Case of the Daily Headache - WSJ.

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HEALTH JOURNAL

March 22, 2011

Breaking the Headache Cycle

Changing Habits Can Help Ease Pain That Remains Mysterious to Doctors
By MELINDA BECK

It's 4 p.m. You've been squinting at the computer all day. The phone won't stop ringing and ... here it is again ... that tightness that wraps around your head and s-q-u-e-e-z-e-s. Tension headaches are the most common kind of headache, affecting about 40% of people in a given year. Yet they're also the most neglected by medical science and the least understood. That's in part because headache experts seldom see them. "In 20 years of practice, I can count on two hands the number of people I've seen with tension-type headaches," says David Dodick, a neurologist with the Mayo Clinic in Phoenix. Most sufferers just tough them out or treat them with over-the-counter pain killers, which are generally effective. But neurologists warn that taking such pain relievers more than 10 days a month can cause what's known as rebound or medication-overuse headaches, which have the same dull, aching pain as tension headaches themselves. "They give you temporary relief but they render you vulnerable to another attack," says Dr. Dodick, who is president of the American Headache Society, a professional group of headache experts. Exactly how and why tension headaches occur is a mystery. Much more is known about migraines, which affect only 12% of the population, but are far more severe and tend to be pulsating and one-sided. Experts used to believe that tension headaches were caused mainly by muscle tension, especially in the neck, back and shoulders. But studies using electronic sensors to measure muscle contractions found no consistent correlation between headaches, muscle tension or tenderness around the head. In fact, some sufferers had more muscle tension on headache-free days. Another theory held that the tension was emotional or psychologicala physical manifestation of anxiety and stress. But there isn't a clear correlation there either. Some people under enormous stress never get headaches, and some people get them even at times of little stress. "It's no longer clear to anybody that anything is tense," says Richard Lipton, vice chairman of neurology at Albert Einstein School of Medicine in the Bronx, N.Y., who says that realization was what prompted the International Headache Society, which officially classifies headache disorders, to adopt the term "tension-type headaches" in 1988. Now many headache experts believe that people who get tension-type headaches have a dysfunction in the pain-perceiving areas of the brain that make them overly sensitive to stimulation at times. This so-called central sensitization is also thought to be the same mechanism involved in fibromyalgia, a mysterious, widespread pain disorder. To be sure, tension headaches often involve sore, contracted musclesbut experts now think the pain perception starts in the brain and is referred out to those areas, rather than vice versa. Similarly, under this theory, stress doesn't cause the headache, but it does amplify the pain. Tension headaches often go hand-in-hand with depression, although it's not clear which comes first. "People who are depressed have increased rates of headaches, and people who have frequent headaches often become depressed," Dr. Lipton notes. A class of older antidepressants called tricyclics, such as amitriptyline (Elavil) or imipramine (Tofranil), are effective at staving off chronic tension-type headaches in many people who have not found relief with over-the-counter medications. Experts think the drugs' pain-relieving properties prevent the headaches; the dosage is usually far lower than would be used for depression alone. Tricyclics don't cause rebound headaches like other pain killers, but side effects can include drowsiness, dizziness and low blood pressure. "We know these drugs work on pain receptors, but we still aren't clear on the exact mechanism, even though they've been available for 50 years," says Merle Diamond, associate director of the Diamond Headache Center in Chicago.

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Case of the Daily Headache - WSJ.com

9/6/12 12:28 PM

Anti-seizure drugs, muscle relaxants and migraine medications may also help prevent chronic tension headaches. Doctors can select one based on a patient's lifestyle, for example, avoiding one that is sedating during the daytime, says Katherine Henry, chief of neurology at Bellvue Hospital Center in New York City. Although the precise mechanism of headache pain is elusive, plenty of things seem to exacerbate headaches in susceptible people. "A lot of the things that trigger migraines are also triggers for tension-type headaches," Dr. Diamond says. One peak time for tension headaches is early morning, which could be due in part to inadequate sleep, interrupted sleep due to obstructive sleep apnea, an awkward sleeping posture, caffeine withdrawal or a hangover. Another peak time is late afternoon, when the events of the day have people hunching up their shoulders, grinding their teeth and tensing their neck muscles. Among other office irritants: Eyestrain from staring at a computer screen and working under fluorescent lights and poor air quality in offices where windows don't open. What's more, skipping lunch can drive blood-sugar levels down, sitting for long periods of time can contribute to muscle soreness and loading up on caffeine can be counterproductive. "If you drink two cups of coffee, a soda and take two Excedrin [which contains caffeine], you are asking for a headache, and the withdrawal can be intense," says neurologist Alexander Mauskop, director of the New York Headache Center. Indeed, caffeine withdrawal is why some people experience headaches on weekends, even when the workplace stress has lifted, Dr. Henry says. Many experts advise patients who get frequent headaches to track them with a headache diary, noting when they start, how long they last and what else was going on that day. Some are even available as apps for smartphones and computers. There's also no shortage of advice for lifestyle changes that may help stave off tension headaches. Regular exercise and a sensible diet are chief among them. One recent study of 50,000 Norwegians found that those who exercised at least 30 minutes a day, five days a week, had far fewer migraines or tension headaches than those who didn't. Finding ways to relax and alleviate stresssuch as yoga, massage or isometrix neck exercisescan also help stave off tension headaches. Several studies have validated the effectiveness of acupuncture for treating tension headaches, since the needles somehow interrupt malfunctioning pain pathways. Some headache experts are also fans of biofeedback, a technique that trains people to control body functions that are normally involuntary, such as heart rate and blood pressure, to relieve tension headaches, although there too, the mechanism is not well understood. In some cases, tension headaches signal a serious health problem. About 75% of brain tumors start with symptoms that are very similar, including a dull, achiness and feeling of pressure. Still, such cases are rare, involving only about 0.5% of headaches that come to doctors' attention. A sudden, severe headache with neurological symptoms, such as difficulty thinking or numbness on one side could be from a stroke. Experts stress that people should consult a physician about any chronic headache rather than try to tough it out themselves. Many people who have frequent tension-type headaches also suffer from "presenteeism"the opposite of absenteeism, says Dr. Henry. "They keep on going, because they don't want to stop or miss work for 'just a headache.' But they don't function on all cylinders."
Email healthjournal@wsj.com.

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