Margaret Ellis* was diagnosed with migraine headaches about 15 years ago, when she was 44. During a stressful meeting, the Grade 3 teacher experienced an aura, seeing rainbow-like flashing lights in her field of vision. She also developed a horrible headache – which became more intense the following day. As soon as her meeting ended, Margaret rushed to an ophthalmologist, who diagnosed a migraine headache rather than an eye problem. Her doctor prescribed sumatriptan (Imitrex), a migraine-specific drug that offered some pain relief. But over the next nine years her headaches became much more frequent and severe, sometimes lasting for 24 hours. "I was getting them every day. The pain was physically, emotionally and mentally exhausting. I was in so much pain I was in tears. I couldn't teach and had to go on long-term disability," she says. 

Six years ago Margaret finally got the help she needed. After ruling out a brain tumour as the cause, a neurologist referred her to a multidisciplinary headache clinic at the Foothills Medical Centre in Calgary. "I'm very fortunate," says Margaret, who benefitted from a broad-based treatment that combined topiramate (Topamax), a preventive anticonvulsant medication, with lifestyle changes.

Margaret learned relaxation techniques, such as diaphragmatic breathing and visualization, to prevent and lessen the intensity of migraines. She also does yoga and Pilates once a week, and avoids migraine triggers, such as lack of sleep, too much stress and common food triggers such as cheddar cheese, chocolate and peanuts. As a result, she now gets only a few migraines a month. The headaches are shorter and the pain much less severe. On a scale of  one to 10, with 10 being the most severe, the pain has gone down from a nine to a three. Most importantly, her quality of life has been transformed. Margaret, who is now retired, can attend and enjoy family gatherings, go to concerts, see movies and travel extensively with her husband. "I'm having an extremely fulfilling retirement," she says. "Before I felt cut off and alone. I feel like I've got my life back."

Some stats about migraines?

Migraines are the most debilitating type of headache, and tension headaches are the most common, but no matter what the type, headaches exact a heavy toll on Canadian women and men, their families and society.

For instance, more than three million women in Canada suffer from migraines, and 92 per cent of them miss work, school or family functions as a result, according to Headache Network Canada, an organization that provides scientific and medical information on the treatment of headache disorders. Those who suffer frequent attacks – like Margaret, before she got help – lose an average of seven work weeks a year. Migraines alone cost the Canadian economy about $500 million a year. (Figures are not available for the economic cost of all headaches.) 

But it doesn't have to be that way. A 2005 survey by Headache Network Canada found that nearly four out of 10 female migraine sufferers had never consulted a health-care professional about their headaches. "Help is available for all headache sufferers," says Dr. Werner Becker, director of the Calgary Headache Assessment and Management Program, where Margaret was successfully treated.

1. Tension Headache

Location

Tightness around the head like a band. Tightening may occur across the forehead, temples, back of the head and neck.

 
What It Feels Like

A dull, achy, pressure-like pain. Unlike a migraine, it's a more diffuse, less intense pain felt on both sides. The back of the neck, at the base of the skull, may hurt, too.  

Prevalence

The most common type of headache. Nearly 90 per cent of women and about 70 per cent of men will get a tension headache during their lifetime, while 37 per cent of women and 21 per cent of men experience them regularly.  

Frequency and Duration

Extremely variable; can last for a few minutes, a few hours or be constant. Episodic tension headaches are usually brief and occur occasionally, but chronic tension headaches occur 15 or more days a month.

Triggers

Muscular tension, stress, depression and anxiety are common triggers. Others may include lack of sleep, missing meals, inactivity, poor posture, eyestrain, caffeine, alcohol and overuse of pain relievers.

Treatments

Effective treatment often involves a combination of lifestyle changes and appropriate use of pain relievers. Over-the-counter (OTC) drugs, such as acetaminophen (Tylenol), ibuprofen (Advil) and acetylsalicylic acid or ASA (Aspirin), may provide fast-acting pain relief, but it's important to limit the use of pain relievers. With any headaches, in addition to possible side-effects, such as stomach problems, there is the huge problem of medication overuse. Taking pain relievers too often, or in larger-than-recommended doses, can cause low-grade, persistent rebound headaches.

