HEADACHE—
Just about everyone gets a headache now and then. A little of your favorite remedy and that’s that, right? Well guess what, for a lot of people headaches get so bad as to become incapacitating, and it surprised me to find out how often we see people in the ER with the chief complaint of headache. And not surprisingly there are a lot of urban myths surrounding them. Is this a migraine? Do I have a brain tumor or a cerebral hemorrhage? Is it my blood pressure doing this? Can you just shoot me?
So, in addition to trying to provide relief, we must wade through the layers of nonsense regarding cause, as well as trying to come up with something for people who live with frequent or even daily headache, and the disability and lost productivity and decreased quality of life that comes with them. Fortunately, I have all the answers.
An awake and alert nervous system sends out abundant stimulation to the muscles of the body, ideally “lighting up” these orthopedic stalwarts of our existence. They burn up the local stores of our main energy source, glucose, generating CO2 and H2O that the heart and lungs must irrigate and ventilate. If the oxygen delivery lags behind, we generate other byproducts of this muscle activity that must be “re-set” at some point, making us breathe heavy with a racing heart after we stop what we’re doing, for several minutes.
At night, we re-manufacture these nervous system chemicals, called neurotransmitters, that do the stimulating, during restorative sleep patterns. If you stay up all night you might notice how poorly all of this works the next day, and that you seem to get winded with even minor exertion. That’s because there is so little nerve output that only a portion of the muscle gets activated, and in working overtime generates this debt noted earlier.
I’m convinced that this physiologic shortcoming is at the basis of the 95 or so percent of headaches, that are from a hurt in the muscles of the upper back and neck, all working in unison to stand up, and hold our head up. And with the muscles of the spine especially, we’re talking about a tough, powerful, heavily worked and relied upon group of muscles, that hold us up against gravity, in that genius of an “ess” curve, bending in at the neck, backwards for the thorax, inward as the low back’s lumbar region, and then again curving backward as the fused sacrum, or “tail” bone. Headache and backache are the maladies of this reality, when it is not functioning ideally for whatever reason.
When you lay down at night and drift off to sleep, there is a period of hours when the brain continues to generate signals (and we can see them if we have the your head wired, like in a sleep lab). Then, at 3 or 4 in the morning, there is a total shut-off for 20 minutes or so, during which there appears to be no electrical activity in the brain. Then there is a rise of activity to where dreams are generated, what you know as REM (Rapid Eye Movement”) sleep, for several minutes, and then from there to more wakefulness, such that you’re barely asleep. This period of relative wakefulness is accompanied with a “major position change”, where you roll over or something like that. Without this nifty unconscious maneuver you would get bed sores, from laying in one place so still for so long. So thence, sleep comes in these 20 or so minute groupings.
Then, ideally, you pull this off 4 or 5 more times, and wake “fully restored”. Probably, it is during this “off” period early in the pattern that the brain manufactures new neurotransmitters depleted during the day, like the ones to muscles and other commonly utilized parts of the anatomy. During REM, the brain is maybe dumping or re-filing thought activities from the frontal lobes, the bull(crap) of our “minds”. My impression is that people who suffer headache are usually too alert or over -alerted to properly turn the mind off enough for it to slip into these restorative patterns.
Sleep quality, and the ability to perform well at turning yourself off, is probably some kind of gift. For many of us, from environmental factors to inherited traits, something is wagging the dog, and affecting the ability of this important brain function to happen smoothly and consistently. Others will tell you they’ve never had a headache their whole life. They’re the good sleepers.
Hence: headache-prone behavior is caffeine and cigarettes and high-stress lifestyles and realities and poor physical conditioning, and headache-free behavior more like people of even mood, with the intellect to avoid frustrating social realms, eat few pharmaceuticals and no nicotine, and are in good physical condition and shape.
“Normal” people get runs of headaches, lasting a few days to a few weeks. Why would that be? We know people go through episodes for a few months where their brain is alerted of over-juiced for one reason or another, and they will show poor night-time restoration and feel it as the “tension” of tired, sore, fatigued muscles. Other than riding it out and recognizing it and marveling at it and trying to gain self-reflection, , and find the right over-the-counter remedy that works for you, there isn’t much you can do. But it’s a zillion dollar industry, and swirls in urban myth, and the “art” of medicine.
