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    Headaches are a normal part of life. Even migraines are prevalent among the general population.

    People who regularly get tension headaches and migraines but feel okay in between those typically don’t have anything to worry about, said Stephen Silberstein, professor and director of the Jefferson Headache Center. It’s when you’re dealing with unusual headaches that you want to take note of.

    “If the headache feels different than it usually does or if it’s the first time you’ve had this type of headache, then it’s important to look more closely at what’s going on,” Silberstein told HuffPost.

    These types of headaches are called secondary headaches, according to Merle Diamond, president and managing director of the Diamond Headache Clinic in Chicago and member of the National Headache Foundation. And while they only make up about 3 to 4% of all headaches reported, they can signal some severe health concerns.

    Below, experts share the major red flags that your headache may be more than just run-of-the-mill pain and what to do if you start to experience one of these types of pain.

    An extremely painful headache out of the blue

    It’s smart to pause when this happens, especially if you don’t usually get headaches.

    “Head pain that happens really fast and is really bad could be the sign of a brain aneurysm,” Diamond said.

    During a brain aneurysm, the blood vessels in your brain start to bulge due to weakness in the vessel wall. As blood continues to build up, it can lead the vessel to leak or rupture into the brain, causing a stroke. This type of headache is often referred to as a thunderclap headache, which is named for its painful and sudden nature, Silberstein said.

    It’s important that if you have this type of pain you contact your doctor immediately or go to an urgent care centre or hospital to get evaluated.

    New head pain that’s worse in the morning

    Some people may assume that sudden headaches can be a sign of a brain tumour, but Diamond said this isn’t usually the case.

    Headaches associated with tumours are often localised to the part of the brain where the issue is, Diamond said. With a tumour-related headache, you might also notice that your head pain is persistent, and that it’s worse in the morning.

    A headache along with other symptoms, like a fever

    Dealing with a headache on top of a fever, rash or stiff neck could be a sign of a viral infection such as meningitis.

    “This is an acute bacterial infection of the lining of the brain,” Diamond said. “Even if you typically suffer from headaches, it’s important to take note of what else is going on in the body so you can seek care if you need to.”

    The same goes for a headache accompanied by a fever and other symptoms such as a loss of taste or smell, chills, shortness of breath or fatigue. This could be an indicator of a coronavirus infection.

    Headaches that come and go when you stand up or get worse over time

    These types of headaches may indicate too high or low pressure in the head, Silberstein said. Similarly, if you have a headache that is getting worse over time, that can be a red flag for a variety of issues and it’s best to get it checked out. In general, any chronic pain should not go unaddressed.

    Headaches that appear after a certain age

    Something else to keep in mind is your age.

    “If someone is 50 years or older and has never had problems with headaches before, this could be something called giant cell (or temporal) arteritis,” Silberstein said.

    This is when the arteries around the scalp become inflamed, leading to vision problems, scalp tenderness and jaw pain in addition to severe headaches.

    If you’ve had headaches your whole life but now they’re suddenly different, you’re experiencing what’s known as a “fundamental change” and should get medical attention.

    “Let’s say you are 40 years old with a new onset of a completely different headache or a change in symptoms,” Diamond said. “You need to let your medical provider know this, because now the characteristics of your headaches has changed, and we need to figure out why.”

    How to get the right care for your headache

    In an effort to make things easier for yourself when you get a headache, here are some guidelines on what kind of care you should seek and when:

    If your head pain is associated with a neurological issue, get emergency care.

    This includes issues such as blurred vision, weakness in an arm or leg and/or slurred speech. Go to a hospital and get evaluated.

    If your normal headaches have changed, don’t hesitate to call your doctor.

    Your GP should be aware of any fundamental change in the type of head pain you typically experience. “If for some reason they can’t see you right away, don’t be afraid to go to an emergency room or [urgent care],” Diamond said.

    For headaches that are persistent but mild, bring them up at your next appointment.

    Make sure to mention them your doctor so they can help you find relief and monitor accordingly. “If you have a headache you’ve had all your life and this one feels worse than normal, that’s not necessarily a warning sign,” Silberstein said. “But if you suddenly have a headache that comes on with no other reasons, that’s a warning sign you need care fast.”

