I have recently seen an increase in the number of children/adolescents in my clinic, this is common at this time of year for many reasons (see ‘sizzling summer’ article below), but exam stress is also a common contributing factor.
Coincidentally a few months ago there was a study published in the Journal of the American medical Association stated that undergoing CBT* (cognitive behavioural therapy)-in addition to taking the medication amitriptyline-can help children and teenagers with chronic migraine.
In brief, the US study involved 135 children and teenagers. All of who were considered to be chronic migraineurs (experiencing severe migraines between 21 and 28 days per month). After undergoing CBT participants experienced on average an 11.5 day reduction in the number of days in the month that they suffered migraine, compared to those on medication alone.
The researchers concluded that CBT should be routinely offered to younger people as a first-line treatment along with medications.
The above findings are hardly surprising, as it has been known anecdotally for a long time that stress/emotional problems increase the likelihood of migraine in a significant number of people who are already predisposed to migraine.
Indeed, research evidence is mounting that migraines may well ‘start’ as a neurological disturbance/excitability in the deep parts the brain that are also involved with emotion.
Therefore it is likely that any approach that helps reduce the excitability of this part of the brain has the potential to reduce the frequency of migraines. Whether this be relaxation exercises, neuromodulation(to be discussed in a later article), talk therapies/counselling (including CBT & other psychological interventions) or if absolutely necessary- medication (personally I like to avoid this if possible).
This is why it is helpful to have a fully qualified clinical psychologist at my clinic, trained in CBT, just in case this approach should be considered necessary/useful.
*CBT is a well researched(evidence-based) psychological approach which addresses peoples emotional responses, behaviours and thought processes that are unhelpful/ maladaptive by helping them to ‘think’ differently.
•
Modern man has a tendency to slouch. It is likely our ancestors would have been moving constantly as they foraged for food, modern man on the other hand spends the vast majority of his time in static positions — either sitting or standing — when the tendency to slump and sag is just too great.
The trouble is we are fighting against gravity the whole time. For the many of us it only takes about ten minutes of sitting or standing before the ‘postural’ muscles in the spine and abdomen that hold us up start to get tired, and we start to slump.
Most of us know from experience that sitting hunched in front of a computer or driving wheel can lead to a stiff, painful back and shoulders. But poor posture can also TRIGGER HEADACHES. If you find you suffer headaches while at work, it might be the way you sit, rather than the stress of your workload that’s the source of the problem.
As previously mentioned, when sitting at a desk for longer periods, the muscles that support the body, neck and head start to tire and the spine starts to slump. The tendency is then to compensate for this by sticking the neck and chin forward to keep the eyes in a good position thus making sure we can still see the screen (i.e. keeping the eye line horizontal).
The resultant tension in the muscles at the base of the skull, caused by the spine rounding and the neck sticking forward, can pinch the nerves in that area, leading to something called cervicogenic headache. It tends to be characterised by pain that starts at the back of the head/top of the neck and travels up and over the scalp often ending just above the forehead.
So if you always seem to get headaches whilst sitting try the following;
1) Check if altering your posture makes a difference.
2) Ensure you have a good chair that allows you to sit up relatively straight without too much effort.
3) Take regular breaks to give your muscles a rest/change of position.
4) Ask an Osteopath or Alexander technique teacher to check your posture.
5) Strengten your postural muscles with exercises prescribed by a suitable specialist (such as an Osteopath or Physiotherapist) so they are more resilient and can resist the slumping tendency.
6) If possible get an ergonomic assessment of your workstation.
Sugar and the brain.
Although I have discussed the relationship of blood sugar levels and headpain before, with all the recent news coverage of the ‘evils’ of sugar, I thought perhaps it was time to revisit this important issue from the perspective of the brain.
Since the brain needs glucose from the blood to work properly (indeed the brain is second only to exercising muscles when it comes to glucose requirements), it is not surprising that unstable blood sugar levels leads to sub-optimal brain function.
