Headaches are the oldest and most common complaint of mankind. The subtle and not-so-subtle levels of pain range from the dull throbbing of the tension headache to the nausea and flashing lights of the classic migraine. They can last minutes, hours or even days and can debilitate or even inspire.

Today, around 20 per cent of adults suffer from chronic headaches, with migraines comprising 8 per cent of all headaches. Because chronic headaches tend to strike individuals during their 'productive' years, ages 20-50, they are among the most common reasons for missed days at work. Headaches are responsible for more presentations to general practitioners than any other condition, and more drugs are prescribed or bought over the counter for headache than any other condition. There is even a suspicion, though it is poorly researched, that analgesic abuse may be the cause of some chronic headaches (Aten Primaria, 1994; 7: 547-9).

In truth, we do not really understand the mechanism of headache well. They can be muscular, spinal or vascular in origin. They can also be caused by a number of different external triggers, including stress, chemical sensitivity, changes in weather (see box p 3), changes in sleeping patterns and certain foods, especially those containing amines (see box p 5). Women are also three times more likely to suffer from migraines than men, as are those who come from a family with a history of migraine. For women, there is a proposed, but not proven, link between hormonal fluctuations and headache while, in men, hormone levels do not appear to play a role.

Alternative medicine seems to excel at helping conditions which conventional medicine doesn't understand. So it comes as no surprise that there are many ways of treating headaches which are effective and don't produce the unpleasant side-effects of conventional treatment.

Chiropractic
Chiropractic research suggests that chronic headaches may be the result of neck injury or strain. Researcher Wayne Whittingham conducted a study of 105 people, each suffering from regular, sustained headaches. He found that 80 per cent of those treated with nine short sessions of chiropractic manipulation reported benefits two years after treatment (J Manip Physiol Ther, 1994; 17: 369-75).

Even those who find positive results are often reluctant to claim benefit for spinal manipulation (J Manip Physiol Ther, 1995; 18: 435-40; J Manip Physiol Ther, 1996; 19: 165-8). For instance, an analysis of research from 1966 to the present to assess the evidence for the efficacy of chiropractic in the treatment of neck pain and headache found 134 references from four computerised databases. From this evidence, the authors rather grudgingly concluded that, at the very least, spine manipulation provided short-term benefits for some patients and had only a small complication rate. Within the analysis, spinal manipulation compared favourably with muscle relaxants, providing somewhat better relief after three weeks of treatment (Spine, 1996; 21: 1746-60).

Similar results have been found elsewhere. A group of 150 subjects with chronic tension headaches were randomly assigned to receive either 10-30 mg of the antidepressant/sedative amitriptyline at bedtime for six weeks, or chiropractic treatment twice a week for six weeks (J Manip Physiol Ther, 1995; 18: 148-54). Results showed that while both groups improved at similar rates at first, at follow-up four weeks after treatment ceased, chiropractic management was more effective than the drugs for reducing pain and improving overall health. More than 80 per cent of the drug group reported side-effects such as drowsiness, dry mouth and weight gain, as opposed to around 4 per cent in the manipulation group who reported neck soreness and stiffness. Again, the conclusion was somewhat grudging. The authors suggest that, because of small numbers, the study was not conclusive and that further studies should control for the placebo effect of the doctor-patient relationship.

In another study of 53 subjects suffering from chronic headache, half were randomised into receiving spinal manipulation twice weekly or laser treatment combined with deep friction massage (including trigger points) twice a week for three weeks. The use of analgesic decreased by 36 per cent in the spinal manipulation group, but was unchanged in the massage group. The number of headaches per day decreased by 69 per cent in the manipulation group compared with 36 per cent in the massage group, and headache intensity decreased by 36 per cent in the manipulation group compared with a 17 per cent decrease in the massage group (J Manip Physiol Ther, 1997; 20: 326-30).

In a study in New Zealand, 85 volunteers suffering from migraine were randomly allocated either spinal manipulation performed by a physiotherapist, spinal manipulation performed by a chiropractor or mobilisation performed by a medical practitioner or physiotherapist. No difference was found between the groups in terms of reducing frequency, duration or disability of attacks, but the chiropractic patients did report a greater reduction in the pain associated with their attacks (Aust NZ J Med, 1978; 8: 589-93).

