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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 5. - Headaches
RADIO 4
TUESDAY 02/10/07 2100-2130
PRESENTER:
MARK PORTER
REPORTER: ANNA LACEY
CONTRIBUTORS:
ANDY DOWSON
PETER GOADSBY
ANNE MACGREGOR
MICHAEL MULLEN
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
PORTER
Hello. If you, or a member of your family, are prone to frequent headaches - and the odds suggest that at least one of you will be - then this programme could well provide some relief.
Over the next half an hour I'll be looking at the most common causes of recurrent headaches and finding out what can be done about them. Including a radical new approach to helping people with migraine - the clue is in these funky sounds.
CLIP - FUNKY SOUNDS
All will become clear later. But new treatments aren't much good if people don't come forward and ask for help in the first place. And most people with headaches don't.
CLIP
People often ask me what I do and I tell them I'm a headache specialist and they laugh. The first thing they do is laugh. And then there's a sort of quiet bit and then they start talking about either their own headache problems or the experiences of somebody they know who's got serious headache problems and it's like a sort of hidden problem.
PORTER
I'll be discovering why millions of people could be suffering unnecessarily - and finding out what they missing out on - a little later.
But first my guest today is Dr Andy Dowson, he's Director of the Headache Service at King's College London.
Andy - why do we get a headache. Where's the pain actually coming from?
DOWSON
Well I guess it depends which particular type of headache you're actually referring to. If we look at the general population probably about half the population would have tension type headache in a month, about 15% would have migraine, about 2-4% would have a daily headache and then a few would have the other more unusual headaches like cluster headache. And each of them have their own particular causes. So tension we think could come from the soft structures, the muscles becoming tense etc., migraine is more to do with the feeling nerve and the end organ that's involved, that actual feeling nerve, is called a trijeminal nerve and then that has connections into the brain; in cluster headache there's an area that's important in something called a hypothalamus and then in the chronic headaches there's often a sort of winding up and a lot of parts of the brain become overexcited and it all comes together to cause a crescendo of neurological disability.
PORTER
Well in half an hour it's very difficult to cram everything in so I want to concentrate on recurrent headaches that are potentially quite disabling and I really want to look at three areas: tension headache, something to do with painkillers, which we'll talk about a bit later on and migraine.
Let's start with the tension headache. I suspect this is probably one of the more common, if not the most common, cause of headache. What makes you think when somebody tells you a story about their headache, you know the symptoms, that it's a tension headache?
DOWSON
They tend to be generalised headaches and more constant than throbbing like in migraine. They tend not to be worse when you do things, don't have associated symptoms like nausea, like sound sensitivity.
PORTER
We talk about them being tension, I mean they can be brought on by things like stress and anxiety and what's actually happening - is it the muscles literally tightening up - do we know?
DOWSON
I don't think it's an absolute that we know. Some people believe there's a bit of a continuum between these acute headaches and those different expressions of headache. As you say I think that tension type tend to come on when you're under stress more, whereas migraine headaches tend to come on after the stress has been relieved, they used to be called weekend headache when people were relaxing and so forth. So I think there's a lot of mystery about tension headache, we haven't done so much in the way of experimentation about it because it doesn't present so commonly.
PORTER
They're mainly a GP based problem. But there are people who you say have occasional headaches, there are people who have regular tension headaches, it can become an ongoing chronic problem.
DOWSON
It can.
PORTER
And what's going on there, what differentiates them, what's different about them from people who are having the occasional one, are they under more stress and anxiety?
DOWSON
Possibly. I mean one theory is you're born with - the brain you're born with is able to have headaches or not and given the right circumstances it will actually trigger off individual events. Less so with the acute headaches - the ones that come on every now and again - it's usually the migraine that actually disrupts and that eventually causes you to consult. And in chronic headache where you have headaches of some type most of the time again it can be tension type symptoms, that's generally kept in the community, they don't tend to even come and see GPs that often, it's when they get the migrainous, more disabling spikes, on top of that background that they tend to come in. And certainly by the time they come to hospitals and about 80% of the people that we now see in specialist clinics have chronic headache, we would expect them to be having two or three bad days in a week probably, more migrainous type days in a week, on a background of more continual lower grade symptoms.
