Hope Through Research

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Public Health Service National Institutes of Health

Prepared by the Office of Scientific and Health Reports National Institute of Neurological and Communicative Disorders and Stroke

Bethesda, Maryland 20205

NIH Publication No. 84-158 September 1984

Headache, Hope Through Research was written by Diane Striar of the Office of Scientific and Health Reports, NINCDS, NIH.

For 2 years, Jim suffered the excruciating pain of cluster headaches. Night after night he paced the floor, the pain driving him to constant motion. He was only 48 years old when the clusters forced him to quit his job as a systems analyst. One year later, his headaches are controlled. The credit for Jim's recovery belongs to the medical staff of a headache clinic. Physicians there applied the latest research findings on headache, and prescribed for Jim a combination of new drugs.

* Joan was a victim of frequent migraine. Her headaches lasted 2 days. Nauseous and weak, she stayed in the dark until each attack was over. Today, although migraine still interferes with her life, she has fewer attacks and less severe headaches than before. A specialist prescribed an antimigraine program for Joan that included improved drug therapy, a new diet and relaxation training.

* An avid reader, Peggy couldn't put down the new mystery thriller. After 4 hours of reading slumped in bed, she knew she had overdone it. Her tensed head and neck muscles felt as if they were being squeezed between two giant hands. But for Peggy, the muscle-contraction headache and neck pain were soon relieved by a hot shower and aspirin.

An estimated 40 million Americans experience chronic headaches. For at least half of these people, the problem is severe and sometimes disabling. It can also be costly: headache sufferers make over 8 million visits a year to doctor's offices. Migraine victims alone lose over 64 million workdays because of headache pain.

Understanding why headaches occur and improving headache treatment are among the research goals of the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS). As the focal point for brain research in the Federal Government, the NINCDS also supports and conducts studies to improve the diagnosis of headaches and to find ways to prevent them.

Some headaches require prompt medical attention.

Why does it hurt?

What hurts when you have a headache? Several areas of the head can hurt, including a network of nerves which extends over the scalp and certain nerves in the face, mouth, and throat. Also sensitive to pain, because they contain delicate nerve fibers, are the muscles of the head and blood vessels found along the surface and at the base of the brain.

The bones of the skull and tissues of the brain itself, however, never hun, because they lack pain-sensitive nerve fibers.

The ends of these pain-sensitive nerves, called nociceptors, can be stimulated by stress, muscular tension, dilated blood vessels, and other triggers of headache. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a pan of the body hurts. The message is determined by the location of the nociceptor. A person who suddenly realizes "My toe hurts," is responding to nociceptors in the foot that have been stimulated by the stubbing of a toe.

A number of chemicals help transmit pain-related information to the brain. Some of these chemicals are natural painkilling proteins called endorphins, Greek for "the morphine within." One theory suggests that people who suffer from severe headache and other types of chronic pain have lower levels of endorphins than people who are generally pain free.

When you should see a physician

Not all headaches require medical attention. Some result from missed meals or occasional muscle tension and are easily remedied. But some types of headache are signals of more serious disorders such as head injury and call for prompt medical care. These include:

* Sudden, severe headache

* Headache associated with convulsions

* Headache accompanied by confusion or loss of consciousness

* Headache following a blow on the head

* Headache associated with pain in the eye or ear

* Persistent headache in a person who was previously headache free

* Recurring headache in children

* Headache associated with fever

* Headache which interferes with normal life

A headache sufferer usually seeks help from a family practitioner. If the problem is not relieved by standard treatments, the patient may then be referred to a specialist--perhaps an internist or neurologist. Additional referrals may be made to psychologists.

Diagnosis: What the physician looks for

Diagnosing a headache is like playing Twenty Questions. Experts agree that a detailed question-and-answer session witha patient can often produce enough information for a diagnosis. Many types of headaches have dear-cut symptoms which fall into an easily recognizable pattern.

[Graphic Omitted]

A medical history often provides a physician with enough clues about a patient's headaches to make a diagnosis.

Patients may be asked: How often do you have headaches? Where is the pain? How long do the headaches last? When did you first develop headaches?

The patient's sleep habits and family and work situations may also be probed.

Most physicians will also obtain a full medical history
from the patient, inquiring about past head trauma or surgery
and about the use of medications. A blood test may be ordered
to screen for thyroid disease, anemia, or infections which
might cause a headache. X rays may be taken to rule out the
possibility of a brain tumor or blood clot.

A test called an electroencephalogram (EEG) may be given
to measure brain activity. EEG's can indicate a malfunction in
the brain, but they cannot usually pinpoint a problem that
might be causing a headache. A physician may suggest that a
patient with unusual headaches undergo a computed tomographic
(CT) scan. The CT scan produces images of the brain that show
variations in the density of different types of tissue. The
scan enables the physician to distinguish, for example, between
a bleeding blood vessel in the brain and a brain tumor. The CT
scan is an important diagnostic tool in cases of headache
associated with brain lesions or other serious disease. Experts
generally agree, however, that this sophisticated and expensive
technology is not required to diagnose simple or periodic

An eye exam is usually performed to check for weakness in
the eye muscle or unequal pupil size. Both of these symptoms
are evidence of an aneurysm--an abnormal ballooning of a blood
vessel. A physician who suspects that a headache patient has an
aneurysm may also order an angiogram. In this test, a special
fluid which can be seen on an X ray is injected into the
patient and carried in the bloodstream to the brain to reveal
any abnormalities in the blood vessels there.

Thermography, an experimental technique for diagnosing
headache, promises to become a Useful clinical tool. In
thermography, an infrared camera converts skin temperature into
a color picture or thermogram with different degrees of heat
appearing as different colors. Skin temperature is affected
primarily by blood flow. Research scientists have found that
thermograms of headache patients show strikingly different heat
patterns from those of people who never or rarely get headaches.

[Graphic Omitted]

Scientists at this clinic use thermography to diagnose
headache. An infrared camera converts skin temperature, which
is influenced by blood flow, into a color picture or
thermogram. Each type of headache produces a distinctive heat
pattern on a thermogram, so investigators can "see" their
patients' headaches in living color.