    The science of headaches | Understanding and managing pain better

    A searing pain around the eye and on one side of the head wakes up Niranjan on most nights. It lasts between 15 minutes to an hour and on some days returns after short periods of respite.

    It took Niranjan seven years, multiple doctor visits, a battery of tests and hours of internet research to figure out that he has a condition called cluster headache.

    Dr Pravin Thomas

    Dr Pravin Thomas  

    Considered to be one of the worst headaches (affecting one out of 1,000 individuals), it is also called suicide headache. “Some people end their lives because they cannot bear it anymore,” says Dr Pravin Thomas, founder and chairman of the World Headache Society (WHS) and Consultant Neurologist and Chief of Headache Medicine, Basildon and Thurrock University Hospitals, NHS Foundation Trust, UK.

    The cluster is apparently one among 300 different types of headaches, based on the classification by the International Headache Society (a London-based organisation that helps people suffering from headaches). The WHS, that promotes headache science through a network of medical practitioners across the globe, has launched a first-of-its-kind certification course in headache medicine in collaboration with the All India Institute of Medical Sciences (AIIMS), New Delhi.

    (Dr Pravin, who specialises in pain management, is an Honorary Clinical Teaching Fellow at the Queen Square Institute of Neurology, UCL, UK and a visiting professor at the SVYASA University).

    Excerpts from an interview with Pravin Thomas:

    Why do we need a certification course in headache medicine?

    The World Health Organization and the Global Burden of Diseases mention from time to time, that migraine is not only the most common neurological illness but also the most misdiagnosed and mismanaged condition. The disability of chronic migraine is compared to that of paralysis and schizophrenia. Data from around the world shows headache neurology is a minuscule part of MBBS and Post Graduate syllabus.

    The course is meant for MBBS and BDS doctors and soon in the future will also be open to AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) doctors, specialist nurses, physiotherapists, and clinical pharmacologists.

    What are the dangers of self-medication or the excess use of over-the counter-drugs to treat headaches?

    It depends on the type of headache. In case of migraine, overuse of painkillers can lead to perpetuation of headaches and chronic migraine. For other types of headache, the danger of over-the-counter medications can lead to missing the diagnosis and may even cost the life of the individual, along with other medication side effects and costs.

    What are the most common types of headaches?

    The most common type, of course, is migraine. Then there are those which mimic migraine, but are more life-threatening. It is important to diagnose, classify and treat head aches properly.

    Headaches are broadly classified as primary — those with normal brain scans and other tests, and secondary — with an abnormality that can account for the headache. A common cause of primary headache is the cluster headache while viral infections, including COVID-19 can cause secondary headaches. This apart, neck and face pain could also be reasons.

    Can altering lifestyle/food choices help in preventing/managing headaches?

    To some extent, yes, if we are able to control our regular eating and sleeping habits. Certain compounds like monosodium glutamate found as additives in food, or consumption of alcohol can trigger migraines. Some individuals have specific food triggers but more often than not, it is the deviation from the routine that causes headaches. Then there are the uncontrollable factors as well, such as the weather or the work environment. Sometimes slight modifications and adjustments help to contain the trigger.

    Does Yoga help in managing headaches?

    The traditional way of doing yoga does help to some extent. There is no evidence yet if modern day variants such as power or gym yoga are beneficial. A study done at the AIIMS using a series of yogasanas and breathing practices (Pranayams) found it beneficial when done along with the conventional treatment. There are several wellness practices which have gone into oblivion in many of the countries represented in the World Headache Society. Our aim is to also revive the forgotten wellness practices in other countries and couple them under headache treatment, if found effective.

    Are headaches common among children? What should parents do to help them cope?

    Headaches are common in children but their symptoms for migraines can be unique and different. They may not actually get a headache but have abdominal pain, vertigo, loss of consciousness and vomiting and are usually made to undergo tests for the alimentary tract. When the tests come negative, unfortunately, they are blamed for malingering their illness out of laziness to go to school. Or it is treated as a psychological problem. It is important to be sensitised about headache syndromes in children so that they do not suffer loss of education and are not subjected to unnecessary tests.