PORTER
Well we'll come back to causes in a moment. I want to just talk about eye strain, it's another factor widely believed - by both the general public and healthcare professionals - to cause headaches. But can poor eyesight, or the wrong specs or contact lenses, really cause headaches? A question I put to Professor Peter Goadsby from the Institute of Neurology in London.
GOADSBY
There's very little evidence that eye problems will cause headache in a causal fashion. Since migraine is an inherited tendency to have headache anything that will disturb that will trigger headache. So patients who have errors of refraction, that is to say they need their glasses adjusted, can have headache produced from that, it triggers it off if you like. And when it's corrected that aspect of their headache is improved. But almost invariably other things take over and are troublesome. So I think it's rare to have glasses, for example, correct major problems with headache but common to have a migraine sufferer have a worsening of the headache because of some change in, for example, their prescription.
PORTER
In general practice we see a lot of people who think that their eyes may be to blame and we send them off for an eye check, which I've always regarded sort of as a useful way to end the consultation but unlikely to have any impact on their headaches. Besides recognising it as a trigger for some types of migraine can it cause other types of short term headaches as well?
GOADSBY
It's unusual for errors that require new glasses to cause other types of headache.
PORTER
Which is probably why they all eventually come back to see us again still complaining of the same headache. Basically if a patient came to you with a story that when they're doing a lot of close work with their glasses their headaches seem to get worse that would make you think migraine, that's the connection you're trying to make?
GOADSBY
That's one of the first things to think because the migrainer is the person who's susceptible to headache when they have some particular problem. So you might want to resolve the glasses problem and then put a little flag in, you know it's saying it's likely this person's going to come back with headache triggered in other ways because they probably have migraine.
PORTER
Peter Goadsby talking to me earlier. You are listening to Case Notes, I am Dr Mark Porter and I am discussing recurrent headaches with my guest Dr Andy Dowson.
Andy, we may overestimate the importance of any link between eye problems and headaches, but we grossly underestimate the role of another trigger, familiar to doctors of course, analgesia rebound headaches. Headaches that are caused by painkillers
DOWSON
Absolutely, it's by far the biggest problem that we have in secondary care clinics and certainly probably about a third of all new cases that goes to see a GP with headaches will have analgesic dependent painkiller induced headaches.
PORTER
Now the majority of people listening will think well how can a painkiller cause a headache, now I take a painkiller to get rid of a headache? So what's going on?
DOWSON
Well actually before that some people - you're born with your brain that you have and that brain can have attacks of headache and there's a nice study done actually with Peter Goadsby group that looked at a rheumatology clinic and looked where people were going to be given painkillers for their joints and the people who had previously had migraine generally developed daily headache and the people who didn't have previous migraine didn't develop daily headache. So it seems like there's something special about migrainous brains that if you give them regular painkillers it tends to cause more headaches. It happens with all the painkillers, in fact all of the acute medications, the old fashioned ergotamines, which we rarely use now and the newer fangled ...
PORTER
So we're talking things like paracetamol and ibuprofen and over-the-counter - I mean - are any particularly worse at doing this?
DOWSON
Well the biggest one we have in the clinic are the people who take the combination drugs, particularly those that have codeine in this country. But in the States they similarly looked at the different drugs that would actually help people with frequent headaches upgrade and they have a lot of caffeine in their medications, their painkillers, and caffeine had a four times risk of developing chronic headache if used. So we get our caffeine through coffee and cola and things like that and so you have to be careful about those things as well.
PORTER
So these people have been medicating for a headache which may have been migraine in the first place, let's say, and they're actually making themselves worse. They come and see you, you explain to them this is a paradoxical reaction and one of the first things, I presume, they have to do is stop their medication?
DOWSON
They do, yes. If you get once a month migraine that's not a problem, it's when it starts to escalate and it's usually when you're getting about an attack a week that really the danger signals are beginning to be ...
PORTER
And when are they getting these headaches, give us sort of typical story, because it's often women isn't it?
