A headache tutorial

headacheAllison sat in class listening to her professor. She couldn’t concentrate on his complicated formulas and theorems. She had a pounding headache.

Why did she always get a headache right before final exams?

Jessie Mueller, MD, Scott & White Headache Center, explains the physiology behind headaches.

The Causes of Headaches

In the United States, 90 percent of men and 95 percent of women, Dr. Mueller says, will have some sort of headache this year.

But some people have headaches more often. And some of those people have severe headaches more frequently.

Studies show that “people who suffer from headaches have a sensitive or hyperactive nervous system,” says Dr. Mueller. It’s theorized that headaches happen when the brain releases inflammatory substances around the blood vessels and nerves, perhaps in response to stressors in your life.


“People who are prone to having severe headaches react to sensory information and triggers differently than other people. They have a harder time adjusting to change or stressors, for example,” Dr. Mueller explains.

There’s a genetic element, too. The propensity to get frequent headaches can be inherited. “You just picked the wrong parents,” Dr. Mueller says.

Headaches can also be caused by trauma, either physical or emotional:

  • Physical trauma
    • Head injury
    • Car wreck
    • Military accident
  • Emotional trauma
    • Assault
    • Abuse
    • Neglect

“We work closely with Mental Health to help you develop stress management techniques as well as work on unresolved issues,” Dr. Mueller says, “so that we can minimize the triggers that set off your headaches.”

Your Trigeminovascular System – Where Headaches Start

“The part of your brain where headaches originate is called the trigeminovascular system. It’s a system of four branches of blood vessels and nerves that go throughout your brain,” explains Dr. Mueller.

“Because your headaches are due to your sensitive nervous system, you’re going to have to make a huge behavioral sacrifice if you want to minimize your headaches.”

Forehead migraines. “One nerve goes to your forehead area. You’ll have blurry vision and eye pain,” says Dr. Mueller.

Rhinogenic migraines. “A second branch of nerves and blood vessels goes to your nose area. You’ll have facial pain and a runny nose. These symptoms can appear as a sinus headache,” says Dr. Mueller.

Temporal migraines. This nerve goes to the area by your temples and above your jaw. You’ll have pain in your temple area, often just on one side of your head.

Occipital migraines. “This branch of the trigeminovascular system is at the back of your head, in the cervical area,” explains Dr. Mueller, “where your head meets your neck. You can often feel tightening in the back of your neck.”

“You can have a headache in one branch or two branches — or all four can be activated for a headache,” says Dr. Mueller.

Types of Headaches

There are two types of headaches:

  • Primary
  • Secondary

“Primary headaches occur because your sensitive, hyper-excitable nervous system doesn’t tolerate change well. Secondary headaches are caused by another reason or cause, such as a tumor or infection. We treat primary headaches in our headache clinic,” says Dr. Mueller.

There are two kinds of primary headaches:

  • Migraine
  • Tension

Convergence Theory

“New research — called the convergence theory, developed by Dr. Roger Cady, a world-renowned headache specialist — suggests links between tension and migraine headaches. All headaches fall along a converged line of pain,” explains Dr. Mueller.  Convergence theory is generally accepted by the American Headache Society.

Prodrome stage. This first stage of a headache is marked by:

  • General malaise
  • Fatigue
  • Weakness
  • Irritability

Aura stage. “Aura” is the sensation that about 15 percent of migraineurs get before a migraine comes on. Dr. Mueller says it’s sort of a “warning sign,” and may be marked by:

  • Tunneling of vision
  • Seeing squiggly lines
  • Seeing flashing lights

Headache phase. There are three stages of severity:

  • Mild – Green zone
  • Moderate – Yellow zone
  • Severe – Red zone

Postdrome phase. Lasting a few hours to several days, this phase may be marked by:

  • Fatigue
  • Depression
  • Poor concentration

According to the convergence theory, tension headaches are not distinct from migraine headaches; instead, tension headaches are headaches in the green zone that do not progress into the yellow zone.

The convergence theory suggests that not all migraines advance into the red zone. There are varying degrees of severity. Each migraine is different.

Headaches classified as severe may be accompanied by:

  • Sensitivity to movement, sound, light or odor
  • Depression, anxiety or panic
  • Nausea or vomiting
  • Vertigo

Treatment Options

“Each time when you come into the Scott & White Headache Center, we’ll have you fill out two different headache evaluation forms. You rate the level of severity of the headaches you’ve been having and you rate how the headaches impact your life. How we treat you depends on how you assess and grade your headaches,” explains Dr. Mueller.

“We also track your responses over several months or years so that we can make determinations regarding stressors in your life that make your headaches worse,” says Dr. Mueller.

Your treatment depends, Dr. Mueller says, on the stage of your headache. Your headache physician will generally recommend a two-pronged treatment approach:

  • Behavior modifications and stress management techniques
  • Medications
    • Preventive – prevent headaches from occurring
    • Abortive – stop headaches that are occurring
    • Rescue – stop severe headaches that don’t respond to abortive medications

“When we’re treating headaches, it’s always a bimodal approach. Medications alone won’t be enough. Because your headaches are due to your sensitive nervous system, you’re going to have to make a huge behavioral sacrifice if you want to minimize your headaches,” says Dr. Mueller.

Dr. Mueller: “Your doctor can’t do it alone.”

NOTEIf you’d like to know whether you should ask your primary care physician for a referral to the Scott & White Headache Clinic, take the migraine disability assessment test at http://www.achenet.org/midas/.

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A headache tutorial