Here’s mine: Bayer aspirin is magic, and a gram is the dose (three 325’s is 975 mg, or about a gram). Preventive for hangovers when taken late, like 3 a.m. Consider a mild caffeine dose (soft drink chug) for these circumstances. During the day, Excedrin or another caffeine idea tab seems reliable. They usually have some Tylenol (acetaminophen) and aspirin in them, and two extra strength tabs is the dose. You will feel the caffeine. Can you see its role, caffeine that is, in tension headache treatment, by pepping up the nervous system, to send out more electricity to the skeletal system and body? Tylenol and ibuprofen and naproxen alone, good luck with them but I don’t see them as good headache medicines for some reason. Not for me anyway.
Occasionally a headache is bad enough that a trip to the hospital is needed for relief, or perhaps diagnostic worries. I myself have been that bad on too numerous occasions, but have I have never considered an ER visit (well, maybe.) But in all of my headaches I have somehow managed to turn off into a restorative pattern, and wake up with it gone, even just an hour later. Such “power” naps are not as hard as you might think, because eventually you would just collapse into one. Get comfortable, turn of the lights, and think about your favorite things.
The treatment for headaches in the emergency department is to “achieve” sleep, with a combination of narcotic, nausea medicine, hydration (interestingly always a big help). In people who are really suffering, a dose of major tranquilizer, like the ones we treat schizophrenics with, can really be helpful. They happen to be magic for managing these acute headaches, if that tells you anything.
“Migraine” Headache
In the head, only the following can hurt, since the brain itself has no sensation at all: the scalp structures and skull, the membranes that surround the nervous system, and the blood vessels. What we have just discussed above is the skeletal source of that common malady of “tension” headache. When the membranes are the source of the headache pain, the reason is usually infection (meningitis) and bleeding (cerebral hemorrhage), and these are the famous catastrophes. And lastly, blood vessels have sensation, and when pain is originating from them, this is what we call “migraine headache”.
Migraine headache has been associated with severity (they’re actually not consistently that severe), and I like the old saying, “If it’s my headache, it’s a migraine headache”. People are funny that way. Like, this ain’t no regular headache. It’s a migraine! But there is no test that tells you that what you’re feeling is a migraine, despite the sufferer’s insistence or the diagnoser’s assurance. They are among the urban myths, which is to say they exist, but at a far rarer frequency than the world thinks. But as a rule of thumb, any headache that is limited to one side of the head should be considered suspicious for the migraine phenomenon. And the treatment for them is different from the treatment of other headaches, and so getting the diagnosis right is important. Especially for people suffering headache several days of the month.
But what are they? Here are the theories. Arteries have muscle in them, so they can spasm, and this is what we think starts the process of true migraine headaches. Maybe a few inches of the vessel, a twisty spasm, set off by who knows what. After what is probably 20 minutes or so of spasm, starving down-stream tissues release chemistries that make the vessel relax, and it is the resulting flailing and bulging of the artery that leads to the pain and “throbbing” with each heartbeat of this one-sided headache. This pain, often localizable with one finger, goes on for 2-8 hours and sometimes longer, and then usually that’s it. To experience one a month is a lot, and most true migraine sufferers only get a few a year. I honestly think I’ve only seen 30 or 50 “real” migraines, out of literally ten thousand or more headaches that I have seen over all these years. Usually a heavy duty pain shot gives long enough relief that patients can be released to weather the remainder of it at home.
During the spasm phase at the beginning, most migraine people have no symptoms, so the fairly sudden-onset of one-sided throbbing pain, would be a typical “common” migraine. If, during the early phase (of spasm) there is an “aura” or a sense that one is coming, this is “classic” migraine. And there are cases where the spasm can interrupt blood flow enough to an area of the brain that stroke-like symptoms appear, such as numbness or slurred speech, or (often) trouble with vision loss. When the spasm phase switches over to dilation, the re-establishment of blood flow resolves this, and the throbbing arrives as the neurologic feature subsides. This is what is referred to as the “complicated” migraine. “Complicated” by a neurologic complaint or finding. They say there is a real if slight risk of stroke with complicated migraine but I have never seen this.
Treating frequent headache is among the great challenges of primary care. It gets to where they don’t really resemble the typical sort of migraine, and becomes the mild to moderate misery of chronic daily headache. Any number of blood-vessel acting medications are out there, some to try to abort the headache during aura, others used for prevention, and all a patient and their doctor can hope for is to stumble on the right one at the right dose with the least side effects that can allow a person to function.
Dangerous causes of headache
Are you worried something is dangerously wrong, like a brain tumor or a cerebral hemorrhage, or even meningitis? Well, there are warning signs of these that are pretty consistent, and when there’s anything weird accompanying the headache, like sudden onset, a fainting spell, high fevers, stroke-looking signs, a trip to your local emergency department is a good idea.
