How to Deal With Headaches

From environmental factors to stress to genetics, our expert explains it all

Dr. Robert Laureno is chairman of the department of neurology at Washington Hospital Center and a professor of neurology at Georgetown and George Washington universities. For more than 30 years, he’s seen patients, 10 percent of whom, he says, have come to him complaining of headaches. We picked his brain (how appropriate) to learn more about headaches and migraines, plus what to do for treatment if you have them.

What are the most common causes of headaches?

People who have migraines have a genetic predisposition to them. Other people with headaches that aren’t due to medical or neurologic diseases have a tendency for muscles around the head and neck to contract. So the common, non-life-threatening headaches are due to inborn tendencies.

There are environmental factors that can trigger headaches–for example, breathing in carbon monoxide when there’s a leak in your home. And some people get headaches when they’re under stress. But why one person’s stress response is a headache and another person’s isn’t, we don’t really know. Sleep deprivation is another trigger for some people, and allergies are [triggers] for others. Some people also get headaches as a side effect of certain medications.

Are there certain foods that can trigger headaches?
There’s no question that some people get headaches from eating chocolate. However, if you look at a large group of people in a big study, you’ll find that most don’t get headaches from chocolate. Red wine is another headache trigger. Sometimes the patient is able to figure out the cause on his own and eliminate the food causing the headache. Or he might go on a simplified diet and gradually add different foods, a trial-and-error process.

What’s the relationship between caffeine and headaches?
Caffeine is thought to have an effect on the blood vessels in the head; it’s actually an ingredient in some over-the-counter pain medications. For some people caffeine helps with headaches, and for others it can trigger them–it really comes down to the individual patient. I have migraine patients who will drink a cup of coffee to help their headaches. But for other people–for example, a person who drinks a lot of coffee during the week and not as much on the weekend–the caffeine withdrawal might cause a headache.

What’s the difference between a headache and a migraine? How do you know when you have one over the other?
A migraine is a type of headache. Migraines occur in episodes, and they’re typically on one side of the head and throbbing in quality. They typically last for hours. Sometimes a migraine is preceded by a neurologic or visual phenomenon–blurred vision or loss of peripheral vision–for some minutes. Nausea often accompanies a migraine. Headaches that lack many of these qualities are probably not migraines. If someone has a headache all day, every day for weeks or years, that’s not a migraine. If someone has a headache that’s a feeling of pressure all over the head and not throbbing, it’s probably not a migraine. The tendency to have migraine headaches is hereditary, so family history can be a good clue. Migraines are episodic; we would rarely diagnose a headache as a migraine after just one episode.

What’s a neurologist looking for when he’s trying to understand the cause of a headache?
The main job of the doctor is to try to figure out whether a headache is a primary headache or a secondary one. Secondary headaches are ones that are due to some other medical condition. For some patients, the underlying problem might be high blood pressure, a ruptured aneurysm, or a brain tumor. A migraine is an example of a primary headache–one that’s not due to an underlying neurologic pathology. In these cases, the headache is a standalone problem, a primary headache.

How often should a normal, healthy person experience a headache? At what point, or frequency, should you see a doctor?
Anybody who has a headache that’s an unfamiliar kind of experience should see a doctor for sure. If somebody has headaches that interfere with her lifestyle or work, she should see a doctor. Anybody who is concerned about his headaches should see a doctor. If someone has had headaches since age 16 and at age 30 continues to have the same headache episodes but has learned how to manage them, maybe that person doesn’t have to see a doctor. Urgent are headaches that change with the person’s position, ones that are more intense than usual or more frequent. If you have any type of new symptoms in your body associated with headache–numbness, weakness, trouble with vision–certainly you should see a doctor. Or if you’re taking strong medication like anticoagulant or steroid prescriptions and you develop new headaches, you should see a doctor.

What do brain scans do?

Scans show cross-sectional pictures of the brain. If there’s a problem, like a tumor or an area of bleeding, we can see it and have a possible explanation for the headache. A patient who’s having new headaches of a strange type almost always gets a scan. But someone with chronic recurring headaches who had a scan five years ago probably doesn’t need another one–the headache pattern had already declared itself.

What does prescription pain medication do versus over-the-counter meds?
The type of headache–and its cause, when known–would determine the type of prescription a doctor might consider. If you’re talking about simple pain relief for a headache that’s deemed not serious, over-the-counter meds are very often effective. You have to find what works for you. It’s very individualized. By trying a lot of different approaches, people will sometimes develop their own combinations or treatments. A real principle of headache management is understanding that it’s a trial-and-error process. For a given person, you don’t know what will work until you try it. It’s important for the patient to understand, at the outset, that the first treatment might not work. He should not get discouraged. Sometimes the medicine’s not the answer. It could be a food or lack of sleep or a combination of lifestyle and environmental factors. For some people, simply getting an extra hour of sleep at night is the solution.

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