Biofeedback
Among the most widely researched techniques for relieving headache pain is biofeedback. With this therapy, special machines are used to feed back information about specific internal physiological states. These states are thought to be the result of mental and emotional activity. Thus, an increase in finger skin temperature is thought to correspond to the person feeling more relaxed, and so on. The machinery becomes a catalyst for the individual to learn more about these internal states, how they affect the body and how they can be controlled to bring about more favourable states. Though numbers in the study groups are invariably small, the results are remarkably consistent.

According to one of the largest studies (793 patients), biofeedback singly and in combined therapy may be most effective when given over a greater number of sessions (15) and when the symptoms have a shorter history of two years or less (Headache, 1989; 29: 34-41).

In a study of 31 headache sufferers, electromyographic (EMG) biofeedback was compared with a credible sham treatment, which gave no instructions on how to control EMG activity, and a control group, whose symptoms were monitored.

Only the biofeedback group showed changes in EMG activity and significant improvement in symptoms (J Behav Med, 1980; 3: 29-39). EMG feedback can be effective against even the most stubborn muscle tension headaches, succeeding where other treatments have failed (Ann Neurol, 1979; 6: 34-6).

In another study comparing relaxation technique with EMG biofeedback, the relaxation group fared better when it came to the relief of migraine or muscle-tension headaches, but not so well with mixed headache (J Clin Psychol, 1984; 40: 453-7). In yet another study, the two fared equally well, although relaxation technique was more effective in reducing medication consumption at the one-year follow-up (Biofeed Self Reg, 1979; 4: 359-66).

When 23 migraine patients were assigned either to biofeedback-assisted relaxation or a group who relaxed on their own, the biofeedback group reported greater decreases in pain and need for medication (Headache, 1994; 34: 424-8).

One controlled study confirms other research. Patients who received a combined therapy of thermal biofeedback and relaxation supplemented by either audiotapes and manuals or instruction in cognitive stress-coping techniques fared significantly better than controls who simply monitored symptoms (Headache, 1990; 30: 371-6).

Biofeedback has also been tested against drug therapy and shown to both enhance the efficacy of medication and, in some cases, be more effective. Research has demonstrated that biofeedback is at least as effective as the beta-blocker/antihypertensive propranolol (Pain, 1990; 42: 1-13). In one study, relaxation/thermal biofeedback was shown to enhance the effectiveness of propranolol therapy. Although the combined therapy was very effective, it had more side-effects than relaxation/biofeedback on its own (J Consult Clin Psychol, 1995; 63: 327-30). While drug therapy can be effective, the side-effects it produces can mean that sufferers don't stick with their therapy over time. In a study comparing use of ergotamine and biofeedback for migraine, the drug-taking patients were less likely to be following the same regime three years later than those who used biofeedback (Biofeed Self Reg, 1989; 14: 301-8).

Acupuncture
Results of research into acupuncture are mixed and, once again, trial sizes are small. The overall weight of the evidence suggests that acupuncture is more effective than placebo (Cephalalgia, 1985; 5: 137-42) or sham procedures (Clin J Pain, 1989; 5: 305-12), though there is also evidence to dispute this (Pain, 1992; 48; 325-9).

Over eight months, a small double-blind, crossover study of only 16 people who had severe, regular migraine for more than five years showed good results. In it, patients received acupuncture, saline or the opioid antagonist naloxone. Acupuncture was found to cause a significant change in the number of headaches and their duration, with 40 per cent of subjects showing a 50 to 100 per cent reduction. Although pain sensation was not altered, attacks were less severe and less often accompanied by nausea and vomiting. There
was no difference between the saline and naloxone groups (NZ Med J, 1983; 96: 663-6).

Another study concluded that electroacupuncture was most effective in treating muscle-contraction headaches. Of 177 patients with long-term chronic head and face pain, acupuncture reduced pain in 100 (56 per cent) of the group. On follow-up after two years, 47 per cent of the improvers had continued the therapy on a long-term basis, experiencing periods of relief of up to two years, and 21 per cent discontinued treatment on the basis of complete and prolonged relief from pain (Pain Clin, 1988; 2: 15-31). The different applications of acupuncture were also assessed in the study, and the most effective therapy involved 30-minute sessions with deep-needle penetration and low-frequency (2 Hz) electrical stimulation.

