How to battle EVERY kind of headache

GOOD HEALTH FORLIFE

PAIN is the most common reason for a GP appointment — not surprising, given that up to half of all Britons live with daily pain. Today, the second of our expert guides to managing pain tackles headaches and migraines.

WHETHER it’s a dull ache or a stabbing sensation, headaches affect most of us at some point — and for some people they’re chronic.

If you have headaches often, keep a diary, says Peter Goadsby, a professor of neurology at King’s College London. ‘The first rule is to know what you are treating. Keeping a headache diary can help you identify patterns and key symptoms,’ he adds.

Here, Professor Goadsby and other top specialists offer their tips on diagnosing and treating your head pain.

YOUR HEADACHE FEELS LIKE: A TIGHT BAND AROUND YOUR HEAD

COULD BE: A tension headache. OTHER SYMPTOMS: ‘A tension headache feels like someone is putting a band around your head and squeezing it,’ says Dr Fayyaz Ahmed, a consultant neurologist at Hull University Teaching Hospitals NHS Trust and trustee of charity The Migraine Trust.

‘It can be severe, but is usually mild and not disabling and people can still function while having one.

‘They can last hours, but if you have headaches 24 hours a day, seven days a week, it’s unlikely to be due to tension.’ CAUSE: Tension headaches are the most common headaches, accounting for more than 90 per cent, says Dr Ahmed.

‘Triggers such as stress and tension cause the muscles attached to the pericranium, the fibrous membrane that lines the surface of the skull, to go into spasm. Pain can be felt at the back of the head, forehead and temples.

‘They can also be caused by hormone or other imbalances — such as a flood of noradrenaline, which is released when we are under stress — and dehydration, which causes the “ hangover” headache,’ adds Dr Ahmed.

Other triggers include poor posture, lack of exercise, bright light, squinting, eyesight issues, hunger and certain smells. TREATMENT: Most tension headaches can be treated with paracetamol or ibuprofen, says Dr Ahmed. ‘ But I’d discourage those combined with caffeine or codeine, as these can cause [withdrawal] headaches of their own,’ he adds.

‘ You could also try a cold compress to the forehead. There are pain receptors on the blood vessels in the head and pain is caused when these blood vessels dilate. The cold compress is thought to relieve pain by constricting them. Cold also relaxes muscles, as can applying heat at the back of the head.

‘Headaches respond to lifestyle changes to reduce stress, such as getting enough sleep, and headaches caused by dehydration respond to fluids. People who see a doctor about headaches mainly want reassurance, but for chronic headaches we may prescribe the antidepressant amitriptyline or the beta-blocker propranolol to dampen chemical messengers such as noradrenaline.’

ONE-SIDED PAIN WITH NAUSEA AND FATIGUE

COULD BE: Migraine. OTHER SYMPTOMS: ‘Migraines are usually crushing headaches that make you feel sick, but they come in all shapes and sizes,’ says Dr Ben Turner, a consultant neurologist at Barts Health NHS Trust and the private London Bridge Hospital.

‘My best diagnostic test is to see if a headache stops someone working — with a migraine, you tend to be immobilised and want to lie down in the dark.’

Around a third of migraines will have the classic ‘aura’ symptoms of nausea, fatigue, noise and light sensitivity and visual disturbances, and sometimes these symptoms happen without the headaches — a ‘silent’ migraine. CAUSE: Migraine is the second most common type of headache. It is estimated that there are 190,000 migraine attacks every day in the UK, and they’re experienced by more women than men — probably due to fluctuating hormone levels.

‘A migraine is usually a headache with some other feature,’ says

Dr Jessica Briscoe, a GP and headache specialist at the National Migraine Centre charity in London. ‘They tend to be under - diagnosed as people dismiss them as “bad” headaches and don’t see a doctor.

‘We don’t entirely understand what causes them, but think nerves in the head start misfiring — this hyperactivity starts in the mid-brain and fans outwards towards the peripheral nerves in the back of the head, neck or shoulders. Genes also play a role, as migraines tend to run in families.’ TREATMENT: Initially, migraines can be treated with the same methods as tension headaches, advises Dr Ahmed.

Migraines are also classically treated with triptans, which affect the action of a chemical messenger called serotonin. A Finnish study in 2016 showed that serotonin ’ s effect on nerve endings could trigger migraine. Triptans are taken at the first signs of a migraine as pills, jabs or nasal sprays.

New drugs called calcitonin gene -related peptides ( CGRPs), which target neuropeptides, brain chemicals involved in migraines, are currently available on the NHS only as part of trials. The first of these, erenumab, is a once -a-month self - administered injection.

This class of drugs is ‘revolutionary’, says Dr Giorgio Lambru, a consultant neurologist at Guy’s and St Thomas’ NHS F oundation Trust and the private London Bridge Hospital. ‘They block either the receptor or the protein CGRP that is released by nerve endings in the head during migraines — the antibodies reduce inflammation of the nerve endings, dampening brain activity . They work in 40 per cent to 60 per cent of cases.’

But last week , erenumab was rejected by the National Institute for Health and Care Excellence (NICE) for use on the NHS due to its cost. It has, however , been approved for use in Scotland by the Scottish Medicine Consortium and is available privately.

Botox is another option, though its mechanism is not fully understood. It has been approved by NICE since 2012 for migraine patients who have not responded to three drug treatments and are having headaches on 15 days a month. Injections are given every three months.