Bleeds: There is absolutely no room in the head for anything besides the brain, so when there is a blood vessel rupture, either spontaneously or from trauma, all hell breaks loose. The pressure generated from hemorrhage makes all the local nerves stop working, resulting in “neurologic features” that accompany what is generally a sudden-onset of headache. Famously, cerebral hemorrhages (“bleeds”) result in stroke-like symptoms, like confusion and disorientation, visual loss, trouble talking or making sense, and arm or leg weaknesses. Falling. Imbalance. It should not be subtle. Always be concerned about sudden onset of terrible headache, especially with anything neurologic.
Where do spontaneous hemorrhages come from? The brain has a huge amount of blood supply, and its many branchings can leave weaknesses where small, berry-sized bubbles can form, called berry aneurysms. And these can rupture at arterial pressure in people of any age. And if they bleed just a little, a fairly terrible headache can result and improve in a few hours as the blood washes away in the brain’s circulating fluid system, where these hemorrhages bleed into. But most people don’t seem to get this warning of a small bleed, and when a big bleed comes, neurologic disaster results. So for any “thunderclap” headache, where there is sudden onset of “the worst headache of your life”, lasting however long, this could be one of these bleeds and going to the ER about it is a good idea. Your local ER doc should be able to order the right study to figure this out.
A CT scan may not show a small bleed, especially if several hours have lapsed. So the only way of knowing a small one might have happened is by doing a “spinal tap” where fluid in the bottom of the nervous system is checked for red blood cells. Either way, new imaging studies can generally find these weak spots, and with moderate danger, a neurosurgeon can clip an aneurysm, while everyone holds their breath. This is world-class medicine of course.
High Blood Pressure and Headaches
I do not consider high blood pressure to be a cause of either awful tension headaches or the migraine syndrome, although a lot of patients do. But outrageously high blood pressure is a problem of course, and in rare and very extreme case causes a neurologic injury to the brain with stroke-like findings, but without hemorrhage.
But yes, high blood pressure is a cause of a type of cerebral hemorrhage, and they are often catastrophic. As opposed to being on the top and outskirts of the brain like in aneurysm bleeds described above, these are penetrating bleeds, often into to deep areas of the brain where the results can be catastrophic. The pressure they generate, especially after a few days of inflammation that accompany such injury, results in unfortunate neurologic outcomes. And these are usually people on in years more, and who have longstanding multiple medical problems.
Trauma
The Good Lord put the delicate brain in a hard box, the bony cranium, to protect it. But with enough force, things tear and rip and bleed. Veins and arteries both can do it, but we see a lot more where there was enough force to tear a vein. The pressure in these vessels is much lower, and the bleeding slower. But there is pressure generated all the same, and neurologic features result. So with a fall or with other traumas, headache with anything neurological is cause for an emergency room visit.
Maybe you’re heard of the “dura”, the tough, leathery lining of the central nervous system, surrounding the brain and down the spinal cord to the bottom. There are three linings of the brain and spinal cord. The outer is the dura mater (“tough mother”), attached to it the spidery looking “arachnoid” membrane, and below that, the fluid that bathes the nervous system, the cerebro-spinal fluid, or CSF. On the brain itself, the pia mater, or (“soft mother”), a thin and delicate membrane. Like the shrink wrap. Vein bleeds form a clot between the dura and the arachnoid (“sub-dural”), and arteries bleed below the arachnoid into the CSF, as “sub-arachnoid” hemorrhages. They’re all bad. Subdurals are usually traumatic but can be spontaneous, especially in people who take blood thinners. And remember, subarachnoid hemorrhages are usually spontaneous and caused from rupture of an aneurysm, but sometimes no aneurysm is found.
Age is important. You have the elderly, who are fragile and fall a lot, and suffer traumatic bleeds with even minor trauma (and oh, they often fall without anyone knowing.) For the most part, we scan any old person with neurologic symptoms. On the other hand you have children, who are active and wild, and also fall a lot. And while most get a “hickey” and vomit a time or two, most are hardy enough that nothing ruptures and bleeds. And with the incidence low, and the absence of neurologic features, our main effort is reassuring moms and grandmoms. And this is important because if you scan a kid, you raise their cancer risk ever so slightly. We never used to think this, and as people get older, and more people had scans as kids, we are now able to say there is risk, albeit very low, so we only scan kids with danger signals.
Meningitis
The membranes that surround the nervous system mentioned earlier, the dura, arachnoid, and the pia, are called “the meninges”. Infection of them and the cerebro-spinal fluid (CSF) is the condition of meningitis. It is a toxic, germ illness, so people are generally sick and often vomiting, and fever is the norm. When the big germs, the bacteria, are causing the infection, you get worse by the hour and the pressure generated by all this infection can be catastrophic and fatal. The neck stiffens, the pain is terrible, and if you try to bend the neck you find it to be nearly rigid. Antibiotics need to be started without delay.
