While there has been a recognized association between bruxism (grinding) and temporomandibular disorders, this has not been well-studied.
Clenching has been associated with anxiety disorders, and may be highly comorbid with migraine as well. The trigeminal nerve, which is associated with migraine, also innervates the masseter muscle, which is the muscle responsible for clenching the jaw. It is felt by many headache experts that activation of the trigeminal nerve—which happens in migraine—will result in activation of the masseter muscles during a migraine.
Awake bruxism – clenching during the day – is present in about 20% of the population, and is usually stress-related. Bruxism at night affects about 8% of the population, and has been classified as a sleep-related movement disorder.
Clenching is also a possible adverse effect of the SSRI antidepressants.
Clenching, grinding, or temporomandibular dysfunction (TMD) can trigger any type of headache, or make it worse.
If you have a tendency toward clenching, awareness of the condition can help you reduce clenching. Physical therapy and relaxation training can be helpful. If you have a tendency toward clenching or grinding, you should avoid chewing gum. Some people may benefit from an oral device. Read more about that in TMD/TMJ.
1. Lavigne GJ, Khoury S, Abe S, Yamaguchi T, Raphael K. Bruxism physiology and pathology: an overview for clinicians. Journal of Oral Rehabilitation. 2008;35(7):476-494.
Medication overuse headache, which is the current term in the medical literature, has been called “rebound” headache in the past. The perception, however, was that if you took medication, the next day’s headache was the rebound headache, and that’s all there was to it. More recent research has shown that it is not that simple. A pattern of frequent medication usage leads to an increase in the occurrence of headaches. This is sometimes called pharmacologically maintained headache, or analgesic abuse headache. If you are a migraine sufferer, and you start having more frequent headaches as a consequence of using excessive medication, headaches may become less “migraine-like,” and may lose some of the usual migraine features, such as sensitivity to light and noise, or nausea, and the pain may become dull in character.
Present recommendations of the International Headache Society are not to take over-the-counter medications more than 15 days a month, and not to take prescription analgesics more than 10 days a month. Prescription analgesics that can cause medication overuse headache include triptan medications, ergot medications, opioids, and those containing butalbital. Over-the-counter medications most likely to cause medication overuse headache are those containing caffeine. Recent research suggests that triptans are more likely to cause increased headache frequency in men with frequent headaches than in women with frequent headaches.
A survey of family doctors found that this headache type was the third most common headache seen. Headache clinics in the US report that 30% to 80% of new patients seen have medication overuse headache.
Painkillers—How do you know when you’ve overdone them?
Headaches that keep coming back again and again, until they become almost daily, can be a debilitating problem. Your headache is bad, so you take a pill. It comes back again, so you take another one. But if you keep it up and do it often enough, you may actually be bringing on your next headache. If you are taking painkillers for headache three or more days a week, there is a good likelihood that this may be happening to you.
Some people think that in order for their headaches to be termed a “rebound headache” the pattern must be one of taking a pill one day, and then experiencing a headache the next day. While this can be a common pattern seen in analgesic-induced headaches, it is not the only pattern seen. This is one of the reasons the preferred name has been changed in the medical literature to “medication overuse headache”. Some affected people simply have chronic head pain and do not necessarily take analgesics every single day; it is more about a pattern of use.
If you are particularly susceptible to developing medication overuse headache, as little as two days a week may be all it takes to maintain chronic headache. There is a transition that occurs as you take more and more medication, and sometimes you don’t even notice that your headaches symptoms are changing because it occurs so gradually. The pain may become less throbbing and more dull. The headache may involve more of your head, and become less localized, harder to pinpoint. You may not notice as much nausea or acute sensitivity to light or noise as you did with your migraine attacks. You may have as much inability to think or concentrate as you have during a migraine. You just feel somewhat bad all the time.
Some people in this transition phase still get migraine attacks on top of having daily or near-daily headaches. Eventually, those may go away and only daily head pain is the result, often awakening you in the morning or in the pre-dawn hours. If you find yourself slipping into the pattern of frequent painkiller usage, this may indicate the need for a headache preventative medication.
