Edward Lichten, M.D.,PC
555 S. Old Woodward Avenue Suite 700
Birmingham, MI 48009 

Email: drlichten



Lecturer #3:  Edward Lichten, M.D.
Director, Headache Institute for Women
Novi Headache Symposium 1994




INTRODUCTION: From the first days of school we were told "if you give your patient enough time, she will tell you what is the problem that brought her to your office!"

What we have tried to do at our facility, is to give our patients an opportunity to talk about all the problems that trouble them. Before the interview they are given a simplified general history form to fill-in background information and "check-off" po tential medical problems. A copy of this "admission form" is included for your review in Appendix A, page1. Surprisingly, one of the most often "checked-off" item in our gynecological practice was headaches!

In an effort to better treat our patients, I have become the "patient consultant" who is responsible for the initial history and patient education. We have confirmed, just as others have previously, that the vast majority of headache patients can be ade quately diagnosed by history alone without extensive diagnostic testing and multiple drug trials.

Remember, that in the office practice, we find the emergency management of the acute headache case is extremely rare. Focusing specifically on the chronic headache condition, we find these headaches fall into three general categories: [more than 100%- mixed patterns]

  1. Muscle contraction: cervicogenic....50%
  2. Vascular Migraine: hormonal..........30% (dietary 5-10%)
  3. Miscellaneous
    Mixed patterns (Both)........................20-30%
    Psychological Factors.........................20-30%
    Sinus, allergy......................................less than 10%

TAKING the initial history, my initial questions collect the general information: the demographics, previous physician and diagnostic evaluations and previous medication use. This is no different from any standard history.

TAKING the headache history, the questions focus on differentiating the various factors contributing to headache: specifically searching for Muscle factors and migraine factors.

Following this article, is an "Initial Headache History Questionaire" marked Insert-1 and "Additional Headache Questions." The latter is oriented to focus on differentiating between muscle factors and migraine factors in headaches, even though they may co-exist.

To read a specific article about migraine, emergency treatment, hormonally influenced migraine, muscle tension, cervicogenic ad/or analgesic rebound headaches, GO TO the HEADACHE HOME PAGE

Migraine:       Unilateral: one sided 75% of the time, wakes her
            Periodic:   periods of time without headache
            Pulsating:  throbbing, sharp, stabbing pain
            Systemic:   nausea, vomiting, seeks dark room
    WITH AURA:  20% have warning sign or symptom
    COMPLICATED migraine:   neurologic symptoms
            Partial loss of vision: hemianopsia, tunnel
            Numbness, tingling, loss of speech, hearing, balance

Muscle-type:    Unilateral (one side worse)
            Daily:  associated with chronic analgesic use
            Achy:   able to function with medication
            Rare systemic changes: no neurologic sequelae
Mixed:      both

These muscle contraction and migraine types are differentiated by location from:

Facial pain: Runny nose, aching jaws, ear pain, change hearing And, whenever there is chronic disease, there are always psychological factors of depression that affect the individual. Some symptoms of depression to look for are:

Depression: Patient reports a decreased self worth, inability to function, loss of coping skills, change in sleep patterns, decreased or increased appetite, decreased sexual interest.

Look now at the initial headache questions on the following pages. The questions now take on a new focus, when you recognize the major types of headaches.


Many might consider a gynecological practice that focuses on treating migraine to be unique. But since 80% of all headaches occur in women during the reproductive years, there must be hormonal triggers to her headache entity. Some are the hormonal fluc tuations that occur around the menstrual cycle, the use of oral contraceptives, the first trimester of pregnancy and the use of interrupted exogenous estrogens during menopause. One fifth of the women who suffer from migraines, in fact, experience them e xclusively in connection with their menstruation. This is evident when considering a Great Britain study where of 215 women on oral contraception, one-third developed headaches for the first time. Of the 75 women who had suffered from migraine before us ing the pill, half reported a worsening of their migraine attacks.

In light of the fact that these hormonal attributes to migraine are almost entirely ignored, we must specifically note those questions that imply a hormonal component to headache.

    • First migraine with a hormonal event (menarche, oral contraceptive, pregnancy, post-partum, estrogen use)
    • Worse headaches ocur near menstruation
    • Birth control often makes headaches worse; discontinuation may bring some relief
    • Headaches typically occur the week off birth control pills
    • No migraine noted in 2nd & 3rd trimesters of pregnancy
    • Presence of other gynecologic complaints (molimina): premenstrual symptoms (mood swings, depression, food
    • cravings, fluid retention, breast pain) and menstrual pain

Women make up 75% of all headache sufferers who visit physicians and 80-90% of all who suffer with migraine. We have found that more than 50% of their migraines are "hormonal" and poorly responsive to standard medication. They are the most difficult pat ients to adequately treat.

