Pain is the most common reason for a doctor's appointment – not surprising, since up to half of all Britons live with daily pain. Today, the second of our expert guides to pain management addresses headaches and migraines.
Whether it is a dull pain or a stabbing sensation, headaches affect most of us at some point – and for some people they are chronic.
If you often have a headache, keep a diary, says Peter Goadsby, a professor of neurology at King & # 39; s College London.
"The first rule is to know what you are dealing with. By keeping a headache diary, you can identify patterns and key symptoms, & he adds.
Here Professor Goadsby and other top specialists offer their tips for diagnosing and treating your headache.
Peter Goadsby, a professor of neurology at King's College London, and other top specialists have provided tips on diagnosing and treating headaches (file photo)
YOUR HEADACHE FEELS LIKE:
A TIGHT BAND AROUND YOUR HEAD
COULD BE: Tension headache.
OTHER SYMPTOMS: "A tension headache feels like someone is putting a band around your head and squeezing it," says Dr. Fayyaz Ahmed, a neurologist consultant at Hull University Teaching Hospitals NHS Trust and manager of charity The Migraine Trust.
"It can be serious, but it is usually mild and does not switch off and people can still function while having one.
"They can last for hours, but if you have a headache 24 hours a day, seven days a week, it is unlikely that this is due to tension."
How to deal with different types of headaches when they strike is revealed and the experts have also explained why the pain occurs
CAUSE: Tension headache is the most common headache, accounting for more than 90 percent, says Dr. Ahmed.
"Triggers such as stress and tension cause the muscles on the pericranium, the fibrous membrane that covers the surface of the skull, to get into spasm. Pain can be felt on the back of the head, the forehead and the temples.
"They can also be caused by hormones or other imbalances – such as a flood of noradrenaline, which is released when we are under stress – and dehydration, which causes the & # 39; hangover & # 39; headache, & # 39; Dr. adds Ahmed.
Other triggers include poor posture, lack of exercise, bright light, squinting, vision problems, hunger, and certain odors.
Red flags: five signs that it is serious
Certain types of headaches need to be examined urgently if you've never had them before, says Dr. Giorgio Lambru, a neurologist at Guy’s and St Thomas & # 39; Headache Center.
1- Painful, sudden pain at the back of the head, peaking in two to five minutes: & # 39; This is especially important in someone who usually does not experience a headache and needs to be examined with a CT scan and lumbar puncture to check for blood in spinal fluid & # 39 ;, says Dr. Lambru. "Possible causes are bleeding in the brain or meningitis."
2- Headache caused by activity: "Those who strike when you train, cough, exercise or have sex can be a sign of brain pressure," says Dr. Lambru. & # 39; It can be a tumor, bleeding, cancer or a cyst. & # 39;
3- First headache in old age: "Blood tests and a CT scan will eliminate serious causes, such as temporal arteritis, caused by inflammation of the cranial arteries and which usually occur as a dull sleep pain," says Dr. Lambru. "This requires emergency treatment to prevent blindness or stroke."
4- Headache that wakes you up: & # 39; This can be a symptom of a tumor because it is a sign of pressure build-up & # 39; at night. & # 39;
5- High temperature pain, stiff neck, confusion, seizures, double vision or skin rash: "It may be meningitis."
THERAPY: Most tension headaches can be treated with acetaminophen or ibuprofen, Dr. says. Ahmed. "But I would discourage those in combination with caffeine or codeine because they themselves can cause (withdrawal) headaches," he adds.
& # 39; You can also try a cold compress on the forehead. There are pain receptors on the blood vessels in the head and pain is caused when these blood vessels dilate. It is thought that the cold compress relieves pain by narrowing them. Cold also relaxes muscles, just like applying heat to the back of the head.
"Headache responds to lifestyle changes to reduce stress, such as adequate sleep, and headaches caused by dehydration respond to fluids. People who visit a doctor about headache mainly want reassurance, but for chronic headache we can prescribe the antidepressant amitriptyline or the beta-blocker propranolol to dampen chemical messengers such as noradrenaline. & # 39;
ONE-SIDED PAIN WITH NAUSEA AND TIREDOM
COULD BE: Migraine.
OTHER SYMPTOMS: "Migraine is usually a crushing headache that makes you feel sick, but they come in all shapes and sizes," says Dr. Ben Turner, consultant neurologist at Barts Health NHS Trust and the private London Bridge Hospital.
