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Headaches - Migraines

Headache Facts

types of migraineThere are 150 types of headaches and almost half of all adults worldwide suffer from headache disorders. Tension headache is the most common, followed by migraine. Other common headache types include new onset persistent daily headache (NPDH), chronic migraine (CM) and cluster headache. There are also secondary headaches which are caused by an underlying medical condition such as severe hypertension, infections of the head and neck (i.e. meningitis), tumors, subdural hematoma, obstructive hydrocephalus, brain bleeds and aneurysms (see below to learn more about the warning signs).

22migr 01Approximately 28 million Americans suffer from migraine (13% of the population/one in every four households). Of those approximately 20% are females and 8% are males. Perhaps more surprising is that 52% of migraine sufferers are undiagnosed. In fact migraine is often misdiagnosed as tension headache (a catch-all phrase) or sinus headache (a relatively rare condition). With one study estimating that over 90% of all patients diagnosed with sinus headache actually have migraine.

migraine burdonThe world health organization has ranked migraine as number 19 among all diseases world-wide causing disability. Migraine alone is the cause of 1.3 percent of all disability due to illness (when taken together all headache disorders accounting for double this burden). In the US it is estimated that industry loses $31 billion per year due to absenteeism, lost productivity and medical expenses caused by migraine, and in Europe 190 million days are lost from work every year because of migraine with an estimated cost of 155 billion euros ($229 billion US). Finally 24% of migraine sufferers report headaches so severe that they have sought emergency room care for migraine, and more than half (51%) of migraine sufferers report a 50% or more reduction in work and/or school productivity, and 66% report a 50% or more reduction in household work productivity.

headache 1Probably the biggest trigger of headache is stress, especially migraine. Many women often experience a migraine just prior to the onset or during their periods (menstrual migraine) which is felt to be secondary to a rapid drop in estrogen. Some patients experience headaches when there is an abrupt change in the weather, i.e. when a low pressure system comes through or during the full moon. Certain odors such as household cleaners, perfume, cigarette smoke and even the smell of coffee can trigger a headache. Certain classes of medications (anti-depressants, nitroglycerin, diabetic drugs, cholesterol medications, blood thinners, antibiotics), along with exercise and even sex are things to consider. Foods such as peanuts (peanut butter), aged cheeses, certain fresh fruits (ripe bananas, citrus fruits, papaya, red plums, raspberries, kiwi, pineapple), dried fruits (figs, raisins, dates), Cultured dairy products (sour cream, buttermilk, yogurt), artificial sweeteners (Aspartame), Chocolate, MSG containing compounds (Chinese food, soups), Smoked fish or aged meat (hot dogs, sausage, bacon, lunch meat), certain beans (fava, broad, garbanzo, lima, pinto), onions, olives, pickles, avocados, caffeine, and alcohol (red wine and vodka are common). One side not about caffeine which not only can trigger a headache, but can also help relieve a headache. The key with food triggers is not to just stop eating a food because it is a known headache trigger. Individuals must try certain food and see if they are actually their headache triggers. Finally, not eating is often an unrecognized trigger especially in young women who often skip meals to keep up with the pressure to stay thin.

stoiber hzoom8Migraines can last from 4 to 72 hours. There are three phases to a migraine: The initial phase which is also known as the “prodrome”. It can begin a few hours or even a day before the actual headache pain and is characterized by symptoms such as nausea, fatigue, irritability, increase energy, excessive thirst, food cravings, yawning and urinary urgency. Not all patients will experience this phase however in those that do headache specialists will often use the prodrome as an opportunity to prevent the headache from occurring. The second phase can last a few hours or even days and is termed the “headache phase” and characterized by the typical signs and symptoms of migraine (see below). Some patients may also experience an “aura just before the onset of pain, “Migraine with Aura”. Typical auras include: Visual changes (blurred vision, zig zags, floaters, scintillating scotomas i.e. flashing or sparkling lights which are usually located in the periphery. Sensory symptoms i.e. numbness, tingling, or a pins and needles sensation which is usually located on one side of the body, but can also involve just the face or extremities on both sides. Trouble with speech which can include; slurred speech, trouble getting words out and even an inability to speak at all. Motor symptoms i.e. paralysis, which is again is usually one sided and could also involve drooping of one side of the face. Patients with motor symptoms often have a genetic predisposition which is termed “hemiplegic migraine” As a rule patients who experience aura, especially those with speech issues and all who experience motor symptoms need to undergo a standard stroke work up prior to officially defining their symptoms as migraine like aura. The final phase i.e. “postdrome” can last up to 24 hours and includes symptoms such as extreme tiredness, sluggishness, confusion and dull head pain. It is felt to be a result of the brain resetting or rebooting after the very intense physiological process that occurs with the earlier phases (see below).

