We’ve all had headaches—whether mild annoyances or severe attacks that knock you down for the count. But as common as they are, it’s surprising how little we know about them. For example, what’s the difference between a headache that you only feel on one side of your head versus one you feel all over your head or one that switches sides? How do you know if you should see a doctor for your headache or if you should just let it pass? We sat down with Yale Medicine neurologist and headache expert Deena Kuruvilla, MD, to get some of those questions answered.
While there are multiple causes for headaches, including inflamed sinuses, allergies or neck problems, most headaches are actually migraines, says Dr. Kuruvilla. This is not just a matter of semantics: “The most important thing is not to be misdiagnosed with the wrong thing,” she says. “Don't end up going down the sinus surgery route or the neck surgery route if you don’t have to.”
What are the different types of headaches?
We see all common types of headaches, including migraines, cluster headaches and tension headaches. But, by far, the most common headache we see are migraines. In fact, a lot of people come in complaining that they have a tension headache and it turns out that it’s really a migraine.
How do I know if I have a migraine or another type of headache?
Migraine is the most common neurological cause for disability in the world, and headache is the fourth most common reason for patients to seek help from an emergency department. That’s why there’s a good chance that your headache is a migraine.
We know so much more about migraines than we did 20 years ago: We used to think that migraines were caused by changes in the blood vessels of the brain. But now we think that migraines are complex disorders involving several parts of the brain. One of the key players is the trigeminocervical complex, which is located in the brainstem. This command center is responsible for releasing inflammatory factors like calcitonin gene-related peptide (CGRP), which trigger abnormal electrical activity. This causes migraine headaches.
Sometimes people with migraines experience auras, with vision changes (such as floating dots, wavy lines, flashing lights or blind spots). Or they may have difficulty with speech, sensation, or movement. If you’re feeling more sensitivity to light or loud noise and/or you have nausea or vomiting with your headache, you’re probably suffering from a migraine.
Why does the differentiation matter?
Different headaches require different treatments. Migraines are the most studied types of headaches, so there are a lot of treatment options for those. However, different medications are used for cluster headaches. And hemicrania continua, a headache disorder related to cluster headache, can only be treated by a particular type of medication called Indomethacin.
You told me that the most requested treatment for migraines at Yale Medicine is Botox. That’s really surprising—can you explain how it works?
Sure. Botox is a neurotoxic protein produced by the bacteria clostridium botulinum. Most people know it as a procedure to prevent wrinkles, but it can also be injected around superficial nerves at specific sites. This blocks the release of chemicals involved in pain, which prevents the inflammation involved in a migraine. There are between 31 and 38 injection sites around the head, in the upper neck and shoulders. Botox is FDA-approved for chronic migraines, which means headaches for 15 or more days a month for at least 3 months.
I have an excruciating pain on only one side of my head around my eye that tends to come at the same time every day. What is it?
If your doctor has ruled out dangerous underlying causes of headache, such as a tumor, you might have a cluster headache. These are also known as “suicide headaches” because of how severe the pain is. The word “cluster” refers to the fact that the attacks usually occur in cycles, lasting a few weeks to several months. A typical cycle of attacks might last one to three months, recurring every year, or twice a year at roughly the same time.
We know that the hypothalamus and circadian rhythms are involved in this specific headache disorder, which might be why they occur during specific sleep stages at night and at specific times of the year, usually in January or July.
These headaches are a part of a family of headaches called the trigeminal autonomic cephalalgias. The other headaches in this family are the ones we call hemicrania continua. If you have these headaches, you might have tearing in your eyes, a stuffy or runny nose, bloodshot eyes or drooping eyelids.
Ugh. Are headaches treatable or do I just have to suffer through them?
Fortunately, there are a lot of proven treatment options for headaches, especially migraines. In addition to all the medication options we may consider, there are also procedures we can do and natural approaches to try. As we talked about earlier, Botox is really effective for frequent migraines. Another option to break a severe headache is to inject anesthetic medication into nerve sites, tight muscles or the sphenopalatine ganglia (a group of nerve cells linked to the trigeminal nerve). These procedures have fewer side effects than oral medications, because they affect a small nerve and not the whole body.
For cluster headaches, we try to prevent them from happening by prescribing medications, such as a blood pressure medication, Verapamil, the psychiatric medication lithium, and anti-seizure medications Topamax and Depakote, to name a few. Also, because cluster headaches seem to be linked to circadian rhythm, we see patients feeling better after using melatonin as well.
For tension headaches, anti-depressants seem to work well.
I kind of don’t want to take any more medications for my headache—are there other options?
Definitely—there are lots of non-prescription medication treatments for migraines. We often suggest taking magnesium or vitamin B2 (also known as riboflavin) supplements—some research shows that low magnesium levels can contribute to migraines. Growing evidence also shows that acupuncture may help.
There are also some devices, for which you might need to get a prescription from your doctor. One is the Cefaly device, which looks like a headband that you wear around your forehead to stimulate the supraorbital nerve with electrodes, has also been shown to be pretty effective for headaches. And there’s also the spring transcranial magnetic stimulation device, which has been shown to be effective in migraines with aura.
How do I know if I should see a doctor for my headache?
If your headaches are associated neurological symptoms (confusion, changes in vision, dizziness, speech changes, weakness, numbness, etc.), you should go to your closest emergency room. Also, anyone who feels like they are experiencing the worst headache they have ever had should go to the nearest emergency room to be checked out.
If your headaches are increasing in severity or frequency, if they worsen or do not improve with over-the counter-medications, or are causing you distress, you should schedule a doctor’s visit.
To schedule an appointment with one of our headache specialists, contact the Headache and Facial Pain Center at 203-785-4085.