HEADACHES

Headaches can be a serious problem with a head injury. If you are in pain every day (headaches can also wake you in the middle of the night), headaches will wear you down mentally and emotionally. How common are headaches in head injury? In one study of head-injured people, 50% reported having a headache when they were discharged from the hospital. After one year, 33% of this same group of people said "my head still hurts." That's a long time to have a headache. I'm going to describe three common types of headaches that people with a head injury get. There are many other variations on the types of headaches that can develop, but most head-injured people will have one (or more) of the following:

PAIN IN THE BACK OF THE HEAD/NECK/SHOULDER

This type of head pain is described as a pain that starts at the base of the head/neck area. The pain commonly gets worse as the day goes on and it may spread over the top of the head to the front part of the head. What is causing this? You have to remember that when you were in a car accident, your head was traveling at a high rate of speed. For example, a car is traveling 50 mph and it suddenly stops. Everything in the car goes from 50 mph to zero in an instant, and your head is thrown forward. The only thing holding your head on the top of your body is a bunch of muscles, some bones, and some cartilage. Your neck consists of bones, rubbery disks (bones don't bend--the disks help the neck to bend), and muscles so you can move your neck and head. When your head is thrown forward in the accident, the disks that are between the bones can get squished. These squished disks may press on nerves in the neck. Pressing on the nerve can make parts of the body numb or decrease strength in parts of the body. Another problem that can happen at the same time is stretched muscles. If you take a rubber band and stretched it almost to the breaking point, then let it come back, you may have noticed a change in the rubber band. A similar thing happens with muscles. If you really yank on them, they come back in knots. Sometimes, you can actually feel the knots. This stretched muscle problem is called myofacial pain disorder by doctors. The pain at the back of the head can go on for a long period of time (possibly for years, especially if you keep re-injuring or stressing the sore muscles). So, the first type of head pain is due to muscle tension and/or nerve problems. Unfortunately, this type of headache can trigger a migraine-type of headache following a head injury.

MIGRAINE-LIKE HEADACHES

The second type of headache is much tougher. Following a head injury, you can develop a headache that resembles a migraine headache. Pain tends to be in the front of the head. Many complain that their forehead or temples throb. It is commonly described as a "pounding" pain. Emotional stress or intense concentration tends to bring on or make these headaches worse. One possible explanation of this problem is a change in the vascular system of the brain. The brain has veins and arteries that supply blood to it. The brain weighs only about three pounds but uses 30% of the oxygen and energy in your body. So there's a lot of blood flowing to the brain. Think of this blood flowing through a hollow tube, like the water flowing through pipes in your home. These pipes, however, can change their diameter. If the veins and arteries couldn't change shape, all the blood would run down to our feet. The heart is pumping the blood around the body and veins constrict to keep a constant pressure. If I make the diameter smaller and put more pressure on the system, I develop high blood pressure. If my blood pressure is too low, I'll faint because there's not enough pressure to make things work. With head injury, these very finely tuned little pipes get stretched or injured. Remember, the brain is yanked forward and backward in an accident. Things get stretched and don't work the way they normally do. In a classic migraine headache, blood is flowing at a normal rate and the tubes (veins/arteries) suddenly get much smaller. During this constriction phase, some people get a warning sign. They may become very sensitive to light, or they may lose their peripheral vision (the outside of their vision goes black and they just see the middle part). That's just the start. The veins go from being very small to "giving up", in which they suddenly open wide. When this happens, the pounding or throbbing headache begins.

THE "STABBING" HEADACHE

The third type of headache is described as a sudden, sharp pain. One person described this as "I'm walking along and all of a sudden I feel like someone is jamming a hot metal rod through my skull." It is a severe pain that will nearly bring some people to their knees by its intensity. The pain may last from a few seconds to a minute or two. Most doctors don't treat it because it lasts for a very short period of time. There are some drugs (typically of the anti-seizure variety) that can help with this problem. Some of my patients have reported improvement when a physical therapist or massage therapist works on the neck area. If you are thinking about this option, ALWAYS talk with your physician first!

COPING WITH HEAD PAIN

If you have one or more of these headaches, what should you do about them? Let's start with the neck/back of head pain. After an accident, your doctor may send you to a physical therapist. It is important to find a physical therapist who is familiar with this problem. The first time a physical therapist works on your neck, the pain may get much worse. I've even had one or two people say the pain was so bad that they passed out. And this was just from simple moving or stretching. Many people say "I went to this physical therapist and it made me worse so I'm not going back." Tell your physical therapist that you hurt. But remember, it gets worse before it gets better. Physical therapy alone may not be enough. You may have to continue loosening these muscles up by exercising. Of all the exercise approaches, most of my patients feel that swimming is a big benefit. A warm water pool is probably one of the very best ways of preventing these headaches. Its also very helpful for a lot of people who have back pain.

Migraine-like headaches are a lot tougher to deal with. These headaches will generally require some form of medication. Medications that doctors use to treat headaches tend to generate a lot of questions. There are two medication approaches: controlling pain that already exists and preventing headaches from getting started. To control pain, many people use drugs like Motrin, Darvocet, and Tylenol. One problem with pain medications is that you have to take them every 4 to 6 hours. They can interfere with your thinking and memory as well. In using pain killers, be aware of the following:

• If you use pain medications more than three days per week, you need to be aware of something called "analgesic rebound headache". Chronic use of pain killers can cause you to have MORE headaches (an increase in the number of headaches).

• Don’t assume that all over-the-counter medications are safe! For example, long term or intensive use of Tylenol can produce liver damage. People also seem to feel free to take extra amounts of over-the-counter pain killers (if two pills work, six must be better). If you have chronic head pain, ALWAYS talk with your doctor about over-the-counter medications.

