Q: I suffer from both migraines and tension-type headaches. Yesterday, I woke up with what seemed like a normal tension-type headache. I took a Fiorinal® , but steadily my headache worsened until the pain increased to level 8 out of 10. I worried it could be a migraine (although normally my migraines do not start like this) and took a Relpax®. The pain continued to a level 10 and my head felt like it would literally burst. For the first time in my 18 years of migraine I thought about going to the hospital. At one point I was worried it could be a brain aneurysm. It took almost 24 hours to ease up.
Can you please help me understand what kind of headache I had and what I can do next time I have such a headache?
A: It remains a puzzle in the headache world why someone with fairly typical migraine that is easily identified as such will, out of the blue, have a major change in symptom profile and intensity. We often see this kind of change in pattern in migraine sufferers in their 40s and 50s during menopause or with aging, but we also see it at other times for no apparent reason at all.
Sometimes it happens because the factors that lead to triggering a migraine—such as stress, lack of sleep, weather changes, consumption of certain foods, certain phases of the menstrual cycle and even a letdown from stress—pile up, leading to an atypical, severe episode of head pain. An example would be a student who is experiencing the stress of exams, along with poor sleep, too much cheese pizza and the start of her period. If you look back at the time of your bad headache, you may find a combination of such factors. Preventing similar headaches in the future may be a matter of good self care, including adequate hydration, rest and exercise.
The pain medication you mentioned (Fiorinal) is okay but probably could have been taken every two to three hours for three to four doses along with 400 mgs. of liquid ibuprofen. Relpax is a good choice for acute migraine treatment, but it needs to be taken early. It may be taken again within two hours of the first dose if it is less than 70% effective.
If these episodes continue as you have described, it will be important to check your blood pressure during and in between headaches. A neurological consultation to go over your history and medication use, as well as an exam, would be the next step in deciding on other diagnostic tests, preventive strategies and acute pain management.
Finally, major head pain that comes on and intensifies over hours and then fades to no pain is not typical for a bleeding or leaking aneurysm or for brain infection. With an aneurysm, the pain is often sudden in onset and very severe. It is frequently accompanied by a depressed level of consciousness and stroke-like symptoms, such as weakness, loss of speech, nausea, stiff neck and sometimes fever. The pain lasts for days. I don’t think you had a bleeding aneurysm, although if you had shown up at an emergency room with the report of the “worst headache of my life” you would have earned an MRI scan and maybe a lumbar puncture, “just to be on the safe side.”
Doug Mann, MD, UNC Professor of Neurology, Chapel Hill, NC