"My best diagnostic test is to see if a person has stopped working because of headaches – with migraine you tend to be immobilized and lie down in the dark."
About a third of the migraines have the classic & # 39; aura & # 39; symptoms of nausea, fatigue, noise and light sensitivity, and visual disturbances, and sometimes these symptoms occur without headaches – a & # 39; silent & # 39; migraine.
CAUSE: Migraine is the second most common form of headache. It is estimated that there are 190,000 migraine attacks in the UK every day and are experienced by more women than men – probably due to fluctuating hormone levels.
"A migraine is usually a headache with a different function," says Dr. Jessica Briscoe, a general practitioner and headache specialist at the National Migraine Center charity in London. "They tend to be diagnosed too little because people reject them as & # 39; bad & # 39; headache and not seeing a doctor.
"We don't fully understand the cause, but think nerves in the head are starting to fail – this hyperactivity starts in the middle of the brain and blows out to the peripheral nerves in the back of the head, neck or shoulders. Genes also play a role, because migraine often occurs in families. & # 39;
Dr. Ben Turner, a neurologist consultant at Barts Health NHS Trust and the private London Bridge Hospital, said: "Migraine is usually a crushing headache that makes you feel sick" and his best & # 39; diagnostic test is to see if a headache stops someone from working & # 39; (file photo)
THERAPY: Initially, migraine can be treated in the same way as tension headache, Dr. advises. Ahmed.
Migraine is also treated classically with triptans, which influence the action of a chemical messenger called serotonin. A Finnish study in 2016 has shown that the effect of serotonin on nerve endings can cause migraine. Triptans are taken as pills, jabs or nasal sprays at the first signs of a migraine.
New drugs called calcitonin gene-related peptides (CGRP & # 39; s), which target neuropeptides, brain chemicals involved in migraine, are currently only available as part of tests on the NHS. The first of these, erenumab, is a self-administered one-month injection.
Do you really need expensive pills?
Specific remedies for headaches are useful, but are they worth the extra costs?
When it comes to migraine, "drugs that combine paracetamol and codeine are not great," says Paul Booton, a retired general practitioner, a consultant at the National Migraine Center and a former professor of general practice at St. George's Hospital in London.
"Codeine does not work for migraine and can aggravate nausea and illness – and it is more likely that this will lead to headaches due to excessive use of drugs," he says.
However, community pharmacist Sultan Dajani points out that the all-in-one migraine product Migraleve is popular with customers, as it is the only freely available product that contains an anti-nausea medicine with a painkiller.
He adds that many people also find these pills easier to take because some people get confused about how many different pills they have taken if they have a headache.
"If you have a limited budget, you can save yourself a lot of money by buying generic painkillers and then getting a prescription for disease medicine from your doctor," he adds.
Meanwhile, Peter Goadsby, professor of neurology at King & College London, says about headache that there is no substantial evidence that painkillers specifically marketed as painkillers are better than standard painkillers.
"What is important is the dose," he adds. "Some of them work faster, but the time difference will only be around 15 to 30 minutes."
This class of drugs is "revolutionary," says Dr. Giorgio Lambru, consultant neurologist at the NHS Foundation Trust and the private London Bridge Hospital of Guy and St. Thomas. "They block the receptor or protein CGRP that is released by nerve endings in the head during migraine – the antibodies reduce inflammation of the nerve endings and dampen brain activity. They work in 40 to 60 percent of the cases. & # 39;
But last week, erenumab was rejected by the National Institute for Health and Care Excellence (NICE) for use on the NHS because of the costs. However, it is approved for use in Scotland by the Scottish Medicine Consortium and is available privately.
Botox is another option, although the mechanism is not fully understood. It has been approved by NICE since 2012 for migraine sufferers who have not responded to three drug treatments and who have a headache 15 days a month. Injections are given every three months.
Some patients may be offered transcranial magnetic stimulation (TMS), where the patients themselves apply a magnetic pulse to the back of the head from a handheld device to the & # 39; excitable & # 39; to calm nerve cells.
IT FEELS LIKE YOUR HEAD IN A VICE, WITH BURNING EYES
COULD BE: Cluster headache.
