CHAPTER 5: SPECIAL POPULATIONS: WOMEN, CHILDREN …



Chapter 5: Special populations: Women, Children and teens

I am, being woman, hard beset

Elinor Hoyt Wylie "Let no charitable hope"

Throughout this book, we've emphasized that each person with headache is unique. You may share some characteristics with other headache sufferers, such as a sensitivity to particular foods or environmental toxins, but certain populations deserve special attention because their patterns of head pain are often quite distinct. These groups include women, children and teens.

Until puberty, the incidence of headaches is pretty well distributed between males and females. In fact, slightly more boys are likely to suffer from headaches than girls. But at puberty, hormonal changes set in, and set the stage for headaches -- especially for girls.

Before going any further, it may help to understand the role of hormones in headache.

The hormone-headache connection

Hormones help the body keep a healthy biochemical balance by informing it of outside stimuli, and regulating its responses. Essentially, they are messengers produced mostly by endocrine glands distributed throughout the body, and that travel through the blood to activate necessary changes in the body. Some of these changes contribute to headache.

The endocrine system

Adrenal glands

Located above the kidneys, the two adrenal glands produce two different types of chemicals: catecholamines and steroids .

The catecholamines include hormones that activate the fight or flight response to stress. The greater the stress, the higher the output of hormones such as adrenaline.

There are three categories of steroid hormones: mineralocorticoids which regulate the balance of fluid in the body; glucocorticoids which perform several functions, including the control of blood pressure; and, sex hormones , estrogens (female hormones) and androgens (male hormones). We'll look more closely at estrogens and their role in headache later on in this chapter (see The headache cycle in women ).

Pancreas

The pancreas is an organ located behind the stomach that produces insulin and other hormones that regulate blood sugar levels -- the energy of the body. In Chapter 3, we talked about how skipping meals can cause headaches due to low blood sugar levels.

Pituitary gland

Found in the head, the pituitary gland is control-central for the hormone system. The pituitary is connected to the hypothalamus , which teams up with the pituitary to help it control hormonal functions. For example, the pituitary produces hormones that control other hormone-producing systems.

The pituitary produces gonadotropins which are vital in the female reproductive cycle, including follicle-stimulating hormone (FSH) and lutenizing hormone (LH).

The pituitary glands also make prolactin , which is responsible for producing breast milk in pregnant women. Prolactin levels are also known to jump during periods of stress, and might be part of why headache sufferers respond to stress triggers.

Thymus

The thymus is a gland located behind the breastbone and seems to play an important role in the immune system.

Thyroid

The thyroid is a gland that sits in the hollow in your neck. It secretes hormones that help control metabolism. Higher-than-normal thyroid levels (known as hyperthyroidism ) speed up the body's metabolism, and produce symptoms such as headache, nervousness, palpitations, fatigue and loss of appetite. Lower-than-normal thyroid levels (known as hypothyroidism ) slow the body down, creating symptoms such as headache, accumulation of fluids in the body (edema ), dry hair and skin, weight gain, a slow heart rate, and others.

The headache cycle in women

We mentioned earlier that, in women, the adrenals produce estrogens, and that the pituitary glands produce gonadotropin hormones, LH and FSH.

From puberty through menopause, women are ceaselessly influenced by fluctuations in these hormones, due to the repeated cycles of menstruation and, sometimes, pregnancy. In some women, precipitous drops in estrogen are thought to be responsible for premenstrual headaches.

The menstrual cycle

Below, we'll look at how hormone levels change during the menstrual cycle, and how these changes can contribute to headaches. Keep in mind that, while 28 days is the average length of a menstrual cycle, most women have shorter or longer periods.

Days 1-5: Menstruation

The first day of menstruation marks the first day of the cycle. At this time, progesterone levels have dropped, and the uterus contracts, causing painful cramps in some women, to help release the lining of the uterus -- menstrual bleeding.

Headache-causing factors

Migraine: Before menstruation, estrogen levels drop quickly. It's thought that this sudden fall triggers migraine. The premenstrual phase sets the stage for a migraine during menstruation.

Tension-type headache: Stress and pain couple during menstruation to create ideal conditions for a tension-type headache. The heightened activity of the adrenal glands during this time pumps more estrogen into the system, which also might contribute to headache.

Rebound headache: Many women rely heavily on anti-inflammatory drugs during the first few days of their periods to relieve cramping and back pain. In some cases, rebound headaches (see Chapter 2) could result after discontinuing them.

Days 5 - 9: Post-menstruation

With the exception of FSH, hormone levels are low. FSH levels are increasing to stimulate the ovaries to ripen an egg within the follicle (a kind of nest that forms on the ovary) , which in turn, puts estrogen production in faster motion.

During this time, women are feeling what one woman I know calls her "mid-cycle high" -- as a result, headaches are generally at an all-cycle low.

Days 9 - 14: Proliferative phase

Days 9-14 are called the proliferative phase because this is when the egg starts to mature. FSH levels decrease, estrogen levels increase and luteinizing hormone begins to accumulate. Again, the slow, steady rise in estrogen does not cause many headache-related problems during this time.