A physician analyzes the results of all these diagnostic
tests along with a patient's medical history in order to arrive
at a diagnosis.

Headaches are diagnosed as:

* Vascular

* Muscle contraction

* Traction

* Inflammatory

Vascular headaches--a group that includes the well-known migraine--are so named because they are thought to involve abnormal function of the brain's blood vessels or vascular system. Muscle contraction headaches appear to involve the tightening or tensing of facial and neck muscles. Traction and inflammatory headaches are symptoms of other disorders, ranging from stroke to sinus infection. Some people have more than one.type of headache.

Migraine headaches: A painful malady

The most common type of vascular headache is migraine.
Migraine headaches are usually characterized by severe pain on
one or both sides of the head, an upset stomach, and at times
disturbed vision.

Basketball star Kareem Abdul-Jabbar remembers experiencing
his first migraine at age 14. The pain was unlike the
discomfort of his previous mild headaches.

"When I got this one I thought, 'This is a headache'," he
says. "The pain was intense and I felt nausea and a great
sensitivity to light. All I could think about was when it would
stop. I sat in a dark room for an hour and it passed."

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Basketball star and migraine sufferer Kareem Abdul-Jabbar
(holding a ball) has played some of his best games after
overcoming headache attacks.

Symptoms of migraine. Abdul-Jabbar's sensitivity to light
is a standard symptom of the two most prevalent types of
migraine-caused headache: classic and common.

The major difference between the two types is the
appearance of neurological symptoms 10 to 30 minutes before a
classic migraine attack. These symptoms are called an aura. The
person may see flashing lights or zigzag lines, or may
temporarily lose vision. Other classic symptoms include speech
difficulty, weakness of an arm or leg, tingling of the face or
hands, and confusion.

The pain of a classic migraine headache is described as
intense, throbbing, or pounding and is felt in the forehead,
temple, ear, jaw, or around the eye. Classic migraine starts on
one side of the head but may eventually spread to the other
side. An attack lasts 1 to 2 pain-wracked days.

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If you were about to experience a classic migraine headache,
you might find it difficult to read this pamphlet. You could
lose part of your vision temporarily and see zigzag lines and
black dots. Such visual problems--and other neurological
symptoms--often precede classic migraine.

Migraines involve blood flow changes in the brain.

The common migraine--a term that reflects the disorder's
greater occurrence in the general population--is not preceded
by an aura. But some people experience a variety of vague
symptoms beforehand, including mental fuzziness, mood changes,
fatigue, and unusual retention of fluids. During the headache
phase of a common migraine, a person may have diarrhea and
increased urination, as well as nausea and vomiting. Common
migraine pain can last 3 or 4 days.

Both classic and common migraine can strike as often as
several times a week, or as rarely as once every few years,
Both types can occur at any time. Some people, however,
experience migraines at predictable times -near the days of
menstruation or every Saturday morning after a stressful week
of work.

The migraine process. Research scientists are unclear
about the precise cause of migraine headaches. There seems to
be general agreement, however, that a key element is blood flow
changes in the brain. People who get migraine headaches appear
to have blood vessels that overreact to various triggers.

Scientists have devised one theory of migraine which
explains these blood flow changes and also certain biochemical
changes that may be involved in the headache process. According
to this theory, the nervous system responds to a trigger such
as stress by creating a spasm in the nerve-rich arteries at the
base of the brain. The spasm closes down or constricts several
arteries supplying blood to the brain, including the scalp
artery and the carotid or neck arteries.

As these arteries constrict, the flow of blood to the
brain is reduced. At the same time, blood-clotting particles
called platelets clump together--a process which is believed to
release a chemical called serotonin. Serotonin acts as a
powerful constrictor of arteries, further reducing the blood
supply to the brain.

Reduced blood flow decreases the brain's supply of oxygen.
Symptoms signaling a headache, such as distorted vision or
speech, may then result, similar to symptoms of stroke.

[Graphic Omitted]

One theory of the migraine process: (a) a patient's nervous
system responds to a trigger such as stress by creating a spasm
in the arteries at the base of the brain. The spasm and the
release of serotonin reduce blood flow to the brain.
Blood-borne oxygen is decreased, causing the "aura" of
neurological symptoms; (b) arteries in and around brain tissue
then dilate or widen to meet the brain's energy and oxygen
needs. Pain-producing chemicals are released and nerve endings
on the scalp are stimulated. The patient then feels a throbbing
pain in the head.

Reacting to the reduced oxygen supply, certain arteries
within the brain open wider to meet the brain's energy needs.
This widening or dilation spreads, finally affecting the neck
and scalp arteries. The dilation of these arteries triggers the
release of pain-producing substances called prostaglandins from
various tissues and blood cells. Chemicals which cause
inflammation and swelling, and substances which increase
sensitivity to pain are also released. The circulation of these
chemicals and the dilation of the scalp arteries stimulate the
pain-sensitive nociceptors. The result, according to this
theory: a throbbing pain in the head.

Women and migraine. Although boys and girls seem to be
equally affected by migraine, the condition is more common in
adult women than in men. Both sexes may develop migraine in
infancy, but most often the disorder begins between the ages of
5 and 35.

The relationship between female hormones and migraine is
still unclear. Women may have "menstrual migraine"--headaches
around the time of their menstrual period--which may disappear
during pregnancy. Other women develop migraine for the first
time when they are pregnant. Some are first affected after

The effect of oral contraceptives on headaches is
perplexing. Scientists report that some migrainous women who
take birth control pills experience more frequent and severe
attacks. However, a small percentage of women have fewer and
less severe migraine headaches when they take birth control
pills. And normal women who do not suffer from headaches may
develop migraines as a side effect when they use oral
contraceptives. Investigators around the world are studying
hormonal changes in migrainous women in the hope of identifying
the specific ways these naturally occurring chemicals cause

Triggers of headache. The existence of a migraine
personality is a controversial theory which suggests that
migraine patients are compulsive, rigid, and perfectionistic.
Most scientists believe, however, that not all migraine patients
have these traits and that not all individuals with these
personality characteristics have migraine.

