The most comprehensive headache guide
Anton Loboda, an anaesthesiologist and resuscitator specializing in pain management, spoke about pain and answered a number of questions. We publish his pain guide with the permission of the author and from his first person.
About the medical specialty: pain management ("work with pain")
It is worth saying that I went to medicine precisely to save people from pain, I became an anesthetist-resuscitator for the same reasons and now I am leaving for a separately developing specialty - a specialist in pain management (pain management) for the same reason.
Why pain specialist? And so all the specialists know everything. The problem is that the specialist to whom they come with pain will only look at their own and if they don’t find their own, they will send them further down the list. For example: a person has chest pain, he goes to a cardiologist, he refers to a pulmonologist, he goes to a neurologist, and this can continue either until the pain is chronic or goes through independently. Moreover, the patient remains without a diagnosis, respectively, without a recommendation for prevention and, if necessary, treatment of pain upon their return.
The pain specialist evaluates the pain, finds the source and then, if necessary, sends it to the specialists with a diagnosis while trying to anesthetize as much as possible and give recommendations for pain relief.
What is pain
The pain is different. There is a concept of acute pain, it is instant and intense. There is the concept of chronic pain, and often there is no longer any substrate for pain, everything has already healed and gone, but the pain is there and then this pain is not intense, but more debilitating.
In general, pain is the body's reaction to an irritant with a subjective emotional color. This is really an evolutionarily verified mechanism that is protective: damaged - do not load. Another question: the mechanisms of damage are different and the structures are damaged different and the pain from these structures is perceived differently. But sometimes everything will already heal, but the pain is still there.
A person comes to you with 10 out of 10 points on a visual analogue scale, and leaves with 2 out of 10. A very clear result: from unbearable pain there was a low background pain.
After local injection therapy, it is possible to understand whether it got there or not there, whether it is a source of pain and / or how much the injected structure contributes (if at all) to its contribution.
Headache and myths about it
You can talk endlessly about a headache, it is individual from the beginning of its formation to the trigger moments, because of which it arises. The head really hurts in a special way and the patient usually cannot clearly state this feature. Something hurts, somehow, somewhere, as if. While I will describe three types of pain, the most frequent, and then I will add extravagant cases. Immediately scatter a couple of established myths!
Myth: Headache is a sign of high blood pressure.
True only in the case of the crisis (figures above 180/120 mm Hg). In terms of migraine, generally elevated blood pressure is the prevention of seizures or their relief.
Firstly, the pain itself in part stimulates the sympathoadrenal system, which gives rise to blood pressure. Secondly, the increase in pressure is psychologically pumped up. Thirdly, there is the concept of an error in measuring pressure: an incorrect technique for measuring pressure, a tonometer jams, were not prepared for the measurement.
Especially the last moment when a person comes to me a couple of times from the office after 3 mugs of double espresso, 2 cigarettes, a sleepless night and bring me it from some super important meeting. And in panic he demands a pill, I give him a pill, but not from pressure, but soothing, and ask for 10 minutes in a darkened room to lie down to count his breaths. And, lo and behold, the pressure is normal.
There was a study in sports medicine, where runners, weightlifters and swimmers measured pressure during physical exertion. An untrained person would immediately say that a person has a hypertensive crisis and urgently needs pills, but they did not die and their pressure returned to normal at the end of the load. The mechanism for increasing pressure during stress and physical exertion is approximately the same. And their head, by the way, did not begin to hurt from the increase in pressure.
Myth: No-spa will relieve a headache.
This is not true. If no-spa helps, then the placebo effect has not been canceled for the same tension headaches. With them, you can take almost anything, and it will work, only most likely because you really want to work.
There are 4 main types of headache:
Further about them in more detail: how to determine and treat them.
Tense type headache
You have to be honest and say that it is not known what exactly hurts there: research has been going on since the mid-1980s. At first, it was believed that the muscular hypertonicity of the occipital region and neck gives pain, they checked - no, the muscles are normal. However, they decided to leave the term “stress type headache” or “tension headache”. What I managed to find out: pain is clearly related to stress. Accordingly, the problem is not only outside, but also inside, or rather, somewhere in the area of the hypocampus.
In green, the doctor noted places of usual soreness with enthesopathies.
He often talks about enthesopathies, especially in the area of the base of the skull - an interesting thing. Entheses are areas of muscle attachment to the periosteum. These points are innervated very intensively (that is, there are many nerve endings in them) and, accordingly, minimal trauma to this area causes pain.
The analogue of the inflammatory process that follows after traumatization can be maintained for quite some time due to the fact that we are active people and, perforce, twist and turn our heads and give tension to an already injured area. I often see this in practice: for severe patients or with severe headaches, I inject painkillers in the area of the attachment of the occipital muscles and everything goes fine.
