In the Global Burden of Disease study, headaches were the second most prevalent disorder in the world (Lancet, 2016). If you’re reading this and you’re surrounded by people, take a look around you; 1 in 5 people are affected by tension-type headaches (Stephens et al., 2016) in particular, and that one might be you, or your friend, or a family member.
If the stats aren’t frightening enough, individuals who get regular headaches think it’s normal, or they just live with it or have medication in every corner just waiting for the next headache to strike. HEADACHES ARE NOT AN ASPIRIN DEFICIENCY. I deal with this almost daily in my practice. Stories of patients suffering from headaches for years. Stories beginning with “I’ve tried everything.” And the only solution they were given after numerous tests? Medication. We’ve been fed this lie that the only way to fix or manage headaches is through the constant misuse and abuse of medications. If the prescription works so well, why do we keep refilling it? Did you actually know that certain medications are responsible for headaches? (Discussed later).
I must say, I really struggled to compile this blog post. Headaches can be exceptionally complicated, and it is truly impossible to cover even a tenth of the information, and despite a staggering amount of research, the underlying etiology is not always well understood. I am going to attempt to shed some light on understanding the type of headache you may have, what could be some triggering factors to consider and what you can potentially do to limit the intensity and frequency of your headaches.
First things first, a headache is not just a headache, the complexities are way greater than that, and headaches can be multi-faceted. There are numerous different classifications and presentations, and understanding your headache may help treat it successfully. Let’s take a look at the International Classification of Headache Disorders (https://ichd-3.org/) in order for you to first understand that headaches can be extensively diverse.
PRIMARY HEADACHES: Are disorders by themselves. They are caused by independent pathomechanisms and not by other disorders.
- Migraine (with or without aura)
- Tension-Type Headache (TTH)
- Cluster Headache (and other trigeminal autonomic cephalalgias)
- Other primary headaches
SECONDARY HEADACHES: Develop as a secondary symptom due to another disorder that is known to cause headaches.
- Headache attributed to head and/or neck trauma
- Headache attributed to cranial or cervical vascular disorder
- Headache attributed to non-vascular intracranial disorder
- Headache attributed to a substance or its withdrawal
- Headache attributed to infection
- Headache attributed to disorder of homeostasis
- Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
- Headache attributed to psychiatric disorder
CRANIAL NEURALGIAS AND FACIAL PAINS: This refers to neuropathic pain of the head that is caused by a lesion or disease of the somatosensory nervous system. They are characterised by pain in the distribution of the nerve/s.
- Cranial neuralgias and central causes of facial pain
- Other headache, cranial neuralgia central, or primary facial pain
As you can see, the types of headaches one can experience are extremely diverse and numerous questions need to be asked within a case history in order to correctly establish a list of differential diagnoses. The information I gather should help me ascertain whether this is a headache I can successfully treat, or if it needs either further investigation or urgent referral. Some classifications need to be handled by neurologists, but for the most part, according to studies, primary care practitioners are the ones who should be ideally handling headaches.
As much as I want to dive into the details of how each headache presents, I don’t think it’s helpful, it’s like Dr. Google. Allow a professional to diagnose your headache for you. What I personally think is more beneficial to you is understanding potential triggering factors and tips to help reduce your headache attacks. I am going to unpack some triggering factors more than others based on questions individuals have specifically asked me and I hope it helps to explain how these things can trigger your headache attacks.
We need to understand that triggering factors can be physical, psychological and/or environmental.
[ Sleep ]
- 50% of individuals who have Tension-type headaches (TTH) and migraines suffer from insomnia (Fernandez-de-las Penas et al., 2017).
- Sleep disturbances, insomnia, and poor sleep quality are associated with a higher frequency and intensity of headache attacks (Fernandez-de-las Penas et al., 2017).
- Data suggests that roughly 50% of patients that suffer from sleep apnea, and 80% of those with narcolepsy also have headaches (Williams, 2010).
So what is the connection between sleep and headaches? There are numerous connections, however, I will attempt to explain in a short, less anatomical description. There are two main hormones that are important for sleep. Serotonin is the brain chemical that regulates the sleep/wake cycle, whereas melatonin is responsible for healthy sleep. Serotonin is synthesized by the pineal gland to produce melatonin. During our REM sleep, serotonin is shut off, and melatonin secretion is decreased. If we have an irregular or delayed secretion of melatonin, it can result in sleep disturbances and poor sleep quality. This decreased secretion is seen in individuals suffering from Cluster type headaches or menstrual migraines (Williams, 2010). Furthermore, poor sleep posture can have a direct effect on the natural curvature of the spine which stresses our joints and increases tension in the musculature.
[ Sex ]
- Significant sex differences exist in migraine and other headache-related disorders (Peterlin et al.,2011).