Patient education includes consideration of the dietary restriction of a P.M.S. diet as a initial treatment for migraine. Please consider the following:

SODIUM: The effect of estrogen in the pre-menstrual phase is associated with fluid retention. Women feel bloated, complain of breast tenderness and find that rings get tight. Thus, it is suggested that women eliminate foods high in sodium to ease flui d retention prior to menses. Diuretics that lower cerebral spinal fluid pressure are preferred. (Spirolactone_, Acetazolamide)

HYPOGLYCEMIA: As estrogen levels fluctuate within the luteal phase of the menstrual cycle, so, too, do blood sugar levels. Thus, women become hypoglycemic as they approach menses. To reduce the effects of a hypoglycemia headache, it is best to eat at re gular intervals - six small meals a day - and to avoid foods that are high in simple sugars.

And the DIETARY TRIGGERS for the Premenstrual Syndrome are the same as for MIGRAINE!


The following foods may contribute to or cause headaches:

1. (20%) CHOCOLATE/CAFFEINE: Caffeine containing substances can cause headaches because they contain phenylethylamine. However, since they also constrict blood vessels, headache sufferers may use them on a regular basis as a preventative. With continu ally use, blood vessels adapt to a semi-constricted state. Then, when the substance is withdrawn, blood vessels will dilate, causing considerable headache pain. Victims of tension headache find the continually intake of dietary or caffeine in tablet for m (often compounded with aspirin, phenacetin and butabarbital) temporally helpful. However, in both migraine and muscle headaches, stopping the intake of caffeine drugs can cause withdrawal headaches.

2. (20%) DAIRY PRODUCTS: Cheese contains tyramine which may have a direct effect on blood vessels. Dairy products often contain high fat and high sodium content and may cause fluid retention. As such, fluid may be retained in the brain and cause a feeli ng of pressure in the head.

ICE CREAM: Holding ice cream or ice in the mouth or swallowing it quickly may cause a localized pain in the palate. This is felt to be a reflex secondary to cooling or a glossopharyngeal nerve stimulation. Common in patients with migraine.

3. (30%) ALCOHOL: HANGOVER: Alcohol is a dilator of blood vessels. Some wines and other alcoholic beverages also contain tyramine, another potent vasodilator. Red wine is especially high in histamine and may trigger headaches where white wine may not. The throbbing hangover headache is more likely the result of acetaldehyde and acetate -breakdown products of alcohol - circulating in the blood and affecting arteries in the skull by the release of prostaglandins. That is why coffee or tea (the caffeine helps constrict blood vessels) along with aspirin or ibuprofen are the usual remedies. Dalessio suggests fructose to accelerate the metabolism of alcohol and others suggest ibuprofen (Advil, Motrin_, Anaprox_) an hour before [although they increase alcohol 's "punch."]

4. SALTS: CHINESE FOODS/MSG: Sufferers of this complain of pressure or tightness in the face followed by a headache within twenty-five minutes after eating Chinese foods. The cause is felt to be related to MSG_ (monosodium glutamate) which is widely use d as a food additive, especially in oriental foods. MSG dilates blood vessels and people who experience headaches related to it are usually susceptible to migraine and other vascular headaches as well.

HOT DOG/NITRITES: Some people develop headaches after eating hot dogs or other cured meats. These types of headaches result from the sodium nitrite used to treat the meat. Nitrites dilate blood vessels, and even the minuscule amount found in cured mea ts may cause headaches.

5. ADDITIVES: ASPARTAME/NUTRASWEET: Aspartame (Trade Name Nutrasweet_) is a sugar substitute 200 times sweeter than sugar. It is found in many carbonated diet beverages and other diet/diabetic foods as well. Since its introduction to products in 1981, t here have been reports of headaches after consuming aspartame. Foods and beverages containing should be avoided if a headache occurs shortly after consuming such.

6. FASTING/HYPOGLYCEMIA: Lowering of the blood sugar level (hypoglycemia) can trigger migraines, and a dull pressure headache often accompanies any prolonged fast. A regular morning headache may be caused by low blood sugar. Similarly, when a person susceptible to hypoglycemia eats sugar, the pancreas is stimulated and blood sugar levels rise rapidly; then they drop abruptly. As such, a headache may occur.