DOWSON
Yeah can be. I mean the most common group of people seen in my clinic would be sort of middle aged women usually, maybe coming up to menopause will actually be an additional risk factor for headaches. They've often had migraine before, not always but usually, sometimes they've had other life events happened to them - they sometimes have injuries to neck - and then they develop the chronic headaches.
PORTER
Is there a particular time - does the headache - do they wake with it, does it come on during the day, are there any features that can differentiate it from other headaches?
DOWSON
Pretty much most of these patients have a chronic neurological disorder, so they really have very little time when they feel hundred percent normal. Migraine, as you probably know, often is there on waking or in the first hour of waking, at least half of the attacks, so the worst headaches tend to come on more in the mornings than in the afternoons. But the headaches are often there all the time but it isn't the only thing they get, they get other things like tired all the time, sleep disturbance, mood changes, stiff necks. And often those things help us to choose the medications we might help them with in terms of treatment.
PORTER
So the idea is to wean them off their painkillers that they're on that are compounding the problems and to do that you might sometimes add in another medication?
DOWSON
Different schools of thought. A lot of headache doctors will say to the patients until you've stopped all your painkillers I'm not going to do anything else to help because it actually retards the benefits of the regular drugs. But in primary care the reality is that often it's very difficult to get the patients to do that.
PORTER
If I wean a patient off and they've been having these headaches for nine months, a year, could be a lot longer obviously, how quickly can I expect to see a response or how quickly can they expect to see a response?
DOWSON
If you stop them dead usually it's pretty tough for two or three weeks, the patients really get withdrawal symptoms - if you're taking 8 or 10 or more of the combination analgesics, that's the equivalent of a reasonable dose of morphine, so to stop that dead is a real problem for a lot of people. But usually within three weeks the worst of those symptoms are actually through the system.
PORTER
Ok, I want to move on to migraine now, we've mentioned it a lot already. At least 1 in 10 of the UK population will be affected by migraine to some degree, at some time - that's a minimum of six million people. Most of whom, like Rob Killick, self treat and never seek their doctor's advice.
KILLICK
I first had a migraine in my mid-20s and I remember it was actually very scary because the first time it happens obviously you've got no idea what's happening and I was walking to work and suddenly couldn't see. I haven't been to the doctor, in general I'm not that type of person.
PORTER
Rob Killick, one of millions of headache sufferers who don't seek help, and his story will be all too familiar to Anne MacGregor. She's Director of Clinical Research at the City of London Migraine Clinic.
MACGREGOR
A large number of epidemiological studies have been done in the UK, as well as in the States, and they all show that about 60% of people who can be identified as having migraine from their symptoms don't seek medical help.
PORTER
Do we know anything about these people and first of all how bad their problems might be, could it be that they're just having very infrequent headaches?
MACGREGOR
It may be that they're having very infrequent headaches and therefore they don't perceive they actually need any help. Quite often we've found that people don't recognise the symptoms they're experiencing as being migraine, so they don't realise there can be specific help out there for them that maybe different from just taking a couple of painkillers for a normal headache.
PORTER
Do we know how these people are self-medicating, what they're using to alleviate their headaches?
MACGREGOR
We know that many people just go along to the chemist or even just from the supermarket and buy simple straightforward painkillers for a headache. If they go along to the pharmacists, some of the switched on pharmacists will actually say well tell me a little bit about your headaches and it's picked up as migraine. Then they might start being given more migraine specific treatments.
KILLICK
Often I feel very happy, which is then followed by a loss of focus on things that I'm looking at and very shortly after that I have to go and crawl into a dark place because I can't bear the light. That lasts around about half an hour to an hour, after which I feel as if my brain's being zapped a bit but I can basically carry on. As far as I'm aware there isn't anything that they can do in terms of preventing it and most of the stuff which you can use to alleviate it you can get anyway from the chemist, the pharmacist. I've never really seen the point in wasting the doctor's time.
