If your headache had a single cause, you likely would have solved it by now.
That may sound harsh, but think about it. If all it took was that one magic pill or that one procedure, then you probably would have tried it at some stage and you’d be done with them and not reading this. Whether we are talking about a natural approach or a conventional approach, “the single cause-single solution” of complex conditions is so last decade. And just as a spider web is complex and elegant, every minor defect or irregularity or damaged strand causes effects to the whole.
A famous physician in certain circles has been known to say “if you sit on five tacks, the only way to be out of pain is to remove ALL FIVE tacks.” Well, I don’t know about you, but I’ve never sat on five tacks. I’ve never known anyone to sit on tacks. But I absolutely understand the meaning of this analogy. It is attractive to find a cause of a problem, fixate on that, put all your hopes into that cause. We’re here to tell you that’s not how this is going to work. What is going to work is to look for any possible dysfunction, even the ones that are not “bad enough” for medicine, and improve that function. That may sound like a lot of work, and it can be, but it doesn’t have to be.
Cervicogenic/ structural headaches
It is absolutely true to say that some headaches arise from neck dysfunction. The small structures in the neck, especially near where the neck meets the head, can be compromised and head pain is the result. Muscle tension is at the crux of this problem. That is why spinal manipulation or manual therapy performed primarily by chiropractors and physical therapists works sometimes. It is also why muscle relaxants like Flexeril (cyclobenzaprine) and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen work sometimes. Massage and all of its various forms often affect headache pain via a structural or cervicogenic mechanism. We said that muscle tension is at the crux of cervicogenic or structural headaches which offers the question, “what causes muscle tension?” Hold that thought.
If you have had the experience where any of these interventions has “taken the edge off” or reduced the intensity, frequency, or duration of your chronic headache, but hasn’t fixed it, you have a structural factor to your headaches.
You’ll notice we didn’t say cause of your headache. Structural factors are common. Structure causes are less common.
If your head feels like it’s on fire, you might have an inflammation factor to your headaches. There is one intervention that affects both structural factors as well as the inflammatory factor.
NSAIDs. Boring headache remedies like ibuprofen, naproxen sodium, and aspirin reduce inflammation as well as reduce muscle tension. Other natural approaches to reducing inflammation exist as well. Curcumin, ginger, boswellia serrata, and white willow bark top the long list of natural anti-inflammatories. However, inflammation is caused by injury. Low-grade, chronic inflammation is caused by chronic, low-grade injury. Sometimes, this takes the form of food intolerances, stress, unresolved viral or other infections, environmental insults like mold, or even just poor health habits. Let’s consider that most people do not take the extra step to determine the cause of their inflammation factor. That means people suffering with inflammation factor headaches who aren’t addressing the cause(s) of inflammation need to constantly quench the fire within. Anti-inflammatories, specifically the pharmaceutical variety, have significant side effects with long-term use. Your stomach, your kidneys, and your cardiovascular system suffer.
If anti-inflammatories help but interventions in the structural area generally don’t, you likely have an inflammation factor to your headaches.
Many people are familiar with blood sugar problems in large part to the diabetes epidemic that is plaguing Western civilization. However, blood sugar (glucose) as it relates to headaches is often overlooked. Headaches can be the result of hyperglycemia, or too much glucose in the blood, or it can be the result of hypoglycemia, which is too little glucose in the blood. We refer to this as the glycemic factor. The glycemic factor may be the most overlooked contributor to chronic headaches. Perhaps one reason for this is that simple blood testing is ordered to determine if you are at risk for or have developed diabetes but not ordered when trying to figure out your headaches. Even when fasting glucose is ordered, it is often times normal even when there is problem brewing.
