Have you ever had a headache so bad that you sought relief at the hospital’s Emergency Room? Many of us have, and have not always had satisfactory results. The East Bay Headache Support Group is pleased to have Dr. Stuart B. Shikora talk about what to expect when you arrive at an Emergency Room with the complaint of severe head pain. What treatment options are available to you, and what can you do prior to the visit to maximize your chances of finding quick relief for your pain? These and other questions will be explored during Dr. Shikora’s presentation.

Dr. Shikora practices Emergency Medicine at Mt. Diablo Medical Center in Concord and Kaiser Medical Center in Walnut Creek. He trained at Hahnemann Medical College in Philadelphia, and is board certified in both Internal Medicine and Emergency Medicine. Dr. Shikora’s practice of Emergency Medicine covers 24 years, during which he served as Chairman of the Emergency Department and President of the Medical Staff at Mt. Diablo Medical Center.

A migraine sufferer will speak about her experiences, and Michael Stein, M.D., will outline specific steps a migraineur can take to defend his/her lifestyle against the often devastating effects of migraines. There will be a question and answer session, and brochures with helpful information about managing your headaches.

Registration begins at 6:30 pm and the meeting is from 7:00 to 9:00 pm. Call 800-373-4503 to register and/or get more information. We hope to see you there...and bring a friend!

You feel a migraine coming on and take a 50 mg tablet of sumatriptan. You know from experience that sumatriptan works for you. While your headache won’t go away completely, you’ll improve enough within an hour or so that you can continue to function.

Suppose someone had secretly replaced your sumatriptan with a look-alike tablet that contained only flour. Would you know the difference?

You might not. Because of a phenomenon known as the placebo effect, you might get just as much pain relief from the flour pill as from the real drug.

In studies of pain-relief medicines, about one-third of people given a dummy (placebo) medicine will report improvement. The actual percentage can vary considerably from study to study, but it is usually substantial.

In mind-body medicine, the placebo effect is credited to the self-healing powers of the mind, to the individual’s belief in and desire for cure. The individual’s beliefs and expectations certainly play a part, but there are more down-to-earth explanations for the placebo effect that should also be considered.

Pain intensity can vary from one moment to another. For pain conditions and some chronic diseases, such as lupus, psoriasis, or multiple sclerosis, there are often alternating cycles of improving and worsening symptoms. Just by chance, you might start an effective drug when you are entering a phase of worsening symptoms and decide it is ineffective, since you have no way of knowing that your symptoms would be worse without it. This is one of the reasons why pain specialists often urge their patients to give a new medication a longer trial, even if it doesn’t seem to be helping right away. Or, you might take an ineffective drug during a cycle of milder illness and believe that it has helped you. So, sometimes a placebo appears to have miraculous powers when the illness was improving on its own.

From childhood on, we’ve learned to associate relief with a pill, capsule or injection. This is partly a conscious expectation, but it can be unconscious as well. Decades of experiments with animals have shown that they can be conditioned to respond in specific ways to a given signal or stimulus. The most famous example is Pavlov’s experiments with conditioning dogs to associate the sound of a bell with food. After many such experiences, they would begin to salivate when they heard the bell, before the food appeared. Other experiments with animals have produced results very similar to a placebo effect, where the animal’s nervous system learned to respond in a particular way to a pill or other stimulus.

If you have already learned, consciously and unconsciously, to expect migraine relief from a little white tablet, then you might well get comparable relief from the flour pill that looked just like it. These placebo effects tend not to last, however. If all the pills in your prescription had been changed, you might get progressively less relief as you continued to take the placebo tablets.

Expectations can affect response to an active drug. Two British studies examined the effectiveness of acetaminophen for relieving pain after childbirth. The first study compared acetaminophen to a placebo; the second study, done in the same hospital ward with similar patients, compared acetaminophen to another pain reliever, naproxen. The women in the first study, who knew that they had a 50-50 chance of being given a placebo, reported less pain relief from taking acetaminophen than the women in the second study, who knew that they were going to be given one of two effective pain relievers.

Our powerful expectations are partners in helping medication work. Besides pills and capsules, the whole experience of seeking and getting medical attention is thought to have a potential placebo effect. The white-coated nurses and doctors, the diplomas on the wall, the examination table, the familiar instruments, and the authoritative diagnosis can all have an impact in making the person feel better that something is being done—even before any medication is prescribed. So the next time you are thumbing through old magazines in the waiting room, think: you might actually be getting help already.

Excerpted from the Summer 1999 issue of Headache, newsletter of the American Council for Headache Education (ACHE).

The two symptoms of headache and dizziness have considerable overlap. Both are very common conditions, so they are bound to occur together in some people. However, the relationship between headache and dizziness is often much more complicated than sheer coincidence in the same person.

