It’s Friday. My week has been one of those where I had a plan. It was a good plan, a valid plan, an eminently deliverable plan. What I hadn’t counted on was everything that was going to get in my way before I even got to the plan each day. Everything that got in the way was urgent and needed to be done immediately and I had to drop everything to do it. So, my plan to do all of the things I had to do anyway that were also immediate and urgent got pushed back. In addition, my heating at home packed up and that’s been just another thing to get sorted out urgently and immediately. It’s coming at me from all sides, and now, it’s Friday and it hasn’t stopped yet.
Here I sit with a pounding headache. It feels like I have an elastic band fitted tightly around my skull and there is a tonne weight sitting on the top of my head. I’ve done OK with getting everything done regardless of how much there was to do this week, but it has required late nights and working on my laptop in bed (it’s freezing because of the heating problem). I know it’s superhuman to get everything done and appear unflappable, but indeed it turns out that I am not from Krypton (Superman and Supergirl’s home world); there is a cost and that cost is borne by me.
Part of this is emotional. Not only does my ever-growing to-do list and my ever-diminishing time stress me out, but I also don’t really feel any satisfaction about managing it all. At least six people have asked me for something this week and it is in my personal nature to respond by the time they needed me to. Urgently and immediately of course. None of these people would have any idea of the requests of the other five, and so don’t know that my efforts for them are Herculean in the face of all of the other pressures.1 As a result, I don’t even get the validatory shot of immense gratitude my emotional system feels it needs to compensate for the effort. And the cost is all mine. Is this sustainable? No. The graveyards are full of indispensable people.
We own our time. We must also own the consequences of our use of that time. We deal with stress constantly, so why is it that sometimes it gives us a headache? In this chapter, we are going to break down what it is about our emotional response to life that gives us a headache, and how that changes our behaviours to make matters worse. We will also think about how stress responses change our body posture and conversely how poor physical health can cause us to feel stressed.
Can you remember the first time you ever experienced a tension headache? They can be experienced at any age, but most people report the teenage years as the most common point of onset. I spoke to a group of seven-year-olds recently about their experience with headache in general. First, I asked them what a pain in their head felt like. Some looked at me blankly, which I took to mean that they had never experienced a headache, lucky tykes. Some described a ‘thumping’ when they got ‘really hot’ and didn’t feel well at all. Having asked them why they didn’t feel well, it turned out that these kids experienced a headache as part of a cold or other illness that caused a temperature spike. And then there were the kids who described tension headache as if they were reading from a medical textbook, which I am guessing they hadn’t read at this stage in their intellectual development. Headache to them felt like somebody pressing down on their heads, and they put their hands up to their heads to show where the bottom of a hat should be. One child even went so far as to say, ‘It’s like if your hat is too tight.’ Savvy kid. The children went on to describe a number of stressful situations they may have experienced, such as if there were loud noises or if they felt frightened or if they got into trouble or were falsely accused of something they didn’t do … the list went on.
I came away stunned by two things. The first was that in light of the plethora of causes I was given for their headaches they are ever well enough to go to school. The second is how amazing it is that a seven-year-old can attribute a pain in their head to an external event. It’s easy to see how they can do this if they fall on their knee and it hurts, but they are describing how emotional events make them feel pain in a place they haven’t bumped. This is phenomenal awareness for little people whose frontal lobes aren’t yet fully wired up. If you are under 23 and reading this, don’t get cocky; yours isn’t fully functional either, which might explain some of the rubbish decisions you have made in the past. But that’s an entirely different story.
The point is, even from this early age, we seem to attribute our headaches to emotional causes, and the biggest of these is stress. Stress isn’t really an emotion per se, but it is our body’s response to events our brains perceive as a threat to us. In my case this week, it was born out of having too much to do and not enough time to do it. This became emotionally tough because I wanted to do a good job in every task but felt pushed for time and the fear of not delivering made me tense. Or was it that in order to deal with what was on my plate my body went into fight-or-flight mode and it was this that my brain interpreted as tension? Let’s break it down.
The body, the brain and the bear
The relationship between the mind and the body in emotion generation and perception has been a debate topic for thousands of years. If you see a bear running towards you down your local high street, you might think to yourself: ‘That’s unusual, what a lovely specimen’. Or, if you are not me, you might have a more ‘Aaarrgh, I’m going to die’ reaction. This is your brain’s response to the bear, and your feeling of threat then kicks your autonomic nervous system into gear to release the neurochemicals (a chemical that affects the nervous system) and hormones required to give you the energy to get out of there pronto.
