The experience of headache has been around as long as the human race. Our ancestors believed that headache was visited upon us as punishment for offending the gods or that it occurred when humans became possessed by evil spirits. Through the ages treatment has been directed at the suspected cause; not surprisingly, headache remedies were aimed at ridding the body of demons. Thus, the earliest neurosurgeons bored holes in the skull through which the headache-causing demons could escape. Skulls with evidence of such surgery (called trephination) have been found in Peru and date back to the thirteenth century (Figure 1-1).

Hippocrates, a physician who practiced in ancient Greece, noticed that vomiting ended some attacks of head pain, so he prescribed herbs to cause it. He also used another treatment—the application of leeches or bloodletting through small cuts, a practice that persisted through the Middle Ages. The ancient Egyptians wrapped the heads of sufferers in linen along with a clay crocodile holding in its mouth wheat from the gods’ storehouse (Figure 1-2).

In the seventeenth century, Thomas Willis theorized that headache pain was related to swollen blood vessels in the head. Erasmus Darwin, Charles Darwin’s grandfather, further explored these theories. Interestingly, both Charles and Erasmus Darwin suffered from migraine headache.

In the late nineteenth century, an English neurologist named Liveing was the first doctor to write that headaches, similar to seizures, were “nerve storms,” affecting the nerves of the head more than the blood vessels.

Folk remedies such as tying rags around the head or applying tobacco stamps to the head had their advocates, as do herbal remedies still. Heat, cold, acupuncture, chiropractic manipulation, nerve blocks, diets, laser therapies, hyperbaric oxygen, and hysterectomies have also been proposed as headache treatments. There is no shortage of conflicting opinion and information, adding to headache sufferers’ confusion about which treatments may help.

It is generally not possible to completely cure your headache.What you can expect is fewer headaches and better control of the pain. The remainder of this book tells you how to take control of your headaches.


More patients who visit doctors complain of headache than of any other single ailment.Yet migraine—and headache in general—continues to be underdiagnosed, misdiagnosed, and mistreated. Recent studies show that more than half of migraineurs have not been diagnosed with migraine by a physician. If patients do not have the diagnosis of migraine, they will not get the proper treatment for it. Although medical students and even neurology residents in the hospital learn a great deal about serious causes of headache, such as tumors, strokes, aneurysms, and meningitis, they do not learn much about migraine and tension-type headache, the types they will see most frequently in their offices.

In the past several years, some off-the-shelf pain relievers have been approved by the United States Food and Drug Administration as effective for migraine or “migraine pain” and have been allowed to advertise on television and in newspapers and magazines. These medications, such as Excedrin Migraine, Advil Migraine, and Motrin Migraine Pain, can be effective when used infrequently for mild attacks. However, since they are available without prescription, the manufacturers do not have to provide a safety warning in the ads, even though the medications can cause major problems. We warn our patients taking off-the-shelf painkillers to be aware of gastrointestinal symptoms, heartburn, stomach ulcers, long-term liver or kidney problems, easy bruisability, and the development of daily headache (analgesic rebound headache, also called chronic migraine with medication overuse).

Headaches may occasionally be due to allergies or sinus problems, but the majority of patients with allergies do not usually get headaches from them. Acute sinus infections can make someone very sick and cause a headache, but people with frequent headaches in the sinus areas, who think that chronic sinus problems are the cause of their headaches, usually, in fact, have migraine. A recent study found that of over 2,500 patients who thought they had sinus headache, more than 90% had migraine headache. In addition, many people who worry that their headaches result from psychological factors seek treatment for sinus and allergy problems, which they would rather believe are the cause of their headaches.

The bulk of nonprescription pain medication is consumed by migraine sufferers and people with chronic daily headache. Headache sufferers are the main purchasers of the 20,000 tons of ASA (Aspirin), plus much of the acetaminophen (Tylenol), ibuprofen, and other anti-inflammatory and sinus medications, consumed yearly in the United States. Lacking a proper diagnosis, these individuals rely on off-theshelf medicines because they have never received a prescription for a migraine-specific medication.

Until the middle of the twentieth century, over the counter meant that you could ask your pharmacist for a bottle of Aspirin, for example, and he or she would personally give it to you—over the counter. Today, only prescription medications are passed over the counter; nonprescription medicines are purchased off the shelf and are available in pharmacies, convenience stores, supermarkets, and gas stations (Figure 2-1).

As noted above, if nonprescription medication is used improperly, it can have serious consequences. When overused, ASA (Aspirin), specifically, and Excedrin Migraine and Anacin, both of which contain ASA, can cause or aggravate peptic ulcer, irritation of the stomach (gastritis), bleeding, bruising, ringing in the ears (tinnitus), and kidney damage; ASA can also aggravate asthma. Similarly, ibuprofen (Advil Migraine and Motrin Migraine Pain) can cause ulcers, bleeding, and kidney damage, and acetaminophen (Tylenol) can cause liver damage. Additionally, many sinus and allergy preparations contain ingredients that can increase your blood pressure.

At our Center in Stamford, CT, we frequently see patients who take 8 to 12 tablets per day of various off-theshelf products. When the stronger prescription medications for headache are taken too frequently, the problem becomes worse. The more frequently a pain medication is taken, the greater is the risk of causing chronic severe headaches that respond poorly to all treatments. So, although off-the-shelf pain relievers and other medications targeted for headache can be effective when used properly for occasional headaches, overuse can result in headaches that are harder to treat, more painful, and more constant.These are called analgesic rebound headaches, rebound headaches, or chronic migraine with medication overuse (see Chapter 8).

The impact of headache on our society is enormous; migraine is truly a hidden epidemic. A Canadian survey shows that 92% of migraine sufferers have disability that ranges from diminished ability to function to requiring bed rest. Art created by headache sufferers has shown how headache can affect every aspect of their lives. Migraine victims feel isolated from the world around them at work, school, home, and play.

Headache is the leading cause of absenteeism from the workplace and accounts for the loss of some 150 million work days per year in the United States alone; the cost of lost labor hours is estimated to be as high as 17 billion dollars (US) each year. Headache can also disrupt every aspect of life outside the workplace and—in an era when some medical costs are not adequately covered by insurance 6 companies—can result in unnecessary medical expense if misdiagnosed or inadequately treated.

Society may not understand headache or its impact on those who suffer from it.Workers who telephone their bosses or co-workers to say they cannot come to work because of a headache may be considered malingerers, or worse.The claim of disability because of the flu is more believable, and the claim of a broken bone is never questioned.Valerie South, of the International Headache Society, points out that “migraine is more than just a ‘headache’; [it] is a debilitating disorder of the central nervous system.”

Our mission is to educate you about headache so you can improve your quality of life and thereby decrease the impact of headache on you and your family. If you are one of the many migraine sufferers who have significant disability from migraine, this will be your first step toward decreasing the level of that disability and improving your functioning.