Google ‘headache’, and you will very likely convince yourself you have a brain tumour. The list of worrying diagnoses that can cause a headache is staggering. These, however, are the rarities. As unpleasant and annoying headaches can be, the vast majority are safe and best of all treatable. In fact, headache is not even listed as a symptom in the 2015 NICE guidelines on early diagnosis of cancer.
When we see people attending the surgery with a headache it is usually because it is not going away, keeps coming back, or is severe and upsetting. Sometimes the headache will be joined by other symptoms like nausea, visual changes such as blind spots or sparkling jagged lines and even numbness in the body or slurred speech. When these headaches occur repeatedly, and last (anything up to 72 hours) we have a bona fide case of Migraine.
Though a miserable and upsetting type of headache, migraine is very treatable. We are very lucky these days, as we have at our disposal several interventions, both medical and non-medical that can reduce or stop these unpleasant episodes.
First things first. A migraine is not a ‘bad headache’. Bad headaches are not nice, but migraines can be agonising. For many migraine sufferers, the onset of an episode means their day is over. No soldiering on, no taking it easy at work. If they are lucky, an individual will have only a grimace-inducing headache and profound lack of energy but otherwise be reasonably okay if left to rest.
For some, however, it can mean instant vomiting, temporary near blindness, slurred speech, weakness in the arms or legs, and worst of all: a headache that renders you a moaning heap in the corner of a darkened room. I have personal experience of this – describing the pain is not easy, but it is somewhere between a very bad hangover and a constant hammer blow to the head. The physical symptoms that present before the pain is known as an aura, and for most a sequence of symptoms, one followed by the next culminates in a headache which may last hours. When it is all over it can feel like you have run a marathon – washed out and delicate.
An interesting feature of migraine is that for some, the headache never comes. In these cases it is the aura arrives, usually with strong visual elements and perhaps some tingling in the arms or around the lips, then it passes.
Migraine for many is triggered by specific actions: drinking wine, eating chocolate, sleeping in too late, stress, onset of your period… If we can identify the trigger, avoidance is sometimes enough to ‘cure’ the problem. This can be difficult but is worth the effort. In the case of menstrual migraines, starting treatment when the period is expected can remove the effect of this trigger. Where no trigger can be found, we start to consider treatment options.
Migraines are fairly tolerable if they occur once or twice a year, but for some, it can be weekly or even daily. In the past, this could be incapacitating, with strong pain relief the only way to function. With increased understanding of the mechanism of migraine, we are now able to offer preventative treatments including daily medicines and even acupuncture, or ‘as required’ medicines to terminate the episode rather than slightly dulling its effects. This is a real advancement in managing this condition and for many, it means the onset of another episode is a non-issue. For the milder migraine, or where the preventative does not work, we still rely on pain relief and anti-nausea treatments to ease symptoms.
When painkillers are the enemy
A well-recognised scenario involves a new headache and some sensible thinking. When pain strikes, a quick dose of paracetamol can settle things and we get back to our day. But if the pain continues or worsens, we naturally consider something stronger. Over the counter, it is simple to purchase paracetamol with codeine. It is stronger and the pain settles better, although we may get a little constipated due to the side effects.
Now what if the pain returns?
Well, a good idea might be to look at possible causes or ask a doctor. Inevitably though some people chose to take more paracetamol and codeine – after all, it worked so well last time. The pain settles, and on we go. When the headache rears its head again, more pain relief. Before we know it the only way to keep the pain at bay is with 4 doses a day which is the maximum. After a while, the pain creeps back in, and never fully resolves, even with all the painkillers. What a headache!
What has gone wrong?
‘Analgesia induced headache’ is a well-recognised paradox. Essentially it is where overuse of painkillers for headache causes…headaches. It can be an easy trap to fall in to. The initial trigger for the headache is long gone, whether it was a mild migraine, a day or two of stress, a mild hangover, muscle tension, straining the eyes etc. But step by step the painkillers were needed and have now been around too long, triggering pain instead of settling it. It is a fairly common cause of chronic headache and one to be mindful of. Some simple advice is all we dispense in such cases.
When to worry
Though it is always worth seeking help with a persisting or recurring headache, there is generally no urgency. On the other hand, there are one or two symptoms we regard as red flags – NOT TO BE IGNORED. This is because they hint at a potentially serious or time-sensitive diagnosis. If these occur contact your GP or attend A&E asap:
Sudden severe headache reaching maximum intensity within a few minutes
New headache associated with neurological symptoms – things like weakness, altered speech, altered vision
Headache following head trauma (Within past three months)
Headache caused by coughing, sneezing or exercising
Headache with painful or red eye(s)
If you believe you may have migraines, or any headache of concern, feel free to come and discuss your symptoms with us.
Dr James Hunt