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Programme no. 4 - Headaches
RADIO 4
THURSDAY 3RD JULY 2008 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: ANDREW DOWSON
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
MYERS
Hello. Today it's your chance to talk to the doctor about headaches. Now if you only have the occasional headache you're not likely to need specialist advice, although you may like to know whether some painkillers are better than others. Then again if you have a headache 15 days in every month, as some people do, you may want to find out what's causing your chronic daily headache. Or if the pain is one sided and you also feel sick or see strange lights you may have migraine and may also want information about how the latest prescription drugs can help you.
Now it may be that you're experiencing headaches that are unusual for you, in which case you may be after reassurance that it's nothing serious, such as a brain tumour. The lines are open for whatever your questions on headaches and my guest in the Check Up studio today is Dr Andy Dowson, he's from King's College Hospital Headache Centre.
And our first caller is on the line already, she's Monique, she's in Birmingham with headaches at the back of her head I think, is that the case Monique, you tell us?
MONIQUE
Yes that's the case. Basically I have an eye headache, if I can classify it as that, and it hits the back of my head and extreme pain, there are times I feel like removing that eye out of my head because it's so vast into the back of my head.
MYERS
Oh I'm very sorry to hear that. And you are experiencing it at the moment?
MONIQUE
No, it's died down, it takes about three days before it disappears.
MYERS
Okay, and has this been for some length of time that you've been having this kind of level of pain in your eye and at the back of your head?
MONIQUE
Oh yes, yes I do.
MYERS
Well we've got an expert who perhaps can help you in that case. Dr Dowson what advice can you give to Monique, she sounds as though she's struggling? I also should add that the phone line's not great Monique so forgive us if we don't come back to you, but let's try and get some advice at least.
DOWSON
Well I think it looks like this is a question about diagnosis perhaps, it doesn't seem as if she knows exactly what it is that she's likely to have. And doctors do look for specific symptoms to help - to signpost towards whether it's a tension headache or a migraine headache. I think if one question was asked is - is your headache a debilitating headache, does it stop you doing things and hers do sound as if they fall into that category. So that probably puts her into the migraine group. And of course the doctor symptoms that we look for are one sided headaches, which she ticks the box; severe; made worse by activities; throbbing nature to them; feeling sick, having light and sound sensitivity and a combination of those, you'd have to have every symptom, is usually what we look for. As I say you don't have to have everything. So if only she had the pain at the back of the head it would be still possible to be migraine and I think that's one of the things that is nice to know, it's just the disabling headaches which are important, the site of them can vary enormously from person to person.
MYERS
And is it worth making clear perhaps at the beginning that a migraine is not a particularly severe headache, it's a different category of pain and of, if you like, disability and needs treating differently perhaps from what I would do if I had a headache which is take the aspirin?
DOWSON
Well yes it can be a bad headache but as you say it's possible to have migraine without a headache in fact. I mean the childhood migraines can sometimes be tummy pains or getting dizzy and certain people as they get older the things that happened before headaches are called auras sometimes - flashing lights, zig zag lines - and sometimes they can come with no subsequent headache. So there's quite an array of different pain. About half the people do well with simple painkillers, the other half need migraine specific treatments.
MYERS
Okay, well perhaps we'll come on to that but thanks for your call Monique, please stay listening and I'm sorry about the line.
Let's go to Jill who's in Powys and I think is very familiar with migraines, perhaps you'll just explain a little bit and then tell us what your question is Jill.
JILL
Yes hello, hello to both of you. Yes I've been suffering from very debilitating and very severe headaches for a number of years and I think it all started with a diagnosis that the great hormonal change was upon me and I'm in my mid-50s now. The doctor has tried me on all sorts of migraine tablets, none of which have worked. I don't have the flashing lights but I do have the sensitivity and extreme dizziness for days and days. And they're just getting more frequent now, they were sort of monthly but they are at least every fortnight now and because they last several days each time one is cancelling everything in life all the time and it's that sort of thing - where do we go from here?
