Reader's Mail Archive – March/April 2009

Constant Headache after Motor Vehicle Accident

Q: My husband was in a car accident five years ago and suffered a brain injury and many broken bones. He now suffers with constant chronic headaches which are gradually worsening over time. The doctors said all his injuries have healed and CT and MRI scans showed “nothing significant to cause headache.” All kinds of therapies and pain medications have been tried, which either did nothing or made his condition worse. The doctors don’t know why he has a terrible headache all the time.

It seems to me that there should be some kind of testing procedures available that would locate the cause of the headache. And why don’t the pain medications ease his pain?

A: Morning headaches can be from different origins. Migraine attacks typically start in the morning or wake a person up from sleep. Hypnic headaches also can wake a patient, usually between 1 a.m. and 3 a.m. These last for about one hour and typically occur in people aged 65 and older. Hypertension that is not well controlled may cause morning headaches as well. Salt does not trigger headaches, but too much salt in the diet may be responsible for high blood pressure. You should see your healthcare provider to monitor your blood pressure, especially in morning hours. The pituitary gland, if enlarged due to a tumor, may also cause headache and other symptoms.

George Urban, M.D.
Diamond Headache Clinic
Chicago, IL

Headache Causing Disability Probably Not Tension

Q: I am under the care of my doctor for headaches. After reading about tension-type headaches, I feel like these are what I have been having. I have mild-to-moderate headaches for two weeks at a time. No over-the-counter (OTC) medicine helps. My doctor gave me a sample of migraine medications, but they didn’t help. I don’t know what to do from here or how to get treatment. Exactly what should I tell my doctor so that he can help me? Do you have any advice to help prevent the headaches? I work full time and I’m a wife and mother to two kids. I can’t continue having these headaches.

A: Unfortunately, headaches are a common symptom following head injury. The headaches may occur regardless of whether the head injury was mild or severe. Headaches that persist for greater than three months following the head injury are called chronic post-traumatic headaches. Although these headaches may occur in isolation, they are often part of the post-traumatic syndrome, which consists of headaches, personality changes and difficulty with concentration, nervousness and sleeping.

The diagnosis of post-traumatic headache is made by considering the timing with which the headache began in relation to the head injury. With severe head injury, diagnostic tests such as MRI of the brain may be abnormal. Often, however, diagnostic tests are normal, especially if the head injury was mild. Recent research has suggested that injury caused by mild traumatic brain injury cannot be seen by typical diagnostic tests in many cases. Tests used in research studies can sometimes detect changes in brain structure that are very small in size, as well as abnormalities in brain function.

The treatment of chronic post-traumatic headaches is often difficult. The best approach includes a combination of therapies involving medications, physical therapy, biobehavioral therapy and cognitive therapy.

Todd Schwedt, M.D.
Washington University Headache Center
St. Louis, MO

Electric Shocks from Occipital Neuralgia

Q: My 23-year-old son has been suffering from electric shocks and other symptoms of occipital neuralgia. His life has been a living hell as his doctor only told him that he must deal with his “anxiety.” Finally his dentist referred him to a neurologist who diagnosed him with this condition.

Is there anything I should be aware of at this point? I do not want him to go on suffering as he has already been sick for eleven months.

A: Vertigo or dizziness is a symptom that can occur by itself or in association with migraine and can occur even in the absence of headache. It is thought to be a variant of migraine. Treatment is symptomatic relief using medications and rest. Spells of labyrinthitis (inflammation in the inner ear) can occur without any triggers and can last for days to weeks. Most important is to rule out any other causes. If the symptoms persist for a couple of weeks, and particularly if the symptoms are getting worse, seek evaluation (usually from an Ear, Nose and Throat specialist). Treatment typically involves use of medications, like meclizine, and possibly some specific head and neck exercises.

J. W. Banks, M.D.
Ryan Headache Center
St. Louis, MO

Headache Began Suddenly and Hasn’t Gone Away

Q: My wife has been suffering from a new daily persistent headache since January 1, 2008. At least, this is the latest diagnosis; she was first diagnosed with hemicrania continua. The headache began when she was washing dishes. Suddenly, she suffered a pain like an ice pick poking through her right eye. Since then, she has spent time in the hospital, undergone numerous CT scans and pretty much any other test you can imagine. She has also tried all of the popular migraine medicines and some not so popular. Basically, none of the doctors have known what to do.

A: Occipital neuralgia manifests as intermittent stabbing pains located at the back of the head (the occiput). Although the stabs of pain are short-lived, some people have a constant aching pain that persists between the stabs. There is tenderness and/or triggering of pain when pressure is placed on a specific area between the base of the skull and neck. This spot is where the occipital nerve is closest to the skin. Some people with occipital neuralgia find it painful to touch this area and may avoid activities like laying the back of their head on a pillow.

