THE EXPERT'S GUIDE TO BANISHING HEADACHES

From the skull squeezer to the night-waker ...

THERE was good news last week for people who suffer with severe migraine, with reports that the first new drug for the condition in 20 years, erenumab, halves the number of attacks and could be approved for use in the NHS within months.

An estimated eight million Britons suffer from migraines, and many more experience headaches at some point. But headaches are not all the same — nor is their treatment. Here, the experts explain the different types of head pain, and how best to treat them.

PAIN AT BACK OF HEAD

SYMPTOM: Dull pain either radiating across the forehead, or focused on the back of the head, typically getting worse throughout the day.

POSSIBLE CAUSE: Pain at the back of the head often occurs in people in their late 30s and early 40s and is a sign their eyes are struggling to see objects close-up as part of the ageing process, says Daniel Hardiman-McCartney, clinical adviser at the College of Optometrists. The back of the head is where the occipital lobe, the part of the brain involved with vision, is located.

Pain around the forehead tends to be caused when the eyes are not perfectly aligned — the muscles around the eye and forehead then strain to cause alignment, leading to pain. This often strikes teenagers when studying intensively or those who start using a screen more, as the eyes are unprepared for intensive reading and screen use.

TREATMENT: GPs often refer people with headaches to an optometrist to rule out vision problems. They are a good first port of call, says Daniel Hardiman-McCartney. ‘Optometrists can pick up more serious causes, such as raised pressure around the brain, by studying the back of the eye, and give advice on keeping a headache diary, so that when you go to your GP you have all the information they need to hand.’

SKULL SQUEEZER

SYMPTOM: A constant squeezing ache on both sides and all over the head.

POSSIBLE CAUSE: A tension headache is the most common form of head pain, affecting eight in ten people at some point.

Around a third will have this type of headache several times a month, according to the NHS and one in ten has one every week.

Being unable to switch off from work pressures, poor health and too little sleep increase the risk of getting tension headaches, according to a study in the journal Neurologic Clinics in 2009.

The traditional explanation is that this headache is caused by tension in the muscles of the head and neck, but this is quite rare, and the new thinking is that most people suffering frequent headaches actually have mild migraines (caused by chemical changes in the brain), says Fayyaz Ahmed, a consultant neurologist at Hull and East Yorkshire Hospitals NHS Trust.

This has implications for preventative treatment.

TREATMENT: Dr Ahmed recommends 1g (2 x 500mg tablets) of paracetamol or 200mg to 400mg of ibuprofen or the painkiller sumatriptan — available over the counter as Imigran Recovery.

If that is not sufficient and your GP decides it is a mild migraine, they can prescribe preventative medication which includes the antidepressant amitriptyline, which blocks serotonin, a brain chemical thought to play a key role in headache and migraine.

Under NICE guidelines, doctors may refer patients for up to ten acupuncture sessions to help prevent chronic tension headaches.

THE FACE ‘EXPLODER’

SYMPTOM:

Throbbing pain behind the cheeks, nose and around the eyes, usually on one

side of the face, that’s worse in the morning.

POSSIBLE CAUSE: Sinusitis — where the small air pockets in the skull that allow air and mucus to flow through the nose, become infected. The lining of the sinuses becomes inflamed, leading to a painful build-up of pressure. Sinusitis often occurs with other symptoms of infection such as fever, and green and bloody discharge from one nostril.

People often blame headaches on their sinuses but Nick Silver, a consultant neurologist at the Walton Centre NHS Foundation Trust in Liverpool, suggests 90 per cent of headaches blamed on sinusitis are caused by something else. TREATMENT: Inhaling steam, to loosen mucus and clear sinuses, may be helpful for sinusitis-induced headaches, along with over- the- counter painkillers such as paracetamol and ibuprofen, says Professor Anne MacGregor, a specialist in headache and women’s health in the NHS and Harley Street.

Over-the- counter decongestants can be helpful but should only be taken for a few days or they can make the problem worse, she adds.

That’s because decongestants narrow vessels in the sinuses that produce mucus, and when the effect wears off, the vessels rapidly expand, causing a sudden increase in mucus production, so people take more decongestants, and it causes a cycle.

If it persists, go to the doctor to discuss whether it could be a different type of headache, such as a migraine.

