Headaches

Headaches.

I have had my share of them over the years.  More than average I dare to say.  I have had medical tests, CT and MRI scans, dental visits and special mouth guards to prevent teeth grinding while sleeping and have taken more over the counter and prescription drugs than the local drug addicts during my years.  I still remember my first severe headache on a trip with one of my friends to Six Flags of Texas in Dallas.  What a miserable time.  Ultimately I had sinus surgery ten years ago, which relieved almost all of them.

Believe me, I know how you feel.  When the pain is so bad you wish someone could drill a hole in your skull to relieve the pressure and all you can do is lie on the cold, tile floor with an ice pack on your head after taking tons of medicine and pray “God, please take away the pain.”  I’ve been there.

If I could break down my patient’s main reasons for wanting an eye exam into three categories, they would be in this order:

1. Blurred vision –either just a slight blur or a major blurring at distance or near, with or without lenses.

2. Wellness checkup – they see okay with or without vision correction but want to make sure everything is healthy and maybe update their contact lens prescription while having no apparent problems.  Perhaps previously diagnosed with a medical eye condition and ensuring there is no progression.

3. Headaches – There are so many things that can cause a person to experience a headache, it can give somebody….. well, quite frankly,  a headache trying to find the cause.
Since there are so many causes of a headache, a good patient history is absolutely important.  When did they start, do you have a history of headaches before, how often do they happen, how long do they last, what region of the head do they hurt at, what time of day do they generally happen, are they disabling or can you still function, do you have any vision abnormalities like spots or wavy lines before or during the headache, does medicine help the pain, do you get dizzy or nauseous with the headache, do they seem to happen related to certain activities such as reading or computer use, what other medical problems do you have that you know about, what medicines do you use or recently stopped using?  Doctors have to consider the patients age, sex, family history, history of seasonal allergies, medicines being used or even discontinued recently and any medical conditions you might have.    Your diet, water intake and sleep apnea even can play a large role.  Headaches are perhaps one of the most challenging diagnoses due to the many possible causes.  I will cover the most common in order of prevalence that I often encounter.

1. Uncorrected basic vision

When someone comes in with a complaint of frequent headaches, after the preliminary testing, one of the first tests we do is a refraction of the eyes.  That is the part where we determine how the eye can see and what glasses prescription might be needed to make the patient see more clearly and see more comfortably.  You know, “Which is better, one or two?”

The most common cause of headaches that I see in my office is uncorrected farsightedness, especially in school age children.  If the patient is farsighted, they can see far away easier than up close.  They may be able to see up close too but they have to work twice as hard as normal to do it if their eye is using it’s near focusing ability (accommodation) to help the patient’s far vision.  It does that subconsciously like an auto-focus camera.  The eye should only “focus” or tense up when looking at objects within arm’s reach for the most part.  Uncorrected farsightedness (hyperopia) makes the eye, without even thinking about it; try harder to keep the vision clear while looking far away.  That constant, unneeded focusing causes strain and ultimately headaches in the frontal region of the head or around the eyes usually by the early or late afternoon after focusing the eyes more than average.  Basic single vision glasses worn all the time will typically resolve the headaches even though the vision of the patient has been clear anyway up until this point.  The eyes are just working too hard and the extra muscle tension causes the headache.  So farsighted glasses correction is more for comfort than to help the vision in many cases.

2. Uncorrected near vision after 40 years old

After the dreaded big 4-0, (typically 43 years old) the focusing system of the eye that helps to see up close begins to weaken.  The lens in the eye becomes stiffer and less flexible, which causes the automatic focusing of the eye to strain even more to make your near work activities harder and harder to see.  It’s not a weakening muscle, it’s simply the lens not able to flex anymore very well, like a piece of old rubber that doesn’t flex very well.    At this point, we need extra help to see up close clearly and comfortably.  Whether we need a prescription or not for the far away vision and more power for up close, then at that point a multi-focal lens with multiple focusing powers is recommended so people can see at all distances.  When patients that are 40 years old or over seem to get headaches after reading or other near vision work, quite often this is a sign they need a multifocal lens such as a progressive lens or a bifocal.  This is like using a tool to take the load off the eyes and make them focus better and not to have to strain to see.  If you get headaches after reading or looking up close and your arms seem too short anymore, more than likely you need help with the focusing in the form of a multi-focal lens.  Glasses or contacts can help.

3. Binocular vision disorders

The eyes are separate organs that work as a team (think of a pair of horses yoked together) to give clear, comfortable, binocular single vision.  When the coordination of the two eyes is not optimal, they have to work harder than normal , if they can, to keep the eyes aligned exactly in the same direction in order to not see double.  Imagine someone that slouches or is pigeon toed is told to “straighten up” and they have to exert more muscle effort to get the back or feet lined up straight.  The eyes can do the same thing and it causes a lot of muscle strain and possibly a headache.  Sometimes an eye that turns inward, outward or is higher or lower than the other is not easy to discern.  The uncoordination of the eyes is possibly caused by uncorrected vision but also could be caused by a genetic muscle or nerve problem or even by a medical condition such as diabetes, hypertension or even a stroke.  If basic glasses with or without a bifocal doesn’t’ help, then prism power can sometimes help.   A prism bends light so the muscles don’t have to work so hard to see one picture.