   
Prevention

Many people with chronic tension headaches suffer from depression. Tricyclic antidepressants, such as amitriptyline, are commonly used to help reduce the frequency and intensity of headaches. Anticonvulsants, such as divalproex (Depakote), used to treat epilepsy, have also proven to be effective for chronic headaches. Lifestyle changes and nondrug therapies can have a major impact on the frequency and severity of chronic tension headaches.

2. Migraine headache

Location

Occurs most often on one side of the head, but may affect both sides.

What it feels like

Throbbing, pulsating pain usually on one side of the head. May be felt around the temples, or behind one eye or ear. "Migraines make it painful to move your head," says Becker. Other symptoms may include vomiting, sensitivity to light or noise, nausea, and numbness or tingling on one side. About one in seven migraine sufferers experience auras (visual disturbances that include flashes of light, zigzag lines or blind spots) before a headache begins.

Prevalence

Women are three times more likely to suffer migraines than men. About 25 per cent of Canadian women and about eight per cent of Canadian men get migraines during their lifetime. "Migraine headaches are the type that bring patients to doctors most often by far," says Becker, because attacks affect an individual's ability to function.

Frequency and duration

About 60 per cent of migraine sufferers experience one or more attacks per month, while 25 per cent have attacks at least once a week. Headaches last from four to 72 hours.

Triggers 

Stress, fatigue, skipping meals, hormonal changes, glaring or flickering lights, loud noise, weather changes, overexertion, caffeine, chocolate, red wine, beer, nicotine, aged cheeses and flavour enhancers or preservatives are just some triggers. "The most common trigger is stress," says Becker. "A given trigger may not cause a migraine every time, but combined with another trigger they add up to reach your migraine threshold."

Treatments

Migraine-specific triptans, such as sumatriptan (Imitrex) and zolmitriptan (Zomig), are the drug of choice for treating severe or frequent migraines. Triptans prevent the swelling of blood vessels and inflammatory response that accompanies migraines, notes Becker. OTC pain relievers, such as acetaminophen, ibuprofen and ASA, may be effective for mild or moderate migraines, but taking these drugs too frequently can lead to rebound headaches. (Overuse involves taking OTC pain relievers on more than
15 days per month or taking more than the recommended daily dose.)

Resting in a dark, quiet room and applying an ice pack to the base of the skull may ease pain during an attack. Massage, biofeedback (a type of alternative medicine designed to enable you to use your thoughts and will to control your body) and other relaxation techniques may provide relief, too.

Prevention

Combining lifestyle changes with preventive medication is the most effective treatment for frequent migraines. Certain cardiovascular drugs (beta blockers, such as propranolol, and calcium channel blockers, such as verapamil) can help prevent migraines. Tricyclic antidepressants, such as amitriptyline, and anticonvulsant drugs, such as topiramate (Topamax), are also effective in preventing migraines.

"With preventive medications, patients have to be realistic. A 50 per cent reduction in frequency and intensity is considered to be a successful treatment," says Dr. Rose Giammarco, a neurologist and director of the Hamilton Headache Clinic, noting that a preventive drug must be taken for at least six weeks to see if it's effective. Botox injections reduce migraine and tension headaches in some people.

 

3. Hormonal headache

Location

Hormonal headaches are typically migraine headaches, occurring on one side of the head and influenced by the menstrual cycle.

What it feels like

Throbbing pain affecting one side of the head and often more severe before or during a menstrual period. Other symptoms may include nausea, vomiting and sensitivity to light and sound. An aura may precede a menstrual migraine but it is not typical. May be accompanied by other premenstrual symptoms such as cramps and muscle or joint aches.

Prevalence

About 60 to 70 per cent of women with migraines get headaches during the time around menstruation. Most suffer menstrual-related migraines, which means they also get headaches at other times in their cycle in association with other triggers. Less common is "true menstrual migraine," says Giammarco, "which occurs only during the menstrual cycle and doesn't occur in relation to triggers other than hormones."