"Migraine is triggered by things that are not so terrible."

Rather than focusing on character traits, says one
headache specialist, it would be better to view people who get
migraines as having an inherited abnormality in the regulation
of blood vessels. Many sufferers have a family history of
migraine, but the exact hereditary nature of this condition is
still unknown.

"It's like a cocked gun with a hair trigger," explains the
specialist. "A person is born with a potential for migraine and
the headache is triggered by things that are really not so

These triggers include stress and other normal emotions,
as well as biological and environmental conditions. Fatigue,
glaring or flickering lights, the weather, and even certain
foods can set off migraine. It may seem hard to believe that
eating such seemingly harmless foods as yogurt, nuts, and lima
beans can result in a painful migraine headache. However, some
scientists believe that these foods and several others contain
chemical substances such as tyramine which constrict
arteries--the first step of the migraine process. Other
scientists believe that foods cause headaches by setting off an
allergic reaction in susceptible people.

While a food-triggered migraine usually occurs soon after
eating, other triggers may not cause immediate pain. Scientists
report that people can develop migraine not only during a
period of stress but also afterwards when their vascular
systems are still reacting. The "Preacher Monday-Morning
Headache" is named for those clergymen who get migraines a day
after the stress of delivering a Sunday sermon. Migraines that
wake people up in the middle of the night are also believed to
result from a delayed reaction to stress.

Other forms of migraine. In addition to classic and
common, migraine headache can take several other forms:

Patients with hemiplegic migraine have temporary paralysis
on one side of the body, a condition known as hemiplegia. Some
people may experience vision problems and vertigo--a feeling
that the world is spinning. These symptoms begin 10 to 90
minutes before the onset of headache pain.

In ophthalmoplegic migraine, the pain is around the eye
and is associated with a droopy eyelid, double vision, and
other sight problems.

Basilar artery migraine involves a disturbance of a major
brain artery. Preheadache symptoms include vertigo, double
vision, and poor muscular coordination. This type of migraine
occurs primarily in adolescent and young adult women and is
often associated with the menstrual cycle.

Benign exertional headache is brought on by running,
lifting, coughing, sneezing, or bending. The headache begins at
the onset of activity, and pain rarely lasts more than several

Status migrainosus is a rare and severe type of migraine
that can last 72 hours or longer. The pain and nausea are so
intense that people who have this type of headache must be
hospitalized. The use of certain drugs can trigger status
migrainosus. Neurologists report that many of their status
migrainosus patients were depressed and anxious before they
experienced headache attacks.

Headache-free migraine is characterized by such migraine
symptoms as visual problems, nausea, vomiting, constipation, or
diarrhea. Patients, however, do not experience head pain.
Headache specialists have suggested that unexplained pain in a
particular part of the body, fever, and dizziness could also be
possible types of headache-free migraine.

Treating migraine headache

During the Stone Age, pieces of a headache sufferer's
skull were cut away with flint instruments to relieve pain.
Another unpleasant remedy used in the British Isles around the
ninth Century involved drinking "the juice of elderseed, cow's
brain, and goat's dung dissolved in vinegar." Fortunately,
today's headache patients are spared such drastic measures.

[Graphic Omitted]

Common sense rather than scientific discovery was the basis of
many early migraine remedies. This 19th century French cartoon
shows a family responding to the needs of a migraine sufferer
by creating a dark, quiet atmosphere.

Drug therapy, biofeedback training, stress reduction, and
elimination of certain foods from the diet are the most common
methods of preventing and controlling migraine and other
vascular headaches. Joan, the migraine sufferer, was helped by
treatment with a combination of an antimigraine drug and diet

Regular exercise, such as swimming or vigorous walking,
can also reduce the frequency and severity of migraine
headaches. Joan found that yoga and whirlpool baths helped her

During a migraine headache, temporary relief can sometimes
be obtained by using cold packs or by pressing on the bulging
artery found in front of the ear on the painful side of the

Drug therapy. There are two ways to approach the treatment
of migraine headache with drugs: prevent the attacks, or
relieve symptoms after the headache occurs.

With biofeedback, migraine may become less frequent.

For infrequent migraine, drugs can be taken at the first
sign of a headache in order to stop it or to at least ease the
pain. People who get occasional mild migraine may benefit by
taking aspirin or acetaminophen at the start of an attack.
Aspirin raises a person's tolerance to pain and also
discourages clumping of blood platelets. Small amounts of
caffeine may be useful if taken in the early stages of
migraine. But for most migraine sufferers who get moderate to
severe headaches, and for all cluster patients, stronger drugs
may be necessary to control the pain.

One of the most commonly used drugs for the relief of
classic and common migraine symptoms is ergotamine tartrate, a
vasoconstrictor which helps counteract the painful dilation
stage of the headache. For optimal benefit, the drug is taken
during the early stages of an attack. If a migraine has been in
progress for about an hour and has passed into the final
throbbing stage, ergotamine tartrate will probably not help.

Because ergotamine tartrate can cause nausea and vomiting,
it may be combined with antinausea drugs. Research scientists
caution that ergotamine tartrate should not be taken in excess
or by people who have angina pectoris, severe hypertension, or
vascular, liver, or kidney disease.

Patients who are unable to take ergotamine tartrate may
benefit from other drugs that constrict dilated blood vessels
or help reduce blood vessel inflammation.

For headaches that occur three or more times a month,
preventive treatment is usually recommended. Drugs used to
prevent classic and common migraine include methysergide
maleate, which counteracts blood vessel constriction,
propranolol, which stops blood vessel dilation, and
amitriptyline, an antidepressant.

In a study of propranolol, amitriptyline, and biofeedback
conducted by the Houston Headache Clinic, scientists found that
migraine patients improved most on a combination of propranolol
and biofeedback. Patients who had mixed migraine and
muscle-contraction headaches received the greatest benefit from
a combination of propranolol, amitriptyline, and biofeedback.