4. Medical eye problems

The most common medical eye problem  that can cause a headache from a more uncommon type of glaucoma called acute angle closure glaucoma.  When the drainage system of the eye is narrow, it can be difficult or even impossible for the inner eye fluid (aqueous humor) to drain properly.  This makes the fluid pressure inside the eye to increase rapidly and often times there is signs of a red eye, blurred vision and a severe headache over the eyebrow to the point of nausea.  There are treatments to relieve the condition.

Inflammation inside the eyeball itself, usually related to an auto-immune condition such as rheumatoid arthritis, can cause pain in and around the eye that can be construed as a headache.  Rarely a corneal abrasion or a bacterial ulcer on the eye’s surface can cause inflammation and pain enough to cause a frontal headache.

5. Eyewear and lens problems

Eyeglasses are precision made devices that must have very exact measurements in order for the brain to see clearly and comfortably at all distances.  If the frame is crooked on the face, it can cause eye strain and eventually a headache.  The same goes for a lens that is not centered in front of the pupillary axes.  Even what the material the lens is made out of can sometimes cause subtle distortion that could cause a headache.

6.  Sinus headaches

Having personal experience in this area, I can attest that these can be extremely painful.  When the air spaces in the bones of the skull that surround the eye called sinuses get inflamed  from infection or irritation from allergens,  the tissues expand and gets congested.  That causes a pressure feeling around and between the eyes but even on the side of the temples and down to the jaw.   It can cause the eye to feel like it’s going to pop out it hurts so badly.  Often times a patient will wake up with sinus pain due to sleeping on one side causing fluid to build up and congest the sinus passages more.  Increased water intake, decongestants (Sudafed), mucous thinning medicines (Mucinex) and sometimes antibiotics and nasal steroid inhalers when needed, can generally help but long term treatments may be needed such as nasal saline rinses, antihistamines, and immunotherapy (allergy shots).  Cysts (fluid filled bubbles) can develop and block off the drainage of sinuses at times building up pressure and pain and are not easily seen on CT or MRI scans.  Frequent severe headaches that are not getting better should be evaluated by an ENT (ear, nose and throat specialist) or neurologist (specialist of the brain and nervous system) if sinus and brain imaging with CT or MRI scans did not reveal any problems.

7. Tension headaches

Tension headaches generally happen later in the day but can happen at any time due to the stress load, work ergonomics (how your body is positioned at work) or anxiety the patient is suffering from, whether they realize it or not.  They tend to make the head hurt like a tight band around the head or start in both temples and work backwards.  They usually happen while at work or school in the afternoons but can wake up a person due to neck or back vertebrae misalignment.  Sleeping wrong on a pillow can cause muscle tightness and a resulting headache.   Resting and using pain reliever medicine usually makes tension headaches better.  Children can often get headaches from internalizing anxiety from bullying, domestic abuse or the stress caused by fighting or divorcing parents.  A child’s home life can impact them severely.

8. Migraines (vascular) headaches

Not all headaches are migraines as some people mistakenly believe.  A migraine headache is generally a severe headache on one side of the head that is preceded by some sort of visual distortion such as spots or wavy lines.   The pain is so severe a patient may experience nausea or dizziness and is usually sensitive to light and sounds.  Over the counter medications generally don’t help very much except for some that have caffeine and so migraine sufferers usually have to lie down and rest in quiet, dark locations until it gets better.  They can happen at any time and can be brought on by menstrual cycles or even certain foods.  Sometimes the cause is never found.  They tend to happen in women more than men.  There are prescription medicines that can help prevent or thwart migraine attacks.   Migraines are considered a diagnosis of exclusion however.  Your doctor needs to be fully confident that all other causes of headaches including tumors and aneurysms have been completely ruled out and excluded before they can be called a true migraine headache.  The International Headache Society has listed specific signs and symptoms that must be present or not present to officially classify your headache as a migraine.   I recommend keeping a journal of your headaches:   date and time when they happen, what you ate and drank that day, associations that made it worse such as reading or computer use, medicines used, menstrual cycles, etc… that might help isolate any specific triggers.

9.  Severe Medical Problems

Very rarely, a very serious medical problem can cause headaches.  The main serious medical problems causing headaches would include:

·         Hypoglycemia (low blood sugar)   Usually happen with poor diet, get a feeling of weakness, shakiness, moodiness and breaking out in a sweat and nausea.

·         Hypertension (high blood pressure)   Usually start at the base of the back of the skull where the head and neck meet, have ringing in the ears, sometimes dizziness.

·         Aneurysm (small area of ballooning outward of blood vessel)  Usually a quick forming, stabbing pain that is incredibly painful.  Often described as the worst headache ever.

·         Benign increased intracranial pressure (higher than normal fluid pressure in the brain and spinal cord caused by poor drainage or reabsorption of fluid)   Often related to females that are considered overweight and over 30-40 years.  Rarely, some people have smaller than average drain openings (foramens) in the skull that keeps fluid from circulating well.

·         Inflammation of cranial arteries – usually hurts on one side of temple, vision decrease in one eye, over 60 years old. It is not normal for someone over 60 years old to have frequent headaches unless they have a long history of them.

·         Poor blood circulation from a blood clot or stroke – usually sudden, associated with numbness or paralysis of facial muscles or limbs, eyelid drooping, sudden loss of vision.

·         Brain tumor – usually very gradual onset of headaches and other symptoms such as vision or hearing loss, behavior changes, depression, and can feel like general sinus pressure in some cases.

If you are experiencing frequent headaches, please see your medical physician for a medical evaluation and a reputable eye doctor for an comprehensive eye and vision examination to find the source and make sure it’s not serious.