Headache: Don't just take an over-the-counter painkiller

Yale: The person in the airplane seat next to yours is wearing strong perfume and, minutes after takeoff, you get a headache. A week after a cold, your sinuses remain clogged and you get a headache. The barometric pressure drops as summer cools into fall, and pain jabs through your head again. Conventional wisdom holds that those are three different causes of three different headaches. But now researchers say those episodes were most likely going to happen anyway.

Most of the things that people have thought of as triggers—stress, weather fronts, diet—don’t cause headaches, but when you’re getting a headache, they feel worse."

Christopher Gottschalk, MD

“Most of the things that people have thought of as triggers — stress, weather fronts, diet — when we have studied them, we’ve come up empty-handed every time,” says Christopher Gottschalk, MD, a neurologist and director of Yale Medicine’s Headache and Facial Pain Center. “It’s not that they cause headaches, but that when you’re getting a headache, weather changes and perfumes feel worse.”
According to Dr. Gottschalk, that means that almost all headaches are best treated as migraines — recurring and often debilitating headaches that often last from 4 to 72 hours. Migraines are associated with nausea, light sensitivity and moderate to severe pain, often on one side of the head, that can throb and that usually worsens with activity. (Women are more susceptible to migraine than men.)
In a well-known study of 1,203 adult patients from more than 15 countries, including the United States, 94 percent of patients complaining of recurrent headaches met formal criteria for a diagnosis of migraine. “That means that almost every other diagnosis typically offered to patients—‘tension,’ ‘sinus,’ ‘stress’—wasn’t even on the table,” says Dr. Gottschalk. What’s more, migraine medications cure both “tension” headaches and migraines—and the “tension” types respond more quickly.

Don't dwell on the cause—act

There are few health complaints more common than a headache: In a given year, half of Americans will experience at least one. But it is still one of the most underdiagnosed and undertreated medical conditions, in part because cause and effect can be jumbled. For most headaches, doctors have not yet pinpointed the cause.
Here’s what they do know. During a migraine, a patient’s brain stem is activated, sensitizing nerves in abnormal ways and setting off a reaction of pain elsewhere in the brain.
The effect is often so profoundly painful that patients who are suffering tune out some of the confusing names and explanations, says Dr. Gottschalk. They just want relief.
“I see people who are in tears, who say, ‘This is robbing me of my ability to take care of my kids,’” he says. “They say that ‘I can’t play. They’ve given up on me, they know that mommy’s going to be sick or can’t hear any noise.’ Their biggest regret is not just the pain, but how it interferes with their ability to interact with people.”
There is no real reason for patients to wait out headache pain, he says. “If you treat a migraine-type headache when it’s mild,” he says, “you’ll get better quicker.” The available treatments work more effectively on mild headaches than they do on severe ones.
So focus on just one question: Does your headache interfere with your normal functioning? If so, see a doctor.

Understanding—and addressing—the pain

Dr. Gottschalk works with a patient to find the cause of her pain.
Photo credit: Robert Lisak

There are a variety of ways to treat migraine, since it’s a chronic condition that also has acute flare-ups. Yale Medicine neurologists choose from preventive options, including antiseizure medications such as topiramate, low doses of tricyclic antidepressants such as amitriptyline, or high doses of beta blockers. There are also acute medications, which fall into three main classes: triptans, such as Imitrex, higher doses of NSAIDs such as ibuprofen or naproxen, and antinausea drugs. Since migraine attacks can slow the digestive process, Dr. Gottschalk often advises patients to administer drugs via a nose spray or injection. Injections of onabotulinumtoxinA, commonly known as Botox, are also used as a preventive treatment for chronic migraines.
The Headache and Facial Pain Center also helps patients to understand that what they once thought of as “triggers” are actually warning signs of impending headaches. In so doing, they can treat pain before it starts, preventing headaches from becoming debilitating. It does take time for a doctor to reorient a patient to this approach, Dr. Gottschalk says, but “just presenting the perspective goes a long way to changing someone’s understanding.”
Once that happens, a patient’s observations are often remarkable. One woman told Dr. Gottschalk: “You’re right! My dog stinks when I have a migraine!” Asking colleagues, friends and family members to help spot warning signs can also help.
Dr. Gottschalk also treats some rarer types of headaches in his office, too. For migraine headaches that start with an aura—a special case that includes a visual display of flashing lines about 20 minutes prior to the headache—patients can now use a portable brain stimulator that they can apply to the back of their heads “and give themselves a zap.”
And, if at any point, medications aren’t working, an acute treatment room that’s quiet and dim awaits patients at Yale Medicine’s Headache and Facial Pain Center. There is space for two patients to recline in cushioned chairs while specially trained nurses administer an intravenous treatment of migraine medication, NSAIDs, a steroid and/or a nerve blocker.
Dr. Gottschalk is also pursuing the next generation of treatment, through game-changing research and clinical trials now underway. He is especially excited about a breakthrough medication that helps the body’s immune system target a protein in the brain that is triggered by migraine. Soon, Yale Medicine patients may be eligible for a clinical trial in which they would get an infusion of this antibody every month—in effect, stopping headaches before they start.