MACGREGOR
We often say to people we can't cure your migraine but you should be at a point where you're in charge, rather than it being in charge of you. And that may be medical drugs that they take just when they get a migraine attack or if they're getting very frequent attacks it may be that they need a course of a preventative treatment that they may be take three to six months to try to break the cycle of attacks.
PORTER
And how effective are these preventative drugs - so called prophylactic medication?
MACGREGOR
The preventative drugs have varying effects on different people really because although most people may have a similar experience with their migraine to another person with migraine the reasons why they each get their migraine attacks might be completely different. So what works for one person might not work for somebody else. So we do say to people it is worth trying a different number of preventative treatments if the first one doesn't work. Having said that some of the studies also show that lifestyle changes can be as effective as some of the preventative medications.
PORTER
Let's just have a look at that area, I mean the recognised triggers - what sort of things might be causing the headaches in these people?
MACGREGOR
It's probably easier to say what is not likely to be causing headaches in these people that everybody believes might be the case, which is cheese, chocolate, alcohol - all the good fun things in life. We now have recognised that at the beginning of a migraine attack many people crave often very sweet things, wake up the next day with a really bad stinking migraine and blame it on the food that they've eaten. What's far more likely to be a trigger for migraine is going too long without eating. Other things that can be recognised triggers are hormonal changes in women and again many women don't bother their doctors about period related problems because that's what they have to expect to have if they're women. So particularly during the reproductive years, when women are having regular periods, then migraine can often link to the menstrual cycle. Now for women who need contraception then we have the added advantage of being able to switch off menstrual periods, often running pills back to back, to abolish that oestrogen withdrawal trigger. For women who are not needing contraception then we have some other tricks of either trying to control the menstrual bleeding or sometimes just supplementing the oestrogen levels or looking at some of the more diverse treatments that we can use to try to control that specific trigger in migraine.
PORTER
Anne MacGregor.
Andy, a lot of people complain of headaches after exercising - I am one of them - is that a migraine based phenomenon.
DOWSON
I'm another one of them as well. In fact yes I think so. When I got them was first game of the season, I think, getting dehydrated and maybe a bit hypoglycaemic as well - both triggers, obviously, for migraine. In the old days when they used to use the really heavy footballs there was a famous footballer for Bolton Wanderers I think if he headed the ball, very powerful header, it used to give him a kind of impact headache which was a migrainous one. But very common for us to see this is youngsters - children - they do the sport, they get their migraine after the sport and by getting them to hydrate before, use the isotonic fluids, maybe a snack before, during and certainly straightaway after it can minimise.
PORTER
So their sugars don't go too low.
DOWSON
And fluid levels, you know, the volume of the blood as well is important.
PORTER
Well snacking before exercise and keeping well hydrated certainly seems to help prevent my exercise induced migraines, but there may be another contributory factor. Along with as many as one in four of the population have a minor heart defect called a patent foramen ovale or PFO.
It's a small hole in the wall between the upper chambers of the left and right side of the heart. In the womb a PFO is a natural short circuit that allows a developing baby's circulation to bypass the lungs - which of course are unexpanded and full of amniotic fluid. But after birth, when the baby starts breathing, the PFO should close off diverting all blood flow through the lungs. Mine didn't which means small amounts of blood still bypass my lungs, particularly when I exercise hard. And that bypassing may be triggering headaches, as Anna Lacey discovered when she met Liz Norwood.
NORWOOD
It's like someone drilling into your head, I mean the intensity is just - it's not like having an ordinary headache. People used to say oh yes I get migraines but I sort of work through them. Obviously they're all individual people but with mine they were absolutely blindingly painful. When I was a child I used to bang my head against the floor to try and sort of take it away. And the slightest bit of light or noise or smell would lead me to vomit.
LACEY
Liz Norwood has had migraines since she was five. As she got older, the frequency increased until she was having them at least once a week. But for her and many other migraine sufferers, the treatments currently on offer either don't work, or provide only temporary relief.
So when she heard about a study looking for volunteers to test a possible link between migraines and a hole in the heart, she felt she had nothing to lose.
I went to the Royal Brompton Hospital in London to speak to Dr Michael Mullen, a consultant interventional cardiologist, and asked him why there should be this link between the heart and the head.
