"I'm very brave, generally, only today I happen to have a headache."
So spoke Tweedledum through the looking glass, remember, as he was about to have the great rattle-battle with the other tweedle.
Alice, if you believe the experts, was full of references and allusions to Lewis Carroll's own headaches, especially the pre-headache visual distortions to which he was subject.
The experts are probably right. Migraine sufferers love to talk about their headaches, comparing notes on their often bizarre auras, even bragging about the extent of their disablement. One I know always called all the people on his cafergot connection -- I was one -- whenever there was a thunderstorm to see if the others had a headache too. (We usually did. Atmospheric pressure has a lot to do with precipitating migraines.)
But, though it may be hard for the migraine-afflicted to accept, there are fairly common headaches that hurt more, much more.
One is the cluster headache. It is vascular, as is the migraine, and often one-sided, but there the resemblance stops. These headaches, which strike many more men than women, come in groups. They may, some suspect, be related to heavy smoking, and they are often associated with distinct facial characteristics.
Although the headaches are of relatively short duration -- rarely longer than four hours at a pop and usually under one -- the burning pain is so severe that it can wake a person from a sound sleep, has been known to drive victims to suicide attempts. While a person with a migraine takes to his or her bed, people with cluster pace the floor, so brutal is the pain.
"Basically," headache specialist Dr. Seymour Diamond told a group of colleagues recently, "nobody cures a patient with cluster headache."
There are often natural remissions with these headaches. Sometimes they occur several times a day or a week for about two or three months. Then they disappear altogether. "So," says Diamond, "the hypnotist or the biofeedback technician or the acupuncturist will say 'Oh, I cured cluster headache.'"
"In fact," he said, "the majority will have a spontaneous remission and the headaches may not return for months or years . . . But I never tell a patient with cluster 'I'll cure you,' just 'I'll help you.'"
There are, he says, drugs that help with cluster. However, the drugs useful for migraines, such as ergotomine or propranolol, do nothing at all for cluster.
Muscle-contraction headaches, including the so-called tension (as in muscle, not psyche) headache, probably account for 90 percent of the headache patients seen by the general practitioner, estimates Dr. Diamond. Even more of the ilk are occasional, brought on by fatigue and temporary stress, and are treated at home with non-prescription analgesics.
Diamond feels that by the time this kind of headache is severe enough to get to a physician, it is usually associated with chronic depression. In fact, in his technical handbook, "The Practicing Physician's Approach to Headache," he writes, "We suggest that most patients with this form of headache are, in fact, suffering a depressive illness with headache as one of their somatic complaints." This headache is often connected with a sleep disturbance, especially waking often and early.
Many of the patients at the Diamond Headache Clinic in Chicago have this type of headache superimposed on migraine. Most of the patients are victims of more than one type of headache, and, often, of the backlash from or inadvertent abuse of dozens of alleged pain-relieving drugs.
Only a few headaches, relatively, stem from such organic causes as brain tumors or circulatory diseases, but Dr. Diamond feels passionately that no headache be treated until a diagnosis has been made.
"I'm not making an indictment of the psychologist, although they'll take patients who are not diagnosed and treat them with biofeedback," he said (at a biofeedback conference) "but my fellow physicians who take the same patients and treat them with the Fiorinals, the Empirin-Codeines, the Darvon Compounds . . . all the habituating drugs . . . and don't make a diagnosis . . . the sufferer is the poor headache patient. Psychologists may miss a brain tumor, but the GP can miss the tumor and at the same time further cause problems habituating the patient."
More and more frequently, specialists are exploring the use of non-drug techniques to treat headaches: relaxation and autogenic (self-hypnotic) techniques, along with biofeedback. These are especially effective for muscle-contraction headaches.
Dr. Joel R. Saper, University of Michigan headache specialist, notes in his book, "Freedom From Headaches," that biofeedback "is becoming the treatment of choice for muscle-contraction headaches, especially in young people." Migraines also respond and patients with more than one kind of headache have also benefited from the non-drug therapies.
But again, specialists urge, the careful diagnosis first. "Only 2 percent of headaches seen by the internist are due to organic disease," Diamond told a room full of physicians, "so it's remote that you'll have one, but," he said, with eloquent understatement, "it would be important that you make the diagnosis."