Each year, approximately 2 million people in the United States sustain head injuries, which may result in significant and persistent post-concussion symptoms. The most common post-traumatic symptoms are headache, dizziness, cognitive difficulties, sleep disturbances, anxiety, irritability and depression. We have asked Dr. Jeffrey Klingman to address the support group on the topic of headaches arising from head injury. Dr. Klingman is a neurologist on staff at Kaiser Permanente in Walnut Creek and a Clinical Assistant Professor in the Neuro-logy Department at UCSF.

This promises to be a very interesting and informative lecture. If you know someone with headaches that are due to head injury, be certain to invite them to join us

The goals of the National Headache Awareness Week, sponsored by the National Headache Foundation, are:

• To gain recognition of head pain as a real and legitimate condition.

• To encourage sufferers to see a physician for proper diagnosis and treatment.

• To let sufferers know there are new treaments available. 

Contact the National Headache Foundation at 1-800-843-2256 for more information.

I have lived with headaches all my life, certainly since I was 9 years old. I remember being a thirdgrader, assigned to draw a picture of myself. I drew myself in profile with the back of my head elongated. I had so many headaches, always located right below my crown, that I visualized the back of my head as a long oval. For years I treated them successfully with aspirin or, rarely, with acetaminophen and codeine, which I had saved from a surgery for those few times when aspirin didn’t work. I thought of my headache episodes as relatively harmless, treatable nuisances. I never wondered what caused them.

Aspirin Sensitivity: The Catalyst

Then several things forced me to seek help for my headaches. One winter evening 3 years ago I developed hives after taking aspirin. I was told that if I took aspirin or any NSAID again, I could die. For the first time in my life, I discussed my headaches with a physician. The allergist who diagnosed my reaction knew me well; I had been a patient in that clinic for 17 years. When I told him that acetaminophen with codeine was the only other medication that relieved my headaches, he trusted me. He gave me a onetime prescription and urged me to work with my primary physician to find out more about my headaches. "I’m sorry, but I’m not a headache expert," he said, honestly enough.

The Frustration of Not Being Heard

Four weeks later, I lost him. My exhusband’s business (through which I had COBRA coverage) changed healthcare plans. The credibility I had developed over time with my doctors didn’t transfer. The new plan’s physicians knew nothing about me. In the meantime, I doled out my headache medication as if it were gold. I always asked myself, "How bad is this headache? Is it worth being sedated?" Once a month, when the headache was bad enough, I toughed it out and waited until bedtime before I treated my pain.

After the initial greetings and medical histories, I approached first one new physician, and then another, about my headaches. I was embarrassed to discuss pain directly; I hoped to convince them that I had a legitimate need for codeine. The reaction was hardly enthusiastic.

When I said: "The only thing that works for my HEADACHES is Tylenol with codeine..."

They heard: "The only that works for my headaches is Tylenol with CODEINE."

Once the "junkie alarm" was tripped, nobody could believe that the headaches were really the reason for the appointment.

To be honest, my own attitude toward my headaches didn’t help, either. I felt selfconscious bringing them up. I had a hard time describing them. I really thought that the only problem with my headaches was that aspirin had been taken away from me as a choice. So I held back. I only talked about what worked to treat them. If I had talked about pain, I would have said, "I usually have to call a friend to keep from screaming." Perhaps, then, I would have communicated more effectively.

Ten months after my aspirin reaction, I had a headache that scared me. When the codeine wore off, my pain came right back. I felt so hopeless. I lost control and screamed at my 11-year-old son. The next morning I realized that it was time to act. My headaches were affecting the quality of my family life, and I found it unacceptable to punish my children for my pain. They, and I, needed a solution.

I looked in my new health plan directory under "neurologists" and found "The Headache Institute." If they can’t treat my headaches, no one can, I said to myself. Luckily, I didn’t need a referral.

I still felt selfconscious at my first appointment. It was hard to take my pain seriously. But the nurse who talked to me was the first health care professional who actually knew the questions to ask. "How often do you have to take Tylenol with codeine? How long does it take for the medication to take effect? Are you sensitive to sound? Does anyone else in your family have headaches?" Nobody had asked me those questions before. Although I had never thought of myself as sound sensitive, I thought about my last headache, the week before. I had postponed some scheduled home repairs because I knew I wouldn’t be able to stand the sound of drilling.

More Than a Diagnosis

By the end of the appointment, I had a diagnosis of common migraine and a medication (sumatriptan) to take that was non-sedating and non-habit forming. I had more than a diagnosis and treatment, though. My new doctor offered me compassion for my pain. When I described a recent headache that had come on after a stranger was rude to me in public, he shook his head and said, "Don’t you hate being vulnerable?"

"I know you can’t schedule your headaches," he said as I left. "If you get a severe headache and your medication doesn’t work, call. If it’s in the middle of the night, call. I will treat you in the emergency room. I consider migraines an emergency." Nobody, including me, had ever taken my headaches so seriously.

As I drove away, I thought about my years of mystery headaches and of my childhood self-portrait with the long aching head. Then I burst into tears as if 35 years of pain were being released.

I had an answer. I felt sorry for my poor head and sad that it had been so easy for me to trivialize what my new caregivers took so seriously. I also cried from relief that my wandering was now at an end.

My migraine diagnosis has meant more than having the proper prescription. I am thankful that I, like my doctor, can now treat my headaches like a big deal. In so doing, I have found the courage, ironically, to quit being brave.

Paula Moyer, Minneapolis, MN

Excerpted from the Winter 1997-1998 issue of Headache, the newsletter of the American Council for Headache Education.

A. Your question about the actions of nonsteroidal anti-inflammatory medications is an important one. Non-steroidal anti-inflammatory agents are drugs that are used to reduce inflammation, as well as pain. The pain relief (analgesic effect) usually occurs after only one or two doses. The anti-inflammatory benefits may not be seen for several weeks once the medication is prescribed daily. For arthritis patients and some headache patients, this medication may be prescribed for a long time.

There are many nonsteroidal anti-inflammatory drugs including ibuprofen (Motrin and Advil), naproxen (Naprosyn and Aleve), etodolac (Lodine), indomethacin (Indocin), and flurbiprofen (Ansaid). Several have been shown to be very effective in both preventing and aborting headaches. In well-controlled studies, a small percentage of people taking these medicines, especially indo-methacin, have reported headaches as a side effect. This is to be expected, as so many people react somewhat differently to medications.

You may be aware that some combination pain relievers have been associated with the phenomenon known as "rebound" headache. But this type of problem has NEVER been documented in any well-controlled drug study with nonsteroidal anti-inflammatories by themselves.

Several products combine aspirin with caffeine and have been associated with this type of problem when taken in doses exceeding the labeling instructions. Withdrawal from drugs containing caffeine may also cause headaches. Some analgesics, such as Excedrin, Anacin, and Vanquish, contain caffeine.

Barbiturates or opiates (narcotic-like substances), often found in combination analgesic products, can be associated with an increased number of headaches. Ergots such as Cafergot, when taken in excess, usually more than every fourth day, can also contribute to rebound headaches.

For a person who is elderly and may have reduced kidney or liver function, the nonsteroidal anti-inflammatories with the least amount of side effects are those in the "propionic acid" category. This includes drugs like naproxen and ibuprofen which can safely and effectively provide pain relief and reduce inflammation.

Excerpted from the "Ask the Pharmacist" column in the Summer 1997 issue of NHF Headlines, the newsletter of the National Headache Foundation.