migraine physiologyThe exact physiology of migraine is unknown. At baseline, a migraineur who is not having any headache has a state of neuronal hyperexcitability. In lay terms their brain is on edge and susceptible to triggers. The current accepted hypothesis, i.e. neurovascular theory, suggests that migraine starts deep within the brain (midbrain and/or hypothalamus) which then activates a structure in the brainstem, the trigeminal nucleus caudalis (TNC) which then sends signals to blood vessels triggering an inflammatory response causes the blood vessels to swell. This results in activation of nerves located on the surface of blood vessels that send signals to the brainstem to activate peripheral nerves (trigeminal and occipital) that send pain to the head. In addition signals are sent back to the TNC which in turn results in further blood vessel activation, i.e. similar to how a hurricane develops. Imbalances in brain chemicals, including serotonin (which helps regulate pain in your nervous system), increases in Dopamine (which may account for the prodrome and nausea), decreases in Magnesium, also may be involved. Finally, it has been hypothesized that patients with Migraine with Aura experience “Cortical Spreading Depression (CSD)”, which is a wave of electrical activity which begins in the sensory areas of the brain i.e. occipital lobe and spreads to the brainstem resulting in the triggering of a migraine. The exact role of CSD and migraine is now under intense debate in the basic science world.

Serotonin levels drop during migraine attacks. This may trigger your trigeminal system to release substances called neuropeptides, which travel to your brain's outer covering (meninges). The result is headache pain.

heriditaryYes, you have about a 45% chance of having migraine if one of your parents also have migraine. New research from the University of California, San Francisco has identified a genetic mutation that is linked to migraines. The mutation occurs in a gene called casein kinase I delta (CKIdelta). It encodes for a protein involved in calcium signaling.

benbrook vzoom12Migraine by nature is disabling and with that the pain is intense, usually described as throbbing, pounding or vise like. Some patients will also experience a background stabbing or burning sensation. The headache is usually associated with sensitivity to light (photophobia), noise (phonphobia) and may include nausea and/or vomiting. Physical activity and/or bending will almost always worsen the pain. In fact a good way to tell the difference between a migraine and a tension headache is migraine will worsen with physical activity. Other symptoms can include sensitivity to smell (osmophobia) and typical aura described above.

ImitrexThere are a number of options available. Most patients i.e. those who have less than 6-8 headache days per month, will only require abortive treatment (treat the headache when it occurs), others require preventative therapy.

The key to abortive treatment is to treat early and appropriately. Studies now show that as the migraine progresses and the pain increases, gastric stasis occurs. This results in a lack of absorption of oral medications which renders them ineffective. Furthermore, some individuals will experience a rapid onset of their headache symptoms and require delivery options that bypass the gut (nasal or injections). Treatment options include over the counter medications, of which there are 5 major players (everything else is the same medication packaged and sold under a different name. They include; Aspirin, Tylenol, Aleve, Ibuprofen and Excedrin.