Only about 10% of those who would benefit from preventative medications are on an effective regimen. If you are already on a medication for prevention, you should work with your doctor to make certain it is as effective as it could be, and to decrease your pain medications to make sure you are not in danger of developing medication overuse headache. Oh, and by the way—over-the-counter painkillers are just as guilty of causing problems as prescription painkillers are.
Chronic Daily Headache may not be due to medication
Between three and four per cent of the population have chronic daily headache. Not everyone with daily headache has medication overuse, however, and in many cases the daily headaches came first, and the medication overuse occurs as a result. It is therefore difficult to interpret studies that say 50% to 86% of chronic daily headaches are due to medication overuse. It may just be that the same person has both.
At US headache clinics, between 30% and 86% of new patients seen have medication overuse headache as a component of their problems. It is the third most common type of headache encountered by primary care physicians. A recent large population-based study (Bigal et al, 2008) found that barbiturate-containing medications, such as butalbital, and opioids (narcotic analgesics) were the most likely to cause a transformation from episodic migraine to chronic migraine. The prevalence of transformed migraine is 2.5%, and that due to medication was found to be 1.5%.
There are long-term risks to taking daily pain medications, even over-the-counter ones. These include stomach irritation, ulcers, gastrointestinal bleeding, and acid reflux disease (heartburn) from aspirin-containing headache remedies and anti-inflammatory medications. Long-term use of NSAIDs and acetaminophen can cause kidney damage, and excessive use of acetaminophen can result in liver damage.
The treatment for medication overuse headache is simple, but that doesn’t mean that it’s easy: stop taking daily pain medication. Depending on how long you have been taking pain medications and on how much you have been taking, the recovery period can vary from three weeks to three months. It tends to be longer if the medication you have been overusing includes narcotic painkillers. No one can wave a magic wand to make you instantly better, but headache specialists can help support you through the process. Preventive medicationscan help, but take time to work, and may not be fully effective until you have weaned off the analgesic medications. Behavioral treatment strategies such as cognitive behavioral therapy, relaxation training, biofeedback, and hypnotherapy can also be helpful.
The best strategy? Avoid medication overuse in the first place. If you have frequent headaches, and you are using medication more than ten days a month or more than two days each week, you may be suffering from medication overuse headache. Think twice before grabbing that medication bottle. Seek help instead.
1. Bigal, ME, Serrano, S, Buse, D, Scher, A, Stewart, WF, Lipton, RB, Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study, Headache, 2008; 48(8):1157-1168
2. Bigal ME. The paradoxical effects of analgesics and the development of chronic migraine. Arquivos de Neuro-Psiquiatria. 2011;69(3):544-551.
If you have the opportunity to see Lily’s Mom, do so. This movie is about a woman, Mary, from a dysfunctional family who is in a bad marriage, and who has frequent headaches. She is in danger of losing her job because of her chronic migraine headaches, and has no practical support system. But she wants to do her best to support her daughter, Lily.
The story unfolds as Mary, Lily’s mom, sees a therapist and gradually gains control of her life, and then her migraine headaches.
Lily’s Mom starts on a dark note, but quickly pulls you in and you find that you are rooting for Mary as she makes choices to reclaim her life. The movie ends with hope for a bright future.
Lily’s Mom was written, produced, and directed by Dr. Ed Messina, a headache specialist in Michigan. Find out more about Lily’s Mom.
Guest post by Dr. Ingo Anderle, ophthalmic optician
There is a correlation between headaches and migraines and improperly corrected refractive errors and undetected strabismus. This indicates a need to build closer interprofessional relationships between neurology and optometry
This article serves to illustrate the experience I have had with headache patients in my optometric and optical practice, the effects of detecting improper correction of refractive errors, and the detection of hidden strabismus. The correction of these problems results in patients seeing better, having a better life, and having found relief.
To emphasize the need for a closer collaboration between neurology and optometry, I will use two cases I have seen at my practice and treated accordingly.
CASE I
Female patient, 42 years of age, wearing glasses for close to 35 years. Myopic (near-sighted), with astigmatism and anisometropia of 2dpt.
