles around your head, neck, shoulders and TMJ in order to ease your symptoms and avoid headaches in the future. They will also encourage strengthening of the core muscles of your trunk and neck in order to support your head and assist with symptoms. Your Physiotherapist will discuss your posture and alignment and ensure you are aware of the posturing positions that may contribute to your headache pain or related symptoms. In some cases modalities such as ice, heat, ultrasound, interferential current, laser, transcutaneous electrical muscle stimulators (TENS) or muscle stimulators may be used to ease your headache pain or other related symptoms. Tape or strapping may also be used to relieve tension on muscles that may be tight, elongated, or weak. Braces that assist with posturing may also be useful in some cases. Your Physiotherapist will also provide education for self-managing your headache and related symptoms when they occur. They will discuss techniques such as retreating to a quiet and dark room, using self-massage of the head, neck, jaw and temples, applying ice or heat to the painful area or the neck and shoulders, avoiding computer or other screens, drinking water, or eating a small amount of food once symptoms appear. If after a thorough examination your Physiotherapist does not feel that your headaches are being caused by a reason that is amenable to Physiotherapy treatment then they will refer you to your Doctor for further investigation. Similarly, if your symptoms worsen significantly or Physiotherapy treatment is not improving your symptoms as your Physiotherapist expects it should, they will also refer you on to your Doctor for further investigation.