    Are women more prone to headaches than men?

    Yes, migraine is more common in women. Some headaches are more common in men. Genetics and hormones play a role in some migraines, which account for some of the gender differences.

    Pain is subjective. Is there a scale to measure pain? How do doctors quantify pain?

    Pain always remains subjective. It is the patient’s experience. It is difficult to quantify experiences like hunger, desire and pain. Assessments are possible but they can never be accurate. A pain perceived as a needle prick may be given a 2/10 severity score by one individual and the same needle prick may be felt as 9/10 by another individual. Tolerance to pain is dependent on genetics and also the environment of the individual and how the individual was moulded.

    What are the long-term goals of WHS? With special reference to India?

    India and several other countries we represent, are in a stage of transition. We have reached great heights in some fields yet there is a lot to desire for. For instance there are 17,000 neurologists in the USA for a population of 330 million, while there are only 1,200 neurologists in India for a population of 1.3 billion. Therefore there is a huge unmet need for training our clinical workforce in headache neurology so that they can safely and competently practice headache and facial pain management. We aim to educate clinicians and empower patients in all the countries we represent.

    Could you tell us a bit more about the headache certification course?

    This headache and facial pain certification course is perhaps the first of its kind in the world. It is open to both MBBS and BDS doctors, for a fee of ₹2,000. The fee is expected to cover some of the administrative expenses over 1 year, such as learning management system, webinars, office staff salaries and conduct of written and viva exams. The surplus amount would be donated to charity.

    Those in distress or having suicidal tendencies could seek help and counselling by calling 044 24640050.

    Prevention: The Future of Migraine Therapy

    Taking a shower hurts. Shaving hurts. Even your hair hurts when you’re in the throes of a migraine headache.

    Until a few decades ago, people had little more than aspirin to fight the throbbing, debilitating pain of a migraine headache. Then, in the 1980s, researchers developed strong drugs to halt migraine pain once it begins. But those drugs have serious side effects. Some people cannot take them if they are at risk for heart disease or other conditions. Also, if the drugs are not taken within the first hour of migraine headache pain, they don’t help much.

    These older drugs are still prescribed. But more recently, the approach to taming this lion has made a 360-degree turn. Now, prevention is the focus. It involves disabling a migraine headachebefore the pain ever begins. One method is to take non-migraine drugs daily to help prevent a migraine from starting. The drugs affect brain chemicals or blood vessel inflammation that lead to migraines.

    Another is to fine-tune treatment for each patient. The goal is to take fewer drugs, avoid many side effects, and have better control of the beast. For example, you become aware of your pattern of getting a migraine headache, learn what triggers it, and take certain drugs during your own window of vulnerability – that is, the brief window of time you can most benefit from a drug.Finding Your Migraine’s Window of Vulnerability

    The FDA is currently reviewing a new migraine drug called Trexima, which combines the migraine drug Imitrex (sumitriptan) and naproxen sodium (a nonsteroidal anti-inflammatory drug) contained in Aleve and other over-the-counter medications. The triptan prevents blood vessels from dilating. This dilating leads to migraine pain; the anti-inflammatory drug prevents release of an inflammation-triggering enzyme, according to product developers.

    Also in the pipeline: A drug that shows promise as both in preventing migraines and in stopping a migraine once one starts, says George R. Nissan, DO, director of research for the Diamond Headache Clinic in Chicago. The drug works by inhibiting a protein released during inflammation, called calcitonin gene-related peptide (CGRP). CGRP is found in high levels in migraine patients.Continued

    “We’re looking for migraine drugs that don’t have the limitations or side effects of antiseizure or blood-pressure-lowering drugs,” Nissan tells WebMD. “CGRP doesn’t cause constriction of blood vessels, so there would be fewer worries for patients with heart disease, and fewer limitations on its use. However, it may take years until we see it FDA-approved.”Continued

    Stephen Silberstein, MD, professor of neurology and director of the Thomas Jefferson University Headache Center in Philadelphia, has led pioneering studies into this “window of vulnerability” during a migraine headache.