Another recent study showed that propranolol may continue
to prevent migraine headaches even after patients have stopped
taking the drug. The scientists who conducted the study
speculate that long-term therapy with propranolol may have a.
lasting effect on blood vessels, training them to react less
than usual to the triggers of migraine.

Antidepressants called MAO inhibitors also prevent
migraine. These drugs block an enzyme called monoamine oxidase
which normally helps nerve cells absorb the artery-constricting
chemical, serotonin.

MAO inhibitors can have potentially serious side
effects--particularly if taken while ingesting foods or
beverages that contain tyramine, a substance that closes down

Several new drugs for the prevention of migraine have been
developed in recent years, including papaverine hydrochloride,
which produces blood vessel dilation, and cyproheptadine, which
counteracts serotonin.

All these antimigraine drugs can have adverse side
effects. But they are relatively safe when used carefully. To
avoid long-term side effects of preventive medications,
headache specialists advise patients to reduce the dosage of
these drugs and then to stop taking them as soon as possible.

Biofeedback and relaxation training. Drug therapy for
migraine is often combined with biofeedback and relaxation
training. Biofeedback is a space-age word for a technique that
can give people better control over such body function
indicators as blood pressure, heart rate, temperature, muscle
tension, and brain waves. Thermal biofeedback allows a patient
to consciously raise hand temperature. Some patients who are
able to increase hand temperature can reduce the number and
intensity of migraines. The mechanism of this hand-warming
effect is being studied by research scientists.

[Graphic Omitted]

An NINCDS grantee at the State University of New York in Albany instructs a headache patient in thermal biofeedback. A temperature-sensitive device attached to her forefinger is connected to a feedback meter that tells the patient if and how much she is warming her hands.

[This is a unit we call the Stress Computer.]

"To succeed in biofeedback," says a headache specialist, "you must be able to concentrate and you must be motivated to get well."

A patient learning thermal biofeedback wears a device which transmits the temperature of an index finger or hand to a monitor. While the patient tries to warm his hands, the monitor provides feedback either on a gauge that shows the temperature reading or by emitting a sound or beep that increases in intensity as the temperature increases. The patient is not told how to raise hand temperature, but is given suggestions such as "Imagine that your hands feel very warm and heavy."

"I have a good imagination," says one headache sufferer who traded in her medication for thermal biofeedback. The technique decreased the number and severity of headaches she experienced.

In another type of biofeedback called electromyographic or
EMG training, the patient learns to control muscle tension in
the face, neck, and shoulders.

Either kind of biofeedback may be combined with relaxation training, during which patients learn to relax the mind and body.

Biofeedback can be practiced at home with a portable monitor. But the ultimate goal of treatment is to wean the
patient from the machine. The patient can then use biofeedback anywhere at the first sign of a headache.

The antimigraine diet. Scientists estimate that a small percentage of migraine sufferers will benefit from a treatment program focused solely on eliminating headache-provoking foods and beverages.

Other migraine patients may be helped by a diet to prevent
low blood sugar. Low blood sugar, or hypoglycemia, can cause
dilation of the blood vessels in the head. This condition can
occur after a period without food: overnight, for example, or
when a meal is skipped. People who wake up in the morning with
a headache may be reacting to the low blood sugar caused by the
lack of food overnight.

Treatment for headaches caused by low blood sugar consists
of scheduling smaller, more frequent meals for the patient. A
special diet designed to stabilize the body's sugar-regulating
system is sometimes recommended.

For the same reason, many specialists also recommend that
migraine patients avoid oversleeping on weekends. Sleeping late
can change the body's normal blood sugar level and lead to a

Beyond migraine: Other vascular headaches

After migraine, the most common type of vascular headache
is the toxic headache produced by fever. Pneumonia, measles,
mumps, and tonsillitis are among the diseases that can cause
severe toxic vascular headaches. Toxic headaches can also
result from the presence of foreign chemicals in the body.
Other kinds of vascular headaches include "clusters," which
cause repeated episodes of intense pain, and headaches
resulting from a rise in blood pressure.

Chemical culprits. Repeated exposure to nitrite compounds
can result in a dull, pounding headache that may be accompanied
by a flushed face. Nitrite, which dilates blood vessels, is
found in such products as heart medicine and dynamite. Hot dogs
and other meats containing sodium nitrite can also cause

"Chinese restaurant headache" can occur when a susceptible
individual eats foods prepared with monosodium glutamate
(MSG)--a staple in many Oriental kitchens. Soy sauce, meat
tenderizer, and a variety of packaged foods contain this
chemical which is touted as a flavor enhancer.

Vascular headache can also result from exposure to
poisons, even common household varieties like insecticides,
carbon tetrachloride, and lead. Children who eat flakes of lead
paint may develop headaches. So may anyone who has contact with
lead batteries or lead-glazed pottery.

Painters, printmakers, and other artists may experience
headaches after exposure to art materials that contain
chemicals called solvents. Solvents, like benzene, are found in
turpentine, spray adhesives, robber cement, and inks.

Drugs such as amphetamines can cause headaches as a side
effect. Another type of drug-related headache occurs during
withdrawal from long-term therapy with the antimigraine drug
ergotamine tartrate.

Jokes are often made about alcohol hangovers but the
headache associated with "the morning after" is no laughing
matter. Fortunately, there are several suggested remedies for
the pain, including ergotamine tartrate. The hangover headache
may also be reduced by taking honey, which speeds alcohol
metabolism, or caffeine, a constrictor of dilated arteries.
Caffeine, however, can cause headaches as well as cure them.
Heavy coffee drinkers often get headaches when they try to
break the caffeine habit.

Cluster headaches. Cluster headaches, named for their
repeated occurrence in groups or clusters, begin as a minor
pain around one eye, eventually spreading to that side of the
face. The pain quickly intensifies, compelling the victim to
pace the floor or rock in a chair. "You can't lie down, you're
fidgety," explains a cluster patient. "The pain is unbearable."
Other symptoms include a stuffed and runny nose and a droopy
eyelid over a red and tearing eye.