First, people with headache often experience dizziness as part of their head-ache, and people with dizziness often have headache during periods of dizziness. Secondly, each symptom can trigger or worsen the other in certain people, and treatments for one symptom can provoke the other, conversely, successful treatment of one symptom can lead to the improvement of the other symptom. Lastly, certain medical problems and treatments can have both headache and dizziness as associated symptoms.

Headache is generally considered the most prevalent of all human diseases; only 4% of women and 9% of men have never experienced a headache. An estimated 45 million Americans suffer chronic, recurring headaches, and between 5% to 10% of Americans seek intermittent medical care for head-aches. Headache is predominantly a disease of women: 70% of migraine patients are women, and 75% of tension-type headache patients are women.

Dizziness is also very common. Each year, fully 10% of the population seek medical care for dizziness. Dizziness is also more common in women: 75% of motion intolerance patients are women, and approximately 70% of Meniere’s disease (a disorder characterized by dizziness) patients are women.

Several forms of migraine can have dizziness as part of an attack, either before, during, or after the head pain. Migraineurs frequently describe dizziness or vertigo preceding a migraine attack, even if they do not experience the more common aura symptoms such as visual or sensory changes.

In basilar migraine, a subtype of migraine, spinning dizziness is part of an array of aura symptoms, which can include diminished hearing or ringing in the ears, slurred speech, double vision, uncoordination, sensory or strength changes, or even diminished level of consciousness. These neurologic symptoms occur shortly before the headache, and are usually replaced by the head pain itself.

Dizziness can also be felt during a migraine attack; the combination of severe head pain, nausea and malaise during an attack can be perceived as dizziness. Since migraine sufferers often retreat to a dark environment during an attack because of sensitivity to light, the lack of visual information that they normally use to help their sense of balance is not available, and this can increase dizziness.

After the head pain is over, dizziness can be part of the postdromal, or hangover, phase of a migraine attack. Other postdromal symptoms are tiredness and aching; cognitive changes, such as impaired concentration, and appetite changes, such as cravings or poor appetite.

Some diseases of the balance organs are more common in people with headache. Meniere’s disease causes attacks of vertigo with nausea or vomiting, one-sided fluctuating hearing loss or ear ringing, and one-sided ear fullness or pressure. Many investigators believe that Meniere’s disease and migraine are different expressions of the same underlying process. Meniere’s disease is statistically more common in people with migraine versus the general population.

Motion sickness (motion intolerance) is a condition that produces dizziness with seemingly routine motion. People often experience this condition from an early age continuing through life, though they may learn to avoid movements that produce dizziness. Like Meniere’s disease, motion sickness is statistically more common in people with migraine versus the general population.

Benign paroxysmal vertigo is a condition that affects children and produces sudden, brief attacks of spinning dizziness. It may cause the child to cry in fear and hold onto others during an attack. Although these spells typically do not include headache, they are thought to be a type of migraine. Children who experience these attacks often will have migraine later in life, and frequently have family members with migraine.

When occurring in the same person, headache can worsen dizziness, and vice versa, even when they are considered to be separate conditions. The pain of headache can fuel any cause of dizziness, and the distress of dizziness or vertigo can trigger headache or escalate existing headache. Thus, successful management of headache can improve dizziness, and therapeutic maneuvers that treat dizziness can often have the added benefit of less head-ache.

Treating one condition can also open up options to treat the other condition. For example, people with both motion sickness and chronic tension-type head-ache often find themselves in a vicious cycle: spells of dizziness worsen their headaches, and their headache medications worsen their dizziness. If they perform certain exercises to markedly decrease their motion sickness, they can now use medications that previously weren’t tolerated, and can also use non-medication treatments such as cervical spine extension exercises, which, earlier, may have worsened their dizziness.

However, treatments for one symptom can sometimes worsen the other. Virtually all medicines have some reported incidence of headache and dizziness as side effects. Some medicines used to treat headache are more frequently associated with the side effect of dizziness (see table below). If you are suspicious that your medication may be causing side effects, please discuss your concerns with your doctor or pharmacist.

Diseases that affect the cerebrospinal fluid that bathes and cushions the brain can produce dizziness and head-ache; sometimes these symptoms transiently appear after a cough, sneeze, or with lifting heavy objects. Temporomandibular joint diseases can produce both headache and dizziness; clues are pain in the jaw joint with extended use, such as gum chewing, and painful "clicking" or "clunking" of the joint on movement.

Lastly, substance exposure can produce both symptoms. These symptoms, among others, can occur after exposure to toxins such as carbon monoxide or organic solvents.

Medications given for other medical situations can produce the side effects of headache and dizziness, with some oral contraceptive agents and high blood pressure drugs as common examples. Again, the onset of headache and dizziness relates to starting a medication, or symptoms appear following doses of medication.

As always, open discussion with your headache physician about your symptoms, including dizziness, is an important component to your comprehensive care. Discussing your symptoms will allow your physician to ask the right questions and develop an appropriate plan of care for you.

Excerpted from the Summer 1998 issue of NHF Headlines, the newsletter of the National Headache Association.