Headaches: No One Should Have Them

A headache is just a symptom—head pain—and we make the distinction in the headache world between what we call primary headache disorders and secondary headache disorders. A secondary headache disorder is when there is something that’s causing that headache. The most common thing people think about is a brain tumor or stroke, but it can also be something more benign like obstructive sleep apnea or medication overuse. A primary headache disorder is when the headache itself is actually what’s the problem, more at the cellular electrical level where there are issues with the functioning of the nerves and the nervous system resulting in the headache rather than something extraneous causing it. It’s not uncommon that someone will come into your office and say “I get, you know, four headaches per month,” and that doesn’t sound really bad, but when you clarify, they’re just talking about the four headaches where they’re bedridden, but every other day, they have what they call their normal headache—and really, there isn’t a “normal” headache. No one should have headache. It’s a matter of understanding what they mean by their normal headache because they’re making arbitrary distinctions, because they don’t know textbook definitions. Possibly all of those days might be migraine, but in their mind, they’ve defined that some are migraine and some are normal headaches. If you just talk to them about their four headache days, and don’t take into consideration all the other things in the patient’s life and health, you do really miss an opportunity to potentially change some modifiable risk factors that might be contributing to perpetuating their headaches and pain. You need to exclude secondary causes to make sure there isn’t anything else going on. The next most important thing, once you feel you’re in the primary headache territory, is educating the patient. Patients may feel like they’ve done all these tests and there is nothing wrong physically, but they still have headaches and they don’t understand why. They’re told, let’s say, they have “migraine,” but they don’t understand what that means. Then they may go from doctor to doctor to doctor being told the same thing—that they have migraine—but never accept it as the diagnosis or understand what that diagnosis means, and feeling dissatisfied or like something is being missed. Education is a really important step so a patient can actually understand, accept, and then, with that education, move forward, feeling like they know that the treatment that they’re being offered is appropriate and that they’re not being ignored or brushed aside.