The typical cluster patient is tall and muscular.

Cluster headaches last between 30 and 45 minutes. But the
relief people feel at the end of an attack is usually mixed
with dread as they await a recurrence. Clusters can strike
several times a day or night for several weeks or months. Then,
mysteriously, they may disappear for months or years. Many
people have cluster bouts during the spring and fall. At their
worst, chronic cluster headaches can last continuously for

Cluster attacks can strike at any age but usually start
between the ages of 20 and 40. Unlike migraine, cluster
headaches are more common in men and do not run in families.
Research scientists have observed certain physical similarities
among people who experience cluster headache. The typical
cluster patient is a tall, muscular man with a ragged facial
appearance and a square, jutting or dimpled chin. The texture
of his coarse skin resembles an orange peel. Women who get
clusters may also have this type of skin.

Studies of cluster patients show that they are likely to
have hazel eyes and that they tend to be heavy smokers and
drinkers. Paradoxically, both nicotine, which constricts
arteries, and alcohol, which dilates them, trigger duster
headaches. The exact connection between these substances and
cluster attacks is not known.

Despite a cluster headache's distinguishing
characteristics, its relative infrequency and similarity to
such disorders as sinusitis can lead to misdiagnosis. Some
cluster patients have had tooth extractions, sinus surgery, or
psychiatric treatment in a futile effort to cure their pain.

Research studies have turned up several clues as to the
cause of cluster headache, but no answers. One clue is found in
the thermograms of untreated cluster patients, which show a
"cold spot" of reduced blood flow above the eye.

The sudden start and brief duration of cluster headaches
can make them difficult to treat. By the time medicine is
absorbed into the body, the attack is often over. However,
research scientists have identified several effective drugs for
these headaches. The antimigraine drug ergotamine tartrate can
subdue a cluster, if taken at the first sign of an attack.
Injections of dihydroergotamine, a form of ergotamine tartrate,
are sometimes used to treat clusters.

[Graphic Omitted]

A thermogram of a normal person shows a symmetrical heat pattern on the individual's forehead.

Graphic Omitted]

A cluster headache patient's thermogram shows a cold area
(appears white) of reduced blood flow on the left side of the

Some cluster patients can prevent attacks by taking
propranolol or methysergide. Investigators have also discovered
that mild solutions of cocaine hydrochloride applied inside the
nose can quickly stop cluster headaches in most patients. This
treatment may work because it both blocks pain impulses and it
constricts blood vessels.

Another option that works for some cluster patients is
rapid inhalation of pure oxygen through a mask for 5 to 15
minutes. The oxygen seems to ease the pain of cluster headache
by reducing blood flow to the brain.

In chronic cases of cluster headache, certain facial
nerves may be surgically cut or destroyed to provide relief.
These procedures have had limited success. Some cluster
patients have had facial nerves cut only to have them
regenerate years later.

Painful pressure. Chronic high blood pressure can cause
headache, as can rapid rises in blood pressure like those
experienced during anger, vigorous exercise, or sexual

The severe "orgasmic headache" occurs right before orgasm
and is believed to be a vascular type. Since sudden rapture of
a cerebral blood vessel can also occur during orgasm, this type
of headache should be promptly evaluated by a doctor.

Muscle-contraction headaches: The everyday menace

It's 5:00 p.m. and your boss has just asked you to prepare
a 20-page briefing paper. Due date: tomorrow. You're angry and
tired and the more you think about the assignment, the tenser
you become. Your teeth clench, your brow wrinkles, and soon you
have a splitting tension headache.

Tension headache is named not only for the role of stress
in triggering the pain, but also for the contraction of neck,
face, and scalp muscles brought on by stressful events. Tension
headache is a severe but temporary form of muscle-contraction
headache. The pain is mild to moderate and feels like pressure
is being applied to the head or neck. The headache usually
disappears after the period of stress is over.

By contrast, chronic muscle-contraction headaches can last
for weeks, months, and sometimes years. The pain of these
headaches is often described as a tight band around the head or
a feeling that the head and neck are in a cast. "It feels like
somebody is tightening a giant vise around my head," says one
patient. The pain is steady, and is usually felt on both sides
of the head. Chronic muscle-contraction headaches can cause
sore scalps-even combing one's hair can be painful.

Many scientists believe that the primary cause of the pain
of muscle-contraction headache is sustained muscle tension.
Other studies suggest that restricted blood flow may cause or
contribute to the pain

.Occasionally, muscle-contraction headaches will be
accompanied by nausea, vomiting, and blurred vision, but there
is no preheadache syndrome as with migraine. Muscle-contraction
headaches have not been linked to hormones or foods, as has
migraine, nor is there a strong hereditary connection.

[Graphic Omitted]

It's election night, November 1982, and the reporters at this
busy newspaper could be prime candidates for tension headaches.
Circumstances that might trigger headaches include deadline
pressure and glaring lights.

Research has shown that for many people, chronic
muscle-contraction headaches are caused by depression and
anxiety. These people tend to get their headaches in the early
morning or evening when conflicts in the office or home are

Emotional factors are not the only triggers of
muscle-contraction headaches. Certain physical postures--such
as holding one's chin down while reading--can lead to head and
neck pain. Tensing head and neck muscles during sexual
excitement can also cause headache. So can prolonged writing
under poor light, or holding a phone between the shoulder and
ear, or even gum-chewing.

More serious problems that can cause muscle-contraction
headaches include degenerative arthritis of the neck and
temporomandibular joint dysfunction, or TMJ. TMJ is a disorder
of the joint between the temporal bone (above the ear) and the
mandible or lower jaw bone. The disorder results from poor bite
and jaw clenching.