This theory of how we feel emotion was developed by Walter Cannon and Philip Bard in the 1920s. It stated that there is a physiological effect only after we have registered the emotion. This makes sense, although the prevailing view at the time was that of William James and Carl Lange in the 1880s. In contrast to Cannon and Bard, they thought that the sight of the bear would make you tremble, and your brain would interpret this trembling as fear.
Nowadays, we know that the brain and body work together to perceive our emotions. Given that the response your body has to a stressful scenario (releasing neurochemicals and hormones) is the same whether it is a good thing (accepting an award at the Oscars, for example) or a bad thing (seeing a bear on the high street), you need your brain to collect all the other information about what is going on around you in order to decide whether you are happy or frightened. What’s more, it’s worth knowing that our body does provide information to the brain about how worked up we should be. We know this because in addition to being paralysed physically, research has shown that people who have severe damage to their spinal cord feel less emotion about what is going on around them. The higher up the cut to the cord, the less sensory information they receive from around the body and so the less emotion they report that they feel.
It’s a two-way street. The state of your body can make you feel stressed, and we’ll come back to this when we talk about the role posture has in causing tension headache. Equally, your mind can cause your body to react with a stress response based on a previous bad experience.
The stress response is pretty typical in most of us, even if we all have different thresholds for when it kicks in. The most immediate response is the adrenaline rush to give us an immediate boost of energy to deal with a threat. The adrenaline kicks in so quickly that we might not even be consciously aware of our actions before we start to move, hence the historical confusion between James and Lange (body) and Cannon and Bard (brain). It is all controlled by the brain’s perception through our sensory organs of what is going on. If you hear a screech and see a car careering towards you, your brain will quickly calculate whether it is on a trajectory to hit you and how long it will take to get to you. It will also work out what you have to do to get out of the way and set that in motion through the movement regions of your frontal lobe, causing you to jump out of the way of the car before you know what’s even happening. We seriously are talking milliseconds here. In that fraction of a second, this information is also relayed to one of your emotion centres in your brain called the amygdala. Shaped like an almond (after which it is named), it is really active in our fear or threat response. Eventually, we will consciously perceive this as ‘fear’ but in the meantime, your hypothalamus will get kicked into gear by your amygdala.
I am not too proud to admit that the hypothalamus is my favourite part of the brain, full stop. It is like a command centre that sits behind all of the things that we subconsciously do. It controls a really fast neural pathway, the autonomic nervous system, which passes through the brainstem and down to the organs of the body. It also lords over our endocrine or hormone system, through its connections in the pituitary gland, and so it can influence when hormones are released. Both the autonomic nervous system and the endocrine system are important in the body’s response to stressful situations.
The autonomic nervous system
The quickest response is through the autonomic nervous system, which has two complementary branches: the sympathetic ‘fight-or-flight’ system and the parasympathetic ‘rest-and-digest’ system. These two work together so that the body will be in the appropriate condition to deal with whatever is coming its way. When you are under threat, the sympathetic nervous system does many things, driven by the release of adrenaline from the adrenal glands that sit on the kidneys. This is a hormone that is also used as a neurotransmitter in the sympathetic nervous system, activating various organs to react. For instance, it causes dilation of your pupils by contracting the iris, or the coloured part of your eye, opening the aperture and allowing more light to hit the retina at the back of the eye. In much the same way as a camera, this means that you will get a much clearer and brighter picture than you did before. The pathway to your lungs also ensures that your bronchial passages are widened, allowing more air to come in so you breathe deeper and faster than usual. This influx of oxygen means your muscles and your brain will have the optimal levels right when they need to act. Glucose is released from your liver, the only fuel your brain can burn, and the quickest for your muscles to use. Your blood pressure increases as your arteries constrict, squirting blood to your organs quicker than usual; and coupled with an increase in heart rate you feel alert and ready to take on the world. Of course, you will also be sweating, have extreme piloerection and your mouth will be dry as a bone. Blame your sympathetic system – all that excitement sends your sweat glands into overdrive, causes the hairs on your body to stand proud (that’s the piloerection) and inhibits salivary flow. I guess you can’t have all the benefits AND be comfortable too.
The endocrine system
There is a secondary and more long-lasting stress response and again, it is mediated by the hypothalamus and the adrenal glands, but this time with a step through your pituitary gland. While the fight-or-flight response is controlled by your brain, the hypothalamic–pituitary–adrenal (HPA) axis response is hormonal, longer-lasting and has more consequences that result in tension headache. Your body is tightly controlled through feedback loops. If you are low in any of your hormones, a signal is sent to the hypothalamus to stimulate the pituitary gland to in turn stimulate the gland that produces the hormone you’re low in to make more. When you have enough, the hypothalamus stops telling the pituitary to hassle the gland in question to produce more. The problem is that the HPA axis response works to keep the sympathetic nervous system response going and chronic low-level stress keeps the HPA activated. In essence, it means that your body is on heightened alert for a long period of time, and this can have many consequences for your health. Your blood vessels and arteries can get damaged through the fluctuations of adrenaline and this can have effects not only on your heart but also in your cerebrovascular system.