Patient comes in for a check-up to get new glasses. Her history reveals that she has been suffering almost daily from headaches since puberty and increasingly from migraines, which at the time of consultation averaged 3 days per week. Consulting a number of doctors about her migraines and headaches did not provide effective treatment and left her with medication to be taken as required. Patient is working in an office environment, spending about 8 hours on a computer. Hobbies include knitting and other close range activities and the use of a laptop computer at home.
Initial exam reveals her current Rx (2 years old) is over-minussed with 1dpt OS, overall, slight changes in prescribed correction for astigmatism. Fundus eye exam is normal, anterior part doesn’t show any pathologies.
During binocular testing, the patient was shown a split screen red/green image and trial frames fitted accordingly with red and green filter. The patient was asked to describe what she sees and reported that the clarity of image was identical, but that the left hand side green image kept wandering over to the left. This procedure, as well as the way the question was posed, revealed the strabismus and the need of 5pdpt, Base 0º of correction OS. Had the patient only been asked which side was better, rather than to describe her experience, she would have answered they were identical and that would have left the strabismus undiagnosed. Accomodation is still fine for near vision and only long distance Rx is prescribed.
(New Rx OD: -3.00(cyl -0,50 x5º) / OS: -5,75 (cyl -0,50 x75º) P 5pdpt Base 0º)
Glasses were made at our in-house workshop. Prism is fitted only OS. (Lenses used: Zeiss Clarlet 1.67 Aspheric with Lotutec AR.) Centres are fitted at 3mm below pupil centre and at exactly the same I.P.D. as in the trial frames during the eye exam. After wearing the glasses with the new Rx for only 3 days the patient is reporting a significant improvement in visual acuity and not suffering from headaches as before.
At the annual check-up the patient reported an almost complete cessation of headaches and only occasionally suffering from a migraine (usually weather dependent). Vision Rx is stable and reading glasses with Add 1.00 are prescribed.
At the 2 year check-up the patient is reporting the same as the year before, Rx is stable and reading Add has changed to 1.25. The patient requested seperate reading glasses. Prism is fitted at 4pdpt and patient is reporting her satisfaction with her new glasses.
CASE II
Female patient, 35 years of age turns up for a new Rx for new glasses. Medical history reveals that the patient is suffering from moderate to severe headaches over a period of 5 years. The average daily medication taken is Ibuprofen 1200mg or equivalent in Paracetamol (acetaminophen). Her current glasses are of the following RX: OD -4.00 (cyl -0,75 x 25º) P 1,5pdpt Base 270 (vertical prism) OS: -2,00 (cyl -1,00 x 5º). The glasses appeared to be very tilted and not in a straight position on the patients face. When mentioned this, she said “I see better that way.”
Over the past 5 years the patient underwent a number of exams and consulted a neurologist numerous times. An MRI and CT scan were performed, both normal. The patient was at the point of giving up trying to find a cure for the headaches and was trying to live with them and not expecting any improvement.
The exam revealed the following RX: OD -3.00 (cyl -0,50 x30º) /OS: -2,00 (cyl-0,75 x 175º), no vertical prism was detected, and again overminussed OD.The vertical prism in her glasses must have been caused by a mistake during the fitting process of the lenses, since no vertical prism was detected during the exam. Her problems with headaches started soon after she had the current pair of glasses made and since then she did not have an eye exam and no new glasses.
The patient did not want to believe that just a new Rx and new glasses would make a significant difference in regard to her headaches. Understandably, after a 5 year ordeal, MRI and CT scans, and consulting neurologists, she did not have any confidence in finding a cure.
However, new glasses were made and after only 2 days she reported back and could not believe that she had not had a headache and that she was generally feeling a lot better. Two weeks later, I called for a follow up and she reported a continued absence of headaches and came in to order a second pair of glasses.
CONCLUSION
As both cases illustrate, there can be a lack of good quality service available when it comes to eye examinations, and there is a shortfall in interprofessional collaboration between neurology and optometry.
Both patients would have benefitted greatly from being referred to an optometrist by their doctors, but both patients also had the unlucky experience with incorrect prescriptions and/or incorrectly made glasses and a lack of experience in binocular testing.
