While the headline is a play on words, in the past many who suffer headaches have been told, “it’s just in your head.” The medical community today knows better.

The headache is one of the most common medical complaints seen in practice. It can be tremendously debilitating; fortunately, they are rarely due to life threatening conditions. This knowledge can ease patients’ anxiety; however, the headache remains.

The majority of headaches are either tension-type or migraine. The most common headache type, in fact, is episodic tension-type headache. It is almost universally experienced by everyone at one time or another during life. Yet doctors rarely, if ever, see this complaint in practice since these headaches are infrequent and are easily treated with an over-the-counter medicine such as acetaminophen or ibuprofen.

Much more commonly seen in practice are patients with migraines. Approximately 20 percent of the population suffers from migraines, with a predominance in reproductive age women. Migraines have been referred to in the past as “sick headaches” because they frequently can be associated with nausea and vomiting.

The headache usually involves one side of the head (although it may switch sides from attack to attack), moderate if not severe pain, pounding and sensitivity to light and/or sound, and many patients have to lie down in a dark, quiet room. It’s debilitating, to say the least.

Our current understanding is that a primary neuronal dysfunction leads to events that result in migraine. Essentially, the “migraine brain” is characterized by neuronal hyperexcitability and an inability to extinguish stimuli as rapidly as non-migraineurs.

There is a strong genetic component to migraines: 80 percent of migraineurs have a first-degree relative with migraines. This genetically predetermined threshold leaves these patients susceptible to an acute attack depending on the balance of excitatory and inhibitory systems in the nervous system. (The previously held theory of migraine as a “vascular headache” is no longer accepted as the pathophysiology of migraine, although vasodilatation is a recognized epiphenomenon.)

Migraine is a quintessential example of how genetics and environment interact to produce an episodic pain condition. There is a positive side to this genetic wiring: patients with migraines frequently are also more “sensitive” to their environment and the feelings of those around them which can lead to better people skills and relationships, among other benefits.

An exciting event occurred in medical treatment in 1992 with the development of a drug class called “triptans.” Most migraineurs would say these are miracle drugs because, when taken early in the headache phase, they stop the headache entirely.

It is important to remember that “abortive” migraine medications such as triptans (as well as analgesics and opioids) should only be used two days a week. If abortive medications are being used three or more days a week, an episodic migraine can be converted to a chronic daily pattern.

For these patients, it is wise to start a preventive agent at the same time an abortive medication is started. There are a number of preventive options available that are well tolerated, and many have very good track records in terms of reducing headache frequency/severity. Pain intervention options including occipital and/or cervical nerve blocks and botox also have shown varying degrees of success in controlling migraine pain.

Medication, however, should only be one component of the approach to treating headaches. Many people with headaches are not aware that lifestyle changes can significantly decrease their headaches. These changes include stress management, regular sleep times (yes, even on weekends), regular eating habits, and exercise, among others.

In fact, it is sometimes helpful to suggest risk factors (as opposed to triggers) and protective factors that can be managed by the patient in order to prevent headaches. When treating a migraine, it is very helpful (and frequently required in specialist practice) for the patient to keep a headache diary in order to track episodes and monitor effectiveness of therapy.

Headache treatment is an exciting field to be in today because of the education and treatment we can give patients to help them escape the pattern of frequent and/or debilitating headaches. It is a privilege to work with these patients and tremendously gratifying to be part of the solution that helps them reclaim their lives.