When you’re in your stress loop the hypothalamus emits corticotropin-releasing hormone (CRH), which triggers the release of adrenocorticotropic hormone from the pituitary, which in turn causes the adrenal cortex to release cortisol. Cortisol activates systems in the body and is the main agent of our heightened alert state. It stimulates our body to replenish energy stores that are depleted during the stress and increases appetite so that we take on more nutrients to deal with the stress. However, most of the bears we are fighting or fleeing from are metaphorical so the intake of calories doesn’t quite match up with the energy expended. This is one reason why a long-term effect of stress is weight gain, another reason being that cortisol prompts us to be ready with energy to run from the next bear round the corner too, and so squirrels away that extra calorific intake as fat.
Stress headaches and why they matter
So why does all this give you a headache? There are two ways in which the stress headache is born. The first is the effect that adrenaline has on our blood vessels. Adrenaline constricts peripheral blood flow – the blood flow to your extremities – which is why you go pale when you get a fright. It does this to redirect blood to more vital regions, such as your heart, your lungs, brain and the big muscle groups to help you get out of your situation by bringing more oxygenated blood to your heart, allowing it to beat faster, and your muscles, to help them work aerobically for as long as possible. As adrenaline fluctuates according to need, so does the response of the blood vessels. Over a long period of time, this can damage blood vessels, causing them to at best become less efficient and at worst causing them to break and leak blood. The latter can be catastrophic in the brain. Although we have known since Thomas Truelson’s 2003 Copenhagen City Heart Study that self-reported high-stress activity and weekly stress was associated with fatal stroke, it wasn’t clear that stress was an independent risk factor for stroke. Joanne Booth and colleagues from Glasgow Caledonian University reviewed the evidence in 2015 and found that how much stress people thought they were under was predictive of the incidence of stroke, but that the risk was higher in women. This tells us that there are more factors at play than simply adrenaline and blood vessels; the higher risk in women may be indicative of how women cope with stress through their physiology. One other mechanism is that we mount an immune response because we feel we are under attack. Indeed, in 2017, Ahmed Tawakol and his co-workers from Harvard Medical School linked the activity of the emotional regions of the brain to the overproduction of white blood cells, causing blockages and arterial inflammation, leading to higher incidence of stroke and cardiovascular incidents.
Our own perceived stress therefore causes an abnormal immune response, on top of the cortisol flowing around our system simultaneously ramping us up and trying to put out inflammatory fires. Your body is at war with your mind and when the body goes ‘over the top’ the immune response can even lead to complications that impede your recovery.
However, this is all a rather catastrophic view of what can happen with continued stress. Not all headaches result in stroke; this is an extreme, yet possible, outcome. We do have the power to avoid any of the factors that put us at risk of stroke. Tension headaches are possible side effects of stress and so should not be ignored. What’s more, taken as isolated incidents, the headaches are unpleasant and scary in themselves and this adds to the general feeling of stress, which feeds into the circular problem.
A reminder: the pain in your head comes from the fluctuations in constriction and dilation of your blood vessels, which activates pain receptors. These signals are collated and carried by the trigeminal nerve, which you then perceive as pain. This tells you there is something wrong and that something in your brain is not working optimally; in this case, the something is the blood vessels’ ability to bring blood containing vital oxygen, glucose and nutrients to your brain and leave again in an orderly fashion. However, there is another factor at play. Because of the constant stimulation of the sympathetic nervous system caused by the stressor, and also the pain signals from your blood vessels heightening your alert state, your muscles are more contracted than they ordinarily would be, constantly using energy and oxygen. Over a prolonged period, this leads to your muscles feeling harder than normal. It is not always easy for us to release this contraction simply by consciously sending a signal to our body with our mind. In fact, tense muscles can actually become a permanent feature in people who suffer from chronic tension headache.
Another bodily response to stress that has a role in how we experience tension headaches is the release of nitric oxide (NO). This is a gas found in the body that works as a neurotransmitter to relax the blood vessel walls, causing vasodilation and also inflammation. Patients who have angina will know that the GTN (glycerol trinitrate) spray, which delivers nitric oxide into the body, immediately widens the blood vessels that feed the heart muscle, causing instant relief from chest pain. It widens other blood vessels, too, which is why some people develop flash headaches as a result of its use. Indeed, nitric oxide has various actions that have been linked to different forms of headache. When we have a tension headache, nitric oxide that is released from our blood vessels seems to make us much more sensitive to pain in the tissue of the head and neck, including the signals from the tense musculature and the walls of the blood vessels. It even activates the trigeminal nerve directly. The vasodilatory effect of nitric oxide, meanwhile, has been linked to the mechanism of migraine, while the action of nitric oxide in the brainstem is correlated with cluster headache.