Other studies are not so positive. In one comparing acupuncture and physiotherapy for tension headache resulting from craniomandibular disorder, physiotherapy was more effective (Pain Clin, 1990; 3: 22-38). An earlier study showed that both were equally effective (Acupunct Elecro Ther Res, 1984; 9: 141-50).

Several others have attempted to compare acupuncture and physiotherapy. In one, a study of people with tension headaches, 62 patients were divided to receive either acupuncture or physiotherapy. They were assessed for overall function, mental wellbeing and intensity, and frequency of headaches. Both groups improved in overall function - the physiotherapy group somewhat more so. Mental wellbeing increased only in the physiotherapy group. The intensity and frequency of headaches decreased in both groups (Headache, 1990; 30: 593-9).

In a study comparing acupuncture to the drug metoprolol, acupuncture was shown to be at least as effective in reducing the frequency and duration of attacks, though not the severity, and superior in terms of negative side-effects (J Int Med, 1994; 235: 451-6). Another study comparing acupuncture with conventional treatment found greater improvement in the acupuncture group - 24 out of 41 compared with nine out of 36. The study was intended to be crossover, but 19 patients refused to change from one form of treatment to the other! Of those who did switch, a larger proportion expressed a preference for acupuncture as a treatment (J Neurol Neurosurg Psychiatr, 1984; 47: 333-7).

In one small trial involving chronic sufferers aged 17 to 61, patients were given either acupressure on acupuncture points, strong finger pressure to inactive sites, gentle massage to inactive sites or delayed treatment (pain-monitoring group). Those in the acupressure group reported significantly less intense headaches than those exposed to simple massage or pain monitoring. This suggests that not simply the laying on of hands, but pressure, may be a key to healing. Since the pressure helped ease pain whether or not it was applied to acupuncture sites, according to the authors, acupressure may work in a different way than acupuncture (Dissert Abstr Int, 1990; 50: 5890).

Hypnotherapy
Hypnotherapy can be performed with a practitioner or the method can be taught to individuals, who can then practice self-hypnosis as either prophylaxis or cure. In one study, 23 patients who received hypnotherapy all reported significant improvement in their condition (Am J Clin Hypn, 1985; 27: 216-8). When researchers from Brigham and Women's Hospital in Boston, Massachusetts, used hypnotherapy to ease chronic tension headaches among patients, they discovered that the duration of the headache and its intensity was significantly reduced by the therapy (Headache, 1991; 31: 686-9).

When it was compared to the dopamine antagonist/nausea drug prochlorperazine (Stemetil) in a group of 47 migraine sufferers randomly assigned to either treatment, 10 out of 23 in the hypnosis group reported complete remission, compared with three out of 24 in the medication group (Int J Clin Exp Hypn, 1975; 23: 48-58).

In one comparison of self-hypnosis with propranolol in children aged 6 to 12 years with classic migraine, where children were given the drug or placebo and then taught self-hypnosis, the mean number of headaches per child did not differ significantly in the first six months of the trial when children were given either a placebo (and had 13.3 headaches on average) or propranolol (14.9 headaches). However, during the self-hypnosis period, the mean number of headaches dropped to 5.8 over the three-month period. Headache severity did not alter at any point in the trial (Ped, 1987; 79: 593-7).

One study by researchers at the Catholic University in Nijmegen, The Netherlands, compared autogenic training to multiple self-hypnosis, and found no differences between the two techniques. They did, however, find what may be an important difference between subjects who improve and those who do not. Those who attributed pain reduction obtained during therapy to their own efforts experienced longer-term pain reduction (Gen Hosp Psychiatr, 1992; 14: 408-15).

Homoeopathy
Studies into homoeopathy also turn up mixed results. One study of eight different remedies (singly or in combinations of two) or placebo used on 60 patients determined that homoeopathy significantly reduced the number of headaches. In the homoeopathy group, this represented a reduction from 10 attacks per month to 1.8 at the end of four months. In the placebo group, the reduction was less marked, from 9.9 per month to 7.9 (Berlin J Res Homeop, 1991; 1: 98-106).

