"When the head aches, all the members partake of the pains."
-- Don Quixote to Sancho Panza in "Don Quixote" by Miguel de Cervantes, circa 1605 "That," says psychologist Barry Jay Kirshner, "is the truth." Kirshner is a headache therapist in Bethesda, but it was his own migraines, now under control, that related so well to Cervantes' observation.
"Even the mild ones made me almost dysfunctional. Although they seem to be localized in the head, they affect the whole body."
But as bad as headaches make you feel, says National Institutes of Health neurologist Dr. Elyse Singer, people with headaches tend to go to work anyway -- as opposed to people with low back pain, for example, who generally are unable to get out of bed.
"I've seen people with terrible pain every day out there making a living," she says, "subsisting on painkillers and doing pretty well with what they've got."
People may feel forced to perform despite throbbing temples because -- unlike a broken leg or runny nose -- a pounding head can't be seen. "It's hard to substantiate a headache," Kirshner says.
Some do succumb to the pain, however, since an estimated 125 million workdays are lost each year because of headaches. "That translates into more than $6 billion in annual cost to the economy," Kirshner says, "and more than $1 billion spent on headache medication."
This includes most of the 30 million pounds of aspirin consumed in this country each year. An estimated 80 million Americans, or 30 to 40 percent of the population, get headaches, with about half seeking professional help to relieve them.
For the most part, headaches are not fatal. Nor do they, except on rare occasions, signal that anything else serious is going on in the body.
This is one reason this most common affliction has been woefully neglected by medical establishments throughout the ages.
Dr. Seymour Diamond, director of a renowned headache clinic in Chicago, quotes the 18th-century British physician John Fothergill, who told the Royal College of Physicians:
"There is a disease which, though it occurs very frequently, has not yet obtained a place in the systematic catalogues. It is commonly to be met with in practice and is described by those who are affected with it, and who are not few in number, under the compound title of 'sick headache.' "
Diamond has done as much as anyone in the world to "systematically catalogue," categorize, and find causes and treatments for all manner of headache -- from "ice cream" and "hot dog" headaches to "abdominal" migraines. He loves to talk about the headache through history, beginning with the ancient Egyptians, who believed it a form of insanity. Headache remedies are described in the Talmud, the Jewish book of law. And Hippocrates described a classical migraine, aura and all, in 400 B.C.
Diamond cites this Talmudic treatment for migraines in his recent book, "Advice From the Diamond Headache Clinic":
"The remedy prescribed was the slaughter of a white cock with a white zuz a piece of money 'over that side of the patient which is painful . . .' It was cautioned that 'one must be careful with the blood in order not to blind the patient's eyes.' The slaughtered cock was then hung on the door post, and the patient rubbed his head against the bird upon entering and leaving the house."
The so-called "hot dog" headache is caused by the nitrites in the meat, which can trigger headaches in some susceptible people. "Ice cream" headaches occur in some people when any cold substance hits the back of the throat. They last only a few painful minutes.
Known for his willingness to try new, and sometimes controversial, remedies, Diamond was one of the earliest "mainstream" physicians to see the potential in biofeedback as a tool in controlling headaches. He hasn't done a study yet on the white cock and the zuz, but he did recently test a remedy suggested by the British doctor Fothergill and countless old wives -- the use of cold.
He and his colleagues took 90 patients with three different kinds of headaches -- 30 migraine patients, 30 cluster headache patients and 30 with so-called mixed headaches. Each patient placed cold packs over the painful area.
The results: 71 percent of the patients (and 80 percent of the migraine patients) said they had favorable results and would use cold packs in the future. "The use of cold applications will provide symptomatic relief of the headaches and will offer some psychological alleviation of the pain," the study concluded.
Like Diamond, many headache specialists divide headaches into three broad categories:
*Vascular. Caused by an abnormal activity of the cerebral arteries, with pain usually resulting from their over-dilation. They account for about half of the patients seen by headache specialists.