There doesn’t seem to be anything good about the action of nitric oxide, does there? On the contrary: it acts with all of the other bodily systems to cause symptoms that tell us something is going wrong, and it also tries to fix it. One of the biggest roles nitric oxide has in helping us function normally is prompting recovery sleep after a period of no sleep, or sleep deprivation. Disturbed sleep is a huge stress for the body and may be severe in those who are under emotional pressure. And then there’s the issue of fluctuating blood flow. Nitric oxide widens the blood vessels, which activates the pain receptors in the vessel wall. It also sets up an inflammatory response to deal with whatever is causing pain.
Remember, though, that at the same time cortisol is trying to reduce inflammation. The problem is, when you start to look at all of the systems that are trying to ‘fix’ whatever is not working properly in your body to cope with the effects of stress or pain you can often see a maelstrom of competing interests.
The painful cycle
As is becoming clear, cause and effect is cyclical when it comes to tension headaches. I’m still sitting here with my pounding headache and I am trying to reflect on which came first for me this week. I was mentally rushed, which I find stressful, and this has had a physical effect on me. I have sat for long periods of time, drinking endless coffees and not visiting the bathroom even when my bladder was screaming at me. It never occurred to me to stretch, who has the time? When I did need to go from place to place I have walked at full tilt, putting my unprepared muscles in a precarious position. In addition to my headache, I therefore ache all over and this hasn’t helped my posture. I missed lunch most days and in order to wind down at the end of the day, I have sat hunched over my laptop in bed with a glass of wine (or two).
This time, my headache has been initially caused by a mental stress, a heightened alert born out of lack of time. But even without an emotional or mental cause, stress on the body can lead to tension headache all by itself. Posture, bad diet, dehydration, alcohol consumption, lack of sleep and the wrong kind of exercise all put the body and particularly the head, brain and neck region under stress, leading to tension headache. Together with mental stress, you have the perfect storm. I could feel smug about being thorough but really, I should know better than this; everything I did was wrong.
The physical causes of tension headache are well established. Jennifer Crampton, who has been a physiotherapist in Manchester for 20 years, says it can be related to many issues happening in the body; things like posture (when the usual muscles that keep us upright switch off, recruiting other muscles that are less suited to the job), alignment, pinching of nerves, overactivity of muscles, compensation of other muscles following injury and even the alignment of teeth and jaws. She is adept at finding trigger points – areas of hypersensitivity in the muscle when it is pressed – in her patients and these can often be in the neck area or the musculature supporting the head. When touched in this way, she can feel the muscle twitch and her patients report pain in their head, which is a kind of referred pain from the neck area. This all might be due to an injury or a repetitive strain; many of Jennifer’s patients who are recovering from injury or operations that have affected their movement will present to her with tension headache and in this case she can take it as a symptom that something biomechanical may still need to be addressed. But Jennifer also raises an excellent point: what if postural changes are our body’s way to relieve the tension in a damaged muscle and that is then causing the headache? In this way, the headache came first, leading to poor posture to try to correct for or mitigate the pain. Correcting posture without a good biomechanical view of what is happening elsewhere might therefore make the tension headache worse. I am now doubly convinced of the need for physiotherapists in this world.
Physical issues have knock-on effects on mental health and so should never be ignored or shrugged off. It is very common for Jennifer’s patients to feel mentally stressed due to the bodily issues they are experiencing. The inflammatory response that is caused by a painful biomechanical problem that may or may not initially be making itself felt as a headache is interpreted in the brain as a negative emotion, usually as stress, thus increasing the problem and the incidence of tension headache. Emotional stress sets up an inflammatory response, too, in addition to the one the body is having in order to try to solve its physical problem.
Being hunched over a computer all day and then trying work in bed with really bad lighting won’t have helped me. Because of the boiler packing up, my body was as stiff as a frozen fish stick anyway so there will have been a huge inflammatory response there, in addition to the inflammation I induced because of my many ‘rushing around’-related injuries. I am also hitting that point in my life where my eye muscles don’t work as well as they used to and so I suffer from eye strain a fair amount, another cause of tension headache. And to cap it all off, there is a building going up just outside my office and it takes a lot of effort to ignore the noise, which causes a stress response, too. Research shows that if there is noise of greater than 12 decibels when we are asleep, there is a marked physiological stress response; I was dealing with a much louder noise and I was fully conscious! Ochón agus ochón as we say in Ireland. Woe is me. Woe indeed, but a lot of this I could have alleviated myself.