Treatment for muscle-contraction headache varies. The
first consideration is to treat any specific disorder or
disease that may be causing the headache. For example,
arthritis of the neck is treated with anti-inflammatory
medication and temporomandibular joint dysfunction may be
helped by corrective devices for the mouth and

Acute tension headaches not associated with a disease are treated with muscle relaxants and analgesics like aspirin and acetaminophen. Stronger analgesics, such as propoxyphene and codeine, are sometimes prescribed. As prolonged use of these drugs can lead to dependence, patients taking them should have periodic medical checkups and follow their physicians' instructions carefully.

Nondrug therapy for chronic muscle-contraction headaches includes biofeedback, relaxation training, and counseling. A technique called cognitive restructuring teaches people to change their attitudes and responses to stress. Patients might be encouraged, for example, to imagine that they are coping successfully with a stressful situation. In progressive relaxation therapy, patients are taught to first tense and then relax individual muscle groups. Finally, the patient tries to relax his or her whole body. Many people imagine a peaceful scene--such as lying on the beach or by a beautiful lake. Passive relaxation does not involve tensing of muscles. Instead, patients are encouraged to focus on different muscles,suggesting that they relax. Some people might think to themselves, Relax or My muscles feel warm.

[Our series of tapes Stress Control is an excellent program to relax.]

People with chronic muscle-contraction headaches my also
be helped by taking antidepressants or MAO inhibitors. Mixed
muscle-contraction and migraine headaches are sometimes treated
with barbiturate compounds, which slow down nerve function in
the brain and spinal cord.

People who suffer infrequent muscle-contraction headaches
may benefit from a hot shower or moist heat applied to the back
of the neck. Cervical collars are sometimes recommended as an
aid to good posture. Physical therapy, massage, and gentle
exercise of the neck may also be helpful.

When headache is a warning

Like other types of pain, headaches can serve as warning
signals of more serious disorders. This is particularly true
for headaches caused by traction or inflammation.

Traction headaches can occur if the pain-sensitive parts of
the head are pulled, stretched, or displaced, as, for example,
when eye muscles are tensed to compensate for eyestrain.
Headaches caused by inflammation include those related to
meningitis as well as those resulting from diseases of the
sinuses, spine, neck, ears, and teeth. Ear and tooth infections
and glaucoma can cause headaches. In oral and dental disorders,
headache is experienced as pain in the entire head, including
the face.

[Graphic Omitted]

This research patient is rating the intensity of heat-induced
acute pain transmitted by electrodes. From her ratings,
investigators hope to determine whether a chronic pain drug she
is taking for facial pain and headache is effective against
acute pain.

Traction and inflammatory headaches are treated by curing
the underlying problem. This may involve surgery, antibiotics
or other drugs.

Characteristics of the various types of traction and
inflammatory headaches vary by disorder:

* Brain tumor. Brain tumors are diagnosed in about 11,000
people every year. As they grow, these tumors sometimes
cause headache by pushing on the outer layer of nerve
tissue that covers the brain or by pressing against
pain-sensitive blood vessel walls. Headache resulting from
a brain tumor may be periodic or continuous. Typically, it
feels like a strong pressure is being applied to the head.
The pain is relieved when the tumor is destroyed by
surgery, radiation, or chemotherapy.

* Stroke. Headache may accompany several conditions that can
lead to stroke, including hypertension or high blood
pressure, arteriosclerosis, and heart disease. Headaches
are also associated with completed stroke, the latter
occurs when brain cells die from lack of sufficient

Many stroke-related headaches can be prevented by careful
management of the patient's condition through diet, exercise,
and medication.

Mild to moderate headaches are associated with so-called
"little strokes," or transient ischemic attacks (TIA's), which
result from a temporary lack of blood supply to the brain. The
head pain occurs near the clot or lesion that blocks blood

The similarity between migraine and symptoms of TIA can
cause problems in diagnosis. The rare person under age 40 who
suffers a TIA may be misdiagnosed as having migraine;
similarly, TIA-prone older patients who suffer migraine may be
misdiagnosed as having stroke-related headaches.

* Spinal tap. About one-fourth of the people who undergo a
lumbar puncture or spinal tap develop a headache. Many
scientists believe these headaches result from leakage of
the cerebrospinal fluid that flows through pain-sensitive
membranes around the brain and down to the spinal cord.
The fluid, they suggest, drains through the tiny hole
created by the spinal tap needle, causing the membranes to
rub painfully against the bony skull. Since headache pain
occurs only when the patient stands up, the "cure" is to
remain lying down until the headache runs its
course--anywhere from a few hours to several days.

* Head trauma. Headaches may develop after a blow to the
head, either immediately or months later. There is little
relationship between the severity of the trauma and the
intensity of headache pain. One cause of trauma headache
is scar formation in the scalp. Another is ruptured blood
vessels which result in an accumulation of blood called a
hematoma. This mass of blood can displace brain tissue and
cause headaches as well as weakness, confusion, memory
loss, and seizures. Hematomas can be drained to produce
rapid relief of symptoms.

* Arteritis and meningitis. Arteritis, an inflammation of
certain arteries in the head, primarily affects people
over age 50. Symptoms include throbbing headache, fever,
and loss of appetite. Some patients experience blurring
or loss of vision. Prompt treatment with corticosteroid
drugs helps to relieve symptoms.

Headaches are also caused by infections of meninges, the
brain's outer covering, and phlebitis, a vein

* Tic douloureux. Tic douloureux, or trigeminal neuralgia,
results from a disorder of the trigeminal nerve. This
nerve supplies the face, teeth, mouth, and nasal cavity
with feeling and also enables the mouth muscles to chew.
Symptoms are headache and intense facial pain that comes
in short, excruciating jabs set off by the slightest touch
to or movement of trigger points in the face or mouth.
People with tic douloureux often fear brushing their teeth
or chewing on the side of the mouth that is affected. Many
tic douloureux patients are controlled with drugs,
including carbamazepine. Patients who do not respond to
drugs may be helped by surgery on the trigeminal nerve.

