Headaches, A Common Malady

A common problem many people experience from time-to-time is a headache. We can still function through the day with a mild headache but they can sometime become so severe as to incapacitate a person.Ā  There are many known causes of headaches but there are only a few that occur quite commonly and I believe the classic migraine headache not be among the common causes.

Many patients as well as healthcare providers will haphazardly use the phrase ā€˜migraine headacheā€™ when what they really mean to say is ā€œa very painful headacheā€™.Ā  The phrase migraine headache should be reserved for a specific cause of headache that is caused by abnormal blood vessel function within the skull and is treated with very specific medication.

Although your headache may be incapacitating, cause you to vomit, see a colorful halo and cause pain one side of the head, it doesnā€™t at all imply your headache is due to a migraine headache.Ā  For instance, sinus headaches can result in incapacitating pain, visual changes and vomiting just as migraine headaches can.

I donā€™t blame patients for the misuse of the phrase ā€˜migraine headacheā€™ but I do blame physicians and nurse practitioners for throwing the phrase around without any precision.Ā  Its my experience that many healthcare providers donā€™t even seem to understand the difference between the different symptom patterns associated with the different causes of headaches.

Other Causes of Severe Headaches

I probably have undiagnosed migraine headaches 10 times more often than I make the diagnosis.Ā  Why do I feel that I am correct in changing the patientā€™s diagnosis?Ā  Well, to start with, the patientā€™s will tell me the wide variety of migraine headache medications donā€™t help much at all.

Secondly, patients frequently report that the primary healthcare provider or neurologist havenā€™t even asked questions about the patientā€™s allergies, symptoms of lightheadedness, arthritis or muscular tension; clues as to the possible alternative diagnosis of their headaches.

And finally when I carefully asked the patients about the pattern, intensity and timing of their headache pain, what may make it better or worse, the patients will provide me with information that clearly points me away from the diagnosis of migraine headaches and towards a much more likely cause of their pain.

The Most Common Things Happen Most Commonly

As the title of this subsection suggests, the most common medical conditions happen most commonly.Ā  This may sound simple and commonsensical but believe me, this adage is lost on many healthcare providers.Ā  Itā€™s quite simply the key starting point to solving many of lifeā€™s puzzles.

In spite of the lists of causes of headaches that are available on the Internet, few give the reader any sense of which is more common than others.Ā  Even those that do try to provide some sense of frequency, they donā€™t seem to fit my practical observations.

What follows is my practical list of the causes of severe headaches from my perspective as a primary care physician with over 20 years of experience.Ā  The list below is what I commonly start from when diagnosing severe headaches:

  • Muscle Tension Headaches
  • Sinus Congestion Headaches
  • Orthostatic Hypotension Headaches

This list helps guide me to correct diagnosis in about 80-90% of my patients with severe headaches.Ā  Hopefully some of my following pointers will help you understand the cause of your headache as well.

Muscle Tension Headaches

Muscle tension headaches are extremely common and often cause pain in the lower, back portion of the skull called the occiput.Ā  This is where the muscles from the back and neck attach to the skull.Ā  It is also where the muscles that run from the forehead, across of the skull and finally attach to the back portion of the skull.

Patients with muscle tension headaches will often present with pain that starts at the base of the skull and will then radiate forward across the top of the head.Ā  The area in a line at the bottom rear portion of the skull is often very tender.Ā  Sometimes, it can seem as if the pain is only on one side of the head and this is how it gets confused with classic migraine headaches.

Chronic muscle tension arising from stress, spasm or strain in the upper or lower back often triggers muscle tension headaches. Underlying arthritis in the spine might also trigger this kind of pain.

Another pattern of muscle tension headache is pain that seems to start primarily on both sides of the temples.Ā  Most people donā€™t realize it but this area is where the jaw muscles attach to the skull.Ā  Chronic tensing or clenching of the jaw muscles from psychological stress or grinding of teeth while asleep can cause this area of the skull to hurt.

Treating muscle tension headaches involves helping the patients alleviate the source of the muscle tension.Ā  Discussions about psychological stressors, back injuries, posture and possible evaluation for dental guards to minimize nighttime clenching and grind are very helpful for these patients.

Sinus Congestion

Your sinuses are small air cavities encased I the bone of your skull that have narrow openings to the nasal passage.Ā  They are mostly located in your forehead, behind, between or beneath the eyes.Ā  if these narrow openings become congested from allergies, infection or other irritation, the tissue lining the openings swells causing the opening itself to completely blocked.Ā  Pain starts developing after blockage occurs.

The tissue that lines the inside of the sinus cavity constantly absorbs small amounts of gas.Ā  So when the opening to the sinus is blocked but the tissue continues absorbing gas from within that blocked sinus, a vacuum begins developing within the sinus cavity.Ā  The increasing negative pressure from the vacuum is the source of the sinus pain.Ā  So the key to resolving the headache is to open the passage and alleviate the pressure.

