When to Worry About Your Headaches
Headaches can be common, but at what point should you worry if it's something more?
Dr. Perloff and Dr. Zhu discuss available treatment options for headaches, when to worry if it is something more serious and that if they begin to have a negative impact on your every day life, that would be the time to seek the help of a professional.
Shuhan Zhu, MD is an Assistant Professor of Neurology at the Boston University School of Medicine. She joined BU as an assistant professor after completing a fellowship in headache medicine, but her first stint with the university was a few years before. Before her fellowship, she was a resident in neurology at Boston Medical Center. She became chief resident and regularly lectured on clinical neurology topics.
Learn more about Shuhan Zhu, MD
Micahel D. Perloff, MD, PhD, is an Assistant Professor of Neurology at the Boston University School of Medicine. He arrived at the university after completing his fellowship in interventional pain at New York University. For the past five years he has trained residents in clinicals, OSCI preceptor and teaching, and pain research.
Learn more about Micahel D. Perloff, MD, PhD
Melanie Cole (Host): Nearly everyone you know, has had a headache at some point in their lives. And a minor headache can be a nuisance, maybe you take Tylenol or Motrin; but if your headache is severe or lasts a long time, or you are getting a bunch of them; then you really start to worry. My guests today are Dr. Shuhan Zhu, she’s an Assistant Professor of neurology at the Boston University School of Medicine and Dr. Michael Perloff, he’s an Assistant Professor of Neurology at the Boston University School of Medicine. Dr. Zhu, I’d like to start with you. Do we know why we even get headaches? Do we know what they are? Or do we know what causes them?
Dr. Shuhan Zhu, MD (Guest): Well, that’s a very complex question actually. We know there’s a lot of – there’s a complex interaction between genetics and the environment, say much like in the way of why do people get diabetes. It’s hard to pinpoint any one cause. The most common types of headaches would be tension-type headaches or migraine, and these do have strong genetic components, but as we all know from personal experience; our environment really matters a lot as well and whether we develop headaches or – actually develop them or not. So, I would say mixed causes, but difficult to pinpoint on any particular one.
Dr. Michael Perloff, MD PhD (Guest): So, I would like to add to this on the same token headache syndromes and different headache problems in some cases have some similarities. There are some similarities between different types of headaches. But on the flip side, on the other side, there are dramatic differences in etiology and how the headaches can feel and how we treat them too. So, there are some similarities between headaches in terms, but there are some dramatic differences as well.
Host: Dr. Perloff, what are some of the most common types of headaches. As Dr. Zhu mentioned migraines, people have heard about those and tension headaches. What else do you see?
Dr. Perloff: Yeah, I mean so tension and migraine would be the most common and then variants off those. We see headaches that have different causes. So, if you can think of the common tension-type headache you get related to stress or related to poor sleep and people know those headaches. Migraine is more something that is a syndrome like as Dr. Zhu said has genetic aspects but there is added features. So, not usually just a headache. But a headache that comes maybe with nausea, with problems with light bothering you and then if we go on, there are even further types of headaches. There are things like cluster headaches, which is a headache syndrome with autonomic features on one side of the face meaning congestion, eye tearing, things like that. There are occipital neuralgia headaches at the back of the head with shooting nerve pain. So, there’s a lot of different subtypes, but yes, the most common that we see are migraine and migraine variants; different styles of migraines and tension-type headaches due to different triggers.
Host: Dr. Zhu, when I asked you that complicated question, of do we know what causes them, do we even know what they are; if we don’t and it’s such a complicated question; how do you diagnose them because people have sinus headaches and as Dr. Perloff said, migraines, toothache can cause a headache, stress obviously can, eye issues, poor eyesight, dehydration. There are so many causes, how do you diagnose what’s going on so that we can really treat it directly?
Dr. Zhu: I would say the most important aspect of an accurate diagnosis is the medical history. In other words, the patient’s symptoms. So, that’s most of how we diagnose these various headaches, different types of headaches. Because there isn’t really a test to say – you don’t draw a blood level of something and it’s positive when it’s migraine and negative when it’s tension-type headache. It’s really based on that person’s symptoms. And the reason it’s so important to focus on those symptoms is it also gives us an idea if this person may have what we call a secondary cause of headache. As you mentioned, things like dental problems, eye problems, and other problems can lead to head pain that resembles a migraine or tension-type headache. And it’s important to assess whether these other causes may be present, because treating these other underlying causes is one of the methods of managing the pain.
Now we mentioned some of the more common causes of triggering headaches, migraine-type or tension-type. And sometimes it could be less commonly, it could be something potentially dangerous, for instance a tumor or some inflammation within the central nervous system and these are kinds of things that when we see patients, we spend quite a while clearly reviewing the symptoms because that’s where we are going to get the clues as to what is the underlying cause.