What cost dehydration?
Drinking coffee and missing meals is no way to keep your body at peak optimal performance. Add to that a cheeky glass of wine of an evening and you are on the road to not providing the nutrients your body needs to cope with the stress response and repair damage, and you are also dehydrating yourself. I did drink constantly but caffeine and wine are both diuretics that make us urinate more (my poor bladder). And then, to add all of these insults to injury, I had a curry last night to ‘do something nice for myself’. More stress on my kidneys trying to deal with all that salt and lovely spice. But what’s that got to do with my headache?
Well, this might in fact be a dehydration headache, which occurs when we put our bodies through the kind of stress that I have this week, and often happens in combination with a tension headache, or is mistaken for one. As we saw in Chapter 1, your brain contains loads of water, which your kidneys draw upon in times of need. Thanks to all the water I lost by eating and drinking the wrong things, and the lack of replenishment, my brain volume literally shrank, pulling on the meninges and activating the pain receptors there. Not only that, but because my blood was more concentrated, there was less blood volume to carry nutrients and oxygen to my brain, however valiantly my vasodilatory system tried to redress the situation (leading to more pain from my blood vessels, of course). This made me feel foggy, wobbly and irritable. My heart was also racing because I had less blood, so my heart had to beat faster to get the same amount of blood circulating around my system. Little wonder then that my sympathetic nervous system interpreted all of this as a threat.
This is the vicious circle of the stress response and it is hard to know whether it is the body or the mind that is more rancorous. The answer is, we can’t think about the brain as being separate to the body either when we are thinking about what causes headaches or thinking about how to deal with them.
Want some cheese with that whine?
We make bad choices when we are under emotional stress, often and especially when it comes to food. We eat poorly, which when tied up with the cortisol released by the hypothalamic–pituitary–adrenal (HPA) axis response means we gain weight. We drink more alcohol because we think it will help us to relax; we are not really wrong in that view – alcohol is classified as an anti-anxiety agent and sedative hypnotic after all – but there are some other things we should take into consideration when we use it in this way. A couple of drinks will activate the inhibitory neurons in your brain by mimicking a neurotransmitter called gamma amino butyric acid (GABA) and this gives you a more relaxed experience, which can lead to euphoria, or withdrawal, or even violence, depending on the setting. If you have more than a couple of drinks then the receptors for glutamate, one of the main excitatory neurotransmitters in your brain, are blocked, making you feel much less anxious and even sedated because there is even less activity in your brain than normal. Increasing inhibition (through GABA) and decreasing excitation (by blocking glutamate) both feed into how alcohol makes us feel. We often become disinhibited when under the influence of alcohol and that’s because the part of your brain that controls judgement, the frontal cortex, becomes selectively turned off, while the subcortical structures are spared. This means that the part of the brain that is responsible for our more primitive instincts, such as desire, is still active. These regions also control the dopamine reward system, which also stimulates the production of serotonin (the happy hormone) and endorphins, our natural painkillers. Our actions feel good and all is right with the world. And yet, we don’t have our frontal lobe working to tell us right from wrong. And we might get lost, a lot. And we might not remember anything. It explains why when we have been drinking, we tend to make bad decisions, like to eat from the kebab van parked outside of the bar, or to go home with someone we wouldn’t ordinarily consider. This is the neurobiology of beer goggles.
Coming down off a busy day with a glass of wine is one of the great advantages of being a grown-up, but it doesn’t take long before one glass of wine doesn’t work to make us feel as good as it used to. Our tolerance changes, we create more endorphin-binding sites, so it takes another glass to feel as good as we used to. So now, we not only have more dehydration to deal with, but we also have a chemical conflict in our brain. Once we stop drinking and externally controlling the neurotransmitter levels, overnight our brain realises that now it is just not excited enough. In consequence, it works to bring GABA (the inhibitor) levels down and boosts glutamate (the excitor). This results in an unnatural environment, which we interpret as anxiety, that can last for a couple of days. David Nutt from Imperial College London coined the term ‘hangxiety’. That glass of wine you thought would help you wind down has actually maybe made things worse.
On top of all of this, alcohol is a diuretic that overcomes the usual body clock suppression of urine release overnight. Four hours after slipping into a blissful and restorative sleep, you wake up needing a wee. But by now you feel bad about yourself and even more anxious about what you have to do the next day because this is when the GABA/glutamate imbalance kicks in as well. Great, not only are you awake, but you also have to get up and visit the toilet, and you are stressing out. The sympathetic nervous system kicks in to try and be helpful and now that’s the ball game.