7. GUM-CHEWING: Of all products consumed, gum is the least suspected cause of headache. However, if a gum-chewing headache is to occur, pain usually is located in the front and side of the head. The apparent cause is the chewing of large amounts of gu m -two to three packs per day - for continuous periods of time. The constant grinding process involved in gum chewing produces sustained contractions of the jaw muscles. These muscles become stiff when used constantly and a headache may result.


8. Muscle type headaches can develop from poor sleep pattern. An old mattress or a waterbed may offer little back support. Using more than one small pillow may aggravate neck muscle tension. Having scoliosis or uneven leg length or performing a specific activity such as lifting or sitting in front of a monitor or using a phone may aggravate muscle tension producing chronic headaches. Patients may report more headaches on weekends when they sleep late or on vacations. They awake with the headaches after sleeping poorly.

9. Allergy type headaches can be triggered by an old mattress or feather pillow with mites. Mold may be present in an older home. Treatment may be as simple as installing a humidifier and air cleaner, removing plants, and placing mattress and pillows in plastic (or change mattress, pillows). Water beds must be treated chemically and filled for increased firmness

10. Medications: Certain common medications are associated with headache including: tetracycline (Minocin_) commonly used for acne, yellow dye (in Synthroid _.1mg), certain blood pressure medications including Procardia_, and cholesterol lowering agents li ke Lopid_. Carefully record all medications, including over-the-counter preparations. Analgesic rebound can occur from the daily use of caffeine, aspirin, acetomeniphen (Tylenol_), and ibuprofen (Advil, Nuprin_,etc). Check the PDR for prescription side e ffects that may include headache. If possible, discontinue or substitute the possible offending medication for 3 to 4 weeks. In our office, we will substitute two Synthroid_ .05mg daily (white) for on Synthroid_ .1 (yellow). We stop Minocin_ and substitute Erythrocet_ facial wipes. Try to eliminate the cause of headaches before prescribing additional headache medication. For a more complete list of drugs that may induce headaches, consult the PDR.

In summary, migraine is characterized by 1)unilateral 2)pulsating quality 3)severity 4) periodicity [like premenstrually] and 5) nausea/ vomiting, photophobia and phonophobia. Migraines are by nature "severe," yet represent less than one-third of all "headaches." Muscle contraction headaches can be less severe but occur much more frequently; 50% of all headache occurrences. And up to 50% of migraine patients have muscle components as well. Other specific factors, including the jaw, sinus, teeth and intracranla structual anomalies make up significantly less than 10% of chronic headaches.

But it is most important to understand that 90 percent of the time, the correct diagnosis of headache type will be made by an adequate history. Hopefully, the information presented to you will make the "headache history taking" more productive.


1. Age at which the headache first occurred?           _______
2.  Do you have more than one type of headache?     Yes/ No
3.  Have headache(s) changed since the first episode?       Yes/ No
    a.  Are they worse in intensity?                Yes/ No
    b.  Are they more frequent?             Yes/ No
4.  Has there ever been a period of time since the initial episode  
    when the headaches subsided for a period of time? explain
5.  Family history for headaches? (mother/father/sib)       Yes/ No
6.  Experienced any "cranial" trauma [blow to head]?        Yes/ No
    Concussion? Fall?  Auto accident?  whiplash? Other?
7.  Seen a neurologist or a physician for headaches?        Yes/ No
8.  What neurological tests have been done?  RESULTS
    a.  EEG, C.T. scan,   M.R.I.,  Neck or sinus X-ray
    b.  Doppler, V.E.P., B.A.E.R., hearing tests, other?
9.  Felt improvement of headache with: Physical Therapy?    
    Chiropractor? Biofeedback? Acupuncture, or Hypnosis?
10. Have you been on medications for headache?          Yes/ No
    a.  Antidepressants: Elavil___ Prozac_/Paxil_____ Others_____
    b.  Blockade:   Inderal_____ Verapimil_/Calan____ Others_____
    c.  Vasconstrictors: Cafergot___ Midrin___ Ergot____Excedrin____
    d.  Injections: DHE_____ Imetrex_/Sumatriptan____Toradol_____
    e.  Muscle Relaxers: Flexeril___ Valium___Bellergal____Esgic____
    f.  Pain Meds: Fiorinal_/-cet____Codiene___Darvon___Motrim____
    g.  Others: Narcotics/Demerol____Compazine_/Vistaril_____
11. Regarding the menstrual cycle:  any correlation?        Yes/No
    a.  Headaches worse or only occur near menses?      Yes/No
    b.  Worse with oral contraceptives? estrogens?
        Worse after childbirth? stopping nursing?       Yes/No
    c.  Less after pregnancy? nursing? menopause?       Yes/No
12. What event do you associate with worsening headache?
13. In summary: how many days/month are you clear-headed?___
    How often dull headache? How many days incapacitated?___
    How many days able to function with medications?___________
14. Draw on a head below where your head hurts...