Current practice here in Andalucia (southern Spain) is that a doctor (mostly the GP) refers patients with symptoms such as headaches and blurred vision to consult an optometrist IF they currently do not wear glasses. If a patient is wearing glasses, it is widely assumed that they must be correct (both regarding Rx and correctly fitted) and I hardly ever see a referral to an optometrist.
The relationship between wrongly corrected eyesight or undercorrection and headaches is known and nothing new.
In my opinion it would be good to see more referrals from neurologists to the optometrist, even if it is to exclude wrongly/undercorrected eyesight in the diagnostic process.
POINTERS FOR THE OPTOMETRIC PROFESSION
There is a large shortfall in the quality of eye examinations by ophthalmologists and optometrists, especially in the way they conduct the pre-examination medical history (neither age, nor medications taken, underlying health conditions not explored, workplace and hobbies that give an idea on the demand the patient will have on vision and glasses not identified). Also, during the exam itself, leading questions do not assist in getting the correct picture. If the only question asked is whether one or the other option is better or worse, it does not allow the patients to accurately describe the visual picture they actually see. After all, the issued Rx is a subjective Rx.
Dr. Anderle is an optometrist practicing in southern Spain.
In a small study of children with migraine (109 children six and over) the presence or absence of a heart defect known as patent foramen ovale was studied. Thirty-five per cent of the children in the study had migraine with aura. About half of the migraine with aura kids had the PFO heart defect, as compared to 27% of the children with migraine without aura.
What is PFO?
PFO (patent foramen ovale) is a form of heart defect. The foramen ovale is a hole in the heart wall that has a purpose when a baby is in the womb. It allows blood to bypass the lungs, because babies do not breathe with their lungs until they are born, and get their oxygen from the mother’s blood. Once born, this opening usually closes naturally in infants. Sometimes when it persists past infancy, a PFO will still close spontaneously, but this generally occurs before age six.
In the adult migraine population, it has been found that about 25% of all migraine patients have PFO. Trials of PFO closure in adults have been inconclusive. Several smaller, single center trials have shown high response rates to closure of PFO. The only multi-center, double-blind trial of PFO closure failed to show positive results, but was potentially flawed in terms of patient selection and other technical issues.
In this study, the severity of migraine was not associated with the presence or absence of PFO. The study was limited by the inability to place IV lines in control subjects and do a direct comparison of data from the study population and the control population. Because of the small sample size in this study and because of the other controversies associated with testing and treatment of PFO, authorities in the field have recommended further study before recommending PFO closure in children.
Please view this excellent Migraine Art Video, which was put together by James at Headache and Migraine News and Relieve-Migraine-Headache.com. I was struck by the statistic that over a billion people alive today will have a migraine attack in their lifetime. I am also impressed—as I have always been by exhibits of migraine art—by the creativity of migraineurs.
Traveling this year? There are a lot of hidden pitfalls for migraine sufferers who travel. If you are traveling by air you are subject to multiple migraine triggers: pressure changes, dehydration, time zone changes, and skipping meals. Be certain to carry high protein snacks with you and drink water frequently. It’s also a good idea to pack your migraine medication in your carry-on luggage just in case you need it.
Make sure you have enough medication with you for the duration of your vacation. If you think this may be a problem because your insurance limits the number of pills you can get at one time, you may be able to ask for a “vacation override” at the pharmacy so that you can be certain to have enough to last. A good rule is to take twice as much migraine medication as you would normally need, and then you will be sure to have enough, even under the worst possible circumstances.
If your headaches are severe enough that you think you may require treatment while traveling, make certain you have a summary of your care with you. This allows a doctor who is unfamiliar with you to review your history. And don’t forget your health insurance card.
Of course, changes in environment can set off your headaches also. Traveling to a new location with a different climate can be a migraine trigger, especially if there is heat and humidity. Many migraine sufferers find that high altitude can trigger their headaches.
Eating different foods and a different schedule can even be enough to cause migraines in some people. It may be wise to plan on taking it easy the first day or two in order to get used to a new environment and not push yourself too hard. It’s better to do this so that you can avoid a headache and relax on vacation.
