Headache Pain and Migraines  --- September 19, 2007

Samer N. Narouze, M.D., M.S. Director, Pain Medicine Fellowship Program Pain Management Center Cleveland Clinic

Cleveland_Clinic_Host: Welcome Dr. Narouze and thank you for joining us today. Let's begin with one of the questions!
Cleveland_Clinic_Host : Good day Dr Narouze. Let’s start by discussing severe headache pain. If not all headaches are created equal, how can you determine what type of headache it is and how to treat it?

Speaker_-_Dr__Narouze: There are many different types of headaches. Each type can actually have its own causes, symptoms and treatment options.
Speaker_-_Dr__Narouze : It is important to correctly diagnose the headache by listening to the patient's history of pain - in their own words. Where does the pain occur? How frequent? Are there any circumstances (triggers) that can set off the pain?

Cleveland_Clinic_Host: Let's start now with the first question.

Evaluating Headache Pain

mollybegood: What causes headaches? Sometimes I just seem to get them for no reason at all.
Speaker_-_Dr__Narouze : What I think you are describing is a vascular headache and it seems like some patients have a “migrainous brain” which makes them more susceptible for headaches than others.

jj: Everybody gets headaches throughout their life. It’s expected. How do you know when you should call the doctor?
Speaker_-_Dr__Narouze : The following should be considered: Frequent headache
Speaker_-_Dr__Narouze : The worst headache ever
Speaker_-_Dr__Narouze : Intractable- this means it can’t be treated with simple OTC analgesics.
Speaker_-_Dr__Narouze : Nausea and Vomiting
Speaker_-_Dr__Narouze : Weakness or any neurological symptoms.

constantpain: I’ve been thinking about seeing a doctor about my headaches, which are becoming more frequent. How are they evaluated and what are some of the treatments?
Speaker_-_Dr__Narouze : First it is necessary to rule out other secondary causes of headaches (e.g. tumors, stroke, bleeding, infection, changes in intracranial pressure, etc.). There are also many available preventive medications for treatment such as beta blockers, Tricyclic antidepressants, and muscle relaxants to name a few.
Speaker_-_Dr__Narouze : Acute treatment may include analgesics, NSAIDs, Triptans and ergots. Physical therapy, psychotherapy, alternative medicine, acupuncture and Botox injections should also be explored.

tess6605: Do you have a routine work-up that you do on new patients that come to your clinic after years of failed therapy?
Speaker_-_Dr__Narouze : Our evaluation includes a full patient history, physical exam, neurological evaluation, fundus and eye exam. We also look at the family history of headaches trying to identify any possible triggers for the headache.
Speaker_-_Dr__Narouze : We look at the medication history as well. If we find any alarming symptoms, we may proceed for CT or MRI of the brain.
Speaker_-_Dr__Narouze : The evaluation is so individualized that there is a myriad of directions we would take.

naggingheadache: What is the difference between a migraine and a “normal” headache?
Speaker_-_Dr__Narouze : Migraine is a special type of headache that is related to constriction, dilation and inflammation of the blood vessels. Headache experts have determined that these events occur due to hyperactivity of the trigeminal nerve. The trigeminal nerve is responsible for sensations in the face.
Speaker_-_Dr__Narouze : Migraines usually occur on one side and can affect women three times more frequently than men. Migraine usually comes with nausea, vomiting, photophobia (light), phonophobia (noise).
Speaker_-_Dr__Narouze : Twenty to twenty-five percent of migraine patients may experience an aura before the migraine. An aura is a collection of symptoms like twinkling lights or other sensory symptoms. The aura occurs before the headache begins.

What Causes Headaches?

blondie: What different things can trigger headaches or migraines?
Speaker_-_Dr__Narouze : There are many triggers. Different foods that contain nitrites and preservatives such as hot dogs, bleu cheese, yogurt, smoked fish can be triggers. Red wine, chocolate, ice cream can also contribute to headache pain.
Speaker_-_Dr__Narouze : Strong smells, loud noises, even weather changes can trigger a headache.

jsilver: Can drinking red wine give me headaches (it seems like it does)?
Speaker_-_Dr__Narouze : Yes - It may cause vasodilatation of the cerebral vessel and this predisposes to migraine.

peanut22: I clench my jaw during the day when stressed. This seems to cause tightness in the jaw, back of neck and then pain behind my eye. Is there anything I can do?
Speaker_-_Dr__Narouze : Actually - you may want to consider biofeedback and muscle relaxation techniques. These modalities of treatment are available through our multi-disciplinary Headache Center.

mattb: I can never get comfortable at my computer at work, and always have a stiff neck and migraines. What can I do?
Speaker_-_Dr__Narouze : This could be a tension muscle headache rather than migraine and treatment is usually easy and effective. Avoid the trigger as much as possible (work at your computer in a comfortable position, suitable chair and desk height, and for short periods at a time,…)
Speaker_-_Dr__Narouze : Muscle relaxants and physical therapy may also be options.

newtonm: What role does low blood sugar play in migraine prevention?
Speaker_-_Dr__Narouze : Low blood sugar can be a cause of headache pain, but does not necessarily play a part in the prevention of a migraine. It is important if low blood sugar is a trigger to your migraines to pay attention to your diet. You may also need to follow-up with your internist as to the cause of your low blood sugar.