Basically, sugar, a simple carbohydrate, is obtained from various foods/drinks in the diet and transported as glucose in the blood and delivered to all the bodies’ cells to provide energy. Of all the organs and tissues in the body, the brain is the most dependent on a stable minute-by-minute supply of glucose from the blood to function normally.When blood glucose levels drop, the brain immediately suffers, resulting in a number of symptoms, including fatigue, mood changes (irritability, anxiety, depression, etc), headaches/migraines, dizziness/faintness, cognitive problems (forgetfulness, confusion, poor concentration etc.), fainting and even coma if levels drop too far, for too long.
Now you may be wondering why I’m talking about low blood sugar levels when all the media fuss is about diets that are too high in sugar.
Needless to say the biochemical explanation is rather complicated, but basically following a meal high in sugars/simple carbohydrates (more of this later) the digestive processes are able to quickly convert them into glucose that then rapidly enters the bloodstream. This sudden increase in blood glucose is quickly
detected, resulting in an automatic release of higher than usual quantities of insulin (a hormone produced by the pancreas) that basically causes glucose to be removed from the blood and enter the ‘storage’ cells in the liver. This will cause a relatively rapid decrease in blood glucose levels, often leading to lower than optimal levels
( hypoglycaemia ) which results in lowered glucose supply to the brain and the inevitable signs of brain dysfunction mentioned above.
Further confusion arises when it comes to considering foods that cause rapid increases in blood glucose. Most people naturally assume it would be table sugar, sweets, chocolate, cakes, fizzy drinks etc. If only it was this simple. Unfortunately there are many other foods/drinks common in our diets that also cause unnaturally rapid increases in blood glucose, such as white rice, white pasta, white bread, bananas, fruit juices, all alcoholic beverages, and many others.
Then there is the disturbing fact that virtually all processed foods have some form of sugar added; check the label and you will be astonished at the number of products that have a high sugar content, even in foods you would never suspect such as cereals, processed meats, soups, even so-called ‘healthy’ muesli bars, the list goes on and on.
Therefore if you are someone prone to headaches or migraines, it is one more reason to try to limit/reduce the amount of sugar, or sugar ‘equivalents’ that you consume.The relative ‘sugariness’ of many foods and drinks is called the Glycocemic index( the higher the number/index, the more it results in the rapid rise in blood glucose which you are trying to avoid). It is possible to check this either by going online or there are several books on low Glycocemic diets. And needless to say, start checking the labels of foods that you regularly consume for added sugar and be ready for some surprises!
Headpain and sleeplessness.
It has been known for a long time that chronic headache/migraine frequently coexists with sleep problems/insomnia (For example in one study 50% of migraineurs stated that their migraine attacks were triggered by poor sleep). Indeed in many of my patients tackling their sleep problems is a vital step to reducing the frequency of their headpain.
Some recent research to come out of the University of Rochester therefore caught my eye. They have found that the system by which the brain ‘cleans/detoxifies’ itself is 10 times as active during sleep compared to during the day.
Basically the brain produces various chemicals as a byproduct of nerve function, some of them are somewhat toxic such as the beta-amyloid amino acids, these need to be cleared out to keep the brain functioning efficiently.
The disposal process, the glymphatic system, works by pumping cerebrospinal fluid through the brain tissue thus flushing the toxins into the main blood system and then eventually to the liver where they are broken down into less toxic components. As perviously mentioned, the research found this system is much more active during sleep than it is during waking hours.
Clearly if some people are not sleeping so well this ‘self- cleaning’ system may well be less thorough, possibly leading to build up of ‘brain toxins’ which may then predispose them to subtle brain dysfunction &, in certain individuals, triggering a migraine or headache.
This adds weight to the argument that it makes sense to deal with any sleep problems when trying to reduce migraine/headache frequency.
Migraines and snakes!
Recent research at Essex University investigating triphobia (the fear of clusters of small holes) found that 18% of women and 11% of men* -in a sample of 300 adults-found photographs of the lotus flower (a frequent trigger for tryphobia) uncomfortable to look at.