However, in Sweden, 68 patients with migraine participated in a placebo-controlled study designed to test the efficacy of homoeopathy in preventing attacks and relieving symptoms. Both groups experienced a reduction in frequency and intensity of attacks, but the final evaluation done blindly by a neurologist showed that more patients in the homoeopathy group experienced a reduction in frequency and severity of attacks, though the latter measurement was not statistically significant (Dynamis, 1997, 2: 18-21).

When researchers at the Princess Margaret Migraine Clinic in London undertook a four-month, double-blind, randomised, placebo-controlled trial of homoeopathy, both groups improved (homoeopathy by 19 per cent, placebo by 16 per cent). Eleven different homoeopathic remedies were used in all. Interestingly, the placebo showed its most marked effect on mild migraine attacks while homoeopathy seemed more effective on moderate-to-severe attacks. Improvement in the placebo group began to reverse itself after the fourth month, while slow improvement continued in the homoeopathy group (Cephalalgia, 1997; 17: 600-4). The authors concluded that homoeopathy was not without effect, but could not be recommended because a) it was slow to work and b) traditional prescribing methods, matching the remedy to the individual, were too unreliable - though they acknowledged that this is also a problem in conventional medicine.

Herbs
Feverfew is one of the most widely successful herbs in treating migraine. In all, more than 50 scientific papers have been published in the past 15 years which examine its efficacy. One of the most important studies was carried out at University Hospital, Nottingham, in 1988. Seventy-two migraine sufferers were randomly given either one capsule containing dried feverfew leaves or a matching placebo for four months before treatments were switched, with the placebo group receiving feverfew and vice versa, for a further four months (Lancet, 1988: ii: 189-92). The number of migraine attacks fell by 24 per cent in the feverfew group, and 68 working days were lost to headache in the feverfew group, as opposed to 76 with placebo. While feverfew reduced the number and severity of migraine attacks and the degree of vomiting, the duration of each attack was unchanged.

The action of feverfew on migraines is still not widely understood, though recent research suggests that individuals who have low levels of circulating melatonin may be more prone to attacks. Feverfew, the authors of one study suggest, contains melatonin, thus boosting circulating levels of the chemical (Lancet, 1997; 350: 1598-9).

Feverfew is best taken in tablet form since the dried leaves can be bitter and, with tea, there is no way of guaranteeing consistent strength. The active ingredient in the herb is parthenolide.

However, consumers beware. When researchers in Nottingham tested dried preparations, they found parthenolide levels varied widely between products and was not detected in some at all (J Pharm Pharmacol, 1992; 44: 391-5). At least 0.2 per cent of it needs to be present in every 125 mg of feverfew leaf powder to be effective. Feverfew has been shown to be safe, even if taken over long periods (Hum Toxicol, 1987; 6: 533-4).

The Chinese herb Wu zhu yu tang can also help with headaches, particularly those brought on by high altitudes. When eight members of a Himalayan expedition team took the herb after ascending by bus from 1350 m to 3800 m, seven of the team who usually suffered from altitude headache said they were free of symptoms. The herb was also used to treat headaches during the expedition and, in most cases, it either completely or partially cured them (Pain Clin, 1994; 7: 229-33).

Weather is commonly cited by migraine sufferers as a trigger. Patients suffering from chronic pain often report that changes in the weather influence their pain (Pain, 1995; 7: 309-15).

Writings dating back to the eighteenth century describe the relationship between weather and migraine. However, according to the Canadian Medical Meteorology Network, it was not until 1981 that Alan Nursall and David Phillips began to scientifically study the effects of weather on migraine in Canada. They discovered that wet, windy, cold weather had a worsening effect on migraine while clear, sunny and dry weather had an ameliorating effect (The Effects of Weather on the Frequency and Severity of Migraine Headache in Southwestern Ontario, Canadian Climate Report, 1980: 80-7).

A great deal of research has been compiled since this study was done, particularly regarding the role of serotonin in migraine. Nursall speculated in his conclusion that the pathways involved in weather's impact on migraine are connected with at least one of serotonin, prostaglandins and the various other hormonal agents.

