Two boats in Antigua. (Dr. Noorali Bharwani)
Two boats in Antigua. (Dr. Noorali Bharwani)

Headache is not an uncommon symptom. Headache can be on one or both sides of the head. It can radiate across the head.

The type of pain one experiences can vary a lot. A headache may appear as a sharp pain, a throbbing sensation or a dull ache. Headaches can develop gradually or suddenly, and may last from less than an hour to several days.

There are many causes of headache. It can be a sign of stress or emotional distress. It can be due to migraine or high blood pressure, anxiety, or depression. In some cases, there may be evidence of a tumour. Tumour can be benign like meningioma or malignant.

If a person has severe or persistent headache then further investigation is warranted. Urgent medical attention is required if you have weakness, dizziness, sudden loss of balance. Other symptoms requiring urgent attention are numbness or tingling, or you cannot move your body. Majority of the headaches are due to migraine or tension. A headache can be a symptom of a serious condition, such as a stroke, meningitis or encephalitis.

Investigating headache

Radiological investigation of headache is done by having CT scan or MRI. One test usually supplements the other.

The biggest difference is MRIs (magnetic resonance imaging) use radio waves and CT (computed tomography) scans use X-rays. There is some radiation exposure with CT scan. While both are relatively low risk, there are differences that may make each one a better option depending on the circumstances. Usually CT scan is done first and if that does not answer the question then MRI is done next.

Most of the time you do not need these tests. Often these tests are not helpful.

Doctors see many patients for headaches. And most of them have migraines or headaches caused by tension. Both kinds of headaches can be very painful. But a CT scan or an MRI rarely shows why the headache occurs. And they do not help you ease the pain, says Choosing Wisely (2016 Consumer Reports developed in cooperation with the American College of Radiology).

From the individual’s medical history and physical examination, a doctor can diagnose most headaches during an office visit. If your medical history and exam are normal, radiological tests usually will not show a serious problem. The results of your test may also be unclear. This can lead to more tests and even treatment that you do not need.

When should you have CT scan and/or MRI test for headache?

In some cases, a doctor may order a CT scan or an MRI if your physical exam finds something that is not normal.

You may also need a CT scan or an MRI if you have unusual headaches. Go to a hospital emergency room or call 911 if:

  1. you’re experiencing the worst headache of your life, a sudden, severe headache
  2. you have headaches that are sudden or feel like something is bursting inside your head
  3. your headaches are different from other headaches you’ve had, especially if you are age 50 or older
  4. your headaches happen after you have been physically active
  5. you have headaches with other serious symptoms, such as a loss of control, a seizure or fit, or a change in speech or alertness
  6. it occurs more often than usual
  7. they are more severe than usual
  8. it worsens or don’t improve with appropriate use of over-the-counter drugs
  9. it keeps you from working, sleeping or participating in normal activities
  10. it causes you distress, and you would like to find treatment options that enable you to control them better

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Sexual Activity and Mysterious Headaches

Do you get mysterious headaches with sexual activity? May be not. But for one reader of my columns this has become a significant problem.

It is estimated that patients who have headache with sexual activity account for approximately one per cent of all headache patients. It is likely that the prevalence of this headache is underestimated, since patients often feel embarrassed to report intimate details about their sexual activities.

This condition has been given many names: benign coital headache (most of the time no serious underlying cause is found), masturbatory headache, orgasmic cephalagia (as it occurs usually at or near orgasm).

Apparently, headache related to sexual activity has been recognized since the time of Hippocrates. But the first systematic descriptions of this condition appeared in medical literature in 1974. Since then primary headache associated with sexual activity has become a well defined entity.

Coital headache is usually a recurrent, benign headache and is more common in men than in women. It can occur just before, during, or immediately after orgasm. The headaches are usually dull and throbbing and last from minutes to hours. Occasionally, some patients experience a sudden, explosive headache that occurs during orgasm.

Three types of sexual headaches are recognized.

