Health and Healing September 2007
An Interview with Charles Matthews M.D., Director of the North Carolina Comprehensive Headache Clinic
Movement and Headache Therapy- It's All in the Timing
Q- Tell me about what you do at the Headache Clinic.
A- I have the best job I know. I have been the director of the North Carolina Comprehensive Headache Clinic since 1993. Over that period of time, we have seen approximately 30,000 outpatient visits for neurological evaluation and treatment for headache. It's tremendously fulfilling to work with patients who have headache. I enjoy finding the cause for the headache, and in almost all cases there are effective treatments now available. I find that fancy tests such as MRI can be helpful, but in many cases what is needed is to carefully listen to the patient, and to perform a very careful examination specific for headache.
Q- What types of headache do you typically see?
There are many causes of headache, some of which are serious or even life threatening. We see brain tumors, inflammatory conditions such as temporal arteritis, infections such as tuberculosis, chronic sinusitis, and we see toxic causes such as carbon monoxide or lead poisoning. There are also a number of rare headache syndromes, such as cluster headache, hypnic headache, trigeminal neuralgia, cervical dystonia, and some others, that will only respond to a specific approach to treatment. For example, about once every few months we see a rare one-sided type of headache called hemicrania continua, that responds only to a nonsteroidal medication called indomethacin, and not to any other treatment. So, a correct diagnosis is important in headache treatment.
Fortunately, the majority of headaches we see are migraine, mixed muscle contraction and migraine, and cervicogenic (neck generated) headache. I say "fortunately", although there is nothing fortunate about having these "benign" conditions. They may result in lost days at work, damaged personal relationships, and deteriorating quality of life. Some patients with progressive "benign" headaches will develop sleep disturbance, decline in mood, other pain syndromes such as neck or body pain. Some have lost jobs and spouses over headache, and I have seen a few suicides related to uncontrolled headache. Even "benign" migraines have seen found to have an approximately doubled lifetime risk of stroke. So, it's a very serious condition that deserves being taken seriously.
Q- What can you tell us headache and the topic today, which is movement?
A- To a neurologist, movement is a complex activity involving coordination between the environment, the brain, and the body. When you think about it, headaches at some point typically involve the neurological functions associated with normal movement. During a muscle contraction headache, when you feel tightness across the forehead, face, or neck and shoulders, what has to occur is a sustained muscle contraction which fails to relax normally. One can think of this as similar to the pain withdrawal reflex, which is mediated by neurons in the spinal cord. When you touch a hot stove, your spinal cord is wired to pull your hand back before the pain signals have to travel all the way up to the brain and you say "ouch"! The spinal withdrawal reflex saves valuable time when a painful injury such as a burn in occurring, so all of this movement is done by the spinal cord without checking with the brain. In headache, neck or forehead muscles enter a sustained type of withdrawal reflex which the brain cannot control. In fact, loss of control, of which loss of muscle contraction or of blood vessel regulation is only one manifestation, is one of the hallmarks of headache attacks.
Q- Can exercise help headaches?
A- Yes and no. Most types of benign headaches can be effectively treated with an aerobic conditioning program. This can work really well. The best types of exercise for preventing headaches are swimming, walking, and bicycling or using a recumbent bike at home. Swimming is particularly helpful as heat often bothers migraine sufferers and cooling down in the water while exercising is quite helpful. Weight lifting can be a problem, however, especially over the head lifting, which can easily worsen headaches.
On the other hand, it's not a good idea to tell a patient with headache to "just go out and exercise"! While pain with exercise can be a typical symptom with migraine, in which heat and exertion can "trigger" a headache, it can also be a symptom of an underlying structural problem, such as narrowing or impingement of the upper cervical segments, a cyst or growth on the spinal cord, or increased intracranial pressure from a tumor. Rarely, aneurysms may signal their gradual expansion by causing sudden pain while lifting or exercising.
Q-I hear that you use exercise in your treatment program for headache.