Diagnosis of stress type headache
In the USA, both for tension headache and for migraine (but migraine is a separate issue, we will consider it in more detail below) have a system of criteria.
For a tension headache, 2 of the following criteria must be present:
- Pain pressing or squeezing, not pulsating;
- Occipital-parietal / occipital-frontal localization;
- Bilateral (bilateral) of medium or low intensity (on a visual analogue pain scale - this is usually 1–5 points);
- It does not increase with physical activity.
It is worth noting that this pain does not interfere with life, and often when you communicate with such a patient, you start to tell him something, to show him, to distract him in every possible way - the pain disappears, but appears when the distraction factor ceases. This once again confirms that something there in the brain still develops and supports it.
Tension headache is also divided into paroxysmal (acute) and chronic. The attack lasts from 30 minutes to 7 days. In chronic: at least 15 days a month for at least 6 months in a row. It is worth noting here that this pain can be of a background nature and subjectively a person does not even perceive it as a headache, but this is still a headache.
Stress type headache treatment
- NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen (nurofen), ketoprofen (ketonal), indomethacin and other or selective blockers of COX-2 and coxib (celecoxib, eterocoxib);
- Antipyretics / analgesics such as metamizole (analgin) or paracetamol (usual dose of 1 gram).
I prefer to prescribe paracetamol initially, it helps a lot in a dose of 1 gram. Ketorol anesthetizes very well, but I never prescribe it myself and in every possible way I shun it precisely because of gastrotoxicity: it can cause stomach and duodenal ulcers.
Paracetamol is the safest drug at the moment, 1 gram 4 times a day is considered a safe dose. Instead of ibuprofen, I would recommend coxibs, they affect the stomach to a lesser extent, but they also affect the kidneys, however, you can also take them for a long time with stomach protection (taken after meals, diet + proton pump blockers), I judge by patients who are take for life.
In general, NSAIDs will still soon disappear when celecoxib generics appear. (the original is a little expensive).
- stronger painkillers in combinations of paracetamol / codeine, paracetamol / tramadol.
- add antidepressants, but this is for chronic stress headaches.
In our country, a very strange and extremely incorrect attitude towards antidepressants. I just returned from Austria from a school in pain treatment, where a German pain specialist said that 100% of patients undergo a psychiatric examination as part of monitoring for depression.
Pain in itself is a vile thing, except for masochists nobody especially loves it, and here it is for a long time, if not forever, creeping into your life. Either pain provokes and supports depression, or initially hidden depression provokes and supports pain. The connection is proved, it is and something needs to be done with it. In this context, the appointment of antidepressants is justified and necessary.
The goal of antidepressants is to reduce the number of seizures in combination therapy (I always emphasize this because with one pill you can’t remove the complex pain), ideally to zero. And I immediately explain: we do not treat depression as antidepressants, we remove the depressive component of chronic pain. Often patients refuse to take antidepressants, they say why they are to me, I'm not depressed. We have to explain that depression is a serious disease that has a different severity. One person steps out of the window with depression after a couple of years of illness, and someone with mild depression pickles himself for years, without even thinking that the daily negativity that supposedly falls on him is a manifestation of this very mild form of depression, if it is without pain.
And if it’s with pain, then the life of an ordinary person and the life of a person with chronic pain, or rather a person who did not have pain and then it arose and was chronic, are two different lives. For example, you often ask a patient about his past — painfully and he talks about himself as another person: “I traveled / worked / loved to do (insert the missed), but now I can’t because of pain.” And this is one of the origins of the depressive component.
Ideally, of course, you need an examination by a psychiatrist in order to professionally confirm the depressive component and how pronounced it is, which in patients with chronic pain is close to 100%.
It is worth noting that with an unsystematic constant intake of drugs, a drug-induced headache may develop. That is, the pain is no longer associated with the initial headache problem, but with the direct administration of an anesthetic. Usually it develops after 3 months of systemic administration and it is very difficult to distinguish between a tension headache or migraine from a drug-induced headache.
So that this was not a simple rule: no more than two drugs a day, no more than two times a week.
Pills are certainly good, but you need to understand that a headache is not a cause but a consequence. So I recommend changing your lifestyle:
- Regular physical activity / sport (if you don’t go to the gym, at least just walk at least 2 hours a day. Do not stand on the escalator, but go. Do not wait for the elevator, but go up the stairs. Good weather? Walk a couple of metro stations on foot and so Further);
- Quitting smoking and a lot of coffee;
- Normal lifestyle: sleep mode (too much sleep - bad, too little - bad, 6-9 hours - normal), regular meals (usually often fractionally 4-5 times a day in small portions, hunger - a pretty serious stress provocateur) well and so on.