- Migraine occurs in both sexes, but predominantly affects women, with a cumulative lifetime prevalence of 43% in women and 18 % in men (Stewart et al., 2008).
Amongst the potential causes of this are fluctuations of sex hormones, particularly oestrogen levels, genetic factors, exposure to environmental stressors, as well as differences in the response to stress and pain perception (Peterlin et al., 2011). Olsen (2014) noted that hormonal fluctuations can be responsible for triggering menstrual migraines, and interestingly enough research has further shown that women experience an improvement in migraine frequency and/or severity during pregnancy and menopause.
Furthermore, ladies, if you have spent years taking the contraceptive pill and you suffer from headaches, please note the time frame for when the headaches started and when you commenced taking the pill. There are a wide array of contraceptive pills and sometimes what works for one, does not work for another. The pill can have a significant effect on your hormones, and based on what I have seen in practice, it is usually a more negative effect. Please consult your doctor regarding more information on this.
[ Medication rebound (overuse) and side effects ]
- Medication rebound headaches affect 1 – 2% of the global population (Munksgaard et al., 2014).
It doesn’t seem like much, but if you do the math, the statistic is quite high especially when we expect the medication to do the opposite. Medication side effects are a common, sneaky cause of headaches, and the biggest culprit causing this: your simple analgesics, pain-killers. These simple analgesics can offer some relief for the occasional headache, however, when we take them more regularly, they trigger rebound headaches. How? Well, they pre-empt the production of your body’s own pain-fighting molecules and endorphin production, for instance, will decrease (Ingraham, 2019). So when you eventually cease taking these medications, you are left in a state of rebound pain.
Other medications that can cause rebound headaches include Triptans, ergotamine medications, and Opioids (tramadol, codeine).
[ Food triggers ]
- Aspartame and sucralose – artificial sweeteners found in chewing gums and diet beverages
- Tyramine – an amino acid found mainly in cheese and yoghurt can trigger migraines and vertigo symptoms
- High sugar intake
Dietary triggers are quite controversial and what works for one, may not work for the other. But it is important to take note of some of the above foods that are migraine-causing. Research also notes that those that suffer from Irritable Bowel Syndrome (IBS) are statistically more likely to suffer from migraines (Aydinlar et al., 2013) which can support food triggers promoting an inflammatory response.
[ Caffeine ]
Coffee can be both a friend and a foe. If you experience frequent attacks or chronic migraines, or pain increases when you drink caffeinated coffee or other drinks, caffeine is probably a foe for you. It will cause overall irritation and possibly trigger migraine attacks and/or inflammation.
[ Posture and related work ergonomics ]
Often my patients state that their headaches are aggravated during the day as work stress and demand increases. As I’ve written in a previous blog, “Beware of the chair” (https://kinetichealth.co.za/2018/11/12/beware-of-the-chair/), the average person now spends 9.3 hours per day sitting down, that is more than we spend sleeping each day (average 7.7 hours). The reality is, most of our jobs and productivity is centered around staring at a computer for large parts of the day, with poor work station setups, and we truly aren’t safeguarding our spinal health. Computer professionals and enthusiasts often suffer from a combination of symptoms, with a higher prevalence of musculoskeletal pain noted in the neck, shoulders, upper extremities and low back amongst computer users.
Prolonged sitting lends itself to a forward flexed position of the head and neck. And the result of this? Complaints of pain in the upper back and neck, altered postural patterns and those annoying tension headaches. Anyone nodding their heads in agreement? One must remember that neck muscles start at the bottom of the shoulder blades and span up to the base of the skull. Here’s a little perspective as to why a forward flexed head position is detrimental. In the neutral position, the head weighs approximately 4-5kgs. As our head starts to flex (bend) forward whilst constantly looking down at a computer, the head can weigh up to 27kgs (at 60-degree flexion). And naturally, such a drastic increase in pressure results in the acceleration of spinal degeneration. Accompanying this, the muscles at the back of the neck (especially the sub-occipitals) are then stretched and undergo a large amount of strain to keep the head from falling further forward. This forward flexed posture also inhibits the muscles in the front of the neck creating a further muscle imbalance.
[ Physical activity ]
There are two sides to physical activity – a lack of and too much. When reading the research on this, there were many inconsistencies as to whether or not physical activity triggers or reduces headache attacks but based on what I have personally seen in practice, a lack of physical activity can trigger headaches particularly TTH. This lack of movement subsequently increases stress levels, promotes further tension and can promote other psychological triggers. On the other side of the spectrum, too much strenuous activity can also be a triggering factor, more so for headaches of migraine nature. This can be due to the over-exertion causing swelling in the blood vessels of the head, neck, and scalp.