Pain from sinus headaches can be mild if the sinus is only blocked intermittently or can build to a severe level of pain that includes vomiting, near blindness, color aura, one-sided pain.Ā  Sinus headaches may occur intermittently throughout the year but often have a pattern of occurring more commonly during one particular season (Fall more than Spring).

Seasonal fluctuation is the big hint that the mucosal and sinus congestion associated with seasonal allergies are playing a role in the blockage and subsequent vacuum pain of the sinus.Ā  Short-term use of decongestants such as Afrin or Sudafed often can lessen the pain of sinus headaches by opening the passage, temporarily relieving the vacuum within the sinus.

Sinus headaches are sometimes associated with occasional sinus infections as well.Ā  Sinus infections occur as a result of poor sinus drainage due to an anatomically narrow sinus opening, chronic or severe allergies or an anatomical abnormality such as a deviated septum blocking the sinus opening.

A seasonal pattern of headache, partial or short-term relief with decongestants or intermittent sinus infections is the key to diagnosing severe headaches as coming from the sinuses.

Treatment for this kind of headache often revolves around persistent use of allergy medication such as antihistamines and/or nasal steroid sprays.Ā  These treatments limit the swelling of the tissue lining the nasal opening and hence, limit the frequency and duration in which the sinuses may ever become blocked.

Sometime minor sinus surgery is required to repair the underlying anatomical obstruction to the sinus and in my experience, this frequently leads to complete cessation of the sinus headaches.

Orthostatic Hypotension

As I have discussed in previous posts (here and here), orthostatic hypotension (OH) is a common condition associated with poor perfusion of the brain.Ā  OH is associated with occasional lightheadedness, intermittent or chronic fatigue, poor concentration and mild to severe headaches.

OH has many causes but one of the most common is the detrimental effect excessive consumption of carbohydrates (sugar and starch) has on our autonomic nervous system.Ā  Excessive dietary carbohydrates are now recognized as the driving force behind the metabolic abnormality known as insulin resistance and it is the development of insulin resistance that is damaging the autonomic nervous system.

OH is also a very common cause of mild to severe headaches.Ā  These headaches are the result of inadequate perfusion of blood flow through the brain.Ā  As such, they can seem worse after sitting or standing for long periods of time, after eating or after becoming warm or hot.Ā  Sometimes they are associated with intense pain in the neck muscles known as coat-hanger pain.

OH headaches are more likely to improve when lying down than other forms of headaches.Ā  This because laying flat lessens the pull of gravity that contributes to the low brain blood perfusion.Ā  Laying flat makes it easier for your body to pump adequate amounts of blood to your brain; better blood flow means less headache pain.

So the big hints for OH as a cause of headaches is maybe occasional lightheadedness or ā€œwoozyā€ spells just after standing up, fatigue after meals, occasional fatigue or poor confusion and especially the association of intense neck muscle pain.

OH can get substantially better after increasing the amount of salt and decreasing the carbohydrate intake in your diet.Ā  Salt increases your blood volume and makes it easier to maintain adequate blood flow o the brain.Ā  The reduced carbohydrates seems to allow your autonomic nervous system to repair itself.

Where To Go From Here?

Think about your headache pain.Ā  Does occur more in one time of the year over another (Fall vs. Spring)?Ā  Do you seem to get sinus infections more commonly than your friends or family?Ā  Does the pain start in the back of the head or at the temples? Or do you also wrestle with chronic fatigue, have intermittent lightheadedness or intense neck muscle pain?

If you answered yes to any of these, you may need to rethink your diagnosis of ā€œmigraine headachesā€.Ā  It may be your suffering from something else much more common.

Remember, the most common things happen most commonly.

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Patrick Nemechek, D.O.

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tim b
tim b
July 2, 2011 1:36 am

carbs and sugar have been giving me a bad headache lately.

June 3, 2011 6:10 pm

Hi Dr. N,

I googled carbs causing headaches in diabetics and got this article. I hadn’t made that correlation before, esp with the lightheadedness I suffer from occasionally. Stopped and had a bagel today for breakfast…and that sure seems to be the culprit this morning of the monster headache I am now experiencing. Thanks for the insight! šŸ™‚


May 23, 2011 11:15 pm

Hi Dr. Nemechek-

I googled headache/lightheadedness, and found your site. And to my supprise, within your article; I seem to have found the culprit for my problem…sugar! So I will cut ((way back)), and see how things go, ’cause these headaches are getting to be too much. If not, I’ll check in with the Doctor.

You may not even recieve this, since your article is an old one. But thanks for your site anyway.


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