The most comprehensive headache guide
Anton Loboda, an anesthesiologist and resuscitation specialist in anesthesia who specializes in getting rid of pain, spoke about pain and answered a number of questions. We publish his guide to pain 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 with the aim of saving people from pain, the anaesthesiologist-resuscitator became out of the same considerations and now I am leaving for a separately developing specialty - a pain management specialist for the same reason.
Why a pain specialist? And so all 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 be sent 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 until the pain is chronic or independent of its passage. Moreover, the patient remains without a diagnosis, respectively, without a recommendation for prevention and, if necessary, treatment of pain when they return.
The pain specialist assesses the pain, finds the source and after that, if necessary, sends it to specialists with the diagnosis while trying to numb as much as possible and give recommendations for anesthesia.
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 a 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 response to a stimulus with a subjective emotional color. This is a really evolutionary verified mechanism that is protective: damaged - do not load. Another question: the damage mechanisms are different, and the structures are damaged, and the pain from these structures is perceived differently. And everything can already heal, and the pain is still there.
Scale of pain
A person comes to you with 10 out of 10 points on a visual analogue scale, and leaves with 2 out of 10. Very clear result: a low background pain remained from unbearable pain.
After local injection therapy, one can understand whether or not it got there, whether it is a source of pain and / or how much (if at all) it contributes to its contribution to the prick structure.
Headache and myths about her
You can talk endlessly about a headache; it is individual from the beginning of its formation to the trigger points due to which it arises. The head really hurts in a special way and the patient usually cannot clearly state this feature. It hurts something, somehow, somewhere, as if. While I will describe three types of pain, the most frequent, and then I will write extravagant cases. Immediately scatter a couple of established myths!
Myth: Headache is a sign of high blood pressure.
It is true only in cases of the decisive flow (figures above 180/120 mm Hg). In terms of migraine, so generally increased pressure is the prevention of attacks or their relief.
First, the pain itself partly stimulates the sympathoadrenal system, which gives rise to arterial pressure. Secondly, an increase in pressure is psychologically injected. Thirdly, there is the concept of the error of measuring pressure: the wrong technique of measuring pressure, the tonometer has failed, have not prepared for the measurement.
Especially the last moment, when a man comes to my office a couple of times after 3 double espresso mugs, 2 cigarettes, a sleepless night and brings me to him from some super important meeting. And now, in a panic, he demands a pill, I give him a pill, only not from pressure, but calming and ask for 10 minutes in a darkened ward to lie down to count my breath. And, lo and behold, the pressure is normal.
There was a study in the field of 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 he urgently needs pills, but they did not die and the pressure returned to normal after they had finished the loads. The mechanism of increasing pressure during stress and physical exertion is about the same. And the head, by the way, did not start to hurt from the increase in pressure.
Myth: no-shpa will relieve a headache.
This is not true. If no-shpa helps, then the placebo effect with the same tension headaches has not been canceled. With them, you can take almost anything, anything, and it will work, only most likely because you would very much want to act.
In total there are 4 main types of headache:
Further details about them: how to identify and treat them.
Stress type headache
We must be honest and say that it is unknown what specifically hurts there: research has been conducted since the mid-1980s. At first, it was believed that muscle hypertonus in the occipital region and neck gives pain, they checked - no, the muscles are normal. However, it was decided to leave the term “stress type headache” or “tension headache”. What was possible to learn: the pain is clearly associated with stress. Accordingly, the problem is not only outside, but inside as well, or rather, somewhere in the area of the hippocampus.
In green, the doctor noted the usual sore spots in enthesopathies.
More often speaks of enthesopathies, especially in the area of the base of the skull - an interesting thing. Entheses are areas of attachment of muscles to the periosteum. These points are very intensively innervated (that is, there are many nerve endings in them) and, accordingly, minimal traumatization of this area causes pain.
An analogue of the inflammatory process, which follows after traumatization, can be maintained for quite a long time due to the fact that we are active people and willy-nilly head-spinning and giving tension to an already injured area. I often see this in practice: for heavy patients or with severe headaches, I make painkillers shots in the area of the neck muscles and everything goes fine.
Diagnosis of stress type headache
In the United States, both for tension headaches and migraines (but migraines are a separate topic, consider it in more detail below) have a system of criteria.
For tension headache, 2 of the following criteria should be present:
- Pain pressing or squeezing, not throbbing;
- Occipital – parietal / occipital – frontal localization;
- Bilateral (bilateral) of medium or low intensity (according to the visual analogue scale of pain - this is usually 1–5 points);
- Not enhanced with physical activity.
It is worth noting that this pain does not interfere with living, and often when you communicate with such a patient, you begin to tell him something, to show, to distract in every possible way - the pain disappears, but appears when the distraction factor stops. This once again confirms that something there in the brain 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 character and subjectively a person does not even perceive it as a headache, but it 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 COX-2 blockers and coxibs (celecoxib, etercoxib);
- Antipyretics / analgesics such as metamizol (analgin) or paracetamol (usual dose of 1 gram).