OTHER SYMPTOMS: Headache tends to center around the eyes and there is a sharp, burning or pervasive pain. Other important symptoms may include a bloodshot eye or eyes, a drooping eyelid, a sweaty face, blushing, and a runny or stuffy nose.
& # 39; Those affected feel restless and agitated; they will rock, pace or start digging the garden & # 39 ;, says Dr. Ahmed.
CAUSE: "It is said that this is the worst form of headache that affects humanity," says Dr. Ahmed.
"Fortunately, they cause less than 0.1 percent of all headaches, affecting an estimated 66,000 people in the UK, but they are so bad that some people have taken their own lives – people describe it as if they have their heads in a vice . "
Also known as timepiece headache, they are common in families and are more common in smokers, although it is not known why. Men are more likely to be affected than women in a ratio of almost three to one.
Attacks last between 15 minutes and three hours and patients can have up to eight attacks per day, every day for months. They tend to beat like clockworks at certain times of the day – and even on certain days in a week.
Not much is known about the cause, but it can be a kind of malfunction in the hypothalamus, the brain's main clock, which controls many functions, including the sleep-wake cycle.
Headache that is worse in the morning may be due to taking too many painkillers, according to the experts (photo of the file)
THERAPY: "Pure oxygen is the best treatment – the NHS offers an oxygen service for the home that delivers barrels to you," Dr. Ahmed. You inhale it through a mask during an attack. Oxygen causes narrowing of blood vessels, which is thought to relieve pain.
Other treatments include sumatriptan, which works in the same way as triptans for migraine, and recently gammaCore, used to stimulate the vagus nerve, which carries pain messages between the brain and major organs. The device is placed on the neck by the patient to provide a small electrical current for two minutes.
A DULL ACHE THAT IS worse in the mornings
COULD BE: Medication excessive use of "rebound" headache.
OTHER SYMPTOMS: The headache is dull and constant and you will have used painkillers.
CAUSE: It may sound counterintuitive, but if you use painkillers for a long period of time, you may get a headache caused by excessive use of medication, with the withdrawal symptoms of the depleted painkiller causing a headache.
People who take painkillers two or three times a week or for more than ten days a month are at high risk of getting this headache. Drugs associated with it include codeine, acetaminophen, caffeine and triptans.
Dr. Ahmed says: "About 1 to 2 percent of the headache is caused by excessive use of medication. It can be a very difficult cycle to break through and patients can be quite resistant to the idea of not using the painkiller anymore.
Wellness Journal tip
Try to eat two or three different kinds of fruit every day – don't think that three apples will convince you: throw a pear or banana in the mix
"The opioid painkiller code is the worst for causing this kind of headache, which is shocking because it is available to buy ready-made in products such as co-codamol (codeine phosphate and paracetamol combined).
"If the drug and drug regulatory authority could only do one thing, all codeine products would only have to be made by prescription."
THERAPY: "If you have a headache that is too common, it makes no sense to use other medicines because they don't work – the withdrawal will always cause a headache," says Dr. Ahmed. "I have to tell people that they get worse before they get better. Stopping abruptly is the best way. People may need to take time off to adjust. & # 39;
AN INVITING BLUE BLUE
COULD BE: Thunderclap headache, also known as sex headache.
OTHER SYMPTOMS: These are sudden onset, unbearable headache that often coincides with vigorous activity. "The pain peaks within a minute and it feels like you have been hit over your head," says Dr. Ahmed. "This is followed by aura symptoms, such as nausea and light sensitivity, and a stiff neck.
"They tend to engage in activities such as sex, weightlifting, or running."
Thunderclap headache can be treated with & # 39; simple maneuvers can be used to restore blood pressure, such as closing your mouth, pinching your nose and pushing down & quot; Jessica Briscoe (photo of the file)
CAUSE: "An unusual type of migraine – or a bleeding in the brain," says Dr. Ahmed. "A less common cause is a blood clot in the veins of the brain."
THERAPY: "You should go straight to A&E because there is a one in eight chance that this may be a symptom of bleeding in the brain," says Dr. Ahmed. "There is no way to just know about the symptoms."
PAIN THAT HITS IF YOU STAND UP
COULD BE: Postural headache.
OTHER SYMPTOMS: The pain is most severe at the back of the head and worsens by the day. These light up when you change positions and sometimes occur with a racing heart.
CAUSE: The switch position can cause a change in blood pressure in the head and cause headaches.