We used to see meningitis a lot more than we do today, because we are now vaccinating effectively against those germs, and therefore it is extremely rare. Still, patients develop fever and headache, and their neck might just be sore from cranking out the fever and maybe some poor sleep in there, well, how can you tell if it’s meningitis? Hence there is often a “scare” in people and kids who are sick with a virus or whatever, and your astute local ER doctor might want to recommend a spinal tap to see if the fluid shows infection.
Viral meningitis, on the other hand, is very common. There is fever, aches, bad headache, and even signs of meningeal irritation on examination. Viruses are extremely tiny and can make their way into the nervous system, but the inflammation that results is minor, and there is no progression to neurologic injury. And since most people have been sick for several days, it’s easy to conclude that this is not a bacterial infection.
One last thing: encephalitis. There are a handful of viruses that can infect the brain tissue itself, like herpes viruses, and others that can be transmitted by insects during summertime. There is headache, low-grade fever, and very definite neurologic features, usually involving alertness. And since there is treatment for most of them, diagnosing needs to be prompt. Generally, this is not hard to do. The patient is clearly sick, and modern diagnostic tools will generally zero in on them (ideally in the hands of one of the more skilled local clinicians, like an internist or a neurologist.)
What about a Brain Tumor?
Unfortunately, they do happen. Most of the time the complaint is not headache, however. New onset of seizure activity, a major change in behavior, sudden confusion or loss of memory, or disorientation (forgetting what day it is or where you’re supposed to be, or what you’re usually doing), these are not good signs. They’re usually subtle at first, but then become worse and progressive, until finally there’s enough concern that a trip to the doctor is warranted, and a CT scan shows the tumor. In some cases, such lesions are only seen on MRI, but either way, as progressive conditions, eventually they will find us if we don’t find them.
Backache
As with headache, backaches are profoundly common complaints to primary care physicians, are associated with piles of urban mythology, and a zillion dollar industry. And we can all expect back pain in our lives, especially as we get older. The most common culprit, you got it, is the spasm of the spine muscles. But we must sort through everything from disc and spine disorders to kidney stones to abdominal aortic aneurysms and hemorrhages and infection, just like in evaluating headaches. Here are some basics.
The spine muscles, especially in the lower lumbar region, are small but powerful, and when you stretch and injure them they respond with a wicked and painful spasm lasting about 5 days. Getting up from the lying (on your back) position is very very difficult and painful when the muscles are in spasm, and this is the easiest way to tell that a good old muscle pull in the back is the problem.
Muscle relaxants (like cyclobenzaprine, or “Flexeril”) are generally helpful, and there are others that don’t seem to help much. And ibuprofen (e.g. Advil) and naproxen (e.g. Aleve) can be very helpful for back spasm as well, or not.
Herniated discs: The spine is a stack of round bones, and between them is a very tough structure called the “intervertebral disc”. It is made of a tough tissue called fibrocartilage, and there are three concentric rings of this making up the disc. In the center is a semi-liquid goop called the “nucleus pulposis”, and if the disc falls apart some over time, the goop can “herniate” out from the center of the disc. Along with being painful and resulting in some amount of spine muscle spasm and local inflammation from such injury, the herniated nucleus pulposis will often sit on the nerve root right there that is exiting the spinal cord, which sits directly behind the stack of bones. This nerve “entrapment” causes the characteristic radiation of the pain all the way down to the foot on the side it herniates on. Over time (months) the goop dissolves and the nerve pain goes away.
To entrap a nerve root, (the “radicule”) results is a strip of numbness or tingling down a strip of one leg, generally 3-5 inches wide, and goes to a very specific part of the foot. Such nerve entrapment (“radiculopathy”) can be diagnosed at the bedside. There are two levels that go bad generally. At the lowest bone in the lumbar chain, lumbar #5 (or “L5″), and its connection to the sacrum, (S1), there is the nerve irritation mentioned above that goes down the back and outside of the leg to the bottom of the foot, and with it there is the loss of the ankle jerk reflex, which you can normally elicit so easily by smacking the achilles tendon with something. And the other level that often herniates is the level above it (the one between lumbar 4 and lumbar 5), which sends numbness down the front of the leg and toward the big toe, and results in weakness when trying to raise the foot and/or great toe upward. These two levels account for almost all of the low back disc herniations.