[ Anxiety and stress ]
These are both potent drivers of headaches (Martin, 2016). These triggering factors can produce physical pain through an increase in tension resulting in TTH, or furthermore can indirectly cause other triggering factors such as high blood pressure, inflamed arteries, tissue damage, etc, which leads to secondary headaches.
According to the Bruxism Association in the UK, people who grind or clench their teeth, both during the day and/or whilst sleeping, are three times more likely to experience headaches (Mathew, 2017). Bruxism can further contribute to tender jaw muscles, TMJ (temporomandibular joint) pain or a stiff neck.
All the below suggestions are the simplest factors that you can address that can potentially make a difference to your headaches. They might not be the ultimate solution but I hope they can provide some guidance in kicking those headaches to the curb, and increasing your quality of life.
- Keep a headache diary. This is the first piece of advice I give my patients, especially those unsure of their headaches and what triggers them. Keep a simple diary and document the details of your headache attack – what did you eat? How much sleep did you get? Have you done any physical activity? Have you been exposed to high levels of stress? Is your menstrual cycle about to begin? Etc etc. This helps to provide greater insight into understanding your headaches and triggering factors. I have truly seen great results with patients that have done so.
- Consult your doctor regarding current medications, the contraceptive pill and avoiding rebound.
- Seek chiropractic care. There is so much explanation to this but in short – there are numerous research studies that show the following are associated with headaches, particularly TTH and cervicogenic headaches: 1) decreased cervical (neck) and thoracic (midback) range of motion, 2) muscle tightness, 3) Active myofascial trigger points, 4) painful upper cervical joint dysfunction (Ferracini, 2017; Espí-López and Gómez-Conesa, 2014; Couto et al., 2013; Zito et al., 2006). Furthermore, besides physical treatment in the form of manipulation, mobilization, dry needling, soft tissue therapies, stretching, etc, a chiropractor can focus on postural awareness and correction, as well as approach your headache from a holistic standpoint.
- Physical activity. General, healthy levels of physical activity is a no brainer solution for a lot of painful problems. In general, exercise is a great stress outlet, it promotes better sleeping habits and improves our overall mood. This is mainly driven by the increase in serotonin levels, which we have covered previously.
- Caffeine. For others, caffeine may be a friend and it is often administered in the treatment of headaches and occasional migraine attacks. How is caffeine even remotely helpful? It acts to constrict blood vessels and speeds everything up, in particular, the effects of other medications taken with it. Furthermore, caffeine helps to blunt the effect of adenosine – a natural, powerful vasodilator that controls cerebral and meningeal blood flow (basically the flow of blood around your brain), and it is often present in higher amounts during a migraine attack. As mentioned in the triggering factors section, if you a chronic headache sufferer, caffeine probably remains a foe to you.
- Food. This is where a headache diary can really help. Take note of potential food triggers and then begin a process of omitting select foods. Please note, do not omit all food triggers at once. It will be very difficult to pinpoint the actual trigger, start with one food type at a time.
- Nutrients. There are FIVE nutrients that can help reduce headache attacks. Magnesium. Riboflavin (Vitamin B2). Coenzyme Q10. Ginger. Feverfew. Ensure you have sufficient intake of Vitamin B and Magnesium in your daily dietary intake, as a decrease in these nutrients can result in many symptoms that trigger headaches such as, anxiety, irritability, and insomnia.
- Upgrade your eyewear and/or get your eyes checked. You’ll be surprised how much eye strain and computer glare can be responsible for increased tension in the suboccipital muscles of the neck, triggering headaches. Consult your optometrist.
- Invest in a good pillow to ensure quality sleep with supported posture.
- Reduce screen time before bed to subsequently reduce being bombarded by EMFs which affects our body’s ability to produce melatonin.
- Improve computer and/or work station ergonomics. Please see my blog “Beware of the chair” to read some information regarding correct work ergonomics.
- If you suffer from bruxism, consult your dentist about a mouthguard or other possible solutions.
- Avoid tight hats, helmets, swimming googles, constricting bra straps, tight ponytails and cradling a telephone between your ear and shoulder.
- Be careful with heat. I know we all love the feeling of heat instead of cold therapy, however, in the case of headaches, prolonged heat application stimulates vasodilation and increases tissue blood flow (Charkoudian, 2010) which can contribute to a congested feeling which may aggravate attacks. My suggestion, experiment with what works for you and utilize that which causes soothing of your headaches.
- Self-massage and stretching. This can serve as a great home therapy when presenting with TTH and cervicogenic headaches. Run through a couple of gentle, cervical stretches and grab a tennis ball and release the muscles at the back of your head and neck (see image below).
Phew, I know that is a lot to take in but I hope you can take away some useful information from this, and that it can potentially help to reduce the intensity and frequency of your headaches in some way. However, please note, if you are suffering from headaches, especially chronic ones, please seek professional help, do not play Dr. Google.
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