Some patients may be offered transcranial magnetic stimulation (TMS), where the patients themselves administer a magnetic pulse to the back of the head from a handheld device to calm ‘excitable’ nerve cells.

IT FEELS LIKE YOUR HEAD’S IN A VICE, WITH BURNING EYES

COULD BE: Cluster headache. OTHER SYMPTOMS: Headaches tend to centre around the eyes and there is a sharp, burning, or piercing pain. Other key symptoms can include a bloodshot eye or eyes, a droopy eyelid, a sweaty face, flushing and a runny or blocked nose.

‘Those affected feel restless and agitated; they will rock , pace or start digging the garden,’ says Dr Ahmed. CAUSE: ‘These are said to be the worst type of headache to affect mankind,’ says Dr Ahmed.

‘Thankfully they cause less than 0.1 per cent of all headaches, affecting an estimated 66,000 people in the UK, but they are so bad some people have taken their own lives — people describe it as like they have their head in a vice.’

Also known as clockwork headaches, they tend to run in families and are more common in smokers, though it ’s not known why. Men are more likely to be affected than women at a ratio of almost three to one.

Attacks last between 15 minutes and three hours and sufferers can get up to eight attacks a day, every day for months. They tend to strike like clockwork at certain times of day — and even on certain days in a week.

Not much is known about the cause, but it may involve some type of malfunction in the hypothalamus, the brain ’s master clock , which controls many functions, including the sleepwake cycle. TREATMENT: ‘Pure oxygen is the best treatment — the NHS provides a home oxygen service, delivering canisters to you,’ says Dr Ahmed. You inhale it through a mask during an attack . Oxygen causes constriction of blood vessels, thought to relieve pain.

Other treatments include sumatriptan, which works in the same way as triptans for migraine, and lately gammaCore, used to stimulate the vagus nerve, which carries pain messages between the brain and major organs. The device is applied by the patient to the neck to deliver a small electric current for two minutes at a time.

A DULL ACHE THAT’S WORSE IN THE MORNING

COULD BE: Medication overuse ‘rebound’ headache. OTHER SYMPTOMS: The headache is dull and constant, and you will have been taking painkillers. CAUSE: It may sound counter - intuitive, but if you take painkillers for a long period you may develop a medication overuse headache, where the withdrawal effects of the painkiller wearing off induce a headache.

People who take painkillers two or three times a week or for more than ten days a month are at high risk of developing these headaches. Drugs associated with them include codeine, paracetamol, caffeine, and triptans.

Dr Ahmed says: ‘ Around 1 per cent to 2 per cent of headaches are caused by medication overuse. It can be a very difficult cycle to break and patients can be quite resistant to the idea of giving up taking their painkiller.

‘The opioid painkiller codeine is the worst for causing these types of headaches, which is shocking as it’s available to buy off-the-shelf in products such as co - codamol [ codeine phosphate and paracetamol combined].

‘If the Medicines and Healthcare products Regulatory Agency could do just one thing , it should be making all codeine products prescription-only.’ TREATMENT: ‘If you have a medication overuse headache there’s no point taking any other drugs as they won’t work — the withdrawal will always cause a headache,’ says Dr Ahmed. ‘I have to tell people they will get worse before they get better. Stopping abruptly is the best way. People may need to take time off work to adjust.’

AN EXCRUCIATING BOLT FROM THE BLUE

COULD BE: Thunderclap headache, also known as sex headache. OTHER SYMPTOMS: These are sudden onset, excruciating headaches

which often coincide with vigorous activity. ‘The pain peaks within a minute and it feels like you have been hit over the head,’ says Dr Ahmed. ‘ This is followed by aura symptoms, such as nausea and light sensitivity, and a stiff neck.

‘They tend to come on with activities such as sex, lifting weights or running.’ CAUSE: ‘An unusual type of migraine — or a bleed on the brain,’ says Dr Ahmed. ‘A less common cause is a blood clot in the veins of the brain.’ TREATMENT: ‘You should go straight to A&E as there is a one-in-eight chance it could be a symptom of a bleed on the brain,’ says Dr Ahmed. ‘There is no way of knowing from the symptoms alone.’

PAIN THAT HITS WHEN YOU STAND UP

COULD BE: Postural headache. OTHER SYMPTOMS: The pain is most severe at the back of the head and worsens through the day. These come on when you switch your position, and sometimes occur with a racing heart. CAUSE: Switching position can cause a change in blood pressure in the head, creating a headache.

Other possible causes include postural orthostatic tachycardia syndrome (PoTS), which triggers an abnormal increase in heart rate usually after standing up. This occurs because the autonomic nervous system, which regulates bodily function including blood pressure, doesn’t work properly, causing a drop in blood supply to the brain and head pain.

Other possible causes of headache when you stand include a leak of cerebrospinal fluid (CSF), or a tumour. TREATMENT: ‘Simple manoeuvres can be used to restore blood pressure, such as closing your mouth, pinching your nose and bearing down [ like when you go to the loo],’ says Dr Jessica Briscoe.

But you should see a doctor and ask for your symptoms to be investigated. A tilt-table test can diagnose PoTS. The patient is strapped to a table attached to an ECG monitor, to measure their heart’s electrical activity and blood pressure, and tilted to a 60 to 90degree angle.

Drugs for PoTS ( prescribed off-label — they are not licensed for it) include beta-blockers and a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs).

The CSF Leak Association says the condition can be treated with bed rest, intravenous fluids and injections into the spinal fluid to clot over the leak and patch it — as well as fibrin glue to mend the leak, or surgery.