MULLEN
We're not sure what the reason is but what we do know is that when we've seen patients who've had strokes and other problems related to their PFO that fairly often they suffer from migraines. And we found that when we closed these holes the migraine has got better and sometimes been completely cured. And so what we think is that something is passing through this hole, whether it be small blood clots or chemicals that would normally be filtered out by the lung, travelling to the brain where they trigger off the migraines.
LACEY
Now of course people know when they have a migraine because it's extremely painful but do people know if they have a PFO?
MULLEN
No, the vast majority of people will be totally unaware that they have a PFO and many of us will be walking round with one and just not know about it all.
NORWOOD
My life was completely normal in terms of my health, I just felt - I had migraines, I would never have related it to that, I didn't have any heart problems at all.
LACEY
So a complete surprise then?
NORWOOD
I was stunned yeah but really, really relieved because it was the first glimmer of hope really because I'd tried everything else.
MULLEN
To diagnose a PFO we need to do what's called a bubble test and that's where we inject small bubbles into a vein, usually in the arm, and look to see whether they cross over through the heart and reach the blood travelling round the body into the brain.
LACEY
Now you actually find out whether there are any bubbles with this amazing bubble machine, so can you just describe what this actually is we're looking at?
MULLEN
Well this is one of the ways in which you can look for a PFO and this called Transcranial Doppler. And what we actually do is use ultrasound to look at blood flow in the brain, so it's totally non-invasive. And then if there's a hole in the heart we can see bubbles arriving in the brain where they make quite a typical clicking sound as they arrive in the brain.
LACEY
And we've actually got an example of this here, now somebody earlier - they were tested to see if they have a PFO. So can you explain what we're actually seeing on the screen here?
MULLEN
Well what we're seeing now - this is the sound of blood flow in the brain and then you can hear the clicking sounds as there are bubbles arriving in the brain that have been injected in the arm. The patient's now been asked to strain and there you can hear there's a - what we call a complete curtain effect because there are hundreds and hundreds of little bubbles arriving in the brain causing these little clicking sounds. So this confirms this patient has what I would call a significant PFO.
LACEY
So once you find out that somebody has a PFO and in your trial they also have migraines what do you then do to try and close up that hole?
MULLEN
Well closing the PFO is a fairly simple procedure where we go up from a vein - a blood vessel - in the leg, up into the heart and we place a small device, such as this one, inside the heart and as you can see it's like two umbrellas and an umbrella goes either side of the hole and effectively clamps it shut. And then over a period of a few months tissue grows into the umbrella and over it and that completely seals the hole.
LACEY
Dr Mullen and his colleagues tried out this procedure to see if closing up a hole in the heart really can stop migraines. An important aspect of this trial was that the volunteers didn't know for sure if they were really having the hole closed. This was to make sure that people didn't feel that their migraines should improve just because they'd had the treatment. Liz Norwood explained how she felt about the operation.
NORWOOD
Half of us were having it and half of us were just having the general anaesthetic and a small nick in our groin where the tube would have to go up and you wouldn't know whether you'd had the operation or not. So that was another worry really, thinking I'll go through this and actually not have had it done. But I was also excited because everything else had failed and I just hoped that I was actually part of the trial that had had the PFO closed.
LACEY
And as it turns out of course you were part of the group that had had the real treatment. So what has happened to your migraines since?
NORWOOD
Two or three months afterwards I just had my last one and that was over two years ago.
LACEY
But despite this positive outcome for Liz, the procedure didn't work for everyone - including Jane Thomas.
THOMAS
I was on the sham arm of the study to begin with and then a year later they offered me the chance to have the closure.
LACEY
But even though you've now had the proper treatment it's still made no difference for you?
THOMAS
No, it made no difference whatsoever, it's actually worse at the moment.
PORTER
Jane Thomas talking to Anna Lacey.
Andy, you were involved in that study - great in theory but doesn't seem to work for everyone in practice, as we heard there. And you'd want to know it was going to work, wouldn't you, before submitting yourself to a heart operation. Where are we now in terms of evidence?