The first, the dull type, is described as a dull ache in the head and neck that intensifies as sexual excitement increases, peaking at orgasm. This type of headache is little less common than type two.

Type two, also known as vascular or explosive coital headache, is a sudden, severe, explosive headache that occurs just before or at orgasm and persists for a few minutes to 48 hours. This is the most common type of coital headache. Patients find orgasmic headache frightening, distressing and disabling.

Type three is a postural headache, resembling that of low cerebro- spinal fluid pressure that develops after coitus. This type of headache is rare.

When patients first present with coital or orgasmic headache, it is mandatory to exclude serious underlying condition like ruptured aneurysm and bleeding in the brain. When a patient presents with a new type two coital headache of sudden onset, a CT scan should be performed, and even if this is negative, a lumbar puncture should be obtained, says one research paper.

Aneurysm without rupture can present as coital headache. To pick this condition it is necessary to do an angiography and MRI of the cerebral blood vessels. Other cause for coital headache is central nervous system vasculitis.

During the acute phase of pain, usual analgesics (ibuprofen, diclofenac, acetaminophen, ASA) can be tried but are considered of limited value to relieve the pain. In 25 per cent of the patients the pain may last more than two hours and up to 24 hours. Other medications which have been tried with some success are triptans, propranolol and indomethacin.

Fortunately, the prognosis is good and in the majority of patients where no underlying pathology is identified. With time the headaches disappear without any specific treatment.

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Migraine Headaches

Dear Dr. B: I was wondering if you could write your next column on the topic of migraine headaches. What causes them? How can you deal with them?

Migraine is a severe headache. It is often associated with severe pain on one or both sides of the head, nausea, vomiting and visual disturbance. It is the most common type of vascular headache.

Migraine headache affects 28 million Americans, 75 percent of whom are women. The first attack occurs between the ages of five and 35 years. It is rare to have first attack after the age of 40. The frequency of attacks varies a lot. But the frequency becomes less as the person gets older.

There are many types of migraine headaches. The two most common types are – the classic migraine and the common migraine.

The classic migraine is preceded by an aura – a person may see flashing lights, zigzag lines, or temporarily lose vision. There may be speech difficulty, weakness of an arm or leg, tingling of the face or hands, and confusion.

Common migraine is more common in general population. There is no preceding aura. There may be vague symptoms of mood changes and fatigue. There may be nausea, vomiting, diarrhea and increased urination.

What causes migraine headaches?

There is no known precise cause of migraine headaches. The theory is individuals have blood vessels that overreact to various triggers. This results in chemical changes in the blood and in the caliber of the blood vessels in the brain. First the blood vessels narrow and then after a while they rapidly widen and severe headache develops.

Stress and certain foods (like chocolates and cheese) can trigger an attack. Some people are affected by fatigue, glaring or flickering lights, and changes in the weather and at the time of menstruation. This list is by no means complete.

Although many sufferers have a family history of migraine, the exact hereditary nature of this condition is still unknown.

Do I need any tests?

Most of the time migraine headache can be diagnosed by your physician from your symptoms. A physical examination shows no detectable abnormalities during an acute migraine attack. Rarely CT scan or MRI of the brain is done to rule out serious causes like a brain tumor.

What is the treatment?

The object of the treatment will be:

-Drugs to reduce the duration of acute attacks
-Drugs to help treat symptoms
-Drugs to prevent future attacks

There are several drugs in each category. It will be futile to name them here. The best thing is to discuss with your family doctor. He will find an appropriate medication which suits your needs.

Can it be prevented?

You need to identify the factors which trigger your migraine. Keep a diary for few weeks to identify the triggers and then avoid them. Eat regularly and follow a regular sleep pattern. If life is stressful then learn to do some relaxation exercises. Laughter and meditation may help.

You can also visit Migraine Association of Canada’s website: www.migraine.ca (under construction but has some links) or contact them by e-mail: support@migraine.ca.

Thought for the week:

“What good is perfect eyesight when you are inwardly blind?” – From Images and Reflections by Dennis van Westerborg, a local artist and writer.

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