MYERS
Yeah that does sound pretty bad, if as you say they're almost running into one another now. But you think there's a sort of hormonal connection?
JILL
Absolutely, I think that's right because certainly when they come I get all the other symptoms as well - I suffer from IBS with it and things like that and it was all sort of sorted out some years ago that it probably was the change. But it seems to have been going on for about seven or eight years now and having tried all the migraine tablets that seem to be available - we have found one that does help but of course you can't keep on taking them and so you can only take a certain number in a given length of time and what do you do in between times is the question?
MYERS
Andy, over to you.
DOWSON
Well I think you have brought up a variety of different - very interesting points. I mean the first thing is that female hormones are important for people who suffer with severe headaches. Boys are actually more likely to have migraine than girls until the menacae [phon.] when the periods start and then girls become three times at least as likely to suffer. Towards menopause there is a dropping off for some people but the amount of migraine is always more in the female population and the male population from there on, so it never comes back to being the same as the male population. So you're quite right pregnancy can change it, being on the pill can change it, being on HRT can change it. So you know your observations I think are correct. If we look at the general population it's interesting, I think the average time to menopause is 51 or 52 now in this country and about five years leading up to menopause is often a very difficult time for the migrainer - more attacks and even a kind of movement into having a much more frequent headache pattern or even daily headache pattern, as was mentioned in the introduction. So I think all of those things are interesting points. With regard to treatment it sounds like you may have found something you can take as a tablet when you have a headache that's beginning to help you but if you're having a lot of course you need to work in parallel to find something that might reduce the frequency as well. And that's probably where you need to kind of spend a bit of time with your advisors at this stage.
MYERS
You mentioned that something was proving to be quite useful but you were a little bit concerned about keep on taking the tablets and of course that must be something that does worry people, is that the thing Jill? I think she's not there anymore, sorry. Sorry, I don't know if you're still there Jill?
JILL
I am, can you hear me?
MYERS
Yes, can now yes.
JILL
Yes, yes, exactly, that is the point and I take a tablet and I get relief for a day but then it comes back the next day and the next day and you know the restrictions on the amount you can take. Obviously I can't go diving back into that again and there doesn't seem to be anything else at the moment that's helping.
DOWSON
It's rather like - it's almost like you've got the icing on the cake when you're getting regular headaches when you have something that will work on that moment to help you get through the worst symptom. What you really need though is something that will help you reduce the frequency. So there's a number of things that can be tried from over-the-counter things like 5HTP, for instance, to prescription drugs, it's a question of just sequentially going through them in order, that means that you can actually try out each one properly.
MYERS
So even as a specialist you'd be advising people to go and, as it were, shop for some of these remedies, they actually can be helpful whether they're complementary medicines or whatever?
DOWSON
Yes I think it's about sort of a toolbox and different things in a toolbox come from different areas. People with regular headaches often get stiff necks, for instance, and having physical therapies can often be an adjunct to the - an added treatment to the usual medical ones, traditional medical treatments. As I say in people who have chronic headache often 5HTP - 5HT's the shorthand for serotonin pre pre-cursor - brought from a herbal type shop can often be quite helpful before needing to go on to other medications.
MYERS
And as for that further point that Jill was making, will it go at the menopause, it can for some but doesn't for everyone.
DOWSON
Doesn't always unfortunately.
MYERS
Fingers crossed for you Jill, thanks very much for the call. Let's go to Bournemouth and Jane Ward who wants to talk about her bad migraine and vomiting.
WARD
Oh yes, hello.
MYERS
Hello, sorry to hear about that, what happens to you then?
WARD
Yes, I was quite interested to listen to the previous caller because I used to have far more headaches before I actually had a hysterectomy about 20 years ago so I can relate to the hormonal triggers. But I still get them about every - about six times a year my headaches and unfortunately I wake up very early in the morning and I've already got the headache but by that time it's too late to take anything orally because I begin to vomit if I do - if I take something. So I've tried - the doctor gave me some metacloprimide but that wasn't very successful either, so I didn't know whether there was anything other than the oral medication that would be anymore success.