Dr. Perloff: And to add on to that, you know you said if we don’t really know what causes migraine, how do we treat them. Well if you look into a pot of stew with 20 different ingredients, you still see carrots. So, you know there’s carrots in there. So, for example, sleep is a big component of a lot of headache problems and we get the history and we do the exam and supposing the exam is normal, if somebody has very, very poor sleep, that can play into it. On a more biochemical or physiology aspect, migraine headaches have an aspect of something called cortical spreading depression which means a negative impulse across the brain. We don’t know exactly how that happens or why it happens. But if we have a medication that suppresses that or treats it; it can help migraines. So, sometimes we understand aspects of the headache on a biophysical level or aspects of the headaches on a trigger level and we can treat those. Admittedly, we don’t understand everything. But we understand components and that helps us treat and manage headaches.
Host: I think that’s what makes headaches so unique and so fascinating really, Doctors, because they are so subjective, you don’t kind of be able to describe your pain to one of you doctors to tell you what it is that we are going through. Dr. Perloff, when do we worry? Because I think everybody, me included, get a headache and you go oh, is it a tumor, am I having a stroke? When is it that we really worry that a headache is something more serious?
Dr. Perloff: So, lots of times it comes down to when something is new, or something is different. In other words, even if someone has a chronic condition, yes, there has to be a first migraine; so, someone who is in their teens, they might have their first migraine. If someone is going to come up on a bout of a lot of tension-type headaches, there needs to be a first. But if something is different. So, for example, if you are a person who gets an occasional headache and now you have a headache every day for months; that’s something you might want to see a doctor about. If you’ve never had a headache before and you get a new onset headache, if the headache has features that are different like meaning not just a headache, but things that come with it whether it be blurred vision, so basically a change. Now a lot of times, these things are benign headache syndromes, not benign in that they do hurt, and we try to make your pain feel better, but there is not something terribly wrong.
But usually a time to seek help is when something is different to you. Now we do have like a sort of a list of rules that we follow of when we are going to do more investigations or as a physician, be more concerned about the patient and other times when we are going to reassure the patient and say you know, we think everything is okay and do less tests. But that’s a little complicated in each situation.
Host: Dr. Zhu, one of the most common complaints that I hear are teens with their headaches. And Dr. Perloff mentioned teens and migraines maybe they start with the migraines. Stress and teens and headaches and even migraines – you see it a lot now. When do we determine if it is stress related and what do you advise parents to do about it? I mean how often do we take our kids to a neurologist to get a headache checked when they are under so much stress and they are not sleeping, and they are on their phones all the time? There are so many factors that could figure into that.
Dr. Zhu: Again, I think it involves understanding the teen’s medical symptoms and also how it fits into the context of their lives. You mentioned stress and poor sleep as a major one. Partly if a teen doesn’t – cannot control when school starts and that is a common pattern I see where they may improve over the summer or extended breaks and during school times; between the stress and the disrupted sleep, headaches worsen a lot more. Now what can parents do? In these cases, it can be quite difficult because it’s also not possible to adjust some of these stress factors. You know the tests are going to keep happening, school is going to keep starting at 7 or 7:30 a.m. So, that’s when we do what we can do which involves treatments with various medications and we go through various non-medication-based strategies as well for stress reduction and adjusting the environment as possible. Sometimes through letters or phone discussions with the teen’s school to help make it an environment that is as healthy for that teen as possible so that they have less headache burden.
Host: Dr. Perloff, let’s speak about some of those treatments. Dr. Zhu mentioned medication and nonmedication. So, let’s start with the non-medicational treatments. What would you do for somebody if you determined that this headache is a result of stress or the lack of sleep or too much alcohol or any of these number of things that people get headaches from? What are some non-medicational treatments that people can try?
Dr. Perloff: Well, obvious logic, it’s the old doctor’s line if this gives you pain, let’s then stop doing that. So, you try to avoid triggers and some patients will have an idea what their triggers are, but other patients will not. We talked about sleep. Stress is too big for this term and having someone avoid that. Maybe they can’t but for example, I’ll meet patients that they say oh I’ve had bad headaches for about three months, and I’ll say well has anything changed over that time. And it’s like oh it’s only I started a second job and I’m working two shifts. And they are only dedicating five hours of sleep a night. Sometimes something as simple as like a letter to their employer can we change their job shift so they can dedicate eight hours or nine hours to sleep at night could be a cure. So, changing triggers. It could be caffeine. There are people that drink a lot of caffeine all day just throughout their day, tea, coffee, soda and then of course at night, they go to sleep and they don’t drink caffeine while they sleep, so when they wake up, they are in withdrawal. Withdrawal headaches. So, there can be simple things like that.
I admit if we do eliminate triggers and quite honestly, primary care doctors do a pretty good job of a first pass at common headaches, whether it be sleep affecting headaches, stress, caffeine, things like that and a lot of times when patients come to us, some good work has already been done. So, we do reach for medications if we think we can’t change or find the trigger of the headaches.
Host: Dr. Zhu, what kind of medications? We’ve heard about Tylenol and Motrin and first of all, I would like you to start with over-the-counter. What do you like? Do you like Tylenol better than Motrin or Advil? What do you like as far as over-the counter for headaches for normal tension, stress headaches and then when does it become a prescription?