Blood sugar can be affected by many things:
- Stress levels and how you adapt to stress
- What you eat
- How much you eat
- When you eat
- How much, how often, and how intensely you exercise
- Some genetic tendencies can affect how you balance and regulate the amount of glucose you have in your blood stream at any one time and how you tolerate perturbations in that system
So what causes glycemic problems can be a complex puzzle. However, the solution is not out of reach. If you have headaches that come and go based on meals, you have to consider the glycemic
factor. Besides fasting glucose, fasting insulin is a good blood test to have done. Insulin is the only hormone that allows glucose from the blood stream to enter the cell. Hemoglobin A1c also known as glycosylated hemoglobin is a marker for blood sugar over the course of several months. An oral glucose tolerance test is most frequently given to pregnant women between 24 and 28 weeks to detect gestational diabetes. However, it can help determine if you have insulin resistance and you don’t need to be pregnant for the test to work. All of these tests are fine and good and we like having them done, but there’s one procedure that we prefer even more. Measuring your blood sugar at home up to six times per day and writing the results in a log helps identify patterns of the glycemic factor. You can buy a simple glucometer, lancets, and test strips at any drug store. We recommend testing first thing in the morning, two hours after breakfast, 30 minutes before lunch, two hours after lunch, 30 minutes before supper, and two hours after supper. You can note the time of each test and each meal and also how you felt during the day, especially noting when you have head pain. Here is our Glycemic Factor worksheet.
This brings us to hormone headaches which can be closely related to glycemic headaches.
Many women have headaches related to their menstrual cycle. We often see these headaches treated with oral contraceptives or hormone replacement therapy. Many women are acutely aware that their headaches are related to fluctuating hormone levels while others are not. This is especially the case when the headaches do not present themselves the same way or at the same time each month. We have seen progesterone headaches, estrogen headaches, and on occasion we’ve seen testosterone headaches. You may have perceptively noted that we didn’t say “high” or “low” of any of these hormones. That is because head pain may be caused by high or low levels of each of these important hormones. We find it incredibly important not to demonize any one hormone but rather look at hormones within the context of their complex orchestration.
If you note that your headaches are related to your menstrual cycle, be it premenstrually, during your period, after your period, or middle of the month, you may have a hormone factor headache. Similarly, if you have headaches and also have hormone challenges, you have a hormone factor headache. Examples of hormone challenges we ask about are the conditions polycystic ovarian syndrome (PCOS), uterine fibroids, amenorrhea, fibrocystic breasts, and the experiences of heavy or light periods, how long or short periods are, and how regular and how long cycles are. The use of intrauterine devices or a hysterectomy provides additional clues.
We often are told something like this, “Every time I eat X, I get a headache.” The curt response from any healthcare professional would be “then don’t eat that.” However, it is important to remember that food is complex. Meals are made of several types of foods and each food contains and stimulates certain chemicals. Those who do not have any food intolerances may take the complexity of food for granted. Both the assessment and treatment of food intolerance headaches is the strict avoidance of foods. The question you may have would be “how long do I have to avoid each food?” and “how do I know if I react to it or not?” These are easily identified with a well-developed elimination diet. Minimizing intolerant foods is usually insufficient. Trigger foods “in moderation” often results in a sense that you’ve attempted to assess or treat but really only results in giving you a false sense of security. We have worked with many people who have done an elimination diet but had errors in the preparation or execution of the procedure. If you find that certain foods are triggering your headaches, you have a food intolerance factor.
You can have a sleep headache at any point in your circadian rhythm. You may get headaches because you are getting too much sleep. You might be getting too little sleep over the course of a longer period of time resulting in chronic sleep deprivation, starving your body of important growth and repair factors. Additionally, poor sleep, whether you are aware that you are a poor sleeper or not, may result in sleep factor headaches. Using a wearable device like a Fitbit may provide clues to how restful your sleep really is. Medically, we can order sleep studies but that is quite a commitment unless you have a really good idea that sleep and your headaches are somehow correlated. When we talk about assessing and correcting sleep factor headaches, we approach it a bit differently. We encourage strict avoidance of screen time in the evening, significantly more full spectrum or natural light during the day especially the morning hours, eating breakfast, and proper sleep hygiene habits. By simply getting some details about these parts of your life and improving those areas, we can often improve sleep factor headaches in short order. If you work swing shifts like many of our nursing colleagues do, we have to spend a fair amount of effort dialing in your circadian rhythm to minimize your symptoms. While melatonin is a useful therapeutic, the dose and timing can be complex matters. The same goes for those jetsetters who travel across time zones or spend a lot of time traveling to different places and constantly adapting to new routines.