What, you may ask, has this got to do with migraine? Firstly it is well known that certain repetitive patterns, in carpets for example, can be a trigger for migraine. Secondly it has been shown that in some people hyperactivity in regions of the brain such as the amygdala seems to be a predisposing factor to migraine.
Now, the amygdala happens to be part of the “old”- evolutionarily speaking- brain which is programmed to react to danger. It therefore occurs to me that there may well be a `stress`reaction in the amygdala to certain repetitive patterns as an evolutionary relic from the time when repetitive patterns meant to danger in the form of poisonous animals or predators. This `stress`response on an already sensitised amygdala could then be the starting point for the neurological `cascade/storm` that is migraine.
*Also, intriguingly 18% of women and 11% of men is not too far from the prevalence of migraine in the general population !
A) It has long been accepted that there is a genetic component to migraine and another recent US study has now confirmed at least one genetic mutation that seems to make people prone to migraine.
B) More interestingly, new research (again from the US) has indicated that shared genetic susceptibility between migraine and epilepsy. It is this finding which I would like to comment on.
For many years, when asked to explain to patients in layman’s terms what a actual migraine `is`, I have described it as a type of `electrical storm` in the brain, which then triggers secondary changes in the blood flow and also results in certain chemical/metabolic changes.
These three phenomenon (electrical, circulatory and chemical) result in the various symptoms associated with migraine.
Now, epilepsy is also essentially an `electrical storm` in the brain although in a different location and usually more profound than migraine.
In fact one could argue, as I do, that migraine and several seizure type disorders (such as epilepsy) are all variations of neurovascular (that is nerve and circulatory) `storms` in the brain. Thus they may well all exist on the same, albeit rather wide, spectrum of disorders.
It is not surprising therefore that certain medications used to treat epilepsy are also used in the management of migraine!
( I would like to stress that this does not mean that if you suffer from migraine you will go on to develop epilepsy or any other seizure type disorder).
Take a drug holiday!
And no, we are not talking about a weekend away in Amsterdam!
Medication and head pain can be associated in various ways the two most common are;
1) Headache as a side-effect of a medication (which is being taken for an unrelated medical condition.)
The obvious clue would be if your headaches began at the same time (or soon after) starting to take some form of medication. If this is the case, firstly check if headache is listed as a side-effect of that particular medication. If it is then it is worth discussing with your doctor/specialist if there is an alternative.(It should be noted that some side effects of medications may wear off after a week or two of taking them, so if the headache is not too bad you may wish to persevere for short while before visiting your GP)
If headache is not listed as a side-effect, but you still feel that there may be a link, then once again you could ask your GP for an alternative or possibly suggest stopping the medication for a few weeks to see if the headaches disappear, then restart the medication and see if the headaches reappear.
2) Medication Overuse Headache (aka rebound headache). This is a common problem among patients with chronic headache and/or migraine. Research has shown that all forms of painkillers which are commonly taken for headache and migraine, can, if taken too often, actually make headaches/migraines worse! This includes opioids/codeine-based painkillers ( of which there are many; check label or online), non-steroidal anti-inflammatories ( neurofen/ibuprofen/naproxen etc), triptans ( imigran, zomig, sumatriptan etc ) and even asprin & paracetamol.
The question is how often is too often! This probably varies from person to person, but current consensus is that if you have been taking a full dose of codeine-based painkillers more than 10x per month, or non-steroidal anti-inflammatories/triptans more than 15x a month, for more than three months, then there is a distinct possibility that you may have medication overuse headache.
(Some studies even suggest taking painkillers as little as twice a week may lead to increased headache frequency in certain individuals.)
So if you have been taking frequent painkillers for your head pain a `drug-free holiday`, ideally for a minimum of three months, should be seriously considered. However you should be aware that in the short-term the headaches/migraines are likely to significantly worsen before they start to improve.
