New Remedies for an Everyday Complaint
By PETER JARET

Dr. Robert Kunkel has been a headache specialist at the Cleveland Clinic for more than 35 years. He is past president of the American Headache Society and the National Headache Foundation.

Q. How common are headaches?
A. Headaches are one of the most common of all medical complaints. And by far the most common are tension-type headaches. Seventy-eight percent of adults experience at least one tension-type headache during their lifetimes. The symptom is typically a band of painful pressure all around the head.
Migraines are the second most common. An estimated 20 percent of adults suffer from migraines. Migraines are associated with moderate to severe throbbing pain, which is usually accompanied by nausea and sensitivity to light or odors. Migraines tend to get worse with physical activity.
Cluster headaches are relatively rare. These are more painful and debilitating than migraines. They come on suddenly and are located usually behind one eye. Each one may last only an hour, but they occur in clusters, sometimes several in one day. The clusters may occur over a week or two, and then go away for weeks or months. Nobody knows why this cycle occurs. The pain is so intense that people sometimes have to pace the floor or bang their heads.

Q. Are headaches often a symptom of serious medical problems?
A. Sometimes, but much less often than people think. The headaches I’ve been describing are called primary headache syndromes, because they are not associated with other diseases or conditions. Ninety-five percent of all headaches are primary headaches. Headaches caused by an underlying condition, such as a brain tumor or problems with the circulatory system, are called secondary headaches. Although they are rare, it is important for doctors to exclude possible underlying causes when diagnosing a recurring headache.

Q. Are tension-type headaches, migraines and cluster headaches related?
A. That’s controversial. Obviously, all of them involve pain in the head. Some researchers think they may have some other features in common. Tension-type headaches are associated with muscle tension in the neck and head. Migraines and cluster headaches are vascular, meaning they are linked to abnormalities of blood flow in certain parts of the brain. But studies show that migraine and cluster headaches seem to be happening in different parts of the brain, so they are quite distinct.

Q. Do some people experience more than one kind of headache?
A. Absolutely. We see many patients in the headache clinic with mixed headaches. In other words, they may suffer from tension-type headaches and then from time to time also experience a migraine on top of the usual chronic tension-type headaches. We used to call these combination headaches, but now we usually say a patient suffers from tension-type headache and migraine. A typical pattern is for someone who had migraines when they were younger, in their 20s, who then develop tension-type headaches when they are in their 40s or 50s.

Q. Are men or women more at risk of suffering headaches?
A. Migraine headaches are three times more common in women than men. Cluster headaches are five times more common in men than women. Beyond those gender differences, there is strong evidence that migraine headaches are inherited. Abnormalities on three chromosomes have been linked to inherited risk. Cluster headaches may also run in families, but there’s less evidence for that.
Tension-type headaches seem to affect men and women equally, and there’s no evidence that they are inherited. We used to think tension-type headaches were triggered by stress, and that may still be true for some. More generally, they are associated with muscle tension in the neck or face. But even that isn’t always true. Some people who suffer from chronic tension-type headaches do not show signs of increased muscle contractions or spasms. And there are people who have muscle spasms who don’t get headaches as a result.

Q. Let’s focus on tension-type headaches, which are the most common. What’s the most effective treatment?
A. Some people get relief simply by resting and relaxing. Others feel better if they massage the muscles of their temples or neck. Of course many people turn to over-the-counter pain pills, such as aspirin, Advil or Tylenol. These can be very effective in relieving episodic tension-type headaches. People with stubborn tension-type headaches can benefit from prescription muscle relaxants.
Unfortunately, pain medications can cause rebound effect if they are overused: when people stop taking them, their headaches return and may be even more painful. In fact, overuse of over-the-counter pain pills is a common cause of chronic headache pain. Over-the-counter pain medications with caffeine are a particular problem. The caffeine helps speed relief, but it is also more likely to cause rebound.
A good rule of thumb is not to take medication to treat headache pain more than twice in a week. If you find yourself taking an over-the-counter pain reliever most days, you could be suffering from a medication-overuse headache. Then it’s a good idea to talk to your doctor.