I prefer to prescribe paracetamol initially, it helps a lot with a dose of 1 gram. Ketorol is very good for anesthesia, but I never prescribe it myself, and in every possible way I avoid it 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 have a lesser effect on the stomach, but they also act on the kidneys, however, you can also take it for a long time with stomach protection (taken after eating, diet + proton pump blockers), - judging by patients who for life take.
In general, the NSAIDs will soon disappear anyway, when celecoxib generics appear. (the original is expensive).
- stronger painkillers in paracetamol / codeine, paracetamol / tramadol combinations.
- We add antidepressants, but this is for chronic tension headaches.
In our country, a very strange and extremely wrong attitude to antidepressants. I just recently returned from Austria from schooling for pain treatment, where a German pain treatment specialist said that 100% of patients undergo a psychiatric examination as part of monitoring depression.
The pain itself is a vile thing, except for masochists no one really loves it, but here it is for a long time, and even forever climbs into your life. Whether pain provokes and supports depression, or initially hidden depression provokes and supports pain. The connection is proven, it is and something must be done with it. In this context, the appointment of antidepressants is justified and necessary.
The task of antidepressants is to reduce the number of attacks in combination therapy (I always emphasize this because with one pill you will not remove complex pain), ideally, to zero. And I immediately explain: we do not treat depression as antidepressants as such, 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 different manifestations. One person walks into depression through the window after a couple of years of illness, and someone with mild depression marines himself for years without even thinking that the daily negative that supposedly falls on him is a manifestation of this mild form of depression, if it is without pain.
And if 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 chronized - these are two different lives. For example, you often ask a patient about his past - to the pain and he tells about himself as another person: “I traveled / worked / loved to do (insert the missed), but now I can’t because of the pain”. And this is one of the origins of the depressive component.
Ideally, of course, you need a psychiatrist examination 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 original problem of a headache, but with the immediate administration of an anesthetic. It usually develops after 3 months of systemic intake and it is very difficult to distinguish tension headache or migraine from medicamentally induced headache.
To avoid this, the rule is simple: no more than two drugs per day, no more than two times a week.
Tablets are nice, but you have to understand that a headache is not a cause but a consequence. So I recommend changing your lifestyle:
- Regular physical activity / sports (if you don’t work out at the gym, even 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 subway stations on foot and so Further);
- Quitting smoking and lots 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 - quite a serious stress provocateur) and so on.
- Various meditation techniques, cognitive-behavioral techniques, consultation of a psychiatrist and psychotherapist to select and change attitudes to stress and increase stress tolerance. After all, it’s important not only that we experience pain, it’s important how we perceive it and how much we are able to control it, and not it.
Calcium deficiency can also cause 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 is often the case with calcium deficient tetany. All around it is polls say, we need to drink calcium, but few know that calcium is not absorbed from the intestine if there is a vitamin D deficiency. Accordingly, against the background of calcium deficiency, persistent muscle hypertonus is formed, which gives not only headache, but also pain in many parts of the body. Together with muscle pain, there are convulsions of the limbs / face, a feeling of coma in the gol that cannot be swallowed or twitching when swallowing (as a result of a spasm of the esophagus), these are the main symptoms. Anesthetic and relaxing muscle pills in this case will not help or will help, but not for long and not completely. You need to restore vitamin D.
Migraine: what it is, types, how to treat
The oldest disease. From the story I will say that the name was born because of a perverted translation from the Greek word hemkrania (“pain on one side of the head”) into Latin in the form of hemigranea and then into French migrane.
For people with migraine officially declare: at the moment, migraine is not treated . This is a hereditary or acquired thing, which is characterized by dysfunction of the brain. No, this does not mean that there is a tumor or any other pathology. This means that, unlike other people, your brain reacts a little to some of the headache-causing factors.
From here a simple conclusion suggests itself: find provocative 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. We, as doctors, give you the tools, and you have to work with the disease on your own, we will not do it for you.
What is the cause of migraine? As with tension headache: unknown. It used to be thought that the problem is in the bloodstream and vasospasm or their expansion. Checked the blood flow in the attack - everything is fine. Now 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 the cerebral blood flow.
I highlighted the word "change", as this is not a violation, it is a variant of dysfunction. Everything works, but it works a little bit wrong. The light does not blink, it is on, but not as bright as before, and then it 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, etc., anxious and doubtful people, so to speak.
This is what the international community of headaches says in the diagnosis of migraine - the first thing: there should be at least 5 headaches lasting from 4 to 72 hours, and these headaches should have two signs from the ones listed below:
- Unilateral (one-way) localization;
- Throbbing nature of pain;
- Medium to very severe pain (usually 5 to 9–10 on the pain scale)
During a headache there should 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 interfere in any way with other diseases existing at the time of the patient's examination.