It is also important to stress that if you have been taking frequent painkillers for more than a few months giving them up can be extremely difficult and you will almost certainly need to seek the advice and help of your GP/headache specialist to manage your `detox`.
Sinus Headache
Last week I received an e-mail from a friend who lives abroad and that I haven’t seen for a long time. Below is an excerpt.
“Recently I had a nasty virus/cold whatever. The reason I am telling you this is because I do not normally fall for advertised medication, but this time, even after taking a course of antibiotics I was getting unbearable headaches that woke me up at 4 every morning, splitting, throbbing…I was devastated until a friend brought me some Sudofed, which cleared it all out in about a week (but the headache stopped after the first day!)
I know you are mainly concerned with different types of headaches but it is quite puzzling that my doctor wouldn’t suggest taking/trying that, it was just a matter of clearing my sinuses…”
This combined with the fact that winter is a time for colds and flu prompted me to post some thoughts on sinus headaches.
Notwithstanding the above e-mail, the fact is that whereby many people believe that their head pain is due to sinus `infections`(and may even have been told this by their GP) the reality is they often have migraine with associated nasal congestion. That is to say the nasal congestion is the result of, rather than a cause of, the head pain.
It is also worth noting that on many occasions I have had patients in the clinic believing they have sinus headache when in fact there are suffering from some other type of head pain such as so-called `tension type` headache. In addition it is important to remember that dental problems may also refer pain into the sinuses.
Indeed you may also be surprised to hear that as yet research has failed to show a strong association between recurrent low grade sinus problems and frequent headaches. Nevertheless sinus headache does exist and what follows is a brief summary.
Maxillary- tends to give pain in cheek teeth or upper jaw
Ethmoid- tends to give pain between the eyes
Frontal- tends to give pain in the forehead
Sphenoid- tends to give pain on top of the head or generalised over the whole head
In typical cases pain associated with sinusitis is a dull, deep ache with feelings of fullness/congestion, made worse by bending forwards, coughing, sneezing and blowing the nose.The pain will often be worse in the morning, easing throughout the day. It may also interfere with sleep.
It is worth noting that Sinus headaches are more commonly found in association with the following;
1. Frequent illness(viral/ bacterial).
2. Allergies &/or sensitivities; usually inhalant-type (hayfever, dust etc) but also possibly others(for example food).
3. Overuse of decongestants.
4. Smoking.
5. Abnormal anatomy of the relevant parts of the Skull.
6. Presence of adenoids/polyps etc.
7. Coexisting emotional stress.
8. Any other condition that promotes inflammation and/or interferes with drainage from the sinuses.
Unfortunately there are few tests that will absolutely confirm, or alternatively rule out, the diagnosis of sinus headache. X-rays of the head/sinuses are of little value, MRI scans are more helpful and in extreme cases it may be necessary to investigate the sinuses with small cameras (a so-called endoscopy).
However, as with many other types of headache, diagnosis is usually based around the nature of the symptoms and the history of the patient and their head pain, rather than specific medical/laboratory tests.
Once sinus headache is suspected treatment will depend on the cause/causes; in essence resolving any infection, reducing swelling within, and improving drainage from, the sinuses. It is also vital to identify and dealing with any coexistent problems (such as allergies) which maybe contributing/maintaining problems within the sinuses.
An opinion from a headache specialist is therefore strongly recommended for accurate diagnosis and appropriate management/advice.
N.b. Interestingly frequent use of nasal decongestants very occasionally cause a type of headache which is characterised by very sudden attacks of severe head pain (and sometimes associated symptoms of dizziness, visual disturbance, and others) the medical name for this is Reversible Cerebral Vasoconstriction Syndrome and is one of the causes of so-called `thunderclap`headaches.
If you think you suffer from `thunderclap` type headaches you should ALWAYS consult your GP or headache specialist.
“A recent study in Brazil of 5,671 children aged between 5 and 12, found those with migraines were 30% more likely to have below average school performance than those with no headache…..”