In one study of Chinook wind conditions, women were found to be more sensitive to weather changes than men (Int J Biometeorol, 1995; 38: 156-60). In another, when the headache diaries of 13 patients were analysed, Chinook winds increased the probability of headache onset, particularly in those aged over 50 (Headache, 1997; 37: 153-8). In another study, 43 per cent of those polled cited weather changes as the trigger for their migraine (second only to stress at 62 per cent). Strangely, this is an aspect of health which is often overlooked by doctors except in Germany, where some physicians are known to make use of daily bulletins from the National Weather Service to advise patients on the management of common health problems (Can Med Assoc, 1995; 7: 941-4).

Because weather is thought to be mediated by electrical processes, electroacupuncture may be one effective way of treating headaches brought on by unsettled weather conditions (Med Hypoth, 1996; 7: 19-20).

* Investigate food allergy. According to Dr John Mansfield, food allergy is a major cause of migraine (see The Migraine Revolution, Thorsons). This view is substantiated through several other studies. In one study at Great Ormond Street Hospital, 93 per cent of children with severe, frequent migraine recovered once the foods they were allergic to were taken out of their diet (Lancet, 1983; ii: 865-9).

Evidence is still confused about whether food items such as chocolate are really the main culprits (Nature, 1975; 257: 256). Mansfield believes it is more likely to be wheat, corn, milk, sugars and oranges. Others speculate that foods containing amines - which affect the diameter of the blood vessels - are a cause. These foods include any fermented, pickled or marinated food, avocados, bananas, caffeinated drinks, chicken liver, MSG, chocolate, citrus fruits, nuts, processed meats, raisins, red wine, ripened cheese, onions and lentils. Still others suggest that foods with a high copper content - chocolate, nuts, shellfish and wheatgerm - may trigger migraine in some sufferers. Citrus fruits can increase copper absorption. MSG binds to it and transports it. Both citrus and MSG are linked to migraine. Foods containing aspartame may also tigger migraine attacks (Headache, 1988; 28: 10-3).

* Try a high carbohydrate diet. A high carbohydrate diet can help by increasing the amount of the amino acid tryptophan available in the body. Tryptophan is converted in the body to the neurotransmitter serotonin. In the brain, serotonin appears to reduce pain. A high-carbohydrate diet can also reduce migraines caused by hypoglycaemia (low blood sugar). Unrefined carbohydrates and strict avoidance of sugars minimise swings in blood sugar and, according to one study, appear to be very effective in reducing migraine. If you get headaches when you haven't eaten for a few hours or if you are diabetic, you might consider asking you doctor to test for hypoglycaemia. Frustratingly, some people do worse on a high carbohydrate diet. If your migraines bring on flushing and itchiness or you have classic migraine symptoms, try switching to a low-tryptophan diet. Consult a qualified nutritionist before making major changes in your diet.

* Investigate multiple chemical sensitivity (MCS). One of the most common side-effects of chemical sensitivity is headache. Try to rule out sensitivity to perfumes, air fresheners, cleaning fluids and even flavourings in some foods.

* Find a different contraceptive. Women taking the pill can often find that their symptoms worsen (Am J Obstet Gynecol, 1993; 168: 2027-32).

* Try yoga and other forms of relaxation. Several studies support the use of relaxation techniques to alleviate headache pain in both adults (J Consult Clin Psychol, 1991; 59: 467-70) and children and adolescents (Pain, 1986; 25: 325-6). In one study, 20 patients were randomly assigned either to have yoga or no treatment (J Ind Psychol, 1992; 10: 41-7) . The yoga group showed a significant reduction in headache activity, medication intake, symptoms and stress perception. They also showed more positive coping behaviour.

* Essential oils can help. Peppermint oil is often cited as effective relief (Nervenarzt, 1996; 67: 672-81). It is thought that peppermint stimulates nerve fibres which register cold and that this may reduce the pain information transmitted to the brain. In a recent double-blind, placebo-controlled, randomised crossover study of 32 healthy subjects, it was found that peppermint (10 g) and eucalyptus (5 g) together increased cognitive performance and had a muscle-relaxing effect. Peppermint (10 g) with traces of eucalyptus had a significant analgesic effect, which could contribute to reducing sensitivity to tension headache. Capsaicin cream may also be beneficial (Pharm Rev, 1986; 38; 179-226).