For those who do not respond to OTC medications, prescription medications are required. There are 3 major classes: Triptans (Imitrex, Treximet, Maxalt, Relpax, Zomig, Amerge, Axert and Frova) which work on specific serotonin receptors resulting in constriction of blood vessels (vasoconstrictors), are highly effective (80%) if taken appropriately. With the exception of the longer acting forms (Amerge and Frova) there is no significant difference in efficacy among the various types. Available preparations include oral, nasal and injectable and side effects can include chest or throat tightness, fatigue, GI side effects and flushing. Dihydroergotamine (DHE-45 inection and Migranal nasal spray) are a class of medications (Ergots) that have been available for over 50 years. They also work on Serotonin as well as Dopamine resulting in constriction of veins (venoconstrictors). Duration of action can be over 24 hours with and common side effects include nausea and flushing. Both triptans and Dihydroergotamine have the potential to constrict coronary and cerebral blood vessels and are contraindicated in patients with coronary artery disease, heart attack, stroke, uncontrolled blood pressure, blood clots or a risk factor of the above. Prescription NSAID’s include medications such as Toradol (Ketorolac) which is available in an oral and injectable prep, and Cambia. These medications are not quite as effective, however have a better safety profile which makes them more appropriate for use in older individuals. They should not be used in patients with a history of severe kidney disease or ulcers. Other medications often prescribed to abort headaches include Butalbital/Aspirin/Acetaminophen/Caffeine containing compounds (Esgic, Fiorinal, Fioricet), Tramadol (Ultram), Stadol, Demerol and narcotic pain medications. These medications have little effect on migraine physiology (see above) and are notorious for causing medication overuse or rebound headache (see below). If your doctor is currently prescribing these medications see a headache specialist for a second opinion.

Those patients who have more then 6-8 headache days per month or who don’t respond well to abortive medications are candidates for preventative therapy. Often times your physician will choose a preventative based on your underlying medical history. For example is you have high blood pressure, use a blood pressure medication or if you have depression, use an anti-depressant, i.e. use one medication to treat two problems or in other words “kill two birds with one stone”. Anti-epileptic medications which appear to work to lower neural hyper-excitability and migraine threshold are first line preventatives. Drugs such as Topamax, Zonegran, Depakote and Neurontin. These medications are usually well tolerated, lower then number of headache days by about 60% and are contraindicated in pregnancy. Common side effects include drowsiness, trouble thinking, weight loss, weight gain and rare cases kidney stones. Antidepressants are often used in patients who have headache, depression and/or trouble sleeping. There are three main classes of medication: Tricyclic Anidepressants; Amitriptyline and Nortriptyline. Common side effects include dry mouth, drowsiness, and constipation. Selective Serotonin Reuptake Inhibitors (SSRI’s), Prozac, Paxil and Zoloft and Selective Serotonin/Norepinepherine Reuptake Inhibitors (SNRI’s) Effexor, Lexapro, Celexa and Cymbalta. The later two classes likely work on the migraine trigger i.e. depression and anxiety with nausea and decreased sex drive being the most common side effects. These medications take approximately one month to get into the patient’s system and are often difficult to come off of. Recent evidence suggests that Effexor may be the most effective. Patients with high blood pressure often do well with cardiac medications, i.e. beta blockers(Inderal), calcium channel blockers (Verapamil) ACE Inhibitors (Lisinopril). These medications tend to be preferred by primary care doctors, mainly due to their familiarity with use. Side effects can include fatigue and constipation. Vitamins and Minerals have been shown in randomized trials to be effective in migraine prevention in some patients ; Feverfew Butterbur(Petasites hybridus), Magnesium, Vitamin B2 (Riboflavin), Coenzyme Q 10 and melatonin are some examples. Nonsteroidal Anti inflammatory Drugs (NSAIDs), often used in acute treatment, also can prevent migraine. Naproxen and Aspirin are two medications that have shown efficacy. Other medications that have been tried as migraine preventatives include Namenda (used on label for dementia), Antihistamines such as Benadryl and Cyproheptadine (a 5-HT2 antagonist with calcium channel blocking properties), the ergot Methergine (normally used for to induce uterine contraction) and Botox@ which has only been shown to be effective (about a 50% reduction in headache) in large well designed clinical trials for Chronic Migraine (it was not effective in episodic migraine).

brain tumorThere are a number of secondary causes of headache, they include aneurysms, vascular malformations, brain tumors, Chiari Malformations, meningitis/encephalitis, stroke (ischemic and bleeds), uncontrolled blood pressure, over production of spinal fluid (Pseudotumor Cerebri), and obs truction of spinal fluid (hydrocephalus). Some have used the pneumonic SNOOP (not to be confused with the rapper). Systemic symptoms, i.e. fever weight loss and Secondary risk factors i.e. cancer. HIV, and uncontrolled blood pressure. Neurological signs and symptoms. Any headache with associated neurological symptoms i.e. weakness, numbness, facial drooping warrants a visit to your doctor. Onset, Headaches that hit suddenly and severely, without warning can be a sign of stroke or another neurological problem. As can headaches associated with straining, coughing, or sexual activity. Older age of onset of your first headache. Pattern, a change in your headache pattern or character of the pain could signal a more serious issue.

