From Symptom or Underlying Problem?
Here comes the pain again--that familiar throbbing in your temple, or at the base of your skull. Quickly, you pop a couple of over-the-counter pain pills, hope for the best, and go about your day. After all, it's just a headache, right?Not necessarily. It could be a migraine, a potentially serious condition that affects more than 29 million Americans, according to the National Headache Foundation (NHF), a nonprofit education and advocacy group based in Chicago. But I don't get migraines, you think. Don't be so sure: More than half of all migraine sufferers have never been diagnosed by a doctor or were diagnosed incorrectly. "They may have been told that they have sinus or tension headaches because there is overlap between the symptoms. The dilemma is that if they really have migraine, they may not be getting the best treatment," explains NHF board member Lisa Mannix, MD, director of Headache Associates in Cincinnati, Ohio.
Headaches 101
Almost everyone gets headaches, and they can start young. In fact, one study found that among people ages 12 to 29 years old, 91 percent of men and 95 percent of women had experienced one or more headaches. The pain drives 50 million people to doctors each year and is one of the top 10 reasons men and women seek medical care. Anything from the foods you eat to a simple change in your routine can set off an attack.
Some 90 to 95 percent of all headaches are primary. These include tension headaches, migraines and cluster headaches. Secondary headaches, such as those that are caused by brain tumors, head injuries or aneurysms, are far more rare. In these cases, the headache is a symptom, not the underlying problem.
No two people experience a primary headache in exactly the same way, which is why they can be tough to categorize. For example, migraines can be debilitating, life-stopping attacks for some, leaving them bedridden in a dark room with the shades pulled, while others hurt but are still able to go about their business. So how do you know what kind of headache you have? Are they different maladies, or simply different levels of the same problem?
"It's a question we struggle with, to some degree," says Richard Lipton, MD, director of the Montefiore Headache Unit at Montefiore Medical Center in New York.
"There's a lot we still don't know about headaches," agrees Mannix. "Tension headache is so common that we don't fully know what's going on in the brain." A little more is known about migraines and cluster headaches: Migraines affect women three times as often as they do men, and may be triggered by hormonal changes. Attacks typically last from 4 to 72 hours. Cluster headaches are relatively rare and mainly affect men. These attacks are much shorter, from 30 to 90 minutes, and can occur several times in a day. "The pain is behind one eye," Lipton explains, "a stabbing or searing pain often described as feeling like a hot poker in the eye."
The features of a migraine are distinct from those of a tension headache, says Lipton: A migraine is typically one-sided pain; tension headache affects both sides of the head. Migraine pain throbs; tension pain is a steady ache. Migraine pain is moderate to severe; tension tends to be mild to moderate. Migraine is always associated with other symptoms, such as nausea or sensitivity to light, while tension headache is often just that--a headache.
Many people assume that migraines always include aura--flashes of light, zigzag lines or other visual disturbances--but only about 15 percent of attacks have those classic signs. Other symptoms can vary as well, and may include sinus pressure and congestion, which is another reason migraines are often misdiagnosed. In a 2004 study published in the Archives of Internal Medicine, 88 percent of people who believed they had a history of sinus headache actually had been experiencing migraines.
"If an otherwise healthy person comes in to a primary care office and complains of episodic headache for at least six months, the likelihood that it will be migraine is 94 percent," explains Stewart Tepper, MD, director of The New England Center for Headache.
Pain Relief Is On the Way
Even with a correct diagnosis, many patients assume nothing can be done about migraines. "If someone went to the doctor ten years ago, or saw their mom or sister go and not get much help, they may not be too enthusiastic about seeking treatment," says Mannix. "A lot of people tough it out, but there are new medicines that are more effective."One of those people is Bill Hittler. The 47-year-old Plymouth, Minnesota, lawyer and father of three teens never mentioned his migraines to his doctor, even though he had suffered through them with minimally effective over-the-counter drugs for more than eight years. "It wasn't such a big deal," he says. "It wasn't like my life was stopping or I couldn't function at all, so I just put it in the back of my mind." Nearly two years ago, he finally told his doctor about his headaches and was given a prescription for sumatriptan tablets (Imitrex).
Now, as long as he takes the medication the instant he senses an attack coming on, it usually stops his headache cold. "It's a wonderful thing," he says.
Getting a proper diagnosis can mean more than just stopping the pain, because severe headaches can affect more than your head: Migraines have been linked to a number of serious conditions, including stroke and obesity.
Stroke: A recent review of 14 studies suggests that certain migraine sufferers are more likely to have a stroke than those who don't get the headaches; those with migraine who take oral contraceptives are at even greater risk. The likely reason? Changes in blood flow to the brain during an attack, which could result in dangerous clotting.
Brain lesions: Sufferers with aura are also at increased risk of developing certain types of lesions on the brain, according to research from the Netherlands. It's still unclear what these lesions mean for migraine patients, though they have been shown in other studies to increase the likelihood of stroke and dementia.
Stomach problems: Migraine can even affect your stomach. We know about the nausea and vomiting, but during an attack, many sufferers experience gastric stasis, a condition in which the stomach empties too slowly. That, in turn, slows the absorption of pain-relieving medications into the bloodstream, prolonging the pain.
Obesity: The obesity link is less defined, but in a preliminary study from the Albert Einstein College of Medicine of Yeshiva University in New York, Lipton and his colleagues found that the prevalence of chronic daily headache was higher in obese patients, who were more likely to have more severe and disabling headaches than those of normal weight. A group of researchers in Israel, who published related findings in the journal Headache in July, speculate that increased hormone production associated with obesity may be to blame.
"It's likely that exercise, because it improves endorphins, will decrease the frequency of migraine," states Merle Diamond, MD, associate director of the Diamond Headache Clinic in Chicago. But she warns that many people will feel worse before they feel better.
Bottom line: It's difficult to know for sure if, or exactly how, migraine affects other conditions. According to MaryAnn Mays, MD, a neurologist at The Headache Center at The Cleveland Clinic Foundation, migraine sufferers have a higher incidence of depression, fibromyalgia, endometriosis and other pain disorders. "But it's not necessarily that migraine causes those conditions, or that they cause migraine," she explains. "It's more likely that they're diseases that go hand in hand."