A- Yes, but it's better to use it thoughtfully, and you have to be sure about exactly what it is you are treating. Assuming that we are dealing with migraine, patients have typically already begun to restrict their exposure to sunlight, noise, and frequently to social interaction, and may be exhausted from pain and possibly from impaired sleep. At this stage of the condition, the brain is sensitive to stimuli, and exercise can trigger headaches. So, exercise can actually increase pain at this stage. It's not that exercise does damage; it's just that at this stage of headache exercise is not realistic because it hurts too much. I think it can be a little bit of an insult for a doctor to tell a patient who somehow barely manages to get through their day with headaches that if they could just exercise as they should, their headaches would improve. That makes it sound like headache is caused by laziness.
Q- What makes headaches in some people continue to get worse?
A- We become concerned when the headaches follow an increasing or worsening pattern. And then, the doctor has to figure out, why are these headaches getting worse now? Because you still have the same genes that you had when the headaches weren't so bad. You can blame worsening headaches on a 12 year old on genes, because the genes for reproductive hormones are becoming expressed. You can't blame genes on worsening headache in a thirty year old. For patients with frequent or severe headaches, there are a number of reasons why someone who was born with a familial tendency to have headaches may get worse. Frequent causes of worsening migraine include hormonal changes of a variety of sorts, daily use of caffeine or OTC painkillers, as well as a long list of other things that fall into the category of disturbed metabolism or hormonal disturbances. Interestingly, one of the common factors we see is the development of neck pain; it's probably a form of "kindling", in which the brain learns to have a headache in the neck. The neck begins to stay guarded continuously in expectation of a headache, and then the neck pain can itself become a trigger for migraine.
The Russian physiologist Ivan Pavlov did some remarkable work on classical conditioning. As you may already know, Pavlov is famous for investigating conditioning in reflexes. When you show a dog food dry food, he salivates; show a dog dry food and ring a bell, he salivates; after awhile, you just ring the bell and even without food the dog will salivate. Something similar happens when you have chronic headaches and then strain your neck by lifting weights over your head at the gym (this also happens with a minor automobile rear-end collision, or by spending too much time in one position at your job). So, you have attacks of headache; you have neck pain; they occur together; after awhile, headache will cause neck pain, and neck pain will cause headache. Pavlov investigated all these cortical association mechanisms, and they are well demonstrated when people with headache exercise and end up with neck pain that won't go away. The phenomena of association of different pain problems is a common one; another example explained by Pavlov's association work is the persistent sinus pain in people who have both sinus problems and migraine.
So you have to think about why the headache may have worsened at this time in order to treat headache effectively.
Q- What do you mean by inducing a headache remission?
A- Some headache specialists emphasize that the goal of headache treatment is to partially reduce the frequency of attacks with a prophylactic medication. What you get from this approach is simply a preventative medication, which you can expect to take for the rest of your life, or at least for decades (perhaps until menopause). I think this is too gloomy a picture for most patients that we see. I think of chronic headache as typically having two components, the first component being what the underlying condition the patient is suffering from (let's say it would be migraine), and then the conditions that are making it worse and which are typically responsible for the increase in headache pattern the patient may have experienced over the previous few years. Those conditions that worsen a tendency to headache are those for which we hope to obtain a remission. Conditions which worsen headache may include rebound headaches from overuse of OTC painkillers or caffeine, development of neck problems, lack of sleep, emotional changes, vitamin deficiencies (such as Vitamin D, an anti inflammatory agent produced by the body naturally), hormonal problems (menstrual or thyroid being common), and personal habits of rest and diet. I like to aim for a complete remission of that component of headache which has worsened in the first few weeks of treatment, using medication. By remission, I mean freedom from minor daily headache, as well as cessation of significant attacks if they are occurring.
So, early on in the treatment of severe headache, I feel it is helpful to be aggressive with medication. Following the induction of remission, it becomes important at that time to shift treatment away from chronic medication, and onto attention to exercise and other factors that can be improved. We find that the most important time to exercise is when a remission is induced. In my experience, patients who exercise at that time have a 70% chance of being able to do without preventative medication in the future, but only a 30% chance if they do not exercise.
So, for many patients, exercise turns out to be a long term important factor they can control themselves to get away from medication, and back to a normal lifestyle.