Additional Headache Questions
Migraine:       Unilateral: one sided 75% of the time, wakes her
            Periodic:   periods of time without headache
            Pulsating:  throbbing, sharp, stabbing pain
            Systemic:   nausea, vomiting, seeks dark room
    WITH AURA:  20% have warning sign or symptom
    COMPLICATED migraine:   neurologic symptoms
            Partial loss of vision: hemianopsia, tunnel
            Numbness, tingling, loss of speech, hearing, balance
Muscle-type:    Unilateral (one side worse)
            Daily:  associated with chronic analgesic use
            Achy:   able to function with medication
            Rare systemic changes: no neurologic sequelae
Mixed:      both
Facial pain:    Runny nose, aching jaws, ear pain, change hearing
Depression: A complication of any chronic illness: decreased self   
        worth, inability to function, loss of coping skills
Migraine  TRIGGERS: 
    DIETARY:    Caffeine: coffee, Coke, Pepsi, Tea, Excedrin
            Dairy: cheeses, milk, ice cream
                Tryramine: red wine, herring                    Fasting: hypoglycemia
            Salts: Chinese foods (MSG), hot dogs (nitrites),nuts
    WEATHER CHANGES:    low pressure, altitude
    SLEEP PATTERNS: too little, too much, weekends, vacation
    PHYSICAL EXERTION:  exercise, sex
Muscle Type TRIGGERS:
    DIETARY:    daily analgesic use

    SLEEP PATTERNS: Mattress (how old), how many pillows?  
        Restless sleeper, insomniac?  Grind teeth
        Noticed in morning, progressively worse with activity
    CHRONIC ALLERGIES: Feather pillows?  bed mites?  mold?
    POSTURE:    sedentary work: computer, desk
        rounded shoulders, large breasts
ALLERGY: install humidifier and air cleaner, remove plants, place mattress 
and pillows in plastic (or change mattress, pillows)
. Treat water bed chemically, increase firmness.

Vasodilator drugs
    Nitrates and nitrites
    Dipyridamole    (Persantine)
Vasoconstrictor drugs causing withdrawal headache
Drugs causing hypertension
    Monamine oxidase inhibitors: (Nardil)
    Antihypertensives cause rebound hypertension: (Catapres)
    Sympathomimetics: Amphetamine, Phenylpropanolamine
Drug causing intracranial bleeding
    Anticoagulants, drugs acutely elevating blood pressure
Drugs causing benign intracranial hypertension
    Nalidixic acid (Negram)
    Vitamin A
    Phenytoin sodium (Dilantin)
Drugs worsening pre-existing headache
    Estrogen administered cyclically


  1. WE Waters, PJ O'Connor. Epidemiology of headache and migraine in women. J Neurol Neurosurg Psych 1971; 34: 148-53.
  2. E.A. MacGregor, H Chia, RC Vohrah, M Wilkinson. Migraine and menstruation: a pilot study. Cephalgia 1990;10:305-10.
  3. BK Rasmussen,R Jensen,J Olesen. Epidemiology of Headache in a General Population:A Prevalence Study.JClinEpidemiol 44;11:1147-57. vBK Rasmussen,R Jensen,J Olesen. A Population-based analysis of the diagnostic criteria of the International Headache Society. Cephalgia 1991;11:129-34.
  4. BK Rasmussen, R Jensen,J Olsen. Questionaire Versus Clinical Inteview in the Diagnosis of Headache. Headache 1991;31:290-95.
  5. HB Messinger, ELH Spierings, AJP Vincent. Overlap of migraine and tension-type headache in the International Headache Society classification. Cephalgia 1991;11:233-7.
  6. S Solomon, RB Lipton. Criteria for the Diagnosis of Migraine in Clinical Practice. Headache 1991;31:384-7.
  7. DD Celentano, MS Linet, WF Stewart. Gender Differences in the Experience of Headache. Soc Sci Med 1990;30(12):1289-95.
  8. AD Korczyn. Headache: A Clinician's Guide to Dagnosis, Pathophysiology and Treatment Strategies. Drug Induced Headache (Chapter 18). PMA Publishing, Costa Mesa, California, 1993. p. 208

More Articles by Edward Lichten, M.D.:

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Revised: January 1, 2011