I’ll admit I haven’t slept very well this week. I do wake up early when I have a lot on, but this week I’ve been waking earlier than usual and had no luck getting back to sleep. Nitric oxide must be flooding my system, trying to be helpful and get me some rest, but of course it is messing with my blood vessels, too. My immune system will be releasing inflammatory agents and I am tired, and not prioritising well, taking longer to do things than usual. Add to this all of the other things that I have done wrong this week, and the result is that I have a banging headache by Friday. As a kick in the teeth, the so-called weekend tension headache (which should actually be renamed the downtime headache to cover all work patterns), happens as your body and your brain is readjusting to its baseline levels and repairing and restoring function. Part of this is the inevitable inflammatory response and vasodilation in the cerebrovascular system, leading to the cruelty of a headache in your free time.
Arresting the stress
Some physical causes of tension headache are easily dealt with. A new chair leading to better posture and a better prescription for your eyes may just change your life! However, conditions such as arthritis of the cervical area of the spine in the neck are harder to tackle because your immune system has turned on the connective tissue in the joints between the bones of the spine, degrading the cartilage cushion and causing inflammation and pain.
Mental causes that set off the cascade of physical events that are interpreted as stress by your brain are less well defined. We don’t often enough link our physical well-being to our perceived stress levels and vice versa. Tension headache sufferers I speak to tell me that they only realise they have been under ‘too much strain’ when they get a blinding headache. Joining the dots for them is always instructive. You were worried about x, or you have too much on. You dealt with everything, but you ate badly, slept badly and you were not hydrating or exercising properly. Your brain interprets these signals as threat, increasing the stress response.
Where in this process do you think you could have avoided a headache? Most of the people I talk to in the course of my work say ‘by remembering to eat right or drink more water’, or ‘by exercising’ – in effect, optimising their ability to deal with the stress that seems inevitable to them. To a degree, this is true. Our jobs require more and more from us in less and less time. Not all of us enjoy our jobs, which means we don’t get to counteract the stress with little shots of dopamine and serotonin during the day. Many of us have parenting or caring responsibilities in addition to our paid work, making us feel torn, displaced and guilty. We have oxytocin to thank for this one. A fine hormone that promotes bonding not just between lovers but parents and children, it can cause a feeling of unease when you are away from your paramour or offspring. We learn to deal with it over time – I think even the least cynical of us would agree that it doesn’t last long in new relationships – but it is much longer lasting when it comes to our children.
Chill, baby
Over the years that I’ve taught a course on headache, pain and drugs, I’ve asked my students why they didn’t just relax a bit about what was causing them stress. I was careful with my language here – I learned a long time ago that it is unwise to tell anybody in a tizz to ‘calm down’. Although there is no scientific literature on the consequence of this, my own experience has shown that it leads to a motor response that somewhat resembles a right jab. Nobody chooses anxiety, so telling people to chill out once it has happened is pointless. But what about trying to lessen the fight-or-flight, or HPA, response to stressful situations where a big physical effort is not required? How might we do this? This is the key to prevention.
The trick here is to reassert the conscious brain’s control over unconscious processes. This is as hard as it sounds, and requires self-awareness and practice. But master it and it will give you the best of both worlds: you will have the cognitive alertness when you really need it, and adrenaline and cortisol will be released to give you a boost. Even better, that control will mean that not every little thing will cause a big stress response in the body, with effects that result in headache. You really do get to choose what you worry about, and know what it is you cannot help but worry about.
Clinical psychologists call this ‘resilience’ – the ability to cope with a crisis or to return to pre-crisis status quickly. I would actually go half a step backwards and ask if what you are experiencing is a crisis at all. There are the obvious ones we cannot help but raise a stress response to, such as illness of a loved one, bereavement, worry about the whereabouts of a child late home from school, climate change – we need our physiological response to deal with these crises – but some other examples I hear about are no big deal compared to these, and often dependent on the stage of life people are at. Certainly, my involvement with education has made it very clear to me that emotional development is just as important as, if not linked with, intellectual development. And so I have developed a five-point plan:
Resilience 101:
1 Don’t sweat the small stuff.
2 If you are not in control of the situation, don’t worry about it. Worrying won’t change it.
3 Just think about the next step and not the myriad consequences that may be a consequence of all of its consequences.
4 Prioritise, starting with family first.
5 When I look back on this in a week’s time, will I wonder what all the fuss was about? Take the long view.
All of these will help you measure how much of a stress response you should mount, and with practice it becomes pretty automatic, leaving you calmer, with a bit more space than you used to have when you jumped into situations feet first. The five-point plan works for most things, but even recognising when you worry about things outside of your control (such as the health of loved ones) can help you put your stress response into proportion through the other behaviours of the plan.