    For certain people, especially women with menstruation-related migraines and others whose triggers are well-defined and predictable, this pre-emptive approach is indeed the future, he tells WebMD. “More studies are looking at taking preventive drugs during that brief window. For patients, it’s a matter of getting tuned into your particular pattern.”

    For those who can’t take medications or aren’t happy with them, a few supplements also show promise for preventing migraine headaches. “In my own practice, I recommend these if there are at least two well-controlled clinical trials showing benefit,” says Sarah DeRossett, MD, a neurologist and migraine specialist in Atlanta. “Magnesium, riboflavin (vitamin B-2), and coenzyme Q10 all fit those criteria.”Migraine Headaches Connected to Hormones, Lifestyle

    To understand how all this works, it’s helpful to know how migraine headaches develop. The tendency to get them is inherited. They plague teen girls and adult women especially, although a small number of young boys and adult men get migraines as well, researchers say.Continued

    Female hormones such as estrogen influence migraines, though it’s not clear why. The drop in estrogen levels that occurs a few days before a normal menstrual period seems to increase the chances of a migraine, possibly by priming blood vessels in the brain.

    If a woman is taking birth control pills, their headaches are most likely to occur during their “off week,” when estrogen levels drops. Some women start getting migraines only at menopause, when their period stops. For others, menopause is the first real relief from migraines.

    Lifestyle and environment can also trigger migraines. Weather changes, altitude changes, bright lights, sleep problems, stress, smells, cheeses, caffeine, monosodium glutamate (MSG), nitrates, or aspartame are just some of a long list of potential triggers. Every migraine patient has their own headache trigger pattern.Continued

    The evolution of a migraine starts with this trigger: When your brain perceives the trigger, it begins a cascade of events. The headache will start developing within two hours or two days. In the beginning, blood vessels in your forehead start to swell up. This causes nerve fibers, which are coiled around the blood vessels, to release chemicals causing pain and inflammation.Continued

    A vicious cycle develops: The inflammation makes the blood vessels enlarge even more, making the pain only worse. When this chain-reaction process goes on for an hour or two, it achieves a new threshold.

    “It’s called ‘central sensitization,’ and it tends to perpetuate the headache,” explains Seymour Solomon, MD, director of the Montefiore Headache Unit at Albert Einstein College of Medicine in the Bronx, N.Y. At that point, the chain-reaction of pain begins traveling along nerve pathways throughout the head, to the base of the neck and to the spine.

    That’s when everything starts hurting, Solomon tells WebMD. The pain-nerve cells are stuck in the “on” position. The slightest touch or movement hurts. Even the pulse of blood in your brain causes pain. Your intestinal system gets thrown out of whack, too, by the onset of nerve chemicals. You feel nauseous, you throw up, you get diarrhea. Your hands and feet grow cold. The color drains from your face.

    There’s nothing pretty about having a migraine.Continued

    Not everyone has this threshold or central sensitization effect, researchers say. Luckily, these patients can take existing painkillers such as Motrin, Advil, Excedrin, or certain prescription pain drugs. These are nearly 100% effective in kicking their headaches, says Solomon.

    But most people with migraines need more effective drugs. They must take them before the headache lasts an hour. After that, some relief will come, but usually not enough.

    Too many people ignore those very early symptoms, Solomon tells WebMD. “These people get lots of headaches, which are often tension headaches, and they hope against hope that this one isn’t a migraine. So by the time the window is past, it’s too late to stop it.”Continued

    In the early days of migraine research, a class of drugs called ergots (short for ergotamines, such as dihydroergotamine or DHE) was aimed at stopping migraine pain in progress. Then came the triptan drugs, which were even more effective at halting pain. They include:

    Both ergot and triptan drugs are still prescribed today, Solomon says. However, because both drugs work to constrict swollen blood vessels, not all patients can take them. “If a patient has heart disease or high blood pressure, they just can’t take those drugs,” he tells WebMD.Preventing Migraines in the First Place

    More recently, to try to stop migraine headaches from developing at all, doctors have prescribed drugs used to treat other disorders. These drugs are taken daily to suppress the brain chemical or blood vessel activity that leads to migraines. The hope is to prevent a migraine from getting started. These drugs include:

    “All these are able to keep migraines from happening,” says Silberstein. The problem with most, however, is side effects. Topamax can cause numbness, tingling, heat sensations, slowed thinking, and weight loss. Some calcium channel blockers, tricyclic antidepressants, and Depakote can cause weight gain.