There are some very effective preventative types of medications. These tend to be "unusual" types of drugs. For example, some anti-depressant medications can help with headaches. Why? Did you ever notice that when you're depressed you feel more achy? Burn victims, people who have intense pain, often use anti-depressant medications. These medications help decrease both depression and pain. Some of these anti-depressant medications may also help normalize sleep. Without a good night's sleep, you're going to be more prone to headaches. Another medication approach to headaches is to stop them just as they are starting. In this approach, a medication (i.e., Imitrex, Zomig) is used in the very early phase of a headache. Timing of taking the drug is critical with this approach. One of the best ways to deal with headaches is to prevent them. In a new use for a drug that’s been around awhile, the anti-seizure drug Depakote has been approved by the FDA to treat migraine headaches. This drug works very well in about 70 percent of head-injured patients. However, many people have problems with the side effects of this drug. It’s hard on the stomach, so many people have to take this drug with food.

I have one warning about vascular headaches--they tend not to have a "quick fix" with medications and there is a lot of trial and error in finding the medication that works. For many, medication may reduce, but not eliminate, head pain. You need to be very patient in working with your doctor. TAKE MEDICATIONS EXACTLY AS YOUR DOCTOR DIRECTS! Doctors who feel that you are taking medications improperly will hesitate to use more powerful medications that might benefit you. Read the section of this book on Dealing with Doctors. This chapter will help you to establish a positive relationship with your doctor. If you have frequent headaches, a solid relationship with your doctor is essential.

What can you do for vascular headaches on your own? The most common way people deal with a headache is to go to sleep or lie down. Try to lie down early before the headache gets bad. When you lie down, find a dark and/or quiet place. Most of my patients also avoid eating--largely because they report that their headaches make them sick to their stomachs. This next approach may help to prevent this type of headache: Wear dark sunglasses! I have people who go from a dark building out into the bright sunlight and have instant headaches. You can get these headaches especially in the early fall or in the summer when the sun is very low, and when you're looking at or driving into the sun. In general, the cheaper and darker the sun glasses, the better. Some people have used photo gray glasses; they tend to be not dark enough.

Some of the things that you eat and drink may affect the vascular type of headache. For example, some people who drink red wine will get an instant headache. There is an amino acid in red wine that can trigger a headache. In general, it's a good idea to avoid drinking alcohol following a head injury (a hangover is the brain's way of reminding you that you are hurting it). The same amino acid in red wine is also found in some foods (such as hard cheeses). An allergic reaction may also cause a headache. If you have these nasty pounding headaches, pay close attention to your diet to see if food is triggering a headache.

Another important strategy for vascular headaches and muscular headaches is to manage your stress level. Involvement in something very stressful or something that makes you very nervous will often trigger a headache. If you have to do something stressful, it's better to deal with it early in the day when your thinking is better. If you deal with something late in the day when you are really tired, you're more likely to get a headache.

Sleep has an indirect role with headaches. When it's too warm in the house or you have too many covers on the bed, the body heats up and you'll have less restful sleep, which in turn increases headaches. A lot of people do something called "turtling," in which they pull the covers over their face if it's too cold in the house (like a turtle hiding in a shell). If you do this, you're breathing the same air over and over. The problem is that you're breathing carbon dioxide. There is less oxygen going into your brain, which may trigger a headache. The temperature of food can also trigger a headache. Remember taking large bites of really cold ice cream and remember those ice cream headaches? If you get headaches easily, you might have to take smaller bites of ice cream or make sure you warm up your mouth before you take another bite.

Keep a headache journal. Get a monthly calendar and each day rate your headaches on a 1 to 10 scale with "1" being no headache and "10" being the worst headache you've ever had. You can also note what events in your life tend to trigger a headache. A lot of people start to realize how important stress is when they look through the entire month and see the relationship between their bad headaches and the activities of the same time period. They may notice a pattern developing. Some people get more headaches toward the end of the week because stress tends to build up over time. You can get more headaches on the weekends due to family and friends visiting.

It is very helpful to bring this journal to your doctor. If the two of you are struggling with the best drug or a combination of drugs to use, the doctor is going to need some method of rating how they're doing. If your doctor asks "how's your headaches?" after trying a medication and you say "the same," the doctor may stop the medication. Because of the way you reported it, this may have been a mistake. For example, you bring in your headache journal sheet and you had 7's before the medication and now after the medication you have 5's. Your doctor may have been onto something, but you asked to stop it too early. So make a headache journal if you get headaches.

It is important to take medications for headaches (and other medical conditions) at the same time every day (no more than plus or minus 15 minutes). This is a big problem for many people with head injuries because they tend to be forgetful and may be missing important medications. For under $40, Casio makes a watch that can be programmed for five events during the day. The beeping of the watch will remind you when to take medications. A lot of people don't want to carry all the jars of medications with them at once. You can buy little plastic holders for medications that you fill once a day (cost under $10). Another nice thing about these pill holders is that you can double check to see whether or not you took your medication.

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CONTENTS
Common Indicators of a Head Injury || How the Brain is Hurt
Understanding How the Brain Works

COPING WITH COMMON PROBLEMS
Memory || Headaches || Problems Getting Organized || Getting Overloaded
Sleep Disorders || Fatigue || Anger and Depression || Word-finding

Dealing with Doctors || Family Members: What You Can Do In the Hospital Setting

Seizures || Emotional Stages of Recovery || Returning to School
When Will I Get Better? || Who Are All These Professionals?