Headaches are just about the most common ailment imaginable. They’re also one of the most aggravating. They often crop up when they’re least welcome: during busy times at work; when you’re trying to sleep; even when you’re having sex (yes, sometimes this is not just an excuse!).

Yet although headaches are incredibly common, they remain somewhat mysterious. According to Joel Saper, MD, the director of the Michigan Head Pain and Neurological Institute, there are more than 300 causes for head pain. Three hundred! That can make it very difficult to determine specific triggers for individual people.

Some headaches are set off by certain foods or drinks. Dr. Saper reported that one of his patients was overjoyed when he discovered that the source of his chronic headaches was the glass of milk he had each night before bed. When he stopped drinking his nightly soporific, his headaches stopped.

Other headaches can be caused by a deficiency in a vitamin or enzyme that the body needs, like magnesium. Or by a deficiency in something the body has simply gotten used to having regularly, like caffeine. And, somewhat incredibly, still other headaches can be caused by the pills people take to get rid of the pain from their headaches!

The source of the sensation of pain from headaches is almost as elusive as their cause. Even though the pain is in your head, the brain itself doesn’t feel pain, according to Dr. Saper. (Otherwise, neurosurgeons wouldn’t be able to perform surgery with wide-awake patients, as they often do.) The head pain we experience may come from the scalp, skull, covering of the brain, sinuses, optic nerves, or muscles and nerves in the neck.

Headaches can also be caused by a serious underlying condition. Occasional mild headaches shouldn’t be a cause for concern. But severe or chronic headaches should always be evaluated by a physician.

Headaches rank very high on the list of reasons people see their doctors. Roughly 45 million people experience chronic head pain—and that doesn’t include those of us who suffer minor headaches occasionally. Some individuals suffer intense daily headaches. Diagnosing the cause of this kind of head pain can be incredibly challenging.

Celiac Headaches

Q. I suffered from migraine headaches for more than 10 years. I saw several neurologists, but my intense headaches forced me to take early retirement.

In the fall of 2002, I went from 3 headaches a week to almost non-stop. That November, I had only 3 days without headaches. I took migraine meds like Frova, Maxalt and Imitrex, but I mostly lay in bed in a dark room.

I was at my wit’s end. Then my family doctor suggested a gluten-free diet. Gradually my headaches became less frequent, and after several months I was 98 percent headache-free.

I feel I was given a new life! Please share my story so others can benefit.

A. Migraine is not often recognized as a symptom of celiac disease, but we have heard from others like you who suffered until they eliminated gluten from their diets. Celiac is more common than many physicians realize.

In this condition, sensitivity to gluten (a protein found in wheat, barley and rye) can result in symptoms such as fatigue, anemia, nerve pain, memory loss, osteoporosis, infertility, flatulence, diarrhea and digestive tract distress.

Headaches & Caffeine

Q. I am a healthy person and rarely take any medicine. I quit smoking 14 months ago and am trying to stop drinking coffee. Lately I’ve had trouble with fatigue and tension headaches in the afternoon. If I take Extra Strength Excedrin with a Coke on my break, the headache goes away like magic. Regular aspirin doesn’t work as well. Why is Excedrin more effective?

A. Each Extra Strength Excedrin contains aspirin (250 mg), acetaminophen (250 mg), and 65 mg of caffeine. That means that a standard two-caplet dose will provide you with 130 mg of caffeine. Together with your Coke, this probably provides as much caffeine as two mugs of coffee.

It is conceivable that your afternoon slump and headaches are due to caffeine withdrawal. People who customarily drink as little as 2 1/2 cups of coffee can experience symptoms such as lethargy, headache, and anxiety when they stop.

By taking a pain reliever that contains caffeine, you could be easing your withdrawal. An alternate solution is to try to reduce your caffeine intake gradually until you are completely weaned.

According to Dr. Joel Saper, a little caffeine every so often can be therapeutic for headaches. It’s when caffeine is taken daily in moderate or high doses that we become physiologically dependent on it, and then getting too much or stopping too suddenly can produce headaches.

“A friend had a headache that would not go away. I told her to rub a dab of Vicks on her forehead. She thought I was nuts, but it worked. She has been using it ever since.”

Medication Overuse Headache:

Too often, patients try to “treat” their headache pain themselves, by taking aspirin or acetaminophen to make the pain go away. This is fine if it’s just once in awhile, but if headaches occur several times a week, then taking overthe-counter analgesics can actually make things worse by triggering a vicious cycle: what doctors now call a “medication overuse headache.”

This is because frequent use of the analgesics meant to fight headache pain causes irritation of brain receptors. When these receptors become sensitized, which is what happens when they’re exposed over and over to analgesics, they’re more likely to trigger headaches. Thus, more frequent use of painkillers leads to more sensitization, which in turn leads to more headaches. Which can be maddening.

It can take weeks or even months of regular use for this vicious-cycle process to occur, but when it does, it can be difficult to get out of it again. Moreover, when patients are in this cycle, other treatments that may be appropriate for them won’t work. Under the guidance of her physician, the headache sufferer must stop taking the medication she’s been overusing, go through an adjustment period, and then she’ll be able to respond again to therapeutic treatments.

Often headaches will decrease in frequency simply when the frequency of medication use is decreased. Dr. Saper told us an extraordinary story about one of his patients who was hospitalized— and in fact at risk of dying—because for a long time, he had been taking 55 Excedrin per day! When he was carefully taken off of the Excedrin in the hospital, his headaches almost completely vanished, and 25 years later, he hardly ever has them.