Common kinds of vascular headaches include migraines and cluster headaches, which come in clusters -- one a day perhaps for a week, then none for months. Most migraine victims are women, and migraines often are related to menstrual cycles and estrogen. Most cluster victims are men. Victims often say cluster headaches feel as if a red hot poker were being thrust through the eyes. It is probably the most painful of all headaches, but each attack is relatively short-lived.
*Muscle contraction. Caused by contraction of the muscles of the head, neck, shoulders or jaw. These may be caused by tension, poor posture or trauma -- as, for instance, "whiplash" headache.
They account for the vast majority of headache victims and for about 90 percent of the headache problems seen by general practitioners. Victims often describe the feeling as "a band tightening around the head."
*Traction or inflammatory. Caused by some secondary organic disease, such as brain tumors or meningitis. This is the rarest kind of headache.
"Many people have mixed headache syndrome," Diamond says. This might consist, he says, of "a daily muscle contraction headache and a 'hard' or sick headache -- a migraine -- once or twice a month." Some speculate that the anticipatory anxiety connected to migraines can produce the muscle tension that causes the muscle contraction headache.
Headaches hurt. Some hurt worse than others and some -- mostly migraines -- are accompanied by nausea, dizziness, even occasionally hallucinations. Classical migraines start out with an aura -- a visual disturbance that can take the form of dancing bright lights, or the feeling one is looking through a broken window. Migraines tend to throb on one side of the head or the other -- the name is derived from the Greek "hemicrania" for "half a head."
There are various treatments for the various kinds of headaches. Virtually nothing works for everyone, but there are some genuine advances in the treatment of headaches, with and without drugs. These range from relaxation and stress control to exercise and diet to so-called counter-irritant techniques, like pressing so-called "trigger points" on the body. Many believe acupressure or acupuncture, as well as cold packs, work as counter-irritants.
The TENS machine, a small, box-like electrical stimulator, used for many pain conditions, also relieves some headaches. And there has been some success in treating acute migraine attacks with other machines that send mild electrical currents through the head via electrodes placed on the forehead.
Sometimes overuse of drugs, even over-the-counter ones, can make headaches worse. Headache victims are notorious abusers -- albeit accidentally and often through use of prescribed drugs. Painkillers are often addictive, but headache sufferers can even abuse aspirin and acetaminophen, which are not without their own hazards when taken in large quantities.
The first thing most headache specialists try to do with new patients is wean them from whatever drugs they have been using. The watchword of the National Migraine Foundation, a resource organization, is "Your headache won't kill you, but your medicine might."
Diamond does a complete neurological examination on headache patients because, he says, "basically anybody with a chronic headache problem, or an acute one, has a basic fear they have an organic problem -- a brain tumor or a blood vessel problem like an aneurysm. So it is important to take the time with a headache patient doing a careful history and a careful neurological examination and whatever tests are necessary. Because even if the doctor doesn't think anything serious is wrong, it will allay a lot of fears in the patient."
Diamond is continuing research on the heart drug propranolol (in a family of drugs called beta blockers), which has been found to prevent migraine headaches in many victims when taken regularly. Since its usefulness in preventing the migraine headache was discovered a few years ago, it has become the drug of choice for migraine sufferers.
Drugs containing some form of ergot are still considered important aids in aborting migraines, but they have unpleasant side effects, including nausea, in many patients. Now Diamond is investigating the possibility that propranolol may be able to abort the headaches when it is taken just before they strike. Experimental work with drugs that inhibit the action of calcium in the cells is also showing promise.
At the National Institute for Dental Research, which does pain research for NIH, Dr. Elyse Singer is investigating the role of musculo-skeletal mechanical problems in headaches. She is looking for people with frequent muscular contraction headaches with no other major sources of pain and no major psychiatric problems.
Singer thinks there is a gap in the diagnosis of headaches because doctors generally do not evaluate the musculo-skeletal system, which she feels may cause "a lot of people with this kind of pain to go overlooked."
This might include people who have problems with the temporo-mandibular joint (TMJ) in the jaw, or a disorder called myofascial pain syndrome, usually considered to be caused by spasms in shoulder or neck muscles.