Frequency and duration

Menstrual-related migraine attacks typically occur between two days before and three days after menstruation begins and, in theory, are triggered by drops in estrogen levels. Hormonal headaches may also occur around ovulation, when estrogen levels surge and then drop. Migraines improve for many women during menopause, though they may worsen during perimenopause when large hormone fluctuations can occur. Headaches last from four to 72 hours, but tend to persist longer and be more severe than nonmenstrual migraines.

Triggers

Changes in estrogen levels before and during menstruation, around ovulation, during pregnancy and in perimenopause. Falling estrogen levels usually correspond to drops in serotonin, a brain chemical known to reduce pain sensitivity. Birth control pills worsen migraine headaches for some women and reduce them for others.

Treatments

Sufferers of hormonal headaches can ask their doctor for specific recommendations about taking triptans or anti-inflammatories, which can be used as "mini-prevention" drugs taken around the time of the menstrual period.

Prevention

Since women are more sensitive to triggers before and during menstruation, regular sleep, exercise, healthy eating, relaxation therapies and avoidance of known triggers at that time can help to prevent hormonal headaches, suggests Giammarco. If hormone headaches occur frequently, long-term preventive medications, such as beta blockers, calcium channel blockers, tricyclic antidepressants and anticonvulsants, can be effective in reducing their frequency and severity. Each class of drugs has its own benefits and side-effects.
 
 

4. Cluster headache

Location

Pain usually begins on one side of the face, in or around one eye.

What it feels like

"The pain is very severe. It can be throbbing and knife-like, and is associated with watering and reddening of the eye on one side," says Giammarco. "Cluster patients are often agitated and restless because the pain is so intense."

Prevalence

Cluster headaches affect less than one per cent of people. They affect more men than women, by about six to one.

Frequency and duration

They typically come in cyclical patterns, known as cluster periods. Headaches last from 15 minutes to three hours. During a cluster period headaches occur daily, sometimes several times a day, over a period ranging from weeks to months, followed by a remission period. Cluster periods can happen seasonally, such as every spring or fall.

Triggers

Not generally associated with triggers, but during a cluster period alcohol or smoking and certain drugs, such as histamine or nitroglycerine, can trigger a headache. There are no known causes.

Treatments

Acute treatments include inhaling 100 per cent oxygen through a mask, which can provide relief within 15 minutes. Portable units are available for home use. Injectable or nasal spray forms of sumatriptan (Imitrex) are more effective than taking oral zolmitriptan (Zomig), another triptan medication. 

Prevention

Long-term preventive medications, such as lithium, the calcium channel blocker verapamil or the anticonvulsant divalproex (Depakote), are prescribed to reduce the frequency of attacks in patients during a cluster period, and may enhance the effectiveness of acute treatment drugs. To help prevent a cluster attack, stick to a regular sleep schedule, don’t take afternoon naps, don’t drink alcohol during a cluster period and avoid excessive glare and bright lights. 

Nondrug treatments

The lifestyle changes and nondrug therapies listed below can be effective in helping prevent and treat tension headaches, migraines and hormonal headaches.

• Stress relievers: Since stress is a trigger for most types of headaches, doctors recommend relaxation techniques such as massage therapy, yoga, deep breathing, visualization, progressive muscle relaxation and meditation. A preventive technique called "pacing," which involves making time every day to decompress and relax, is also effective. As well, icing the neck, sitting in the bathtub (although hot baths may aggravate migraines) or using ointments can help ease headache pain.

• Healthy living: Getting enough sleep, eating regular nutritious meals and doing regular aerobic exercise can relieve headache pain and reduce risk. Most headache sufferers can also benefit by identifying and avoiding their own personal triggers, says
Dr. Rose Giammarco, a neurologist and director of the Hamilton Headache Clinic. A headache diary can help pinpoint specific triggers, such as red wine, food additives, bright lights, loud noise or fatigue.

• Treating anxiety and depression: Underlying conditions, such as anxiety and depression, can contribute to headaches, and behaviour modification, cognitive therapy or psychological counselling may help deal with them.

• Alternative therapies: Biofeedback and acupuncture may also provide pain relief for some patients.

* Name has been changed

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