Other possible causes are postural orthostatic tachycardia syndrome (PoTS), which usually causes an abnormal increase in heart rate after standing up. This happens because the autonomic nervous system, which regulates body function, including blood pressure, does not work properly and causes a decrease in blood flow to the brain and causes headaches.
Other possible causes of headache when standing include a brain fluid leak (CSF) or a tumor.
THERAPY: "Simple maneuvers can be used to restore blood pressure, such as closing your mouth, pinching your nose and going down (like when you go to the bathroom)," says Dr. Jessica Briscoe.
But you must consult a doctor and ask to examine your symptoms. A tilt table test can diagnose PoTS. The patient is tied to a table attached to an ECG monitor to measure the electrical activity and blood pressure of his heart and tilted at an angle of 60 to 90 degrees.
Drugs for PoTS (prescribed off-label – they are not licensed) include beta-blockers and a type of antidepressant called selective serotonin reuptake inhibitors (SSRI & # 39; s).
The CSF Leak Association says the condition can be treated with bed rest, intravenous fluids and spinal fluid injections to solidify and repair the leak – as well as fibrin glue to repair the leak or surgery.
Medicines without medicines that you can buy immediately
Not everyone wants to take pills. Here we look at remedies and gadgets from High Street that claim to relieve headaches and ask the experts for their opinion …
4-person effective headache relief
£ 4.79, 3.6 g, boots.com
Neurologist Peter Goadsby says that the levomenthol in this stick has a cooling effect that distracts from pain and acts on the cold TRPM8 receptor on the trigeminal nerve, the main nerve in the head (which runs from the lower part of the brain at the back of the brain) head and divides into three branches in the face). "This probably changes brain activity into migraine," he says.
Some high street remedies do not contain medication and can help with pain (photo of a file)
£ 36.88, 120 caps, amritanutrition.co.uk
This supplement combines magnesium, vitamin B2 and coenzyme Q10, all of which play a role in migraine.
A study published in The Journal of Headache and Pain in 2015 showed that patients taking the supplement had fewer headache days per month, from 6.2 to 4.4, compared to 5.2 in a group taking fake pills. Professor Goadsby says, "I have never used this product with my patients, but I have successfully used its individual components."
Dr. Giorgio Lambru adds: "I always use this product together with my private patients."
Cefaly Dual Migraine device
£ 336, amazon.co.uk
It is said that it soothes brain waves involved in migraine, this device delivers painless electrical pulses to the upper branch of the trigeminal nerve.
A study published in the Cephalalgia journal of the International Headache Society discovered that 29 percent of patients using the device were pain-free one hour after use, compared to 6 percent in the placebo group.
Dr. Lambru says: "You have to use it for three months to get the most effect. The theory is that repeated use dampens pain. & # 39;
Lavender oil contains levomenthol that acts on nerve channels that detect temperature changes (file photo)
Lavender essential oil
£ 9.50 for 10 ml, nealsyardremedies.com
Lavender oil is said to have analgesic properties and, once diluted in a carrier oil, can be used to massage the head to relieve headaches.
It cannot be taken.
Professor Goadsby says that lavender oil, like various other oils – such as those with levomenthol – works on nerve channels that detect temperature changes.
"These activate receptors on the trigeminal nerve and it is likely that this changes brain activity in migraine, so there is plausible biology," he says.
£ 33, amazon.co.uk
These glasses are designed to absorb light at the red and blue ends of the spectrum and also offer 100% UVA and UVB protection.
A trial conducted at King & # 39; s College London in 2005 found between 70 percent and 90 percent of migraine sufferers who used the glasses that they were an effective treatment for use in bright light. Professor Goadsby says that the glasses can be useful, but only for a minority, because most people have other sensitivities, such as noise and odor.
How to beat pain: Eight myths about migraine
There are still many mysteries about what causes migraine and headaches and whether certain foods – from ice cream to chocolate – can actually activate them. Here we invalidate the most common myths. . .
EATING SWEET TREATMENTS CAN SPARKS
Although one in ten migraine sufferers claim that foods such as chocolate are a trigger, chances are that a sudden craving for the sweet treat is a consequence of the early chemical changes in the brain that signal an attack, the charity says. Migraine Trust.
In other words, the migraine causes the chocolate craving rather than the chocolate that causes the migraine.