The medication route
There are medical ways to do this. Beta-blockers decrease the activity of the sympathetic nervous system and stop your body from mounting a stress response, which makes you feel calmer.2 Anti-anxiety medication that changes the levels of neurotransmitters in your brain is also widely used in treatment. Drugs that increase the amount of GABA, or decrease the amount of glutamate action in your brain will result in you feeling calmer, but you will need to take more to get the same effect as you adapt.
These medications may help you get a handle on how to deal with the emotional causes of your stress, but they won’t make them go away. The lasting effect comes through the changes that you make to your behaviours to allow you to sustain a chemical balance in your brain naturally. Johann Hari speaks about this eloquently in his book Lost Connections. Everything from dealing with past trauma, through building resilient behaviours to social interaction can be used as ways to rebalance your brain in the long term. Learning how to deal with and respond to the emotional causes of stress is the key. And we have to do this through behaviour. Drugs can help us be more receptive to this learning and get us out of an emotional hole but they are not a long-term solution on their own.
Meditate on this
A less medical approach but one that is no less fascinating to a neuroscientist is meditation. Techniques that focus on breathing are there to slow you down metabolically. A reminder: if the sympathetic nervous system is in gear, we will breathe faster than usual. Consciously slowing down breathing lessens the perception of threat by the brain, and decreasing the inflammatory response, particularly to the brain, where dilation causes pain.
Meditation can change the balance of your neurotransmitters but, given time, will also change how your brain is wired up. I’ve mentioned before that the frontal cortex contains the part of your brain that helps you make decisions and rationalise what is happening. It also houses the bit that works out how everything that is happening relates to you. As part of the emotional, or limbic, system, the insula, which lives deep inside our brains, is very important in our emotional responses, self-awareness and regulation of the body’s state. The amygdala, which we have already met, is also critical in our first reaction to situations. Ordinarily, the medial (middle) frontal regions communicate extensively with the insula and amygdala because it is important for us to see how stimuli, be they internal like heart rate or external like an approaching bear or deadline, are going to affect us in particular.
Sara Lazar from Harvard Medical School has scanned long-term meditators and has found that what meditation does is strengthen the control that the lateral (areas to the side) frontal regions have over the medial region. The lateral frontal regions give us the context of what is happening. Over time meditation enables you to look at what is going on inside and outside of your body more objectively. In the same way that your frontal lobe helps you bite your tongue when your emotions really want you to let rip with a few curse words, in this instance, the lateral frontal lobe takes the sting out of your emotional response, preventing the sympathetic nervous system and HPA from escalating the situation. Even better, by strengthening the pathway between the different regions involved, our empathy for others and our social connections are enhanced. Sara also saw lesser amygdala activity (the area that becomes active in response to threat) in consistent meditators. This field of research is about 20 years old now and is moving on to look at the difference between various meditative techniques such as yoga versus mantra-based methods, and to find out how long the effects last for. One thing is for sure: 50-year-old meditators have the same grey matter volume as 25-year-olds, showing that there is a neuroprotective element to it. Once we know the mechanism of this, we will understand why.
Training your body
Other techniques focus on breaking a stress response through a physical action that you have associated with something that makes you feel happy instantly – installing a feeling of calm instead of anxiety. Psychologists call it ‘classical conditioning’, most famously demonstrated by Ivan Pavlov and his dogs. Every time Pavlov presented food to his dogs he would ring a bell. After some training, every time he rang a bell his dogs salivated as they expected food. The previously neutral stimulus, the bell ringing, became a conditioned stimulus for salivation. Salivating in response to a bell wouldn’t be so good if you found yourself in a stressful situation – and so you make your own association. By training yourself to associate a feeling of happiness with a physical action such as touching your nose or pulling your ear lobe, you can trigger these feelings to mitigate stress in the future. Every time you feel happy, tug on your ear lobe. After some weeks of doing this, if you feel anxious or stressed, tug on your ear lobe again. You should now be releasing those neurotransmitters that are unleashed when you are happy and this dopamine and serotonin gives you the capacity to deal with what’s in front of you more calmly.
Breaking bad – what to do when you have a tension headache
Once you have the tension headache, though, we have to break its resultant vicious circle somehow. There are various ways of doing this. For instance, relaxing the body through massage, heat treatment or stretching (which arrests the contraction in our muscles) will decrease the pain signals from the musculature and so the resultant vasodilation in the head.
Most of us, of course, instead reach for the painkillers. Ibuprofen, paracetamol and aspirin are the main over-the-counter medications for tension headaches. All act to reduce inflammation, with ibuprofen having the strongest action. However, as we have already found, it can cause stomach irritation and wheeziness in asthma sufferers. Aspirin can also be harsh on the stomach lining, with paracetamol (known as acetaminophen in the US) the best tolerated by the gastrointestinal tract. Most of these will also come delivered in a pill containing caffeine, which works as a vasoconstrictor (constricts the blood vessels) and also helps the drug’s movement through the gastrointestinal tract. However, taking regular tablets with water followed by a coffee on their own would suffice – just remember to drink more water afterwards to counteract the dehydration the coffee will cause!