* Sinus infection. In a condition called acute sinusitis, a
viral or bacterial infection of the upper respiratory
tract spreads to the membrane which lines the sinus
cavities. When one or all four of these cavities are filled
with bacterial or viral fluid, they become inflamed,
causing pain and sometimes headache. Treatment of acute
sinusitis includes antibiotics, analgesics, and

Chronic sinusitis may be caused by an allergy to such
irritants as dust, ragweed, animal hair, and smoke.
Research scientists disagree about whether chronic
sinusitis triggers headache.

[Graphic Omitted]

Acute sinusitis headaches can occur when one or all four of the
sinus cavities fill with bacterial or viral fluid. The
particular cavity affected determines the location of the sinus

[Graphic Omitted]

A patient in the throes of a tic douloureux attack feels
sudden, violent jabs of pain in the face, mouth, and head.

[Graphic Omitted]

This child has a good chance of controlling her headaches with
thermal biofeedback therapy, say NINCDS-supported scientists
conducting migraine research at the State University of New
York, Albany.

A childhood problem

Like adults, children experience the infections, trauma,
and stresses that can lead to headaches. In fact, research
shows that as young people enter adolescence and encounter the
stresses of puberty and secondary school, the frequency of
headache increases.

[We have the set Stress Control for Kids]

Migraine headaches often begin in childhood or
adolescence. According to a recent health interview survey,
over a million children age 16 and under experience migraine
and other vascular headaches.

Children with migraine often have nausea and excessive
vomiting. Some children have periodic vomiting, but no
headache--the so-called "abdominal migraine." Research
scientists have found that these children usually develop
headaches when they are older.

Phenobarbital, cypropheptadine, and certain anticonvulsant
drugs are used to treat migraines in children. A diet may be
prescribed to protect the child from foods that trigger
headache. Sometimes psychological counseling or even
psychiatric treatment for the child and the parents is
recommended. NINCDS-supported scientists at the State University
of New York in Albany find that thermal biofeedback can help
children with migraines control their headaches.

About 90 percent of chronic headache patients can be helped

Childhood headache can be a sign of depression. Parents
should alert the family pediatrician if a child develops
headaches along with other symptoms such as a change in mood or
sleep habits. Antidepressant medication and psychotherapy are
effective treatments for childhood depression and related

Research intervenes

Modern methods of diagnosis and treatment enable
physicians and psychologists today to help about 90 percent of
chronic headache patients, according to the director of a major
U.S. headache clinic. These methods are based on years of
scientific research. New research should lead to even more
advanced techniques of headache management.

Some scientists explore the role that certain foods play
in causing this disorder. Others are more concerned with the
function of the autonomic nervous systems of headache-prone
people. The autonomic nervous system automatically controls a
variety of essential body functions, including the flow of
blood throughout the body and the working of the pupils of the

At the Philadelphia College of Osteopathic Medicine,
scientists supported by the National Institute of Neurological
and Communicative Disorders and Stroke are gauging the
autonomic nervous system activity of normal controls and
headache patients with a technique called "pupillometry." This
technique measures the response of the iris, or eye muscle, to
light and darkness. Migraine, cluster, and muscle-contraction
headache patients are included in the study. Each patient sits
in a chair with his or her head in a chin rest. The eye is
stimulated with light and then with darkness. A television
camera in front of the patient picks up the reaction of the
iris and translates it into a graph which provides clues about
the functioning of the patient's autonomic nervous system.

[Graphic Omitted]

NINCDS-supported scientists at the Philadelphia College of
Osteopathic Medicine study a headache patient's reaction to
stress. The stress, in this case, is cold water into which the
patient dips her arm.

Another experiment with the pupillometer involves
measuring eye muscle reaction to light and darkness after
stress. In this study, stress is simulated by dipping the
patient's arm in very cold water for up to 20 seconds.

Preliminary findings from these studies suggest that,
under stress-free conditions, the autonomic nervous systems of
both people with common migraine and of people without
headaches react normally. Paradoxically, migraine patients
during stress show reduced autonomic nervous system activity, a
condition that should prevent the decreased blood flow thought
to cause headaches.

However, NINCDS-supported scientists at Southern Illinois
University in Carbondale report a different connection between
blood flow and migraine headache.

Using an infrared light sensor that measures the diameter
of blood vessels, the investigators have found that, after
stress, blood flow returns to normal more quickly in
headache-free people than in patients with migraine and
muscle-contraction headache. This finding supports the theory
that restricted or decreased blood flow may cause or contribute
to headache.

The scientists also found that different types of
headaches are characterized by different blood flow patterns.

[Graphic Omitted]

An NINCDS grantee at the State University of New York; Albany,
monitors the results of a biofeedback study that compares
home-based headache programs with office-based programs.

After stress, the temporal arteries in the foreheads of
migraine patients expand to a greater degree than the arteries
of muscle-contraction headache patients. People with the same
type of headache also show differences in blood flow
patterns--offering evidence that there are a variety of causes
for each headache type.

Testing new treatments. Scientists are also developing new therapies and analyzing the effectiveness of current treatment methods for headache. The research team at Southern Illinois University is comparing a biofeedback method that monitors blood flow with a method that monitors muscular tension in the head. This research should lead to improved understanding of individual differences in treatment response.

Several scientists are studying the value of biofeedback and other forms of treatment carried out in the patient's home. Home-based programs may be a boon to patients in rural areas who have limited access to medical care and cannot afford frequent visits to headache specialists.

In NINCDS-supported research at the State University of New York in Albany, scientists are comparing the effectiveness of a standard office-based relaxation training program for muscle-contraction, migraine, and mixed-headache patients with a similar program conducted by patients at home. Patients in the home-based program are seen in the office once a month but rely heavily on manuals, cassettes, and portable biofeedback devices.

Preliminary results suggest that home-based and office-based programs are equally effective. "If these relaxation techniques are learned at home," speculates the investigator, "they may transfer more readily to the home situation--where they will be used to cope with daily stresses."

Furthermore, at the University of Washington in Seattle an NINCDS-supported investigator is finding that home-based treatment involving only dietary changes is as effective in treating migraine patients as a home-based program of biofeedback and stress management.