DOWSON
Well again several very interesting points. I think the first thing to say is that people think often of migraine as being a bad headache and it sounds that in your case one of the worst and most disabling symptoms is actually vomiting ...
WARD
That's right yes.
DOWSON
... yeah and other people might find if you're so sensitive to light you can't go outside, that can be very disabling as well. So different things really cause the impact for different people. And you're quite right if you have a need for an acute drug and you're being sick or you're in the stage just before it doesn't really get absorbed and you don't get a benefit. So there are one or two treatments now specific for migraine in the modern family of drugs that we call the triptans, which many of the migrainers will have heard about, which come as a nasal spray and there's one called Zolmitriptan, which particularly is good at being absorbed from the nose And there's an injection of a drug called Imigran or sumatriptan, from the same family, which can also be beneficial. From the sickness perspective, rather than the global migraine, you mentioned one drug but there's another drug called peridone, which can be available via a suppository. These are things you need prescriptions for but there are some options that might benefit you.
MYERS
Jane, does that sound helpful?
WARD
Yes I would certainly try and find out about the suppositories and the injection yeah.
MYERS
Well good luck with that, that sounds like a visit to your doctor. And of course I suppose most people will see their doctor if they're struggling with this but if they are not getting very good treatment from their doctor what are their chances of getting seen by a more specialist clinic such as your own - the King's service?
DOWSON
Well there's patchy services around the country. There's probably only about 20 or so hospital departments - hospitaly based departments ...
MYERS
Why is that, is this a Cinderella service?
DOWSON
Well it's - headache is rarely something that's actually ....
MYERS
Life threatening.
DOWSON
... leads you into being something life threatening. And it's traditionally in the departments of neurology and neurologists do take on - so in your local hospitals neurologists will look after people with headache. But then there are some hospitals that have specific departments that look at headache alone, within the departments of neurology and they're relatively scattered. But we're beginning to get now GPs with an interest in headache and so there's a wider spread of people with expertise and those might not only be able to deliver care to their own practice but for the area and with these new sort of close to home initiatives that the Department of Health are doing there's an increasing range of options for how people might be able to access care.
MYERS
Thank you. I'm not sure whether Chris, who has e-mailed us, would take this question to his GP but he's happy to offer it to us on e-mail at least. He says: I suffer a headache after sexual activity, sometimes just a mild pressure with tension in the neck muscles, sometimes throbbing, lasts for several days. And so he's wondering whether this is something you've heard of and is there anything he can do to remedy it. I guess you'd say one thing he could do but that seems a bit unfair on him and his partner if he has to give up sexual activity because of this. So is there some other way round it and is it something you've come across in your own clinic?
DOWSON
Yes we do see this relatively commonly and I know that it was slightly amusing - the introduction - but in fact that's actually quite a big problem, that if people have such severe headaches that it means they need to avoid sexual activity if often has an enormous effect on the family and it shouldn't be underestimated. So it's something that we should be more sensitive to I think, as doctors. There are things we can do - there are different types of headache that come on at different times of the act of sex, some of them early on are tension type headaches and after sex are often tension type headaches but migraine headaches can also occur more at the point of orgasm. And sometimes if you're in that situation just taking aspirin before can sometimes help to stop it coming on or sometimes we look at preventative treatments that you take on a regular basis to see if that can help you.
MYERS
So there are some things that you can do, so first go and see your doctor Chris if you will and follow that up, thanks for that information.
DOWSON
Yeah it's getting over that initial sort of embarrassment about it, I think it needs - we need to kind of get over that if possible.
MYERS
Okay to Katy now, Katy is calling us about the headache that she has nearly every morning. So what do you think is causing your headache Katy?
KATY
Hiya. Yeah I'm 33 and most mornings I wake up with a headache and it just seems so horrible really because you're supposed to wake up feeling refreshed and I really don't know what causes it. I drink plenty of water, I eat a healthy diet, I get plenty of sleep but I'm not sure what causes it. I do often - you mentioned earlier - I do often have a very stiff neck, well not stiff but pain in my neck area and I do drive a lot - I'm a sales rep so I'm in my car most of the day. But by the end of the day I don't have a headache anymore, it's in the morning when I wake up.