- Various meditation techniques, cognitive-behavioral techniques, consultation of a psychiatrist and psychotherapist to select and change attitudes towards stress and increase stress resistance. After all, it is important not only that we experience pain, it is important how we perceive it and how much we are able to control it, and not it.
Calcium deficiency can also be the cause of pain. Sometimes a patient comes, you look at the lower braids of the muscle, and there they are tense and painful on both sides. This often happens with calcium deficient tetany. Everyone around says without saying that calcium should be drunk, but few people know that calcium is not absorbed from the intestines if there is a vitamin D deficiency. Accordingly, against the background of calcium deficiency, persistent muscle hypertonicity forms, which gives not only a headache, but also pain in many body parts. Along with muscle pain, there are cramps in the limbs / face, a feeling of a coma in the goal that cannot be swallowed or churning when swallowing (as a result of esophageal spasm), these are the main symptoms. Anesthetizing and relaxing muscle pills in this case will not help or will help, but not for long and not completely. Need to restore vitamin D.
Migraine: what is it, types, how to treat
The oldest disease. From history I’ll say that the name was born due to a perverted translation from the Greek word hemkrania (“pain on one side of the head”) to Latin in the form of hemigranea and then to the French migrane.
For people suffering from migraine, I officially declare: at the moment, migraine is not treated . This is a hereditary or acquired thing that is characterized by brain dysfunction. No, this does not mean that there is a tumor or some other pathology. This means that unlike other people, your brain reacts a little incorrectly to some factors that trigger a headache.
From here the simple conclusion suggests itself: find the provoking factors and avoid them, take control. This is one of those diseases (as in many chronic diseases), where the doctor has a very small effect of exposure. As doctors, we give you the tools, and you must work with the disease yourself, we will not do this for you.
What causes migraines? As in tension headache: unknown. Previously, it was thought that the problem is in blood flow and spasm of blood vessels or their expansion. We checked the blood flow on the attack - everything is fine. Nowadays, the concept is not vascular, but neurogenic-vascular. Primarily, for some unknown reason, neurogenic processes occur that lead to sterile inflammation in the brain with secondary changes in cerebral blood flow.
I highlighted the word “change,” since it is not a violation, it is a variant of dysfunction. Everything works, but it works a little wrong. The light does not blink, it lights up, but not as brightly as before, and then flares up again.
Genetics here works somewhere around 70%. A huge negative factor: if a person is neurotic, with excessive susceptibility and mental instability, cognitive-behavioral disorders, acute reactions to stress, panic attacks and so on, anxious and suspicious people, so to speak.
Here is what the international society of headaches writes with a diagnosis of migraine - the first: there must be at least 5 headaches lasting from 4 to 72 hours, also these headaches should have two of the following symptoms:
- Unilateral (one-sided) localization;
- The pulsating nature of the pain;
- Medium to very severe pain (usually 5 to 9–10 on the pain scale)
During a headache, there must also be at least one of these signs:
- nausea or vomiting
- photophobia or phonophobia (hostility / fear of light or loud sounds);
And in the end, everything presented above should not in any way intersect with other diseases that exist at the time of the examination of the patient.
Officially diagnosed migraine options:
- migraine without aura (common migraine);
- possible migraine without aura;
- migraine with aura (classic migraine);
- possible migraine with aura;
- chronic migraine;
- chronic migraine associated with excessive use of painkillers;
- children's periodic syndromes, which may be precursors or associated with migraine;
- migraine disorder that does not meet the criteria.
A few words about migraine with aura and aura. Under the "aura" refers to sensory, motor and visual phenomena, temporary (from 20 to 60 minutes). There are separately, are in combination. The most frequent: a visual phenomenon, like a scotoma, is a loss of a section of vision with zigzag borders, which eventually shifts to the periphery.
Here is the scotoma variant ...
Everything is complicated and individual here, as with pain of tension. The difference is that this is a dysfunctional sore and, accordingly, there are drugs that treat pain (abortion drugs), and there are those that carry out the prevention of its development (preventive).
Usually, if there is vomiting, then they begin with it: they give antiemetics (antiemetics), then they also give NSAIDs, but in the highest dose of effectiveness, then, if it does not help, then tryptans are connected.
For prevention, very different drugs and antiepileptic drugs and antidepressants are used, and drugs to reduce blood pressure such as beta blockers and calcium channel blockers, but not with the goal of lowering the pressure, but with the purpose of preventing migraines. It is foolish to recommend medicines, because everything is very individual: one helps someone, the other does not, and vice versa. The most important thing: to understand what are the provocateurs of migraine development and minimize contact with them, or you are always ready to have abortive medications.