Dr. Zhu: Well, I would say probably what we call the NSAIDS so nonsteroidal anti-inflammatories. Most people are – that includes things like aspirin, ibuprofen, naproxen. These are one of the mainstays and most people will have some improvement with these over-the-counter medications. Tylenol is also a good option, if that person say has upset stomach to ibuprofen. Or they can be used in combination for instance, naproxen with Tylenol or ibuprofen with Tylenol. There are also premixed over-the-counter formulations of medications. The most common one would probably be a branded one would be Excedrin which contains aspirin, Tylenol and caffeine. Now this can be a very good treatment for some people, but all of these over-the-counters, they are useful but they can’t be used indefinitely at the maximum pills allowed per the bottle because it can lead to side effects and lose of effectiveness and for some people, in particular, with the premixed medications such as the ones containing aspirin, Tylenol and caffeine; it can lead to worsening of headache if you used inappropriately over long extended periods of time. So, they are good for many people, but they are not exactly sufficient if someone has very frequent headaches or very, very severe headaches.
And that’s when we reach for prescription medications. So, prescription ones again, what’s appropriate really depends on that person’s individual medical background. There are a lot of different options. A common one that we use would be the family of medications called triptans but it’s not appropriate for everyone so that’s important why it’s partly a prescription medication. We need to understand if you have blood pressure problems, if you have had heart issues, or stroke concerns and based on your age and potentially what else you are taking for other medical issues.
Another common thing that we can prescribe to help with headaches is anti-nausea medications as very severe headaches oftentimes come with nausea and that’s because they are most of the time, they are due to migraine, as that’s one of the most common severe headache conditions. Short of that, there are a lot of other things from injections that we can in the clinic to injections that the patient can do themselves at home. It’s hard to give an overview because there are a lot of choices on what’s appropriate for one person. We individually tailor it to that person’s medical background and medical symptoms.
Host: That was a very comprehensive answer Dr. Zhu. Thank you so much. So, Dr. Perloff, when we are speaking about some of these treatments and we’ve got kids and tension headaches and there’s comorbidities like obesity that could go along with this; tell the listeners what you would like them to know about headaches, about when to worry, kind of wrap it up and summarize it for us. And if you’d like to give some good non-medicational, rest your eyes, or yoga or some of these things that you might recommend on a daily basis, go for that too. So, wrap it up with your best advice about headaches, when we worry, when we don’t and what we can do about them.
Dr. Perloff: Well as far as whether it is about pediatrics or kids or even adults, I mean adults will just quickly go through that they can self-manage. So, if they have a headache that they can’t figure out the triggers on their own or they can’t just treat the headache on their own and it seems to be a new persistent headache or a new type of headache or there are features with the headache that they are worried about; they should see a doctor or tell their primary care doctor and they can help them.
As far as teenagers and kids; as a parent, if you can eliminate the trigger; it can be helpful. That can be complicated for parents working with kids because of their own relationship with the kids and maybe instructing kids to do something or not have screen time or get to bed earlier or avoid those whatever the stressful activity is that they are doing; they might not want to listen to their parents. Or if it is a relaxation technique or different cognitive behavioral therapy; it might be difficult in a parent who is managing the teenager either as a disciplinarian or whatever role to sort of play the person who is trying to help them with their triggers and with their headaches in a non-medical way, not using medications.
So, as far as getting help, there are different cognitive behavioral therapy programs for teenagers, and they can go, and they can learn relaxation techniques and learn how to deal with stress and that can help headaches and migraines a lot. I think asking your PCP for help. Again, this is if over-the-counter medications aren’t working. So, for example, it is reasonable that someone takes an over-the-counter medication two, maybe three times a week. If you are having headaches more than two to three times a week, you probably want to talk to your primary care doctor. When you are getting down in the range of having a headache once a week or here and there for a month; it is reasonable to use over-the-counter medications and as a parent, I think you can help your kids manage medications that way.
Pediatrics, kids that are below teenagers, it’s complicated. And if your kid is having persistent headaches, I think you really need to involve your doctor. So, I would kind of look at it in that step-wise order. So, kids say under the teen years 12 and under; if it’s a persistent headache you really need to involve your doctor even if they are benign headaches, it’s hard as a parent to kind of get these under control. Help is good.
I think in teenagers, if these are infrequent headaches that are here and there and over-the-counter medications are helping and you can help them manage their triggers, their stress, their sleep their different problems; then that’s reasonable for teenagers. If you need help, get it. Because the relationship between parents and teenagers can sometimes make it difficult to help them.
And then lastly, to come back as an adult like we said, new or persistent or things that have extra symptoms, you should probably see a doctor about.
Host: Thank you both of you for being with us today. It’s important information. It’s great information and certainly something that many people think about is oh I’ve got a headache, when do I worry. Thank you for clearing that up so beautifully for us. This is Boston MedTalks with Boston Medical Center. For more information, you can go to www.bmc.org, that’s www.bmc.org. This is Melanie Cole. Thanks so much for listening.
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