Q. Can tension-type headaches be prevented?
A. Yes. Some patients experience fewer and less severe tension-type headaches if they use relaxation techniques such as meditation or deep breathing exercises. Exercise also helps some people avoid headaches. Exercises that improve posture, such as yoga, may be especially helpful, since they reduce muscle tension in the neck and shoulders.
Following a healthy diet probably helps, especially eating on a regular schedule and not skipping meals. We know that skipping meals can trigger migraines, and it may also trigger tension-type headaches. A healthy diet and regular exercise help people maintain a healthy weight, of course, which may help prevent headaches, too. A recent study done by Richard Lipton at Albert Einstein College of Medicine showed that obesity is a risk factor in chronic headache.
Another way to prevent headaches is to identify and then avoid the triggers that cause them. Tension-type headaches can occur when people skip a meal, for instance, or if they are anxious and tend to clench their jaws.
We often recommend that patients keep a diary of when and where headaches occur. Keeping a diary can also help when you sit down with your doctor. The more you know about when headaches occur, what seems to trigger them and what they feel like, the easier it is to diagnose and treat.

Q. Are medications available to prevent tension-type headaches?
A. Yes. Doctors sometimes prescribe muscle relaxants such as Flexeril, taken once a day at night. Low doses of tricyclic antidepressants, such as Elavil, have also been shown to be effective in preventing chronic headache. The problem with these drugs is that they can cause sedation and increase appetite, which is something we don’t want to do.
There’s also interest in botulinum toxin, which is injected at sites around the neck and scalp to reduce muscle tension. The toxin blocks nerve impulses to these muscles, and for some patients can offer two to three months of relief. Our interest is the fact that botulinum toxin seems to work better in the treatment of chronic migraine than it does in tension-type headaches. Botulinum toxin, which most people know as Botox, also seems to inhibit the release of other chemicals from the nerve endings that may cause inflammation around the blood vessels, that in turn may be involved in migraine as well as causing muscle spasms. Although it’s not approved specifically for headaches, many doctors are using Botox. Most of us have some patients who are doing well. But like most treatments, it doesn’t work for everyone.

Q. What do you do to treat your own headaches?
A. I have to admit, I’ve never had a headache, not even a tension-type headache. A lot of my colleagues are surprised at that. Most doctors who specialize in this field became interested because they suffer migraines or cluster headaches. I’ve always been interested in headaches, but not for personal reasons. Even though I’ve never experienced a headache, I like to think that I’m sympathetic to the pain that my patients are suffering.

Ajit Kumar, Natural Healer says:
Simple light Intermittent pressures on different points of scalp can be given, once a day. Relief has been experienced by considerable number of patients.

By JANE E. BRODY
Published: April 29, 2008

Randi considers the Y.M.C.A. her lifeline, especially the pool. Randi weighs more than 300 pounds and has borderline diabetes, but she controls her blood sugar and keeps her bright outlook on life by swimming every day for about 45 minutes.

Randi overcame any self-consciousness about her weight for the sake of her health, and those who swim with her and share the open locker room are proud of her. If only the millions of others beset with chronic health problems recognized the inestimable value to their physical and emotional well-being of regular physical exercise.
“The single thing that comes close to a magic bullet, in terms of its strong and universal benefits, is exercise,” Frank Hu, epidemiologist at the Harvard School of Public Health, said in the Harvard Magazine.
I have written often about the protective roles of exercise. It can lower the risk of heart attack, stroke, hypertension, diabetes, obesity, depression, dementia, osteoporosis, gallstones, diverticulitis, falls, erectile dysfunction, peripheral vascular disease and 12 kinds of cancer.

But what if you already have one of these conditions? Or an ailment like rheumatoid arthritis, multiple sclerosis, Parkinson’s disease, congestive heart failure or osteoarthritis? How can you exercise if you’re always tired or in pain or have trouble breathing? Can exercise really help?

You bet it can. Marilyn Moffat, a professor of physical therapy at New York University and co-author with Carole B. Lewis of “Age-Defying Fitness” (Peachtree, 2006), conducts workshops for physical therapists around the country and abroad, demonstrating how people with chronic health problems can improve their health and quality of life by learning how to exercise safely.

Up and Moving

“The data show that regular moderate exercise increases your ability to battle the effects of disease,” Dr. Moffat said in an interview. “It has a positive effect on both physical and mental well-being. The goal is to do as much physical activity as your body lets you do, and rest when you need to rest.”