Singer wants to learn what patients may be doing that is "biomechanically abnormal and putting stress and strain on their bodies, stretching some muscles, straining some others in abnormal postures," as in "being hunched over" a video display terminal or driving long distances in a poor-fitting car seat. "People who are very tense sit tensely, clench their jaws, grind their teeth, and this is where a lot of the muscle headache tends to blend into certain types of TMJ syndromes."
"Dentists," says Barry Kirshner, "will tell you that TMJ, a dysfunction of the joint between the upper and lower jaw, is the cause of all ills. Some doctors don't think it exists at all. I'm somewhere in the middle, and I've devised some biofeedback programs for dentists that seem to help."
Singer's program at NIH will try to determine how big a role the musculo-skeletal problems play in headache and how they are best treated. She is especially interested in nonpharmacological approaches, although she believes that drugs are often helpful and appropriate. But, she says, "Maybe there is something correctable you can learn to do without drugs."
Dr. Bruce Smoller, a psychiatrist and orthopedist who specializes in general pain management, believes he has found a particular type of headache patient who benefits especially from the antidepressant drug Amitriptyline.
These patients have what appear to be muscle contraction headaches along with depression. Preliminary results with 83 such patients show that the antidepressant drug eliminated the headaches entirely in 67 patients, Smoller concludes in a paper he will present next month at a psychiatric meeting in Dallas. These patients had had headaches "anywhere from three months to 10 years, and had been treated unsuccessfully by a variety of therapists."
Smoller theorizes that some underlying problem, possibly a problem with the metabolism of the brain chemical serotonin, caused the headaches. Some patients benefit from doses of the amino acid tryptophan, Smoller notes. Sold in many health food stores as a sleep aid, tryptophan is needed by the brain to make serotonin. Its use in headaches is experimental.
The biggest headache breakthrough, says Michigan headache specialist Dr. Joel Saper, has been in attitude.
"There is no condition of similar magnitude about which there is so much myth, misunderstanding and mistreatment," Saper says. "When you put together all the things you've heard, and that we presume, you're talking about massive misinformation. And the patient, usually a woman, is the primary victim. They are made to feel defensive, as in 'It is your fault because you're working or because you're not working hard enough or because you have too many children or you don't have enough love, or you have too much love. We've got an answer for you and it's always your fault.' "
But today, he says, "the burgeoning of legitimate pain centers around the country is the true recognition of the failure of past science. And the growth of meaningful specialties toward appropriate treatment of headaches is the real breakthrough." Resources
Among the clinics, specialists and books on conquering headaches:
*Georgetown Family Center biofeedback program, 4380 MacArthur Blvd. NW, Washington D.C. 20007; 625-7815.
*Barry Jay Kirshner, Bethesda Headache Program, 4400 East West Hwy., Suite 329, Bethesda, Md. 20814; 654-4997.
*Washington Pain Assessment Group, Dr. Bruce Smoller, medical director, 5530 Wisconsin Ave., Suite 806, Chevy Chase, Md. 20815; 951-3325.
*The Headache Clinic, 5454 Wisconsin Ave., Chevy Chase, Md. 20814; 986-0777. Free public awareness headache clinic, Oct. 8, 7.30-9 p.m. at Strathmore Hall Arts Center, 10701 Rockville Pike. Call for reservations.
*The National Institutes of Health headache program. Write Headache, c/o Dr. Elyse Singer, National Institute on Dental Research, Room 3C403, Building 10, NIH, Bethesda, Md. 20892.
*National Migraine Foundation, 5252 N. Western Dr., Chicago, Ill. 60625.
*"Advice from the Diamond Headache Clinic" by Dr. Seymour Diamond and Judi Diamond-Falk (International Universities Press, $22.50).
*"Coping With Your Headaches" by Dr. Seymour Diamond and Mary Franklin Epstein, R.N. (Delair Publishing Co. Inc. paperback, $2.50).
*"Headache Disorders" by Dr. Joel R. Saper (John Wright publishing. $30.)