MYERS
And do you take anything for it?
KATY
I do, I tend to reach for paracetamol before I even get out of bed, it's the first thing I do when I wake up and I see that it's almost 7 o'clock, my alarm's about to go off, so I take two paracetamol before I get out of bed.
MYERS
Mmm, okay what do you think about that Andy?
DOWSON
Well waking up with headache used to be one of the symptoms that used to worry doctors a bit and still if you wake up in the middle of the night and you're a child we still suggest that person does need to be assessed properly by doctors and sometimes need to see specialists. We know though that migraine, for instance, actually half of all the migraine comes on on waking or in the first hour of waking, so it's actually quite a common scenario for people who are adults to have sort of waking headaches and it's not really a sinister symptom, as it used to be. There's a couple of things you - that might be relevant. It's interesting that chronic headache, daily headaches, often actually are an evolution from a simple migraine and just uncontrolled migraines can lead to a reduced threshold of the sort of migraine brain so it's easier to trigger off headaches and you get into cycles of headache. Now the regular painkillers that you mentioned can become part of the problem as well and more than a couple of doses a week of painkiller, a very low amount, has been shown to actually drive headache processes and that's called analgesic dependence.
MYERS
Well that's going to sound paradoxical, it's also going to surprise people because of course a lot of people would be taking painkillers at least twice a week to be honest, for one thing or another relating to other pains and headaches as well. So are you warning people off taking regular analgesics?
DOWSON
If you have - I mean the average migrainer has one migraine a month and it lasts a day and if you take some - whatever it is you take over-the-counter if it works in one or two doses that's not a problem. I think it's more if you start to see the usage going up, as in this case, that you just ought to take a look at that. There were some studies done in people who have arthritis and it was interesting they're given the painkillers for arthritis not for headache but the ones who previously had migraine developed daily headaches, the ones who didn't have previous migraine didn't develop daily headaches. There's something about a migraine brain being exposed to lots of painkillers that actually helps it to have more headaches.
MYERS
And just explain that migraine brain - I mean that's like - if you like a susceptibility or a predisposition or is it literally a migraine brain that you can see on a scanner for example, can you see something?
DOWSON
No, it's you know you've been born with the right genes to give you a migraine and ...
MYERS
Or the wrong genes.
DOWSON
Or the wrong genes.
MYERS
Okay. But also you mentioned I think the driving, would - I mean I don't know whether you think that that's possibly more the explanation or whether you would be prepared to try dropping the paracetamol and seeing if that might help but driving, you think, perhaps would cause tension would you say? I don't know if our caller's still with us?
KATY
Yeah. I don't know, I really don't know whether it's sitting in the same position all day. A couple of times in the past five or six years I've been hit from behind and had a very sore neck for a few months afterwards. But I have had cycles of physiotherapy in the past and to be honest they don't seem to make any difference at all.
MYERS
Okay, I think Andy wants to pick that up finally, that point about having been hit perhaps.
DOWSON
Well yeah I think it's quite common actually after injuries to neck and even head to have kind of chronic headache. And there's a bit of a two way scenario here - if you have a bad neck and you have this sort of migraine tendency you tend to get more headaches and if you have lots of headaches and you've got a dodgy neck you get more neck ache and again the two things kind of sensitise and wind each other up. And so if you attack the problem from both ends - you can do your physio or your physical therapy but also think about a migraine preventative at the same time.
MYERS
I think what this begins to I think make the point that this is sometimes quite a complex business and I guess the advantage of seeing a specialist or a doctor who's prepared to listen carefully is that you do need to tease out the various possible causes and maybe even keep a diary of certain events and when you suffer things and to try and be a bit forensic about just what's going on. I guess that's the advantage.
DOWSON
Yeah, absolutely, I mean other things can come into this - the chronic headache patient may get their sleep disturbed for instance and there are various things we could think about for people to get off to sleep and stay asleep you might actually want to give treatments that would help to reverse that. It's been shown that people who snore more actually get chronic headache, for instance, it's been shown if you get a lot of caffeine in your diet it's another thing that can be a triggering factor.
