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Headaches

Headaches are one of the most common reasons that patients consult their physician. The causes of headaches are as numerous as are the ways in which they present. Most patients will already have tried the traditional over-the-counter medications for headaches prior to contacting the physician’s office. These traditional medications include aspirin or products containing aspirin (Bufferin, Excedrin, Dristan), acetaminophen (Tylenol), ibuprofen (Motrin, Advil), naproxen (Aleve), or an ever increasing list of medications in this family. Also many patients will have taken decongestants, such as Sudafed, if they feel their headaches are sinus related. Those patients that seek medical attention usually suffer from chronic headaches or those that do not respond to the traditional over-the-counter drugs. Although many causes of headaches exist, we will discuss the major classes of headaches here.

Sinus headaches result from obstruction of the paranasal sinuses due to such causes as the common cold or allergic rhinitis. The pain is usually located in the mid-facial area, the forehead, the cheeks, or between the eyes. It is classically described as a dull ache and is often associated with nasal congestion and nasal or post-nasal drainage. Simple sinus headaches with pressure and clear post-nasal drip that recur frequently are usually due to allergic rhinitis. If fever and yellow/green post-nasal drip develop, the sinuses have probably become infected and acute sinusitis has developed. If the pain and yellow/green post-nasal drip persist, the patient may have developed chronic sinusitis. In the latter condition, the sinuses have become blocked from within, due to thickening of the mucosa or polyp formation.

Allergic sinus pressure headaches are usually treated with decongestants and antihistamines. In difficult cases, nasal steroid sprays may be necessary. If these are unsuccessful, a CT scan of the sinuses may be ordered to rule out chronic sinusitis that would require surgery. If no chronic sinusitis is found, treatment would then include allergy testing and desensitization (allergy shots). Acute sinusitis is treated with antibiotics and decongestants. If the sinusitis becomes chronic, broader spectrum antibiotics and nasal

steroid sprays are used. If these are unsuccessful, a CT scan of the sinuses would be necessary, followed by endoscopic sinus surgery to clear the chronic inflammation. Often allergy testing and shots are given to prevent recurrence of the chronic sinusitis.

Tension headaches are related to stress and are due to tension in the muscles of the forehead, the temples, and the back of the head and neck. Classically the pain is described as a band of pain surrounding the head and often radiating into the neck. Most tension headaches are relieved by relaxation and over-the-counter pain medications (aspirin, Tylenol, Motrin). Severe cases may require mild narcotics or muscle relaxants. Consultation with a neurologist, orthopedist, chiropractor, or physical therapist may be necessary. Temporomandibular syndrome (TMJ) is a variant of tension headaches that produce severe pain in the jaw and a popping sensation on jaw opening due to inflammation in the jaw joint. Pain medications, warm packs, and a soft diet are used to treat TMJ. Consultation with a dentist is usually recommended.

Migraine headaches are caused by alternating constriction and dilation of blood vessels leading to the scalp, meninges, and brain. They are throbbing vascular headaches that usually affect only one side of the head at a time. There may be associated symptoms such as flashing lights and severe nausea. Migraines may be precipitated by certain foods, including those containing caffeine (coffee, tea, cola) and tyramine (cheese, chocolate, red wines, dark liquors). Mild narcotics are used if migraines are infrequent. Severe or more frequent migraines require consultation with a neurologist for further work-up and treatment. Cluster headaches are variants of migraines, which result in severe throbbing pain in the mid-facial area and are often associated with clear nasal discharge. These will require consultation with a neurologist.

Other causes of headaches include caffeine withdrawal (worse on weekends), traumatic injury (should be obvious on history), viral syndromes (associated with other cold symptoms), eye muscle strain (check need for visual correction), and more severe conditions such as tumors and bleeding within the brain. If no cause has been identified, an MRI will be necessary to rule out more serious conditions. It is important to note that more than one cause of headaches may exist. For instance, allergic sinus pressure headaches may precipitate tension headaches or migraines. Thus treating the allergies will often decrease the incidence of the other headaches.