It is important to keep a diary of migraine: when the head became ill, how, against the background of what, what did it take, helped / did not help, and how much? Step by step, understand yourself and understand what is right and what is wrong, what is necessary and not necessary for you personally. The doctor here only places the beacons and indicates the path, but everyone should go on it himself.
Just want to say one important point in migraines: do not wait for the development of pain. As soon as you understand that it’s starting or has arrived, immediately drink painkillers. The sooner you start, the better the effect.
Cluster headaches - severe headaches usually behind the eye, over the eye or in the temple lasting from 15 to 180 minutes from 1 time to 8 per day. Always 10 out of 10 on a pain scale. Usually they experience lacrimation, conjunctival redness, runny nose, drooping upper eyelid or swelling, all from the same side of pain.
The mechanism of development is not fully known. It is assumed that the genetic factor and the development of nonspecific inflammation in the cavernous sinus and superior ophthalmic vein and the development of pain are somehow connected with the trigeminal-hypothalamic pathway. There are also triggering factors contributing to the occurrence: alcohol, nitroglycerin, relaxation / tension, histamine, high altitudes and blinking lights.
In form, episodic and chronic are distinguished. Episodic is the union of cluster pain in periods, so there are 2 cluster periods, from 7 days to a year, separated by 1 month without pain. Chronic is when the painless period is less than a month.
It is also worth mentioning about neuroimaging, such pains are secondary, and structural damage to the brain is found on MRI. So for all patients with cluster pain, I recommend doing an MRI of the brain.
It helps oxygen, 10-12 liters per minute. It often happens that I give a breathe, and after 15 minutes everything passes. If it doesn’t help much, add triptans, sumotriptan for example. Triptans are good, but they can not be used often and yet there are contraindications - cardiovascular sores, pregnancy. There is abortion therapy aimed not at preventing seizures, but rather at reducing the frequency of seizures. I read about lithium and verapamil preparations.
Avoiding triggers - anything that causes pain, also helps. No provocation, no headache.
Sinogenous facial and headache
Rhinogenic headache also refers to it. This is about you, allergies that always sniff your nose, about you sinusitis with sore sinuses. Yes, headaches accompany sinusitis, and not just accompany, and sometimes are their first sign. Especially mild, sluggish.
Often people don’t even know what the problem is, the head just hurts and that’s all, especially when you bend to pick something up, tie the shoelaces and “it’s so straight the head breaks!” Say the patients. This is not a dull, aching pain in the back of the head, not a throbbing migraine pain, or a falling eye with cluster pain - this pain is bursting. Sometimes you can lightly tap (percussion) in the projection of the alleged sinusitis and you will get a completely reasonable patient response in response to increased pain.
Types of sinogenic facial and headache:
- Frontal (frontal) sinus - pain in the forehead, crown of the head and above / behind the eye.
- Maxillary sinus - pain in the upper teeth and painters. Often these patients are brought by dentists when they check that everything is fine with their teeth.
- Etmoiditis is an orbital pain radiating to the temple.
- Sphenoiditis - Crown, forehead, orbital part, even the back of the head.
Treatment - naturally, it is necessary to treat not so much a headache as its source. First you need to take a picture of the sinuses or CT, to assess whether antibiotics should be prescribed. Then the hormones in the nose, regular intensive flushing, NSAIDs and watch the development. With chronic sinusitis, all sorts of polyps and mucots - a separate issue.
Pain from a hangover - classic tension pain + cervicogenic headache. We have natural mechanisms for changing the position of the body in a dream so as not to “lie down” in a limb or head. Alcohol turns off these mechanisms and we fell in what position, we sleep in that, sometimes this position is inconvenient for the cervical spine and accordingly leads the neck muscles into hypertonicity. You wake up already without alcoholic anesthesia and with combined headaches.
Why is it that even on the eve of sleep, before a hangover, you drink analgin and then it does not hurt? Well, most likely you initially turn off the inflammatory cascade, which then gives pain. Why doesn’t work then? Most likely because the cascade involves in the midst not only the muscles, but also the nerve structures, which the drugs you are taking do not act. Or besides a headache of tension, a migraine attack develops, and as I described above - it must be stopped immediately, with the passage of time it is more difficult to cope with.
I myself can’t endure pain, I take 1 g of paracetamol, it’s better in pops like efferalgan, and I drink a lot of fluids. If you feel sick, then a tablet of metoclopramide under the tongue and after 5-10 minutes I drink water.
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