POST-EXERCISE HEADACHE

SYMPTOM: Pulsating pain on both sides of the head during or after intense exercise

POSSIBLE CAUSE: Post- exercise headaches are believed to be caused by the increased blood flow enlarging the brain’s veins and arteries, triggering pain.

A Norwegian study published in the journal Cephalalgia found that 12 per cent of headache sufferers studied had exertion headaches. Exercising in hot temperatures makes headaches more likely.

It usually happens when people who are not particularly fit increase their exercise levels, says Peter Goadsby, director of the NHS National Institute for Health Research and professor of neurology at King’s College London. Those affected should see a doctor to rule out more serious causes of the pain.

TREATMENT: Ceasing exercise will generally see headaches

wear off, though they can last from a few minutes to two days. Increasing exercise gradually can help prevent the headaches returning.

‘If people take it easier, then generally it settles within six months spontaneously,’ says Professor Goadsby.

The prescription-only painkiller indomethacin, thought to turn off the nerves that transmit pain signals, can be taken — usually at 25 to 50mg — before exercise, after checking with your doctor, to prevent the headache.

DOUBLE-SIDED HEAD SQUEEZER

SYMPTOM: A constant dull squeezing ache on both sides of the head that occurs most days and is often worse in the morning. POSSIBLE CAUSE: Using pain relief medicine to treat headaches more than two or three times a week can lead to more headaches, says Brendan Davies, a consultant neurologist at University Hospitals of East Midlands NHS Trust and a trustee of the Migraine Trust.

It’s thought that the painkillers increase the sensitivity of nerves in the brain, which then respond to the stimulus for headaches such as stress and poor sleep. Up to 2 per cent of the population may have this type of headache, according to a 2014 review published in the Journal of Pain Research.

Dr Davies says about 40 per cent of the patients he sees at his clinic have medication- overuse headaches, adding that while any painkillers taken for more than ten days a month can cause this pain, combined products, such as Anadin Extra and triptans, which treat headache and migraine, are most likely to cause problems, although it is not clear why.

‘ This is such a common but unrecognised reason for people suffering the frequent misery of headaches,’ says Dr Davies.

TREATMENT: Speak to your GP if you think this could be your problem. They may advise you to stop all painkillers for a period of six to eight weeks to see if the headaches reduce. But be aware that head pain can increase for the first week or so, before improving.

AGONISING ONE-SIDED ACHE

SYMPTOM: Agonising one- sided headache, drooping eyelid, blocked or running nose.

POSSIBLE CAUSE: Cluster headaches are said to be one of the most painful conditions that can be experienced. Unlike migraine, it affects five to six times more men than women (which means it can take longer for women to get a diagnosis, says Dr Davies). These headaches usually last between 15 minutes and a few hours, happen up to eight times a day and occur in bouts of four to 12 weeks. They appear to be linked to the hypothalamus area of the brain.

TREATMENT: About 90 per cent will get some or complete relief during an attack by inhaling oxygen from a tank. Sumatriptan injections and nasal sprays, which block the transmission of pain in nerves, are also used as a frontline treatment. Preventative drugs include high doses of verapamil, a drug developed for high blood pressure and heart conditions, and lithium, most commonly used to treat bipolar disorder.

POUNDING ALL-OVER PAIN

SYMPTOM: Throbbing pain around the head for several days.

POSSIBLE CAUSE: Skipping your usual coffee can bring about caffeine-withdrawal symptoms, including headache. This can occur a few hours after your last cup and last for up to three days. It’s thought the caffeine helps over-sensitise the brain’s nerve cells.

The more coffee you drink the greater the headache when it’s withdrawn, a 2009 study published in Psychopharmacology revealed.

TREATMENT: Dr Silver advises anyone who suffers from headaches or migraine to give up caffeine — including coffee, tea, green tea, chocolate, cola and energy drinks.

Symptoms such as head pain and sleep disturbance can worsen for up to a week afterwards, but should then start to improve.

‘If I could choose one thing to improve the way people feel in the UK, I would ban caffeine and painkillers,’ says Dr Silver.

However some doctors point out that caffeine can have a beneficial effect for some types of headache. It is also often included in tablets with painkillers such as paracetamol and ibuprofen, as it boosts their absorption by the stomach.