Watch out for trigger foods—watch for things like hot dogs, sausages, and other processed meats (pepperoni, salami, and similar) which contain nitrites. And need I mention alcohol? Just remember to keep things in moderation, and don’t forget what your trigger foods are.
Children with migraine can be particularly susceptible to motion sickness and carsickness. If you have a child with migraine headaches, it might be best to make frequent stops and take breaks on road trips. In fact, up to 60% of adults who have migraine had motion sickness as children. Sometimes, it doesn’t go away because you grew up.
Foreign travel can present extra challenges. Give yourself an extra day or two to cope with jet lag. Make certain medication is in its original labeled container when you clear customs, and carry a note from your doctor indicating which medications you are on, and that they are for personal use. Check to see if your medical insurance covers you internationally—some do. If not, you may wish to purchase travel insurance. The State Department has additional information about traveling abroad.
Is there a correlation between high blood pressure and migraine? Maybe. There have been studies to suggest that uncontrolled hypertension (high blood pressure) may result in an increase in migraine headache frequency or severity. However, it has also been argued that since both high blood pressure and migraine are commonly occurring conditions, any such relationship is mere coincidence.
Certainly, there can be transient increases in blood pressure during a headache of any type, simply because you are in pain, so it stands to reason that chronic headache sufferers might experience higher overall blood pressure.
Can high blood pressure cause a headache? Usually this is not the case unless blood pressure is extremely high.
A recent retrospective epidemiological study, which means it was looking back in time at previously collected data, actually proposed that maybe hypertension even protects against headache! Other studies, however, seem to suggest that there might be a correlation between hypertension and the transition from episodic to chronic migraine. It has even been suggested that there may be a protective effect for systolic blood pressure (the top number), but a negative effect for diastolic blood pressure (the bottom number).
The MIRACLES Study, also known as Hypertension and Migraine Comorbidity: Prevalence of Cerebrovascular Events, looked at 2973 patients with hypertension, migraine, or both. About 17% of the subjects had both hypertension and migraine, 40% had migraine only, and 43% had hypertension only. In the subjects with both conditions, migraine onset was older than in the migraine-only group, and onset of hypertension was earlier than in the hypertension-only group. Hypertension was harder to control, and there was often a family history of both migraine and hypertension.
The group with migraine-hypertension comorbidity had a 4.4% risk of stroke, as compared to 3.1% in the hypertension-only group, and 0.7% in those with migraine only. In the 40-49 year-old age group, the rate of previous stroke (or TIA) in the group with both conditions was five times higher than in the hypertension-only group.
It is thus likely that there is a migraine-hypertension link in some migraine patients that may be genetically based. Clearly, more studies are required so that we can understand this connection better.
References:
1. Hagen K, Strovmer LJ, Vatten L, et al. Blood pressure and risk of headache: a prospective study of 22 685 adults in Norway. J Neurol Neurosurg Psychiatry 2002;72:463–6.
2. Friedman, D. Headache and hypertension: refuting the myth. J Neurol Neurosurg Psychiatry 2002;72:431.
3. Bigal ME, Sheftell FD, Rapoport AM, Tepper SJ, Lipton RB. Chronic Daily Headache: Identification of Factors Associated With Induction and Transformation. Headache: The Journal of Head and Face Pain. 2002;42(7):575-581.
4. Agostoni E, Aliprandi A. Migraine and hypertension. Neurol Sci. 2008;29(S1):37-39.
5. Mancia G, Agabiti-Rosei E, Ambrosioni E, et al. Hypertension and migraine comorbidity: Prevalence and risk of cerebrovascular events. Evidence from a large, multicenter, cross-sectional survey in Italy (MIRACLES study). J Hypertens 2011; 29:309–318.
Asthma has been found to be comorbid with chronic daily headache. (This was chronic migraine without any evidence of medication overuse.) A Norwegian study of over 50,000 people found that headache (both migraine and non-migraine headache) was 1.5 times more likely to occur in asthma sufferers, as well as chronic bronchitis and hay fever. In this study, more women than men had asthma (although more men had chronic bronchitis).