DOWSON
Well I think you're right, I mean it is heart surgery. I mean the reason why we did the study was because there were these reports coming from divers and from stroke patients that when they had closure of PFO for their other condition that their headaches got better. So if you have those conditions there is a reason for going for closure. We took the starting point of people having migraine with aura, we found that a lot of these ...
PORTER
And by aura we mean these sort of ...
DOWSON
Flashing lights...
PORTER
... visual effects or whatever, yeah, pins and needles.
DOWSON
Pins and needles etc., words getting mixed up - those kind of things. And we found that when the people had a high frequency of headaches, you know more than five days of migraine in a month, and they had auras in their life that there was a high percentage of them - about 40% of them - that we studied actually had these large PFOs. So the second part of the study was then whether we were going to the difference for closure against non-closure and in fact the primary end point of the study was no more migraine and it was exactly the same in the two groups. So we think there may be more subtle changes but we need to do more experiments to actually kind of look at that. So at the moment the state of the art is that if you have migraine alone there isn't evidence there to suggest in clinical practice there should be closed, you're quite right to point out that there could be substantial side effects from having closure from a cardiological operation, but if you have other things that are going on - for instance if you're a commercial diver, for instance - it would be a different story.
PORTER
We've talked about common, largely benign, causes of recurrent headache but what sort of clues in the story would raise alarm bells with you and suggest a perhaps more sinister cause?
DOWSON
I mean the first thing to say - people always worry that they've got a brain tumour and often when people come into the clinic, for instance, I think they're a bit disappointed to see me and would prefer to see a CT scanning machine, that sort of thing. But in fact if you were to have headache alone and to scan all the people on that basis we would only find about two anatomical abnormalities in a thousand scans ...
PORTER
By an anatomical abnormality you're talking things like tumours?
DOWSON
Or a blood vessel and that would - two in a thousand more than we would find by just chance alone findings. So it isn't the way that sinister things usually present, I mean if you have other things like - and so some of the things we look for is - is there a clue to do with the age of the patient, I mean the very young children probably have a higher index of suspicion, often that's the case across the whole of medicine. If you're older and maybe you've had other illnesses, if you've got a history for instance of having a tumour elsewhere you could have a secondary deposit - those kind of things. We think about added features, there is a potential for getting an inflammation of arteries that happens as you get older as well, if you're brushing your hair and it's very tender that might be an indication of that - it's called cranial arteritis.
PORTER
But the bottom line is that sinister - what you're saying is even in a specialist clinic like yours sinister causes are very unusual?
DOWSON
Very unusual, most of the presentations are actually quite acute, so most of them don't go to a clinic, they go to casualty in fact.
PORTER
Present in other ways other than headache.
Okay, very briefly, just wanted to end - I mean great if you come and see somebody like you, a specialist in headaches, but there aren't many of you, do you think we should be doing more to disseminate the sort of knowledge that you have through general practice?
DOWSON
Yes I think we do, we should be doing that, we've been trying to. There's lots of hurdles that patients have to go over to get to a good outcome. One of them you mentioned earlier was actually going to anybody and asking the question in the first place - and it's a tiny proportion that do that - then it's getting the diagnosis, getting a proper assessment and so on and so forth.
PORTER
But are we making inroads into that?
DOWSON
We're beginning to, we have groups, in the UK we have something called the Migraine in Primary Care Advisor Group and it helps not just doctors but all professionals who've got an interest in headache and lots of materials and we have the Migraine Trust who run a bi - every two years have an international symposium and there's patient organisations as well and we're all pulling in the same direction, trying to do better for the patient.
PORTER
Dr Andy Dowson, we're going to have to leave it there. Thank you very much.
If you would like more details on the latest management of migraines, or analgesia rebound headache, then you will find useful links on our website at bbc.co.uk/radio4 - where you can also listen to any part of the programme again, or download it is a podcast.
Next week's programme also revolves around the brain and looks at the latest developments in the field of Alzheimer's disease including a recently discovered link between Alzheimer's and the common eye condition glaucoma and an update on progress on new treatments - including research into a vaccine.
ENDS
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