Medications

newtonm: Are there any good over-the-counter (OTC) products for treating migraines?
Speaker_-_Dr__Narouze : Yes there are several good OTC products that work. You have to determine which is best for you as an individual. Tylenol, NSAIDs (such as Ibuprofen) and compound analgesics with caffeine seem to work best.

sunny: What is the best time to take migraine medication? At the beginning of a headache, or when it is full-blown?
Speaker_-_Dr__Narouze : At the first onset of migraine.

tess6605: What medication do you have the best luck with as a preventative?
Speaker_-_Dr__Narouze : Beta blockers, Topamax and muscle relaxants Zanaflex.

peanut22: Do triptans work best on an empty stomach? And do they work better if you can stop what you're doing and lay down vs. having to continue working, for instance?
Speaker_-_Dr__Narouze : It depends. If you experience nausea or vomiting, then taking the triptans on an empty stomach is better. Definitely if you can rest or even sleep - this is much better.

susan: I don’t want to take any medications, so what else can I do to treat my migraines?
Speaker_-_Dr__Narouze : Migraine is a special type of headache that is related to constriction, dilation and inflammation of the blood vessels. Headache experts have determined that these events occur due to hyperactivity of the trigeminal nerve. The trigeminal nerve is responsible for sensations in the face.
Speaker_-_Dr__Narouze : Our Pain Management Center recognizes that it requires a team approach to treat headache pain. We not only offer the latest in medical treatment for headache, but also alternative medicine, psychotherapy and acupuncture at Cleveland Clinic Headache Center.

Headaches and Hormones

saddle_seat: Do birth control options such as the pill help decrease migraines associated with hormonal changes?
Speaker_-_Dr__Narouze : This is a very important topic. In fact most birth control pills aggravate headaches. If this is the case, you need to take the lowest estrogen containing pill or other birth control alternatives.
Speaker_-_Dr__Narouze : It is the estrogen that has been linked to the headache.

inpain: How can I treat the migraines that I get before my period?
Speaker_-_Dr__Narouze : Preventive therapy with booster doses around the period (B blockers, TCAs,..) have been shown to be effective. You may also begin by starting NSAIDs 2 days prior to the period. Triptans (Frova) which is prescribed may be necessary to take during the period. Evaluation with a headache specialist would help your tailor the best treatment option to your needs.

Headaches and Heredity

kitkat: I suffer from migraines. Are they hereditary? What signs should I watch out for in my children to indicate that they might be getting them?
Speaker_-_Dr__Narouze : Migraine can run in families. Sixty-eighty percent of patients have a positive family history. Before labeling your child with migraine, we need to make sure that there are no other causes of headache.

peanut22: Both my mother and my father-in-law had migraines in their younger years, but they went away when they hit their late 40s or 50s. Is this common? Not that I want to get older quicker...
Speaker_-_Dr__Narouze : Yes - this is more common with women as they approach menopause with hormonal changes, the migraines usually get better, but not always.

Headaches in Children

susan: My 6 year-old daughter is having a lot of headaches. Should I take her to her pediatrician? Could she be getting migraines (I have frequent migraines)?
Speaker_-_Dr__Narouze : It is important to first rule out secondary headaches in this age group, especially tumors). It would be best to have your daughter evaluated by a Pediatric Neurolologist who specializes in headache. At the Cleveland Clinic we have a number of physicians in this specialty.

Diet

chernij: Would becoming a vegetarian, or switching my diet, help me to control my headaches?
Speaker_-_Dr__Narouze : It depends on what your triggers are.

saddle_seat: How is it determined if migraines are being caused by a spinal leak possibly from a rupture in the spinal canal?
Speaker_-_Dr__Narouze : In this case, the headache would usually be positional. This means that the headache gets worse with sitting or standing and eases up when you lie flat.
Speaker_-_Dr__Narouze : Also - there should be a history of a cause for the spinal leak. This could be from a spinal tap or spontaneous leak after a severe bout of coughing for example.

