HEADACHE AND MIGRAINE SERVICES
Almost everyone experiences a headache at some time in their lifetime. It is estimated that up to 36 million Americans suffer from the common ailment of migraine (a severe type of headache), and many millions more endure the occasional headache. Headache and migraine sufferers (or “migraineurs”) are of all types and ages (even infants!), including celebrities, athletes, scientists, politicians and more; the list is long, with such names as Elvis Presley, Thomas Jefferson, Vincent Van Gogh and many more. Unfortunately, many individuals suffer from severe headaches that recur on an all too frequent basis. Despite the severity and suffering headaches can cause, most headaches are benign and not caused by anything dangerous. Nevertheless, sometimes headaches are a sign of an underlying disorder: thus, it is important to be evaluated by a health care professional who understands the causes of headaches and migraines.
The first step in determining if headaches or migraines are serious is based upon a comprehensive medical history and physical/neurological examination. From the information provided from a detailed history and thorough examination, our experienced neurological staff can usually classify the headache type, and a pragmatic decision can be made as to whether or not further observation and monitoring alone is sufficient or whether additional diagnostic testing is necessary. Often, we will ask you to maintain a headache diary/calendar so that both the clinicians and you can better understand the frequency and severity of your headaches/migraines. As part of taking your history, our clinicians will ask you about possible triggers to your headaches/migraines: such as certain foods, particularly processed or “junk” foods; caffeine intake; allergies; pain/click in your jaw; and more.
If it is determined that the headache type is relatively benign and non-progressive, such as tension headaches, certain treatments, therapies or lifestyle changes may be prescribed (see below) and the headache pattern monitored for responses to these interventions. If there is a lack of response to interventions, a persistence of the problem, or worrying factors, additional testing or evaluations may be recommended. Testing usually involves a search for possible causes of the headache. Since headaches tend to be a non-specific symptom, searching for a biological source involves assessing for systemic (i.e. from non-brain/head sources) and neurological (i.e. brain/head causes) abnormalities. If a systemic disorder is suspect, specific testing or general blood work may be recommended to identify a problem causing headache/migraine. Formal eye examinations can be useful when ophthalmological problems are suspected.
As far as neurological causes, many people are concerned that their headache is from a brain tumor. Thankfully, brain tumors are rare, and the vast majority of headache syndromes are not associated with brain tumors. Nevertheless, brain tumors or other “space occupying” lesions within the brain warrant consideration in people with headaches, particularly if the headaches/migraines are of relatively recent onset, and if there are suspicious symptoms or signs: such as a progressive headache pattern (e.g. increasing frequency and severity over time), headaches that are present upon first awakening in the morning, visual changes, balance problems, and abnormal findings on neurological examination. In such cases, a neuroimaging study, such as magnetic resonance imaging (MRI) of the head, sinuses and/or cerebral blood vessels (MRA/MRV), or computed tomography (CT), will often be recommended. On occasion, headaches/migraines can be a symptom or sign of abnormal electrical activity of the brain, which can be assessed by digital High Density Electroencephalography (HD-EEG). Rarely, a lumbar puncture (“spinal tap”) is needed to assess for increased intracranial pressure (i.e. high pressure within the fluid system of the head), infection, inflammation or metabolic disorders.
Many forms of headache, particularly those that occur very frequently, even daily, can be caused or associated with neuropsychiatric or neuropsychological disorders: depression, anxiety, stress reactions, learning disorders, and more. Such disorders often have biological causes, but can also be situational from adverse events or traumas in one’s life. The power of the mind’s influence on the brain’s function should never be underestimated. Thus, in many cases of chronic headaches, comprehensive neuropsychological and/or neuropsychiatric evaluation and testing can identify a suspected or unsuspected learning disorder, mood disorder, or other possible sources of stress to the patient or family that is causing or contributing to chronic headaches, and can be treated successfully.
Since headaches/migraines are non-specific symptoms and have many different causes, then it is necessary that a treatment regimen be tailored specifically for an individual. The type of intervention our clinical staff will choose for you will be based upon information and findings from your medical history, physical and neurological examination, and diagnostic test results. Some of the possible therapies that can help alleviate or lessen the suffering from headaches and migraines include:
- Lifestyle changes: improvement in sleep patterns, reduction in stress, tailored exercise, improvements in dietary/food choices, proper hydration
- Treatments targeted at underlying medical causes, such as allergies, obstructive sleep apnea, and much more
- Avoidance of identified triggers: for example, certain foods, caffeine, red wine, and more
- Cognitive-behavioral directed at underlying emotional/psychiatric issues, such as depression, anxiety or stress
- Integrative therapies such as yoga, meditation, and more
- Symptomatic approaches: such as placing a cool towel on the forehead or back of the neck
- Adjunctive pharmacological therapies (medications)
- Botox injections for chronic headaches/migraines (not offered at CNNH at this time)
The prescription of medications must be done conservatively, judiciously and with careful monitoring. The most important aspect of medication therapies for headaches, particularly chronic, daily headache patterns, is to avoid the overuse of pain medications, particularly narcotic and other addictive drugs. When there is excessive use of pain medications, headaches can actually worsen: what is referred to as “rebound” headaches. Additionally, the pain threshold can be altered or lowered, so that what was tolerable becomes intolerable, leading to more pain medication use, and setting up a vicious cycle. On the other hand, the judicious and proper use of pain medications can help to alleviate suffering from intolerable head pain.