"We have had very limited success in reducing migraine attacks by eliminating certain foods," said Dr. Andy Dowson, neurologist consultant and headache specialist at Princess Royal University Hospital in Kent.
Although women often suffer more from migraine, men can also get the painful headache in some notable patients, including Elvis Presley (file photo)
MEN DO NOT SUFFER FROM MIGRAINES
It is true that women are twice as likely as men to get migraines, mostly due to fluctuations in sex hormones around the menstrual cycle.
The National Institute for Health and Care Excellence (NICE) says that up to 25 percent of women are affected. But that also applies to 2 to 10 percent of men. "There are some very famous male patients, including Elvis Presley and former Manchester United footballer Ryan Giggs," Dr. Dowson.
In 2018, a large study by scientists from Leiden University in the Netherlands showed that hormones are also a key factor in men's migraine. Men with elevated estrogen levels (all men produce something) were more likely to suffer.
Fast solutions from people who are aware
Dissolve soluble aspirin in a carbonated drink
Dr. Jessica Briscoe, a general practitioner and headache specialist at the National Migraine Center charity in London, says: & # 39; The bubbles will enlarge the surface of the active ingredients and bring them into your bloodstream faster, and the caffeine can improve the effectiveness of the aspirin , although the mechanism is not fully understood. & # 39;
Hit a migraine as quickly as possible
"If you feel a migraine coming up, it's important that you take the right painkiller in the right dose and at the right time," advises Professor Paul Booton, a retired general practitioner and advisor at the National Migraine Center.
Ongeveer Approximately one third of migraine sufferers will get warning symptoms up to 24 hours before a migraine begins and this is the ideal time to take pain killers. Take a non-steroidal anti-inflammatory drug (such as three 300 mg aspirin tablets, a combined dose of 900 mg) – or ibuprofen (three 200 mg tablets, a combined dose of 600 mg) – and a prescription-only medicine against diseases such as domperidone in a dose of 10 mg. & # 39; Codeine should be avoided because it does not work for migraine and can make nausea worse.
If you don't usually drink coffee, this can help with a headache
Drink coffee, but only if you do not normally drink much
"Caffeine has a number of analgesic properties," says Dr. Giorgio Lambru, head neurologist at Guy's and St Thomas & # 39; s Headache Center.
"Strong coffee can improve headache pain if you use it occasionally – this also applies to tea and Red Bull. However, if you drink a lot of it in general, a caffeinated drink can make the symptoms worse and cause a rebound headache if you drink less. & # 39;
YOU ONLY GET THEM IN YOUR HEAD
Not true. Abdominal migraine, which causes abdominal cramps, vomiting and loss of appetite, is a recognized clinical condition.
Most cases are reported in children, although it is also found in adults who are wrongly diagnosed with irritable bowel syndrome.
About half of the children who are diagnosed as children develop migraines as adults.
HERBAL PRODUCTS HAVE NO SIDE EFFECTS
Long before analgesic drugs came on the market, people used plants and herbs to relieve headache pain – and this & # 39; natural & # 39; remedies are often experienced as completely safe.
One of the most popular is feverfew, a daisy-like shrub. It is thought that it is taken in a capsule by preventing severe contractions in blood vessels, which can lead to pain. But in 2016, NICE judged that there was insufficient evidence to recommend its use.
Feverfew should not be used during pregnancy because it can cause labor and some people believe it causes mouth ulcers and minor skin irritations.
The Migraine Trust also warns of "feverfew rebound syndrome", where people who stop using migraine after a few years, along with anxiety and insomnia.
MIGRAINES STOP AFTER THE MENOPAUSE
Migraine & # 39; s close relationship with estrogen means that the headache tends to disappear when the levels of the hormone fall, such as during pregnancy and after menopause.
But studies show that about 50 percent of women have the same frequency of seizures during pregnancy, and a third after menopause.
NO MAIN FORCES MEANS GOOD BLOOD PRESSURE
It is a common myth that your blood pressure is only a problem if it is so high that it gives you a headache.
In fact, people usually do not experience a headache unless their blood pressure exceeds a very high value of 180/120 mmHg – high blood pressure is defined as just over 140/90. So don't wait for a headache before taking action to lower your blood pressure.