It is a significant, if non-threatening, injury for this to happen to the spine, and there is often a huge pain felt in the hip, radiated from the spine. Movement is painful and difficult for what is usually 3 months or so, badly curtailing athletic and, famously, work-related activities. For the most part, if nothing is done, you recover by a year or so. I mean, it’s a significant injury to a key part of you, the spine.
What about surgery? The problem is this. If you take patient A and patient B with the same disc injuries, and you operate on patient A (slurp out the nucleus pulposis and scrape out the local inflammation), but not on patient B,and scan them both in two years, they all look the same. So why operate? Great question. Well, the nerve pain is better immediately, but you still have to heal from the injury. But don’t ever forget, a surgeon is someone who sticks a knife in you and tells you it’s going to help. It is so variable person to person that it’s hard to tell whom to treat surgically. And someone else is surely paying the bill.
Bogus back problems (often due to conscious or subconscious malingering) have spoiled the fun in caring for back troubles. Improvement followed by return of “the pain”, and the arrival of the disability mindset is the disaster of such intervention. Long-term narcotic abuse in the “dropouts” of society has destroyed too many marginal personalities to possibly estimate, and the best advice is to just tell people to go back to work. For so many “workers”, if you’re waiting for the pain to go away so you can return to work, it doesn’t happen, whereas returning to “gainful employment” results in resolution of the pain. But chronic back pain and disability is often nothing more than a sign of people with poor nurture and upbringing, and borderline IQ. Throw in a narcotic and that’s it.
Sciatica
The very word “sciatica” makes me cringe. Named for the giant peripheral nerve heading down the back of the thigh, sciatica is a complaint where “my whole leg hurts, doc”, as opposed to the thin, 3-4 inch strip of numbness seen with herniations. That big nerve, the sciatic nerve, must navigate several muscles in the pelvis to emerge down the leg, and as we get older and our pelvis lengthens and we gain weight, the stretch on the sciatic nerve “hurts”. Usually it lasts for months, but much longer in some people.
Abdominal Aortic Aneurysm
The abdominal aorta can develop aneurysm, and the result can be anything from small leaks resulting in acute back pain, to sudden rupture without previous symptoms with a fatal outcome. They present a huge pain in the back. Some people experience a burning in the months before eventual rupture, and figure they’ve strained themselves or something. But they may note that it does not change with movement and there is no radiation of the pain. But then an aneurysm may “leak” a little bit, which may cause a collapse to the floor, a notorious warning sign. When it finally ruptures, a fatal result is the case about half of the time.
So men with blood pressure problems and a history of smoking should wonder if this is the source of this pain, and there are simple diagnostic studies that will show it. Big ones can be felt famously as a “puslatile mass” in the mid abdomen. Happily, these aneurysms can be repaired now with a relatively minor surgical procedure. People at risk, such as smokers and former smokers, male sex, a history of cholesterol and blood pressure problems, and people with family history of these aneurysms, can be screened with ultrasound cheaply and effectively.
Kidney Stones
Among the all-time painful conditions in life: kidney stones. We know back muscle spasms are very painful, and that aneurysm rupture is a huge pain. Add to that the hurt of kidney stones, and you will see that we have to deal very commonly with big back pain, presenting a diagnostic dilemma. Is something terribly wrong?
We talked about how back muscles hurt with movement, and how aneurysms might be seen in certain risk groups, and that low blood pressure could mean the thing is leaking. In kidney stones it is none of these, but they tend to have a pattern. It turns out that kidney stones are very common, especially here in the Midwest. The pain is caused when a small stone (many only 3 or 4 mm round) jabs the muscular ureter, the tube that carries urine down to the bladder. This spasm, so intense of a pain that people get sweaty and vomit, lasts a few hours and stops, presenting the classic example of “colic” (severe pain followed by no pain.) Sometimes it doesn’t subside, and the kidney becomes obstructed and bulges, and this must be dealt with by a procedure performed by a urologist.
Danger: While painful, back problems are not often from a dangerous condition, but like usual, look for warning signs. Low blood pressure and collapse are probably aneurysmal. Colic pain that is one sided and may wrap around rom the flank toward the bladder is probably a kidney stone. Pain getting up from lying flat is probably a spasm. Nerve findings is probably a disc. But there are situations where if something isn’t done, disaster results. Besides aneurysm rupture, there are spinal cord compression conditions that present as back pain. There are hemorrhages along the spine that can be paralyzing, and there are infections and abscesses that can form and do the same thing. So, trouble walking, numbness of both legs, leg weakness, and very importantly, loss of control of urination or bowel movements, are the kind of warning signs indicating immediate imaging and other diagnostics need to be done. And without delay. These are all offered by most local emergency departments.