When headaches won't go away

How to get rid of the throbbing pain—plus, warning signs that your headache could be something more serious.

Published: October, 2012

When one of her bad migraines hits, Jacqueline G. (last name withheld) can't do anything but lie down in a dark room and wait for the waves of pain to recede. "It's completely debilitating," says the 73 year old, who has been plagued by severe migraines since her 20s. "The nausea comes on right away, and then I can't keep anything down—even crackers or ice. And it can last from early morning to 12 at night."

Migraines are a particularly disabling form of headache because they launch a four-tiered attack:

  • The first strike is the prodrome (or preheadache), a sick or moody feeling that may set in a day or two before the actual headache starts.

  • Next, for about 20% of migraine sufferers, comes the aura—flashing lights, bright spots, or other visual phenomena that distort or even interrupt sight for a few minutes to an hour.

  • Then the migraine hits, a crescendo of headache that can involve throbbing pain and nausea, as well as increased sensitivity to sound and light.

  • And finally, the postdrome may occur—a "headache hangover" that leaves you feeling tired and drained from the whole ordeal. This feeling can last for a day or more.

What causes migraines?

Researchers still aren't sure exactly what causes migraines. These headaches may be due to changes in the brain stem and imbalances of brain chemicals such as serotonin, which helps regulate pain.

Women are three times more likely to get migraine headaches than men, in part because the hormone estrogen "primes the pump," says Dr. John Stakes, a neurologist at Harvard-affiliated Massachusetts General Hospital. "After menopause, migraine headaches in women become dramatically less frequent. So there is most definitely an estrogen effect," he says. Yet some women—like Jacqueline—continue to have migraines even after they've seen the last of their menstrual cycle.

Women who get regular migraines often have "triggers" that instigate their headaches. Common migraine triggers include

  • strong odors

  • stress

  • lack of sleep

  • loud noises or bright lights

  • changes in weather

  • low blood sugar from skipping meals

  • foods such as red wine, chocolate, aged cheeses, dried fruits, nuts, beans, cured meats, soups and bouillons made with the preservative monosodium glutamate (MSG), yeasty beers and breads, and diet drinks containing artificial sweeteners such as aspartame.

The anatomy of a migraine

The anatomy of a migraine

A migraine occurs when nerve cells in the brain become activated—usually in response to a trigger such as stress or a particular food. These nerve cells release certain chemicals, which cause the blood vessels in the brain to dilate (widen) and become inflamed. But scientists still are not sure this is the specific cause of the pounding pain and other symptoms of a migraine.

Relieving headaches

When it comes to treating migraines, "my first-line therapy would be to try to remove the triggers," Dr. Stakes says. "Before we go to pills, let's see if we can find a causal factor to remove or lessen."

Keeping a headache diary can help pinpoint your migraine triggers. For one month, write down

  • what time each headache started and ended

  • the intensity and location of the pain (for example, behind your eyes or in the back of your head)

  • what warning signs heralded the headache

  • what you ate that day

  • what you were doing before the headache hit (for example, exercising)

  • what treatment you used, and whether it helped.

Then, go over your diary with your primary care doctor, neurologist, or headache specialist to see where you can eliminate or modify triggers. If trigger avoidance isn't enough, your doctor might recommend migraine medications, which follow two therapeutic approaches:

Acute treatments relieve pain and nausea, but you need to take them at the first twinge of a headache. They include:

Triptans—migraine-specific medicines that narrow blood vessels in the brain, such as frovatriptan (Frova), naratriptan (Amerge), zolmitriptan (Zomig), rizatriptan (Maxalt), and sumatriptan (Imitrex).

Pain relievers—NSAIDs, including aspirin and ibuprofen (Motrin, Advil), can help with less severe migraines. Acetaminophen (Tylenol, others) also helps some women with migraines. Some of these products are formulated specifically for migraines, combining one or more pain relievers with caffeine (such as Excedrin Migraine). Indomethacin (Indocin) is available in suppository form for women who get nausea with their headaches.

Antinausea drugs—metoclopramide (Reglan), prochlorperazine (Compazine), and similar drugs can relieve the queasiness that often accompanies a migraine.

One note of caution: The overuse or misuse of some migraine medicines can trip off additional headaches—called rebound headaches—especially if you use these drugs more than three times a week. Talk to your doctor if you notice that you're getting more headaches than usual while on these medications.

Preventive or abortive treatments can control migraines when you take them on a regular basis. "They can help reduce the frequency and severity of headaches," Dr. Stakes says. These medications are recommended for women who have frequent migraine attacks (more than two or three a week), or whose migraines haven't responded well to other treatments.

Abortive treatments include

  • blood pressure drugs—beta blockers or calcium-channel blockers

  • antidepressants—amitriptyline (Elavil), venlafaxine (Effexor)

  • antiseizure medicines—sodium valproate (Depacon), topiramate (Topamax), divalproex sodium (Depakote).

Botulinum toxin type A (Botox) can help some women with severe, chronic migraines. This is the same therapy that's used to smooth out wrinkles. A recent study in the Journal of the American Medical Association found that Botox injections reduce the frequency of migraines. However, this therapy requires repeat injections, and the benefits may last only a few months. Some alternative remedies, including biofeedback and the herbs butterbur and feverfew, may also help with migraines.

Other types of headaches

Migraines aren't the only type of headache that can cause misery. Others include:

Tension headaches—These common headaches feel like a pressure or tightness on both sides of the head. They can last from 30 minutes to several days. Tension headaches can occur from time to time, or on a daily basis. How to treat them: Address the health problem that's causing tension headaches, such as stress, sleep apnea, depression, or jaw clenching. To relieve the pain, try an over-the-counter NSAID.

Cluster headaches—These sharp, severe headaches typically arrive in "clusters" at the same time of day or night. Cluster headaches are usually focused on one side of the head, often behind the eye. They can last anywhere from 5 minutes to a couple of hours. You may also have a runny nose, tearing in one eye, and a feeling of agitation. How to treat them: Ask your doctor about oxygen therapy, lithium, or triptan drugs. Calcium-channel blockers and antiseizure medicines may also reduce the frequency of cluster headache attacks.

Sinus headaches—This type of headache occurs when the lining of the sinus passages becomes swollen and inflamed. The throbbing pain is often accompanied by pressure around the eyes, cheeks, and forehead; a stuffy nose; cough; and yellow-green mucus. How to treat them: Antibiotics can treat sinus problems caused by bacteria. Nasal steroids, over-the-counter decongestants and pain relievers, and saline nasal irrigation can all help relieve symptoms. If the cause is a physical problem such as a deviated septum, your doctor might recommend surgery.

If you get regular headaches, you'll probably start to see a pattern to the symptoms. If you develop any unusual or particularly severe symptoms, call for medical help right away. Even if headaches have become part of your routine, talk to your doctor or neurologist. Your doctor can get you started on a treatment to relieve your aching head and finally stop headaches from interfering with your life.

When a headache signals something more serious

In rare cases, headaches can be a sign of a serious health issue, such as a tumor, meningitis, or a burst aneurysm. Any of these signs warrants an immediate call for medical help:

  • a sudden, severe headache

  • a severe headache along with a fever, nausea, vomiting, shortness of breath, weakness anywhere in your body, confusion, double vision, or a stiff neck

  • the "worst" headache of your life

  • a severe headache when you rarely, or never, get headaches

  • a headache that starts after a head injury.