Although occipital neuralgia is a diagnosis that is often made by considering headache symptoms and examination findings alone, formal diagnosis is made if the pain is relieved after injecting numbing medication (and sometimes steroids) over the occipital nerve. Pain relief of any duration is suggestive of occipital neuralgia. Although this relief may occasionally persist after the injection, usually the relief is short-lived.

An experienced healthcare provider can help to differentiate occipital neuralgia from other headache syndromes that may cause similar symptoms. Occasionally, symptoms fitting the description of occipital neuralgia can be caused by an underlying problem in the head or neck. In fact, headaches caused by problems in the neck (called cervicogenic headaches) can be difficult to differentiate from occipital neuralgia unless a proper examination and sometimes additional tests (such as cervical spine imaging) are performed.

There are several therapies available that are helpful for the treatment of occipital neuralgia. These include oral medications as well as local therapies such as injections. In patients with a muscular cause of occipital head pain, physical therapy may also be of use.

Todd Schwedt, M.D.
Washington University Headache Center
St. Louis, MO

Struggling with Chronic Paroxysmal Hemicrania

Q: I was officially diagnosed with chronic paroxysmal hemicrania in 2007 and indomethacin relieved the pain. However, I also have ulcerative colitis and I had to stop the indomethacin within a year because it was too hard on my gastrointestinal system. My hemicrania headaches are becoming severe and are truly affecting my life, but I have been told that indomethacin is the only remedy for this condition. I need help before I start to literally pull my hair out.

A: Chronic paroxysmal hemicrania is an unusual headache disorder, more common in women and characterized by multiple attacks (generally from 10 to 20) of sharp pain, often around the eyes, lasting just minutes. They are always on one side and often accompanied by redness of the eye, tearing, runny nose and sometimes a change in pupil size or lowered eyelid.

Relief of the symptoms with indomethacin is universal, but your ulcerative colitis no longer allows you to benefit from this drug. Indomethacin is also available in a suppository form, but unfortunately this is probably not an option for you either. However, there is evidence that other classes of medications can be helpful. Some individuals have responded to sumatriptan. Cortico-steroids also help some patients, although long-term and frequent use of this medication is not recommended. I would suggest asking your neurologist about preventive therapies such as topiramate, gabapentin or pregabalin, which are safe for long-term use.

Tarvez Tucker, M.D.
University of Kentucky College of Medicine
Lexington, KY

Unusual Headache May Be Hypnic Headache

Q: I am an 82-year old male, in relatively good health, who has had occasional ocular migraines (15-20 minute auras without headache) over the past six years. I also get occasional sinus and tension headaches, but last night and this morning I had an unusual headache for the first time. It was on the right side of my head, above the ear, and was characterized by a pulse of pain every five seconds with a lessening of pain in between. I was faintly aware of it during the night, but much more when I awakened at 6 a.m. Its intensity slowly diminished (after some aspirin) four to five hours later.

A: Sometimes patients with migraine can have other headache types that appear later in life. Auras without headache are usually more common as one gets older.

Also, hypnic headache syndrome is a rare headache disorder that has an average age of onset of 66 years old. It is usually a two-sided (but can be one-sided) headache that lasts from 15 minutes to an hour at a time, resolving in no longer than six hours. The headache can recur up to three times a night, often during rapid-eye movement (REM) sleep. It begins abruptly, is throbbing, and usually localized in the front of the head, but occasionally affects the sides of the head or the entire head. There is no associated tearing of the eyes, droopiness of the eyelids or nasal congestion. Rarely, nausea and vomiting may occur.

Hypnic headaches tend to occur at a consistent time, usually between 1 a.m. and 3 a.m. In order for the headache pattern to meet the criteria for hypnic headache, it needs to occur for at least 15 times a month for a minimum of one month. So, if this headache pattern continues during the nighttime, it would be advisable to see a headache specialist or a neurologist.

George Nissan, D.O.
Diamond Headache Clinic
Chicago, IL

What Is Acute Cephalgia?

Q: What is the difference between migraine headache and acute cephalgia? Which one is worse?

A: Acute cephalgia is the technical term for headache, but it does not specify a cause. Migraine is a specific kind of headache characterized by two out of four of the following characteristics: throbbing, unilateral (one sided), moderate-to-severe pain that is worse with movement, and one out of two associated symptoms: sensitivity to light and sound, or nausea and/or vomiting.

Acute cephalgia can be due to migraine, but it can also be due to something as simple as sinusitis or as severe as a ruptured aneurysm. There are many causes of acute cephalgia that could be better or worse than a migraine. Migraine is just one cause of acute cephalgia.

Susan M. Rubin, M.D.
Women’s Neurology Center at Glenbrook Hospital
Glenview, IL

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