A British study of similar size found that the risk of developing asthma in a migraineur was 1.3 times higher than in a non-migraine sufferer.
Asthma can also serve as a migraine trigger, although asthma does not cause migraine. (Migraine does not cause asthma, either.) The association of asthma and migraine is well established, but the cause of that association is not known.
Just as in migraine, it’s important to identify what your asthma triggers are, and avoid them when possible. Obviously, it is not possible to avoid all pollen exposure. However, you can minimize exposure to dust (and dust mites), and to cigarette smoke.
References:
Mortimer MJ, Kay J, Gawkrodger DJ, Jaron A, Barker DC. The prevalence of headache and migraine in atopic children: An epidemiological study in general practice. Headache. 1993;35:427-431.
Wilkinson IA, Halliday JA, Henry RL, Hankin RG, Hensley MJ. Headache and asthma. J Paediatr Child Health. 1994;30:253-256.
Davey G, Sedgwick P, Maier W, Visick G, Strachan DP, Anderson HR. Association between migraine and asthma: Matched case-control study. Br J Gen Pract. 2002;52:723-727.
Özge A, Özge C, Oztürk C, et al The relationship between migraine and atopic disorders-the contribution of pulmonary function tests and immunological screening. Cephalalgia. 2006;26:172-179.
Low NC, Merikangas KR. The comorbidity of migraine. CNS Spectr. 2003;8:433-444.
Aamodt AH, Stovner LJ, Langhammer A, Hagen K, Zwart J-A. Is headache related to asthma, hay fever, and chronic bronchitis? The Head-HUNT Study. Headache. 2007;47(2):204-212.
Becker C, Brobert GP, Almqvist PM, et al. The risk of newly diagnosed asthma in migraineurs with or without previous triptan prescriptions. Headache. 2008;48(4):606-610.
A recent large study has confirmed findings of previous studies that migraine headaches are more common in people who suffer from allergic rhinitis, and that immunotherapy can decrease the frequency of headache in those patients. Data from the Migraine, Allergy and Rhinitis Study (MARS) was analyzed. Allergy patients with headache received formal headache diagnoses, and received allergy testing with either skin tests, or blood tests of IgE antibodies. Of the 536 allergy patients in the study (60% women), 32.5% had migraine.
The most common allergens found were weeds, trees, grasses, and indoor insects. Patients were divided into those with high atopy and low atopy. (People who have allergies suffer from atopy, the genetic predisposition to develop IgE antibodies to allergens.) The average was 3.39 migraine days per month, and each attack lasted an average of 1.5 days.
What the study found was that the number of people with migraine was not altered by treatment with immunotherapy, but that the frequency and disability from migraine was reduced, but only in migraine sufferers under age 45. The study showed a predicted 52% reduction in the frequency of migraine headache and a 45% reduction of the number of days with migraine-related disability in migraineurs ≤45 years of age that received immunotherapy. The study also found that in the younger group, 45 or younger, low degrees of allergic sensitization were correlated with migraines that were less frequent and less disabling, and that migraines were more frequent in those with high degrees of allergic sensitization.
Allergies and Chronic Headache
Allergies are comorbid with chronic daily headache, which means that they occur more commonly in those with chronic headache. This is true of both chronic migraine, and of new daily persistent headache. (New daily persistent headache is a chronic headache that starts off right from the very beginning as a daily or near-daily headache.) It is not yet clear whether controlling allergies can reverse chronic headaches.
References:
1. Ku M, Silverman B, Prifti N, et al. Prevalence of migraine headaches in patients with allergic rhinitis. Annals of Allergy, Asthma & Immunology. 2006;97(2):226-230.
2. Mortimer MJ, Kay J, Gawkrodger DJ, Jaron A, Barker DC. The prevalence of headache and migraine in atopic children: An epidemiological study in general practice. Headache. 1993;33:427–431.
3. Martin VT, Taylor F, Gebhardt B, et al. Allergy and immunotherapy: are they related to migraine headache? Headache. 2011;51(1):8-20.
4. Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Study (SAMS). Headache. 2007;47(2):213-224.
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