Thermal biofeedback training, which involves the conscious warming of parts of the body through thought control, is believed to work because it gives people a feeling of control over their headaches. An NINCDS-supported study at Midwest Research Institute in Kansas City, Missouri, raises the possibility that this feeling of control is a more important factor in decreasing headaches than is the actual warming of the hands.

Patients who had frequent migraines were told that they would be given one of two types of biofeedback: "real temperature biofeedback," where a sound indicated their real hand temperature, or "bogus biofeedback," where a prerecorded sound emitted from the monitor would be unrelated to the patient's effort to warm the hands. Neither the patients nor the technicians training them knew whose feedback was real or bogus. Throughout the 6 weeks of training, the scientists emphasized to the patients that biofeedback should become an integral pan of their lives because it was giving them control over their headaches.

Patients in the bogus biofeedback group had a success rate that rivaled the one in the real biofeedback group. More than 80 percent of patients in both groups reduced the frequency and intensity of their headaches, as well as the quantity of medication they had been taking to control pain.

"It isn't so much the physical mechanism of migraine that matters," explains the principal investigator, "but a person's ability to cope with the syndrome and to take charge of his or her body. The emphasis on self-control is what made these people improve."

Another important area of research is the study of beta-blocking drugs like propranolol, which are used to prevent migraine.

Beta-blockers stop the activities of beta receptors-cellsin the brain and heart which control the dilation of blood vessels. The ability of beta-blockers to halt the dilation of blood vessels in the brain is believed to be a major reason for their antimigraine action. But because the drugs also affect heart receptors--slowing the heart rate--they cannot be used by people who have certain heart conditions.

[Graphic Omitted]

Scientists at Massachusetts General Hospital study these tiny brain blood vessels in the hope of developing migraine drugs with fewer side effects.

[Graphic Omitted]

An NINCDS-supported neurologist at Massachusetts General Hospital prepares brain tissue for a study of beta receptors--cells that control the dilation of blood vessels. This research could lead to the development of new medications for vascular headache.

"I have learned not to worry."

This problem may be resolved by NINCDS-supported research at Massachusetts General Hospital in Boston. A research team there is using biochemical techniques to find out if there is a certain type of beta receptor that exists in the blood vessels of the brain but not in the heart. The discovery of thisreceptor could lead to the development of beta-blocking agents that would affect brain receptors only.

Another NINCDS-funded study at the University of Kansas Medical Center is comparing the effectiveness of propranolol with that of the antidepressant amitriptyline in the preventionof migraine. Physical and psychological characteristics ofmigraine patients are being correlated with their responses to the two drags.

Investigators supported by the National Institutes of Health General Clinical Research Center at the University of Colorado in Denver are studying the antimigraine properties of a class of drugs called calcium-channel blockers. Research onthese drugs is also under way at the U.S. Air Force Medical Center, Wright-Patterson AFB in Ohio. Calcium-channel blockers interfere with the constriction of arteries, an effect that appears to be responsible for reducing the frequency of headaches in patients studied so far.

High technology in diagnosis. Physicians of the future may diagnose their patients' headaches with the aid of a computer.A computer might take a patient's medical history, store information on headache characteristics, and keep data on patients and their treatments. Programs might even be devised to explain to patients the way to take prescribed medications and the side effects of those drugs.

Scientists at Beth Israel Hospital in Boston are taking the first steps toward computer-assisted headache practice in a study funded by the National Library of Medicine. They are creating a working model for a headache interview program in which a computer will collect patient histories and symptoms. The scientists envision that an "automated physician' s assistant" will eventually free health care providers from collecting routine medical information, allowing them to devote more time to physical examination and treatment.

A final word of hope

If you suffer from headaches and none of the standardtreatments help, do not despair. Some people find that their headaches disappear once they deal with a troubled marriage, pass their law board exams, or resolve some other stressful problem. Others find that if they control their psychological reaction to stress, the headaches disappear.

"I had migraines for several years," says one woman, "and then they went away. I think it was because I lowered my personal goals in life. Today, even though I have 100 things to do at night, I don't worry about it. I learned to say no."

For those who cannot say no, or who get headaches anyway, today's headache research offers hope. The work of NINCDS-supported scientists around the world promises to improve our understanding of this complex disorder and how to treat it.

Where to get help

Finding a clinic or physician who specializes in headache is a task made easier by the National Migraine Foundation. The foundation provides a list of clinics in the U.S. as well as the names of physicians in a specific geographic area who are members of the American Association for the Study of Headache. The foundation also supports research and education in migraine headache.

National Migraine Foundation
5252 North Western Avenue
Chicago, Illinois 60625
(312) 878-7715

Inquiries about NINCDS research on headache may be directed to:

Office of Scientific and Health Reports
National Institute of Neurological and
Communicative Disorders and Stroke
Building 31, Room 8A-06
National Institutes of Health
Bethesda, Maryland 20205
(301) 496-5751

Photograph Credits:

Dr. Leonard S. Rubin, Philadelphia College of Osteopathic Medicine, Cover, page 30.

Bill Branson, NIH, pages 3, 5.

Associated Press/Wide World Photos, Inc., page 6.

Adapted from Oliver W. Sacks, Migraine, The Evolution of a Common Disorder, 1970, University of California Press, page 7.

Adapted from an original painting by Frank H. Netter, M.D., in Clinical Symposia, copyright by CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation, page 9.

National Library of Medicine, page 13.

Will Yurman, State University of New York, Albany, pages 16, 28, 31.

Dr. Ninan T. Mathew, Houston Headache Clinic, page 20 (upper and lower).

Courtesy of The Washington Post, page 22.

John Crawford, NIH, page 24.

Adapted from drawing, Massachusetts General Hospital News, November 1982, page 27 (upper).

National Institute of Dental Research,. page 27 (lower).

Dr. James A. Nathanson, Massachusetts General Hospital, page 33 (upper and lower).


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