We are stressed. You are stressed. Everyone seems to be stressed. Sometimes stress results in anxiety and sometimes it results in depression. Antidepressants have a fairly poor track record of correcting head pain. Rather than avoiding pain, we focus on building resilience and our responses to stress. This often requires a commitment to mind-calming exercises as well as targeted nutrients based on your secretion of cortisol throughout the day within the context of your life circumstances. If you note that your headaches are worse after a stressful event, you have a stress factor headache. You can also set off glycemic factor or GI factor headaches with additional stress. Hormone factor headaches will get worse with stress factors as well.
Closely related to stress factors are anxiety factor headaches. Benzodiazepines have a fairly nasty list of side effects. If you have anxiety and are taking anything from this class of medications, addressing metabolic characteristics of anxiety is strongly suggested.
Headaches and your GI system could be a whole topic in and of itself. Psychiatrists, psychologists, and nurses often identify this connection. Gastroenterologists, endocrinologists, neurologists, and family medicine rarely make this connection adequately. Gastrointestinal and digestive impairment, whether it is minor, moderate, or severe, can be a significant factor to chronic headaches. In our experience, GI factor headaches rank alongside glycemic headaches as the most overlooked contributions to chronic headaches.
Why? Perhaps it’s because your GI system can be functionally impaired or sub-optimally functioning but there are many redundancies in the system. If your gastric juices are sufficiently secreted or improperly timed and your food does not get digested properly, you have a whole community of microflora to jump in and do the job. That works in the short run, but long term, that causes a variety of problems including small intestinal bacterial overgrowth, recurrent fungal infections, and poor assimilation of nutrients. And that’s just one example.
There are dozens of such examples. Neurotransmitters are in high concentration in the gut. These chemicals are implicated in stress resilience and depression. When we started assessing everyone for gastrointestinal and digestive dysfunction as well as addressing other factors, our success rate skyrocketed in regards to chronic headaches and many other conditions. While there are many tests, some very invasive, to assess gastrointestinal function, quite often a structured questionnaire and a trial of therapy or two of targeted nutritional supplements help us understand the primary dysfunctions. However, with hundreds of ingredients on the market that have been identified as providing some benefit to GI health, a prudent approach is to carefully select the most elegant formulas based on all of your symptoms rather than focusing too narrowly on one problem. Providing gut rest and allowing it to heal properly using either strategic fasting or an elemental diet is used in the case of moderate to severe impairment.
If your headaches aren’t just getting in your way, but they are wiping you out for a full day or more and you cannot function in even the most basic tasks, you may have a brain-based electrical activity factor. Medications originally intended for seizures are routinely being used for migraine headaches. Topiramate (Topamax), sumatriptan (Imitrex), and gabapentin (Neurontin) are common medications that fit the bill. The trouble with this approach is that often the medications lose effectiveness over time. If these medications help, that is good news! They will provide relief and give us time in order to sort out why there are electrical activity imbalances in your brain. This takes a close look at how your body responds and regulates electrolytes.
Also the structural components of your brain could be part of the challenge. We don’t know too many people who are interested in getting a biopsy of their brain to determine how the fats and structural proteins are situated. Luckily, there are indirect biomarkers of this via simple blood tests like fatty acids in a red blood cell specimen or even the simple lipid panel that your doctor usually runs to assess cardiovascular health. Sometimes healthcare professionals, regardless of their expertise and use of innovative tools, cannot identify the source of an electrical factor headache. In these cases identifying and treating all of the other factors becomes that much more important.
Back to those structural factor headaches…Remember how we said it is important to identify the cause of muscle tension in structural factor headaches? Well, here’s the punchline. Each of the above factors, independently or in any combination, can cause the muscle tension behind structural factor or cervicogenic headaches. Mind. Blown.
Remember, you are allowed to have more than one factor, in fact most do. Digging into each suspected factor and fully treating all factors may result in maximal relief, reduced intensity, reduced frequency, and/ or reduced duration of headaches up to complete resolution.