    “The bottom line is, you pick side effects,” says Silberstein. “I tell the patient, ‘This drug may have cognitive side effects in some people, may make you lose weight, or here’s one that may make you gain weight. Which one do you choose?’ With Topamax, you know right away if you’ll have side effects. With the others, the side effects [such as weight gain] sneak up on you.”Continued

    Despite all these advances, some patients still suffer. “One in 10 migraine patients cannot tolerate certain migraine medications. So we’re better than we were, but we’re still not perfect,” Silberstein notes.

    For some desperate people, the muscle-paralyzing drug Botox, usually given via injection to facial muscles to reduce the appearance of wrinkles, is a saving grace, he says. “Botox seems to work for patients who get frequent migraines, more than those with infrequent ones. If it works, the treatment is every three or four months.” However, Botox treatments can be expensive. “Sometimes insurance covers it, but often it doesn’t,” he notes.Finding the Window of Vulnerability

    In another approach to the goal of preventing migraine headaches, Silberstein and other researchers have looked at “drug timing.” This involves finding the window of vulnerability, a critical time period for migraine headache sufferers. If patients can take their drugs just at this point instead of ongoing, some side effects can be offset. They’ll also take less medication, cutting out-of-pocket costs.Continued

    Two recent studies of menstrual-related migraines produced the first scientific evidence for a pattern of vulnerability in migraine headaches. Researchers say their findings could apply to other types of migraines, not just menstrual headaches.

    It’s an exciting finding. If altitude changes are your nemesis, then taking a long-acting triptan drug twice a day on the day before you go skiing in Utah and continuing it for a week may nip your migraine from starting at all.

    New migraine drugs are also on the horizon. “A lot of drugs are coming down the pipeline, drugs that work by different mechanisms,” says Silberstein. One is a class of enzyme-blocker drugs, such as Aricept, currently prescribed to treat mild to moderate confusion related to Alzheimer’s. This drug is a contender for migraine prevention, he tells WebMD.Alternative Choices for Migraine Pain

    While medications are the mainstay of migraine treatment, they’re not a cure-all. For women who are pregnant or hoping to be, supplements are a safe alternative. For people who can’t get enough relief from prescriptions or who dislike the side effects, supplements can also help.Continued

    “Almost anyone, including children, can take magnesium,” DeRossett tells WebMD. “The only side effect is diarrhea. Some people get it, some don’t. For some, it’s dependent on how high the dosage is.”

    She recommends magnesium “more than other supplements, and have found it to have the most robust effect in preventing migraines,” she says. “I advise vitamin B-2 if a patient has a predisposition to diarrhea.” Some supplements combine magnesium, vitamin B-2, and the herb feverfew. Coenzyme Q10, which the body produces naturally, has also been shown to cut migraine attacks, but it’s pricier than the others, she adds.Continued

    You have to take magnesium for three months to get a benefit, says DeRossett. “People sometimes give up on it too soon.” Taking the correct dosage is important as well: 500 mg magnesium, 400 mg riboflavin (vitamin B-2), and 150 mg coenzyme Q10.

    The herb butterbur can also help prevent migraine attacks, she adds. A recent study found that a daily 75 mg butterbur supplement cut migraine frequency by more than 50%.

    “Our patients are on all kinds of high-powered migraine headache medications,” DeRossett tells WebMD. “These [magnesium, etc.] aren’t in the same ballpark as Depakote or Topamax. But for some people, magnesium might be enough. For others, it might provide added benefit in terms of relief.”

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