farmer vzoom7These headaches usually occur when analgesics are taken frequently to relieve headaches. Rebound headaches frequently occur daily and can be very painful and are a common cause of chronic daily headache. They typically occur in patients with an underlying headache disorder such as migraines or tension headaches that "transforms" over time from an episodic condition to chronic daily headache due to excessive intake of acute headache relief medications. Common medications that cause MOH include; Fioricet, Fiorinal, Esgic, Narcotics, Demerol, Stadol, Excedrin (most common cause), Triptans and Ergots. Any analgesic medication has the potential to cause rebound headaches. MOH is now considered the third-most prevalent type of headache. Population-based studies report the prevalence rate of MOH to be 1 to 2% in the general population. These headaches can be very difficult to treat and can even require hospitalization for medication detox. It is recommended that you seek treatment for a headache specialist/tertiary headache center (see our program).

cluster headacheCluster headache or “suicide headache” is an extremely painful (has been called the most extreme pain a human can endure) and debilitating headache. Unlike migraine, cluster headache has a high male predominance (8 to 1) and usually occurs between the age of 20 to 50 and approximately 69 out of every 100K people experience the disorder. There is a genetic component with first degree relatives being more likely to experience this type of headache. Cluster patients tend to have a characteristic appearance ruddy complexion, multi-furrowed and thickened skin, and a broad, prominent chin: all contributing to a "leonine" facial appearance. The headaches tend to have a seasonal variation i.e. occur in the fall and early spring with most patients having one or two attacks per year. Some patients can go a number of years between episodes (especially older individuals). Attacks usually occur 2 times per day (range 1 to 6 per day) typically lasting 20 to 60 minutes (however can last up to 4 hours). Patients are often awoken (approximately 2 hours after falling asleep) from sleep. Attacks can be triggered by alcohol, nitrates (hot dogs), and naps. Interestingly most cluster patients are able drink alcohol, eat hot dogs and take naps without difficulty when not in their cluster cycle. A typical cluster cycle will last 6 to 8 weeks and approximately 10% of cluster patients will go on to develop chronic cluster headache. Many chronic migraine or new onset persistent daily headache patients are incorrectly diagnosed/labeled as having cluster headache.

Cluster headache pain has been described as lancinating or boring/drilling in quality and is located behind the eye (periorbital) or in the temple. Analogies frequently used to describe the pain are a red-hot poker inserted into the eye, or a spike penetrating from the top of the head, behind one eye, or a twisting knife or screwdriver in ones eye The pain can radiate to the neck or shoulder and often times will begin a a dull or burning sensation in the occipital region (i.e. back of the head). Cluster patients will often develop mild occipital pain without the severe pain early on in their cluster cycles. Cluster headache is associated what is termed autonomic symptoms which include lacrimation from the eye on the affected side (the most common associated symptom), blocked nasal passage (on the same side as the headache), rhinorrhea (runny nose), red eye, and sweating and pallor of the forehead and cheek are often found, but their absence does not exclude the diagnosis.

Physiologically cluster headaches are felt to originate in the hypothalamus which explains the circadian nature of the headache. Like migraine, serotonin appears to be a major player. However, serotonin alterations are more subtle in patients with cluster headache than in migraine. In addition, alterations in testosterone (see treatment), melatonin and cortisol and possibly histamine appear to play a role. In fact levels of these neurochemicals and neurohormones tend to return to baseline when the cluster cycle ends. Similar to migraine there appears to be dilation of meningial blood vessels, however enhanced pulsation of the blood vessels (some have termed vasospasm) occurs during cluster attacks but not during migraine attacks. The intracranial (part inside the head) portion of the carotid artery also appears to be involved which is not a component of migraine.