Medications are used in a number of ways to treat headache/migraine:
- “Symptomatic”: To treat the symptoms of headache/migraine
- “Prophylactic”: To prevent the onset of headache/migraine
- “Abortive”: To stop a migraine attack that has already started
There are medications that are useful and specific for each of these pharmacological strategies. As with the use of any medication, benefits must be weighed against the potential side effect risks, and medications are usually used after non-medication options have been exhausted. Prior to starting a medication approach, a CNNH professional will discuss with you the various options, benefits and risks of non-medication and medication therapies.
Headaches refer to a pain in or around the head and face. There are many types of headache pain: burning, squeezing, aching, sharp, pins/needles, pounding, and throbbing are some of the descriptions. Headaches can be very localized to one spot, or be more diffuse involving most of the head. Headache pain can be localized to different regions of the head: frontal (forehead region), temporal (sides of the head), occipital (back of the head), and peri-orbital/retro-orbital (in, behind or around the eyes). The time of day a headache occurs might provide important information concerning its type and severity: waking from sleep with a headache, early morning headaches particularly upon arising, or late afternoon/early evening headaches after a long day at work or school. In individuals that have difficulty communicating, such as those with Autism, manifestations of headache might be a sudden and severe behavioral change, or a young child rubbing their head along the cool floor.
Migraines are a severe form of headaches, and are characterized by a pattern of recurrent, episodic “attacks”. Classically, migraines occur on one side of the head (but can be bilateral, which means both sides of the head), with a “throbbing/pounding” head pain, associated with nausea, abdominal pain, vomiting, photophobia (sensitivity to light), phonophobia (sensitivity to sound), dizziness and/or vertigo (a “spinning” or rotational sensation). However, migraines are not always “classic”, and might present as a very severe headache. Migraines often have an “aura”, which is a strange sensation or perception that occurs prior to the onset of the migraine headache. Auras can take many forms: changes in vision, sensory changes (such as tingling), hemiparesis (weakness on one side of the body), aphasia (difficulties finding the words you want to say), apraxia (problems with coordination of movements), and distortion of perception (feeling like “Alice in Wonderland”). Migraines can also lead to loss of consciousness (“fainting”) or weakness on one side of the body. Sometimes migraines can cause a seizure: seizures can also mimic migraine attacks. In individuals with established migraine patterns associated with auras, when such “auras” persist a long time, particularly after the migraine attack resolves, this can be an indicator of a more serious neurological problem and warrants immediate evaluation. In any individual with the first episode of an aura, immediate neurological evaluation is necessary, as it may not be a migraine attack, but a more serious neurological disorder mimicking the aura of migraine.
There are also many “migraine variants” that cause various symptoms and signs, including recurrent/cyclical vomiting, seizure-like episodes, recurrent loss of consciousness, torticollis (turning of the head/neck to one side), vertigo, and more.
Headaches and migraines have many different causes. In many cases, there is a tendency for headaches and migraines to run in families. Migraines can occur in children and adolescents, and even infants, and can last into adulthood, although some children and adolescents “outgrow” their headache problems. Sometimes headaches/migraines begin as an adult. There are many possible causes or aggravators of headaches/migraines that include:
- Brain tumors/cysts
- Environmental and food allergies
- Chronic sinus, ear and/or throat infections/congestion
- Temporomandibular Joint (TMJ) disorder (the joint involved in opening and closing your mouth) and other dental problems
- Neck and nerve problems (“pinched nerve”)
- Increased intracranial pressure (there are many causes leading to increased pressure of the fluid system in the head/brain)
- Vitamin/nutritional deficiencies (particularly riboflavin)
- Hormonal abnormalities (especially thyroid disorders or menstrual abnormalities)
- Poor vision
- Glaucoma (high pressure within the eye) and other ophthalmological problems
- Hypertension (high blood pressure)
- Electrolyte imbalance (“salts” of the blood) and hypoglycemia (low blood sugar)
- Congenital brain/blood vessel malformations (“Chiari” malformation, arteriovenous malformations, and more)
- Inflammation of the blood vessels (“vasculitis”)
- Bleeding within the head
- Headache from or after a seizure (epilepsy)
- Toxins or drugs
- Fever and infections
- Sleep disorders and difficulties
In many cases, “tension” or “muscle contraction” headaches occur, usually after a long day at work, school or studying. [Interestingly, the mechanism this type of headache is not necessarily from contraction of head muscles.] Or exertion, excessive exercise, dehydration and exhaustion can cause non-specific headaches or migraines. Migraine-like headaches can also occur in “clusters” that can last for days or weeks. It is noteworthy that the brain itself is insensitive to pain, so that the pain produced by headaches and migraines is from other pain sensitive structures in and around the brain and head: blood vessels, nerves, muscles, mucous membranes, skin, subcutaneous tissues, and teeth.