Officially diagnosed options for migraine:
- migraine without aura (normal 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 that may be progenitors or associated with migraine;
- migraine disorder that does not fulfill the conditions of 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 common: a visual phenomenon, the type of scotoma - is the loss of the area of vision with zigzag boundaries, which eventually shifts to the periphery.
Here's a scotoma option ...
It's all difficult and individual, as with the pain of stress. The difference is that it is a dysfunctional sore and, accordingly, there are drugs that treat pain (abortive drugs), and there are those that carry out the prevention of its development (preventive).
Usually, if there is vomiting, then they start with it: they give antiemetics (anti-emetic), then they also give NSAIDs, but in the highest effective dose, then, if it does not help, they connect triptans.
For prevention, very different drugs are used, anti-epileptic drugs and anti-depressants, and drugs for reducing pressure, such as beta blockers, and calcium channel blockers, but not for the purpose of reducing pressure, but for the purpose of preventing migraine. It is foolish to recommend medicines, because everything is very individual: one person helps, 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 always ready to have abortive drugs.
It is important to keep a diary of a migraine: when the head ached, how, against the background of what, what took, helped / did not help and how much? Step by step in yourself to understand and understand what is right and what is wrong, what is necessary and not necessary for you personally. The doctor here only arranges the beacons and points the way, but everyone has to go through it himself.
Just want to say one important point in migraine: do not wait for the development of pain. As soon as you realize that here it begins or comes, immediately take painkillers immediately. The sooner you start, the better the effect.
Cluster headaches - severe headaches usually behind the eye, above the eye or in the temple, lasting from 15 to 180 minutes from 1 to 8 per day. Always 10 out of 10 points on the scale of pain. Usually there is tearing, redness of the conjunctiva, runny nose, prolapse of the upper eyelid or edema, all from the same side of pain.
The mechanism of development is not fully known. A genetic factor and the development of nonspecific inflammation in the cavernous sinus and superior ocular vein are presumed, and the development of pain is somehow related to the trigeminal-hypothalamic route. There are also trigger factors contributing to the occurrence: alcohol, nitroglycerin, relaxation / tension, histamine, high altitude and flashing light.
The form of isolated episodic and chronic. Episodic is the combination of cluster pains in periods, here respectively 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 neuroimaging, such pains are secondary, and structural brain damage is found on MRI. So for all patients with cluster pains, I recommend doing an MRI scan of the brain.
It helps very well oxygen, 10-12 liters per minute. It often happens that I give a breath, and after 15 minutes everything passes. If it does not help much, I add triptans, sumprotptan for example. Triptans are good, but they can not be used often, and yet there are contraindications - cardiovascular sores, pregnancy. There is abortive therapy aimed not at preventing attacks, but rather at reducing the frequency of attacks. I read about drugs lithium and verapamil.
It also helps to avoid triggers - anything that causes pain. No provocation, no headache.
Synogenic facial and headache
It also includes rhinogenic headache . This is about you, allergy sufferers always sniffing about you, sinus suckers with inflamed sinuses about you. Yes, headaches accompany sinusitis, and not just accompany, and sometimes are their first sign. Especially weak, sluggish.
Often people don’t even know what the problem is, they just have a headache and everything, especially when you bend down to pick something up, tie the laces and “so straight the head splits!” Say the patients. This is not a dull, aching pain in the back of the head, not a pulsating migraine pain, or a bulging eye with cluster pain - this pain is arching. Sometimes you can gently tap (perkutiruet) in the projection of the proposed sinusitis and get a reasonable response of the patient in response to increased pain.
Types of synogenic facial and headache:
- Frontal (frontal) sinus - pain in the forehead, crown and above / behind the eye.
- Maxillary sinus - pain in the area of the upper teeth and painters. Often, such patients are brought in by dentists when they check that everything is fine with their teeth.
- Etmoiditis - afterburn 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 paranasal sinuses or CT, to assess whether it is necessary to prescribe antibiotics. Then hormones in the nose, regular intensive flushing, NSAIDs and watch the development. With chronic sinusitis, all sorts of polyps and mucocells - a separate issue.
The pain of a hangover is a classic pain of tension + cervicogenic headache. We have natural mechanisms for changing the position of the body in a dream, so as not to “stick” the limbs or the head. Alcohol turns off these mechanisms and in what position we fell, in this we sleep, sometimes this position is inconvenient for the cervical spine and, accordingly, leads the neck muscles into hypertonus. You wake up without alcohol anesthesia and with combined headaches.
Why does it happen that even before sleeping, before a hangover, you drink analgin and then it does not hurt? Well, most likely initially turn off the inflammatory cascade, which then gives the pain. Why does not work then? Most likely because the cascade involves not only the muscles, but also the nervous structures, on which the drugs you are taking, do not act. Or, in addition to the tension headache, 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 it.
I myself can not stand the pain, I take paracetamol 1 g, it is better in the pop type efferalgana, and I drink a lot of liquid. If I feel sick, then a tablet of metoclopramide under the tongue and in 5–10 minutes I drink water.
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