Unfortunately, many doctors don’t know that chronic use (or abuse) of painkillers can lead to chronic headaches.

Describing the Headache Can be Challenging:

Physicians’ difficulties diagnosing and treating headaches stem in part from the fact that headaches can be caused by so many different things. As a first step, it may be useful for you to keep a headache diary: a careful record of the headaches you get; when they occur; what type of headaches they are (“ice-pick” or “jabs and jolts,” cluster, or other migraine-type headache; caffeine-withdrawal headache, etc.); any foods or other things you’ve recently consumed; any changes in your exercise regimen or sleep cycle, etc. This information may help your doctor diagnose and treat your head pain.

Recording when and how headaches occur may also help you and your doctor identify other underlying conditions you might have. For instance, those with celiac disease frequently get headaches when they eat gluten. When they remove gluten from their diets, they can have a dramatic reduction in headaches.

Estrogen can also be an aggravating influence for women prone to headaches, particularly migraines. It’s not at all uncommon for women to stop getting migraines after menopause—but by that same token, the migraines may very well start up again in women who go on hormone replacement therapy. And many women also discover that their headaches increase or worsen when they begin taking birth control pills.

The potential causes of headaches are too numerous and varied to cover exhaustively here, which is why keeping a headache diary that you share with your doctor could be helpful. But there are a number of common types of headaches that may be easier to diagnose and therefore treat than others. Again, serious or recurring headaches should always be brought to your doctor’s attention.

Caffeine Withdrawal Headache

Most people know that caffeine can be addictive. But not everyone is aware that stopping caffeine cold turkey—even just for the weekend—can cause a nasty withdrawal headache. The short-term solution is simple: consume some caffeine. But over the long term, it may make sense to cut your caffeine consumption so that you can take occasional breaks without suffering.

Dehydration and Heatstroke

In the summer months, another common cause of headaches is dehydration, and again, the solution is fairly simple: drink some water. But overheating should not be taken lightly. In severe cases, it can lead to brain damage or death.

Heatstroke (not to be confused with heat exhaustion, which is somewhat less serious) happens when core body temperature rises dangerously high and the heat can’t dissipate. In someone suffering from heatstroke, the body temperature will be high, and the skin is usually dry and flushed (not clammy and pale, as generally happens with heat exhaustion). Heatstroke often occurs after strenuous outdoor exercise, but there are also many medications that can make a person more vulnerable to it. It can come on very suddenly, and one possible symptom is headache, along with disorientation, weakness, and potentially loss of consciousness.

Heatstroke is a medical emergency, and one example among many that a headache can signal a very serious medical condition.

Tension Headaches

People often refer to headaches that aren’t migraines as “tension headaches.” It can be hard for non-specialists to determine what exactly constitutes a headache vs. a migraine, but as a general rule, if your headache responds well to over-the-counter treatment, and so long as it doesn’t occur more than once a week, it’s reasonable to tackle it yourself with an OTC painkiller, no matter what you call it.

There’s no best OTC option: aspirin, acetaminophen, and nonsteroidal antiinflammatories (NSAIDs), like ibuprofen, all work differently for different people. A little caffeine may help boost the headacheeasing power of your painkiller, and many headache pills and remedies contain it. (Excedrin, for example, and “Excedrin Migraine”—which is basically the same thing as Excedrin.) Or you can take your preferred OTC pill with tea or coffee.

A few alternative headache remedies we’ve heard about include a dab of peppermint oil on the forehead, or a smidgen of Vicks VapoRub on the temples.

Over the past several decades, researchers have contemplated why it is that women experience so many more migraines than men. One possible answer seems to be that migraines are frequently tied to menstrual cycles and changes in hormones. Both estrogen and progesterone affect the chemicals in the brain that can lead to the cascade that triggers a migraine.

Migraines are about twice as likely to strike during the first few days of a woman’s menstrual cycle than they are during the whole rest of her cycle. As if menstruation weren’t headache enough!

But one upshot is that, in this case, knowing is most certainly half the battle: being able to plan for a potential migraine means you’ll be much more likely to be able to head it off at the pass, as it were, with preventive measures. This means being sure to get enough sleep, stick to your routine (don’t skip coffee or tea if it’s part of your daily regimen, for example), avoid trigger foods and other substances, and not to over-exert.

There are also other things that you may want to consider giving a try. For one, many physicians recommend to women prone to menstrual migraines that they take a nonsteroidal anti-inflammatory (NSAID) like mefenamic acid (Ponstel) for a few days before the onset of their period, and then continuing on for a few days into menses. Other NSAIDs like naproxen (Aleve) or ibuprofen (Advil, Motrin) may also have some positive effect. Just be advised that all of these pain relievers can lead to stomach and GI tract upset, so be sure to take them with some food.

Doctors have also been experimenting with magnesium for women suffering from menstrual migraines, with some success. One study showed a decrease in pain and the number of headache days for women who took 360 mg of magnesium each day starting on day 15 of their cycle through the begin of menstruation. And another study showed some promise for daily supplementation with soy isoflavones.

There are also a few triptans that seem to provide relief from menstrual migraines. The longer-acting ones like Amerge, Frova, and Naramig may be able to stop an anticipated migraine. Oral contraceptives, especially the kind that limit the number of period days, may also help some women.