In years past, doctors were afraid to let heart patients exercise. When my father had a heart attack in 1968, he was kept sedentary for six weeks. Now, heart attack patients are in bed barely half a day before they are up and moving, Dr. Moffat said.

The core of cardiac rehab is a progressive exercise program to increase the ability of the heart to pump oxygen- and nutrient-rich blood more effectively throughout the body. The outcome is better endurance, greater ability to enjoy life and decreased mortality.
The same goes for patients with congestive heart failure. “Heart failure patients as old as 91 can increase their oxygen consumption significantly,” Dr. Moffat said.

Aerobic exercise lowers blood pressure in people with hypertension, and it improves peripheral circulation in people who develop cramping leg pains when they walk — a condition called intermittent claudication. The treatment for it, in fact, is to walk a little farther each day.

In people who have had transient ischemic attacks, or ministrokes, “gradually increasing exercise improves blood flow to the brain and may diminish the risk of a full-blown stroke,” Dr. Moffat said. And aerobic and strength exercises have been shown to improve endurance, walking speed and the ability to perform tasks of daily living up to six years after a stroke.

As Randi knows, moderate exercise cuts the risk of developing diabetes. And for those with diabetes, exercise improves glucose tolerance — less medication is needed to control blood sugar — and reduces the risk of life-threatening complications.

Perhaps the most immediate benefits are reaped by people with joint and neuromuscular disorders. Without exercise, those at risk of osteoarthritis become crippled by stiff, deteriorated joints. But exercise that increases strength and aerobic capacity can reduce pain, depression and anxiety and improve function, balance and quality of life.

Likewise for people with rheumatoid arthritis. “The less they do, the worse things get,” Dr. Moffat said. “The more their joints move, the better.”

Exercise that builds gradually and protects inflamed joints can diminish pain, fatigue, morning stiffness, depression and anxiety, she said, and improve strength, walking speed and activity.
Exercise is crucial to improving function of total hip or knee replacements. But “most patients with knee replacements don’t get intensive enough activity,” Dr. Moffat said.

Water exercises are particularly helpful for people with multiple sclerosis, who must avoid overheating. And for those with Parkinson’s, resistance training and aerobic exercise can increase their ability to function independently and improve their balance, stride length, walking speed and mood.

Resistance training, along with aerobic exercise, is especially helpful for people with chronic obstructive pulmonary disease; it helps counter the loss of muscle mass and strength from lack of oxygen.

In the February/March issue of ACE Certified News, Natalie Digate Muth, a registered dietitian and personal trainer, emphasized the value of a good workout for people suffering from depression. Mastering a new skill increases their sense of worth, social contact improves mood, and the endorphins released during exercise improve well-being.

“Exercise is an important adjunct to pharmacological therapy, and it does not matter how severe the depression — exercise works equally well for people with moderate or severe depression,” wrote Ms. Muth, who is pursuing a medical degree at the University of North Carolina, Chapel Hill.

Feel-Good Hormones

Healthy people may have difficulty appreciating the burdens faced by those with chronic ailments, Dr. Nancey Trevanian Tsai noted in the same issue of ACE Certified News. “Oftentimes, disease-ridden statements — like ‘I’m a diabetic’ — become barricades that keep clients from seeing themselves getting better,” she said, and many feel “enslaved by their diseases and treatments.”
But the feel-good hormones released through exercise can help sustain activity.

“With regular exercise, the body seeks to continue staying active,” wrote Dr. Tsai, an assistant professor of neurosciences at the Medical University of South Carolina in Charleston. She recommended an exercise program tailored to the person’s current abilities, daily needs, medication schedule, side effects and response to treatment.
She urged trainers who work with people with chronic ailments to start slowly with easily achievable goals, build gradually on each accomplishment and focus on functional gains. Over time, a sense of accomplishment, better sleep, less pain and enhanced satisfaction with life can become further reasons to pursue physical activity.
“Even if exercise is tough to schedule,” Dr. Moffat said, “you feel so much better, it’s crazy not to do it.”

Related
Times Health Guide: Physical Activity »
RSS Feed
•Get Health News From The New York Times »