Days 14 - 28: Premenstrual phase

The oocyte, or egg, has matured and is expelled from the ovary to the fimbrae, where it makes its way down the fallopian tube and, ultimately, to the uterus. During this time, estrogen and LH levels fall dramatically; LH first then estrogen. The ovaries produce progesterone to nurture the developing egg in case it has been ferilized by sperm.

The vasculature of the uterus is now growing, producing more blood. If the egg is not fertilized, the uterine lining will shed during the process of menstruation.

Migraine and tension-type headache: the abrupt fall in estrogen and progesterone levels set the stage for migraine. Simulataneously, prostaglandin, a hormone that increases sensitivity to pain, also increases as a result of these hormonal swings. The result is not only conditions for migraine, but a higher sensitivity to pain.

The role of magnesium

There is also evidence that magnesium levels are reduced during the premenstrual phase. As mentioned in Chapter 3, magnesium deficiency has been linked with blood vessel constriction and with the release of substance P, the biochemical that sets in motion pain-causing inflammation. In my studies, about 50% of people with a migraine attack appear to be magnesium-deficient, and this deficiency strikes women with migraines more often than men.

Birth control pills

We've just seen how monthly hormonal changes, particularly in the levels of natural estrogen, can lay the groundwork for headaches in women. Hormonal changes also occur due to other biologic events in a woman's life, including pregnancy and menopause. Estrogen-containing drugs, such as the birth control pill and estrogen therapy (such as Premarin®) which is used to ease the symptoms of menopause, can also affect estrogen levels, and

a woman's vulnerability to headache.

Migraine is one of the most common side effects of oral contraceptives, or the Pill. It can set off a migraine, worsen its severity, or increase its frequency. Though migraine is most common among women who are prone to headache, for some women, taking the Pill triggers their first attack.

The Pill helps prevent pregnancy by raising estrogen levels; it's the increase in estrogen that produces headache-causing changes in blood vessels. Estrogen can increase platelet aggregation, which increases the risk of headache-triggering events. It also heightens the risk of other problems related to blood clotting, such as stroke.

Certainly, the Pill does not cause migraine in all women, nor does it trigger migraine in all women who are vulnerable to it. In fact, some women notice a reduction in the severity and frequency of their headaches when taking the Pill. This effect may be more common among women who normally experience great fluctuations in estrogen and who, by taking the Pill, find that their estrogen levels are more stabilized.

Menopause and hormone therapy

Menopause is defined as the cease of menstrual periods. But, with the exception of women who undergo surgical removal of their ovaries, menopause is a process -- a natural series of biologic events that result in the end of menstruation -- it takes an average of four years for a women's menstrual periods to come to a complete halt. During these years before menopause (premenopause ), women slowly start to experience hormonal changes that can cause headaches. The length of periods may change and the cycle between periods can get longer or shorter. This cyclic instability is caused by changes in hormone levels. The key word here is instability; estrogen levels (and levels of other hormones, such as progesterone) tend to rise and fall even more sharply during this time. The decline in estrogen will often result in dilation of blood vessels -- a set-up for headaches, as well as hot flashes.

Women who undergo surgical menopause due to removal of the ovaries (oophorectomy ) or removal of the ovaries and uterus (total hysterectomy ) are more likely to have a more intense reaction because of the abrupt decline in estrogen.

For many women who suffer from migraines, menopause often harkens a new headache-free era. But a great many women experience other disruptive effects such as hot flashes, vaginal dryness, heart palpitations, joint pain and, possibly, headaches. These effects are directly linked to the loss of ovarian estrogen and progesterone.

Other long-term effects of menopause include osteoporosis (bone loss) and an increased risk of heart attack. For these reasons, many women take estrogen therapy, or hormone therapy, which combines estrogen and progesterone. Hormone therapy takes the form of a pill, creams and skin patches.

Clinical studies have shown that hormone therapy can help prevent osteoporosis, and ease the physical discomfort of menopause; but it could also aggravate headache. In much the same way as the Pill, estrogen therapy in any form (pill, cream or skin patch) can set in motion the biochemical events that lead to headache -- platelet aggregation, serotonin release, substance P release, inflammation of nerve endings and vasospasm.

Any change can bring stress. And "the change of life" can be a substantial stressor for women. As anyone who has experienced a hot flash knows, the physical symptoms alone can be a source of emotional stress. Loss of sleep due to night-time hot flashes (also known as "night sweats") disrupts the body's biorhythms, setting the stage for stress and headache. Also, laden with negative social symbology, menopause may be seen by some women as an adverse change, causing a decline in self-image. Thankfully, today, menopause is no longer as much a veiled subject as it once was, and there are many articles, books and magazines devoted to helping women gain an understanding of menopause -- which, hopefully, will help change some of the negative sterotypes surrounding this natural process. (See Resources for more information.)

Pregnancy

Hormonal changes are highly charged during the first three months of pregnancy. The fluctuations in estrogen can be great enough to bring on the first migraine attack in some women -- or heighten the pain for those who already suffer. After the third month, however, most women experience relief.

After pregnancy, when estrogen and progesterone begin their sharp ascent, headaches might recur, or come on after several headache-free years.