MYERS
Well we've got an e-mail from someone who's asked us to mention the connection with what he or she describes as mandibular dysfunction, so I guess that's the jaw. He said I've never heard of this condition but after suffering for two years of severe headaches a new young dentist suggests trying a brace, which he wears at night, and he's done this, it's solved the problem and he's very grateful for that. We've got another e-mail talking about things that people pick up on. Alison says: I found that my migraines have diminished since I've been careful to drink more water. So seems simple but if it works of course it's the answer. Let's go to another caller though, now we've got Teresa who's waiting in Edinburgh, wants to tell us a little bit about her daughter, who's been having headaches for a few months now. How can we help you Teresa?
TERESA
Yes hello. My daughter, Hannah, has had a permanent headache since the end of April. We saw a neurologist yesterday who diagnosed a classic tension headache. We were relieved of course that it wasn't anything awful but the question is now what can we do to help her, how can we get rid of the pain and how can we manage it?
MYERS
Well I'm glad there's nothing serious and just to pick up on that with Andy our expert in the studio today. I guess that underpins a lot of people who would come to see you, that there is a concern that because it's a headache there's something going on in the brain. And it's quite important sometimes to make sure that people understand that that's not usually the case, in fact it's very rare isn't it?
DOWSON
Yeah absolutely. The most - most of the sinister type of headaches, whether it's associated with a meningitis or a burst blood vessel or inflamed arteries or whatever, are quite acute presentations, so people don't usually have these symptoms predictability over a long period of time, which is obviously the most usual type of patients that I see in my clinic. So the amount of sinister headache in people with established headache patterns is incredibly low. In this one study in Spain it was about 1% of people had the first symptom as headache alone and within weeks they developed other symptoms and signs. But nevertheless I think what you've been through is what a lot of people actually go through, which is they have an appointment which they often have to wait a while for and they have exclusion of tumour or other serious causes and that can actually be quite helpful because if the anxiety's driving a lot of the illness that can actually puncture that. Now I think it's a question of going on and trying to get some sort of treatment to help you break the cycle of that and that probably involves being on some sort of preventative medication.
MYERS
Okay, thank you for that. Well we're glad it's nothing serious and there are lots of treatments, as we've been hearing, which hopefully will help your daughter and would be relevant for a 13 year old?
DOWSON
Oh yes. Headache's very common in children, it's an adolescence - it's not just an adult's illness.
MYERS
And we'll go to our last call and I think that's going to be - we'll go to Jean very quickly whose daughter's having cluster headaches which are getting more frequent, so she's really struggling is she Jean?
JEAN
Yes she is. She's on sort of three types of tablets at the moment but obviously they all make her very dizzy - sorry they make her quite sleepy. And they are sort of becoming more frequent.
MYERS
Okay I'm going to have to jump in because we've got so little time left but we did just want to make reference to cluster headaches and Andy, very quickly, if you'd just say a little bit about cluster headaches, just to let people understand that they are quite serious and quite debilitating but there is treatment.
DOWSON
Yeah absolutely. Probably one of the worst types of headaches to have. Nicknames for it - suicide headache because of the very intense nature - alarm clock headache because people often wake up with it. But it usually focuses on an eye, the headaches are relatively short - from 30 minutes to three hours - but come in clusters. And when you have them really the key is to go and get something that works for individual headaches but more importantly break the cycle with some preventative treatment.
MYERS
Sorry to cut you off, we've not had chance to say a lot about that, but there's a very good website - the ouch website - you might want to check up, more details on that.
Thanks everyone for your calls, for your e-mails, thanks Andy for your answers. You can listen to the whole programme again, if you can, by going to the Â鶹ԼÅÄ website and follow the trail to Check Up. You can speak to someone with more sources of information, you need to call 0800 044 044.
And I hope you'll join me again at the same time next week, we'll be taking your questions about feet.
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