Headache and migraine are surprisingly common in young people. For instance it is estimated that migraine affects 2% of five-year-olds and 18% of 13 to 14-year-olds. Tension type headache affects up to 25% of children with other headache types also affecting large numbers.
Unfortunately the head pain is often undiagnosed and untreated. This may be for a number of reasons such as; atypical presentations (symptoms in the young may not be the same as those in adults) or more than one type of headache being present at the same time leading to diagnostic difficulties. Frequently parents and schools do not take the problem seriously and/or are under the mistaken belief that there is no effective treatment.
It is known that head pain is a major cause of school absenteeism, in the worst cases resulting in several months a year of missed school. Needless to say it also has a negative impact on home life, as well as social and sporting activities.
Although the head pain may fall under a typical classification such as;
• Tension type headache (episodic and chronic); a mild to moderate dull headache lasting a few hours with no other symptoms although occasionally there may be associated anxiety or depressed mood.
• Migraine without aura (episodic and chronic); typically moderate to severe throbbing pain aggravated by activity and lasting hours to days. Associated symptoms include nausea/vomiting/light + noise intolerance and dizziness among others.
However it is not uncommon for children and teenagers to suffer from any one of a number of atypical `syndromes, which are different to adult headache types. These include;
1. Atypical migraine with or without aura; mild to severe head pain which may be difficult to describe, sometimes only lasting an hour or two with nausea and vomiting usually present. Aura symptoms consist of visual and/or sensory disturbance, muscle weakness, speech problems and others
.
2. Abdominal migraine; recurrent discrete episodes of dull, occasionally severe abdominal pain with associated nausea/vomiting/lack of appetite/lethargy and possible headache (but not always!). The attacks may last hours to days during which the child will look pale and be unable to participate in usual activities. Rest and sleep results in significant improvement.
3. So called “ Alice in Wonderland” syndrome; a special type of migraine with extreme and bizarre aura symptoms including distorted images, feelings of déjà vu, and hallucinations . Headache is usually but not always present.
4. Benign paroxysmal vertigo; tends to affect younger children (under five) consists of discrete episodes during which the child feels suddenly unsteady, becomes frightened and may fall. Episodes last between a few minutes and a few hours during which the child will also usually feel and look unwell but recovers spontaneously.
5. Post-traumatic headache/migraine; children may experience intense headache, dizziness, confusion, vomiting and lethargy following a minor head injury even in the absence of any significant brain/skull trauma.
Importance of early diagnosis.
Ensuring the early ,accurate diagnosis and expert management of head pain in children and adolescents is essential as the frequency and or severity of attacks can often be reduced by following simple advice regarding lifestyle (food/drink/sleep patterns/exercises etc) or specifically tailored treatment.
Even a moderate reduction of headache days will usually result in less disruption of the Childs/Adolescents education and a significant improvement in quality of life.
Several clinical trials have implicated caffeine as a possible trigger or aggravating factor to migraine/headaches in certain people. it therefore makes sense to reduce, or ideally completely remove, caffeine from your diet for a trial period to see if it makes any difference to the frequency of your headaches/migraine. Sadly this means more than just giving up coffee as caffeine is found in many drinks, several Foods and some medications.
These include:
- Coffee.
- Tea.
- Many Colas and fizzy drinks.
- Most `Energy` drinks and some `Sports` drinks.
- Coffee and Chocolate flavoured drinks (including liqueurs)
- Foods containing Coffee/Chocolate/Cocoa products or flavourings.
- Some ice creams.
- Many over-the-counter medications contain caffeine (including some painkillers). Always check the label and ask the pharmacist about caffeine free alternatives.
- Several prescription drugs contain caffeine, however do not stop taking these without consulting your doctor first.
- It is worth noting that even some so-called caffeine free coffee/tea still contain some caffeine.
- As well as checking labels, there are several websites listing caffeine content of various foods/drinks.
- You should also be prepared for a possible short term worsening of your headaches and/or migraines when you first give up caffeine. This usually passes after a few weeks