Headache caused by high blood pressure usually occurs on both sides of the head. The pain tends to pulsate and gets worse with physical activity. Some studies show that this happens because, because blood presses on the vessel walls, it can overload the brain and even leak into tissue.
De pijn ontstaat omdat dit zwelling veroorzaakt wanneer de hersenen weinig of geen ruimte hebben om uit te breiden in de schedel.
KOUD KAN DE HERSENEN MAKEN ‘FREEZE’
Naar schatting heeft één op de 20 mensen vaak last van ijshoofdpijn, die zich voordoet bij het eten of drinken van iets kouds dat een tijdelijke stekende pijn veroorzaakt, meestal aan de voorkant of zijkanten van het hoofd.
Maar hoewel het ook bekend staat als hersenvries, heeft deze hoofdpijn weinig te maken met de hersenen en meer met hoe een plotselinge temperatuurdaling de bloedtoevoer beïnvloedt. Neurowetenschappers van het Wake Forest Baptist Medical Center in North Carolina ontdekten dat de schok van een plotselinge temperatuurdaling een ernstige en onmiddellijke vernauwing veroorzaakt van twee belangrijke slagaders die bloed naar de hersenen leveren.
Deze vernauwing, waarvan wordt gedacht dat het een beschermend mechanisme is om schade aan de hersenen te voorkomen, wordt geïnterpreteerd als pijn door receptoren in het weefsel dat de hersenen bedekt.
‘Het kan ondraaglijk zijn, maar voor de meeste mensen is het binnen een paar seconden voorbij’, zegt dr. Dowson.
MIGRAINE IS NIET LEVENSBREEDEND
Voor sommigen kan het zijn – hoewel de verhoogde risico's klein zijn.
Een groot onderzoek in 2016 aan de Universiteit van Harvard wees uit dat vrouwelijke migraine-patiënten 50 procent meer kans hadden op een levensbedreigende beroerte dan vrouwen die geen migraine hadden, vooral als ze ook aura hadden, zoals misselijkheid, lichtgevoeligheid en visuele stoornissen.
Maar het aantal getroffen door cardiovasculaire problemen was nog klein.
‘Het is de aura die een risicofactor is voor dingen zoals een beroerte’, zegt dr. Dowson. ‘Mensen die meer dan een paar afleveringen van aura hebben gehad, moeten voorzichtig zijn (omgaan met andere risicofactoren zoals hoge bloeddruk en opletten voor symptomen).
"Iets eraan verandert de biologie van de bloedvaten, zodat je meer risico loopt op een ischemische beroerte, het type dat wordt veroorzaakt door een blokkade die de bloedtoevoer naar de hersenen afsluit."
Het dagboek van de pijnexpert
Dr. Jessica Briscoe, afgebeeld, die nu in Londen werkt, had haar eerste migraine op 12-jarige leeftijd en leed ook aan buikmigraine vanaf de leeftijd van zes of zeven
Dr. Jessica Briscoe is een huisarts en adviseur bij het National Migraine Centre in Londen.
Ik had mijn eerste migraine op 12-jarige leeftijd. Ik herinner me dat ik in de speeltuin was en schittering ervaarde alsof ik in de zon zat, maar terugkijkend realiseer ik me nu dat het aura-symptomen waren. Ik kreeg toen hoofdpijn, kon niet praten en voelde me ziek.
Ik leed ook vóór die leeftijd op zes of zeven jaar aan buikmigraine (een type dat maagpijn veroorzaakt – zie hierboven).
Pas toen ik geneeskunde studeerde, nam ik triptanen om aanvallen te behandelen, omdat ik me voorheen niet echt bewust was van deze medicijnen.
Magnesium-tabletten zijn zeer nuttig geweest als preventieve behandeling voor mij, maar ik heb ook geprobeerd injecties van zenuwblokken, steroïden en plaatselijke verdoving in de zenuwen achter in mijn hoofd te doen. Deze zijn verkrijgbaar bij NHS gespecialiseerde pijnklinieken en de effecten duren tot 12 weken.
Mij is ook nortriptyline voorgeschreven, een medicijn waarvan wordt gedacht dat het zenuwuiteinden kalmeert en helpt bij pijn.
Als ik migraine krijg, neem ik aspirine, het medicijn tegen misselijkheid domperidon en soms een triptan. My attacks have gone from three a week to one or two a month.
The information given here should be taken in a general context — always consult your own GP with any health worries.