Wired to the moon?
Caffeine withdrawal headaches are also a thing, particularly in heavy coffee drinkers. I had a student who once piped up in class that if she didn’t have coffee within half an hour of getting up, she got a headache. I asked how many coffees she would have in the day. The answer was a whopping 13 mugs! Her headache was being caused by the fact that her blood vessels had gotten used to being constricted all the time. When that external constriction was released, her blood vessels dilated, sending warning pain signals. This was too much to bear for my student which was why she drank so many coffees. Such withdrawal effects are a huge component in addiction – and she freely admitted her addiction to caffeine.
Paracetamol: pain and empathy killer
There is something really interesting about paracetamol, and this could also apply to other over-the-counter painkillers. Dominik Mischowski and his team from Ohio University have shown that people who have taken paracetamol are less empathetic to other people’s pain. This isn’t trivial; empathy is a big part of why we behave the way we do towards others and so paracetamol’s ability to manipulate this might be seen as a social side effect as opposed to the physical side effects clinical trials usually monitor. Dominik’s view is that because a decrease in perception of pain (through the action of paracetamol) is linked to a decrease in acknowledging the pain of others, there must be a shared mechanism between the two in the brain and that this is a basis for empathy. We already know there is a sensory component of pain (what does it ‘feel’ like?) involving sensory regions of the parietal lobe, but also the frontal regions we’ve just talked about, and the limbic system, too. But there is also another pathway that is much more subcortical, involving a region known as the ‘zona incerta’, which is very important in how we experience pain. What may be a tickle for me may be excruciating for you. Activity in the zona incerta is modulated by many factors, such as your levels of circulating endorphins (natural painkillers) but also your experience, your upbringing, your educational status, your social position, your diet and your relationships. In a further study, Dominik found that participants who had just taken paracetamol are less sensitive to the pleasure they would usually gain from happy stories (called positive empathy). So perhaps feeling happiness shares a mechanism with being able to detect other’s emotional states.
There is a lot more to do to confirm these findings and also we have to bear in mind that in this experiment the paracetamol was being taken by people who were not feeling pain to begin with – and so its effects may be different if they were. It is also interesting that despite paracetamol being developed by an American chemist, Harmon Northrop Morse, in 1878, and first used clinically by the German Joseph von Mering in 1893, it remains a bit of a mystery. We are still not completely sure how it produces its effects. We know that its anti-inflammatory action happens at the level of injury, blocking the release of prostaglandin, which begins to heal damaged tissue causing the inflammatory effect. By stopping this effect you effectively halt the pain signals from being generated there. But certainly in some people, paracetamol acts in the central nervous system, too, boosting the serotonin pathway from the brain to the body, otherwise known as the descending pathway, which blocks the ascending pain signals in the spinal cord – the ones coming up from the body to the brain. We know this to be true because if you block the serotonin receptors, you can stop paracetamol from being as effective a painkiller. This is useful to understand – especially because anti-emetic (anti-nausea) drugs are packed full of these serotonin receptor blockers, but are frequently given together with paracetamol post-operatively. This means that one of the ways in which paracetamol works is cut off. Go figure. This illustrates why understanding mechanisms is so important.
Paracetamol also encourages the activity of your natural endorphins, making them hang around in your synaptic clefts (the gaps between your neurons) for longer. This may be dependent on your natural levels of endorphins but it would seem to explain the feeling of relaxation and even euphoria that some paracetamol users report, even outside of its painkilling effects.
One last mechanism worth mentioning is that paracetamol would seem to block our old friend nitric oxide, too. Nitric oxide synthase inhibitors (or, put another way, drugs that stop nitric oxide from being produced) have been suggested as a treatment for tension headaches for 20 years. Development has been slow, though, no doubt due to the many effects that nitric oxide has in our body, leading to lots of side effects if we block it medically. And of course as it turns out, paracetamol may already be blocking nitric oxide anyway!
Immersion therapy
If all else fails, settle down and watch a movie. Movies are medicine. Seriously. By taking your mind off the pain and diverting your attention not just from your aching head but also from what caused it to ache in the first place, you will feel better in no time. Watch something funny; laughing gives you a quick hit of serotonin that will make you happier and block those pain signals. It also helps to drink water, watch your posture (unless you are being hugged; never turn down safe oxytocin, that’s my motto) and wear your glasses. Oh, and eat a couple of squares of chocolate – that boosts serotonin too. It all helps and it’s what I am off to do right now.