Headaches and children

We often think of headaches as an adult disorder, and become particularly alarmed when a child complains of chronic head pain. While any sudden pain should be taken seriously in children since it may signal a serious underlying problem such as meningitis or encephalitis, the vast majority of headaches in children are benign. (See page [TK] of Chapter 2 for the warning signs of potentially dangerous headaches.)

But chronic benign headache is surprisingly common among children. It can occur in children of any age, from infancy through teenage years. Unlike adults, headaches strike children with less gender bias than adults: males and females are almost equally afflicted.

Headache sources in children

Children are prone to the same types of headaches as adults (except, of course, hormone related headaches), though they may be more vulnerable to headaches related to trauma due to falling down or bumping their heads. They may also be more sensitive to infections, reporting headache symptoms that are really caused by an ear infection, cold or sinus infection. With teenagers, particularly young women, the relatively sudden escalation of hormones could be a powerful headache trigger, often potentiating the first headache attack.

As with adults, headaches can be brought on by stress, improper posture, dietary factors, environmental assaults (bright lights, odors, etc.) or emotional distress. Indeed, the child may be more sensitive to the toxins in the environment, and is not well-armed to cope with potential sources of food allergies.

Migraine in children:

variations on a theme

Migraine is not uncommon among children; more than half of migraineurs have their first migraine attack before the age of 20.

Symptoms

Very young children may not be able to express the source of their discomfort. They may appear restless and irritable, pale and "fragile". If they have a severe headache, they may seek out a quiet, dark room -- just as adults would. Most migraine symptoms mimic those experienced by adults (see Chapter 2); they are more likely, however, to have pain on both sides of their head, whereas adults usually have pain only on one side. In addition to the migraine described for adults, migraine in children may take other forms:

• Abdominal migraine. Expressed as nausea and/or vomiting, with or without headache, lasting for hours or days. Children may be more prone to motion sickness. Clearly, it is important to rule out other potential causes for abdominal pain before marking it as a migraine.

• Basilar migraine . A prodrome to head pain, or accompanying head pain, experienced as weakness or numbness of the limbs, unsteadiness, dizziness or loss of consciousness. Some children also experience an acute confusional state , which can occur separately from the headache, where they become drowsy and/or listless and irritable. They may see shapes changing, or smell odors that do not exist. These symptoms usually disappear within an hour. This type of migraine may persist into adulthood.

• Hemiplegic migraine. Numbness and/or weakness of an arm or leg on one side of the body, along with head pain. May also persist into adulthood.

• Ophthalmoplegic migraine . Weakness of the eye muscles causing double vision, usually accompanying headache. Again, it is important to rule out other possible causes before settling on a diagnosis of migraine. May also persist into adulthood.

Tension-type headaches

Children are subject to the same responses to stress as adults. Bodily stresses caused by improper posture might be a source of headache-causing muscle tension -- which is more easily corrected at a young age. Also, as with adults, the source of tension-type headache can often be traced to emotional issues. Symptoms of tenstion-type headache in children are similar to those in adults.

Emotional factors

Children are often exquisitely sensitive to emotionally charged-issues at home, with friends and at school. In their book Headache Free (Bantam Books, 1996) Roger Cady, MD and Kathleen Farmer, Psy. D. describe the sick child as "an emotional barometer for the climate at home." Just as headache may be a symptom of an underyling physical disorder, it may also be the most clearest signal of deeper emotional problems -- depression, anxiety, frustration or hopelessness. How is the child doing at school? Is she experiencing great pressure from friends or schoolwork demands? Does he have fears or insecurities about his role in the family? Rather than view the child's chronic headache as a mere play for attention, parents may be well advised to see it as a real call for help.

Evaluating the child's headache

Even the most articulate and self-aware adult can spend several frustrating years before finding a doctor who can diaganose the cause of her headache. Children are at an even greater disadvantage. How do you distinguish between a headache that is potentially severe and life-threatening and one that is benign? Roger Cady, MD, and Kathleen Farmer Psy. D suggest asking the child the following questions:

• Where does it hurt?

• When did the hurt begin?

• How did the hurt begin?

• Does it hurt as bad as skinning your knee?

If the headache continues to recur, Cady and Farmer suggest these ways of delving more deeply into emotional issues:

• Do your feelings hurt as much as your head?

• Are you mad at one of your friends?

• How is school going?

• Have you had any problems on the school bus?

Headache alternatives for children

An understanding of the sources of your child's headache is your best guide to the solution. Pay special attention to the timing of your child's headache -- did it occur after eating a particular food? Does it always happen after going to a certain friend's house? There may be a food or environmental sensitivity at work. You'll find pointers for detecting these sensitivities -- and solutions for averting them -- in Chapter 6.

Opening discussions about emotional issues can help defuse anxieties. Children are especially responsive to relaxation and biofeedback techniques -- described in Chapter 8.

Postural problems can be detected -- and reversed -- in several ways. See Chapter 7.

In short, holistic alternatives described in the next half of this book may be particularly appealing to the parents who want to avoid chronic drug therapy for their children with headache.

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