Sex and Migraines

cn90: Can having sex cure a migraine?
Speaker_-_Dr__Narouze : Serotonin (a chemical mediator in the brain) is involved with both migraine and orgasm. This may be the link.
Speaker_-_Dr__Narouze : However, it is well known that exercise might aggravate migraine. So - sex may worsen the symptoms of migraine or cause a new headache. But this is more common in men.

Rebound Headaches

peanut22: My migraines always seem to hit two days in a row. Then not for another week. Is there any reason or just a fluke?
Speaker_-_Dr__Narouze : Actually this is the norm. Migraine is an episodic form of headache that comes in cycles.
Speaker_-_Dr__Narouze : However with the progression of the disease or misuse of medications, the frequency may increase and become more of a chronic daily headache syndrome.

tess6605: What do you do when you get migraines so frequently and treat them, but then you end up getting rebound HA's. It is a vicious cycle, but the pain and nausea gets so bad you have to have something for it.
Speaker_-_Dr__Narouze : As you said, this is a vicious cycle. We usually try to limit the migraine specific medications to only 10-15 days per month to prevent medication overuse 'rebound headaches'.
Speaker_-_Dr__Narouze : To differentiate, sometimes we will stop all the medication for about 2 months and then reevaluate. If the headaches improve, then we would know it was a rebound headache secondary to medication overuse.
Speaker_-_Dr__Narouze : If the headache is the same or even worse, then we would consider it a chronic migraine and it is okay to use more medication as needed as long as the medication is beneficial.

aaron: From aaron: How can rebound headaches be avoided?
Speaker_-_Dr__Narouze : We would limit simple analgesics to 15 days per month. Migraine specific medications 'Triptans,' to only twice a day for 10 days per month.

tess6605: Are rebound HA's more likely to happen with Opioids then with any other pain medication? I use Nubain and phenergan injections for my migraines and have for years, it is the only thing that works most of the time and I am not able to take anything by mouth because I am not able to hold anything down. I have also tried suppositories and they do not work either.
Speaker_-_Dr__Narouze : You would need to come in for a thorough evaluation. But, generally speaking, rebound headaches are more common with opioids.

Occipital Stimulator

saddle_seat: Have you heard of an occipital stimulator as treatment and how sucessful has this treatment been with patients where drug therapy, physical therapy, and acupuncture have failed? If you get an occiptal stumulator can you continue to have chiropractic adjustments?
Speaker_-_Dr__Narouze : Yes- we are one of the few centers in the United States participating in the first randomized controlled clinical trial evaluating the efficacy of the occipital stimulator.
Speaker_-_Dr__Narouze : The preliminary results are encouraging.
Speaker_-_Dr__Narouze : And yes - you can continue having chiropractic adjustments.

aaron: From aaron: What is an occipital stimulator?
Speaker_-_Dr__Narouze : An occipital stimulator is a small electrical wire positioned across the greater occipital nerves over the back of the head and connected to a small device 'pacemaker' placed under the skin.
Speaker_-_Dr__Narouze : At the first sign of a headache, the patient activates the stimulator which electronically stimulates the nerve. The stimulator masks the pain and allows the brain to make a morphine like substance that will help alleviate the headache pain.
Speaker_-_Dr__Narouze : Some patients use it continuously to prevent headaches.

tess6605: Are patients able to go about their daily lives with this occipital stimulator, or does this morphine like substance actually "drug" the patient?
Speaker_-_Dr__Narouze : No - the stimulator merely blocks the headache pain sensations. It does not restrict the activity of the patient nor the consciousness level. The patient will not feel 'druggy' at all.

Bells Palsy & Headaches

tess6605: I ended up with Bells palsy when I was approx 7mos pregnant. I started with my migraines right after I had my daughter. I still do have sxs of the palsy especially when I do get my migraines. Could these be related at all?
Speaker_-_Dr__Narouze : Bells palsy and migraines can be related. A patient with migraine may present with facial numbness - which involves the trigeminal nerve. Speaker_-_Dr__Narouze: However, rarely they present with symptoms like Bells palsy which involves the facial nerve. If the symptoms of Bells palsy persist after the headache goes away, I would be concerned and recommend that you see a neurologist.

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Narouze is over. Dr. Narouze, thank you again for taking the time to answer our questions today.
Speaker_-_Dr__Narouze : Thank you for letting me be a part of this chat session. I enjoyed answering your questions today.

Cleveland_Clinic_Host: If you would like more information regarding headaches and migraines, please visit the Cleveland Clinic Pain Management web site at http://cms.clevelandclinic.org/anesthesia. For general health information you may also wish to visit http://www.clevelandclinic.org/health.