There is a multi-facet approach to treating cluster headache, which employs the use of abortive, transitional and preventative medications. As cluster headaches tend to come on quickly and are short lived, abortive medications need to be fast acting and involve the use of injectable and nasal preparations. The mainstay abortive treatment is Imitrex (Sumatriptan) injection, this medication typically aborts a cluster headache in 10-15 minutes and if taken early enough the patient may never experience severe pain. The nasal form of this medication along with nasal Zomig have been shown to be effective in other studies. Dihydroergotamine (DHE-45 injection and Migranal nasal spray) have also been shown to be effective however are not as fact acting as the Imitrex injections. One unique characteristic of cluster headache is its response to oxygen. Often times oxygen response will seal the diagnosis of cluster. Many physicians however are not versed in the proper use of oxygen in cluster headache which needs to be high flow (8 liters), using a non-rebreather mask and involves the patient placing their head between their legs and breathing deeply. Unlike migraine and because of the sever nature of the pain necessitating the need to prevent the headaches whenever possible. Cluster patients require transitional medications such as prednisone, long acting triptans, and methergine while preventative medications are titrated (brought up to) to a therapeutic dose. Prednisone is by far and way the most widely prescribe transitional medication and usually started at a high dose i.e. 60 mg and decreased slowly over a period of two to three weeks and is highly favored by a number of cluster patients. The medication is not without side effects (i.e. increased appetite, bloating, fluid retention, insomnia and agitation) and when given in multiple cycles can cause osteoporosis. The mainstay of preventative treatment is the calcium channel blocker verapamil. The medication is given in the sustained release formulation (Verapamil SR or Calan) and dosed twice a day. Cluster patient often require doses that are 2 to 3 times that used for high blood pressure, i.e. 720 to over 1000 mg per day. Side effects include constipation and sexual dysfunction. For patients who are not controlled with Verapamil or cannot tolerate the medication, a second medication may be added or substituted. Other preventatives used in cluster headache include Topamax, Depakote, Lithium, Methergine and Melatonin. Some patients also benefit from serial occipital nerve blocks which our physician has extensive experience with. There are also a number of cutting edge treatments on the horizon including Psilocybin which is derived from psychedelic mushrooms and being studied in Europe, and testosterone which in a recent study presented by Dr. Conidi at the International Headache Society meeting was found to be 85% effective in terminating the cluster cycle with one or two injections.

Unfortunately and as stated above almost 10% of cluster patients will go on to develop chronic cluster headache. These patients are at high risk for suicide and it is essential that they are seen by a headache specialist with experiencing in managing chronic cluster. There are a few medical and interventional procedures currently being employed and studied and include; testosterone replacement therapy (our facility), Psilocybin (Europe), occipital and dual neurostimulation (see our headache management program) and deep brain stimulation (Italy and a few centers in the US).

physiologyThe international headache society criteria define it as a headache that occurs 15 or more days a month with headache lasting 4 hours or longer for at least 3 consecutive months in people with current or prior diagnosis of migraine. Approximately 3.2 million Americans suffer from CM however an estimated 6% of the population suffer from the disorder, with 80% remain undiagnosed. A majority of patients in our practice meet the IHS criteria for CM or as others prefer to call it Chronic Daily Headache. At present Botox@ is the only FDA approved treatment for CM. Our facility specializes in the treatment of CM (see “Our Headache Program” for details).

refractory migraineThere is no standard definition, which in itself is a major problem. Some have proposed that the headache significant impair function and life activities along with the quality of life despite modification of triggers, and an adequate trial of abortive and preventative medications. Patients should also have had an adequate work up for secondary causes of headache. One study estimated that over 5% of all patients at tertiary headache centers have RM. Risk factors for the development of RM include obesity, stress, having three or more headaches a month, poor sleep and primary sleep disorders (obstructive sleep apnea), caffeine excess, psychiatric issues (bi-polar disorder, anxiety and major depression), history of physical abuse (past and ongoing), and most important medication overuse. As a tertiary headache center our practice also sees a number of patients who have essentially tried a majority of standard migraine/headache treatments including Botox. Please see our headache program for cutting edge treatment options for CM.

To make an appointment to be evaluated for Headache call:
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