Tucson Lifestyle May 2016 : Page 44
In Health Headaches: Know Your Enemy! BY anne kellogg | Photogr aPhY BY kris hanning ( except wher e noted) If you are a chronic headache sufferer and haven’t gotten the relief you need through over-the-counter medications or from a prescription given to you by your general practitioner, it may be time to break out “the big guns” and see a neurologist. “head a che relief dream team” or hydrocodone, and it usually turns out the patient has chronic migraine with aura,” says Dr. de Leonni. “Narcotics are rarely a solution for the primary chronic type of headache.” “Migraine patients also are predisposed to hav-ing diffuse pain, especially in their backs, and they sometimes are prescribed an opiate, which just makes our jobs as neurologists even harder,” adds Dr. Carnahan. “It’s helpful if they can limit or stop opiates altogether so we can get a better idea of their headache profile, but that’s not always easy. Going cold-turkey off some of these meds can result in seizures.” Another interesting side note is that, most often, aspirin is not recommended for severe headaches. Dr. de Leonni says, “First, the efficacy is just not there. Also, because I’m trained in stroke and vascu-lar neurology, the majority of my patient population is already on a baby aspirin or a full aspirin regimen John LaWall, M.D. , Adult Neurologist and Head of the Banner – University Medical Center -South Neurology Residency Program, and Associate Professor of Clinical Neurology University of Arizona College of Medicine Mateja de Leonni Stanonik Spindler, M.D. , M.A., Ph.D., Neurologist, Vita Medica Institute, with training in neurology, psychology and neuroscienc-es with an emphasis on women Louann Carnahan, DO , Adult Neurologist with a specialty in epilepsy at the Center for Neurosciences ne thing our panel of neurologists agrees on: they do not prescribe narcotics or opioids for headache relief! “I get referrals from emer-gency departments or urgent care centers where the patient was given a prescription for oxycodone O 44 TUCSON LIFESTYLE | May 2016 TucsonLifestyle.com
In Health: Headaches: Know Your Enemy!
If you are a chronic headache sufferer and haven’t gotten the relief you need through over-the-counter medications or from a prescription given to you by your general practitioner, it may be time to break out “the big guns” and see a neurologist.
“headache relief dream team ” John LaWall, M.D., Adult Neurologist and Head of the Banner – University Medical Center - South Neurology Residency Program, and Associate Professor of Clinical Neurology University of Arizona College of Medicine
Mateja de Leonni Stanonik Spindler, M.D.,M. A., Ph.D., Neurologist, Vita Medica Institute, with training in neurology, psychology and neurosciences with an emphasis on women
Louann Carnahan, DO, Adult Neurologist with a specialty in epilepsy at the Center for Neurosciences
One thing our panel of neurologists agrees on: they do not prescribe narcotics or opioids for headache relief! “I get referrals from emergency departments or urgent care centers where the patient was given a prescription for oxycodone Or hydrocodone, and it usually turns out the patient has chronic migraine with aura,” says Dr. de Leonni.“Narcotics are rarely a solution for the primary chronic type of headache.”
“Migraine patients also are predisposed to having diffuse pain, especially in their backs, and they sometimes are prescribed an opiate, which just makes our jobs as neurologists even harder,” adds Dr. Carnahan. “It’s helpful if they can limit or stop opiates altogether so we can get a better idea of their headache profile, but that’s not always easy.Going cold-turkey off some of these meds can result in seizures.”
Another interesting side note is that, most often, aspirin is not recommended for severe headaches.Dr. de Leonni says, “First, the efficacy is just not there. Also, because I’m trained in stroke and vascular neurology, the majority of my patient population is already on a baby aspirin or a full aspirin regimen For heart attack and stroke prevention. If we were to prescribe additional aspirin to these patients, their stomachs might bleed due to ulcers.”
“The most common types of headaches come under the heading ‘Primary Headache Disorder,’ and can include migraine, tension, cluster, and several more esoteric varieties,” says Dr. LaWall.“Usually the patient already has been assessed by his general practitioner or another physician to ensure the pain is not caused by some other problem like a tumor, ruptured aneurysm or spinal fluid pressure buildup in the head.”
Believe it or not, there are no clinical tests to diagnose headaches! “We first take a patient’s headache history and do a physical exam to determine what the diagnosis is,” says Dr. LaWall. “The most common one is migraine, and a history and exam usually are sufficient to determine that diagnosis. If we find something unusual like the patient having weakness on one side or something, we’d send him for imaging in case there’s a structural abnormality like a tumor or lesion on the brain. Most of the time, we come up with an accurate diagnosis the first time we see the patient and then work out what will bring him relief.”
“By asking specific questions about his associated symptoms, we can target what specific type of headache he has,” says Dr. Carnahan. “Our job is to tease out the symptoms to determine their classification.The International Headache Society criteria really are the Gold Standard for what symptoms indicate a migraine versus cluster versus tension headache. It’s our job as neurologists to ask the right questions of our patients because they might not know if a symptom is important or not.”
Asking for a description of the type of pain can offer good, solid clues. Are there are other symptoms? In some migraines, for example, the nausea and vomiting can arrive before the pain. That’s why doctors ask their patients to keep a headache journal, where they write down everything that might have led up to an episode, from arguments with their significant others to barometric pressure changes to food triggers or work stressors (see the sidebar Know Your Triggers). Sometimes the patient and neurologist can then see cause-and-effect: for example, eating aged cheese and drinking red wine resulted in a migraine later that night. “When you talk to patients and get them to reflect over a few weeks to discover their headache Patterns, you usually find some kind of a trigger. You just have to convince them it’s worth looking for,” Dr. de Leonni says.
The most important way to help your neurologist to diagnose your headaches is do some detective work. The three most common headache “offenders” are profiled, along with treatment and prevention recommendations by our experts.
Recognizing the Culprit:
Like the Excedrin commercial says, “If you have migraines, you know pain.” Typically, they are characterized by periods of pain that impact the sufferer’s life due to “The Three S’s”: Severity of pain, Sensitivity to light/sound/motion, and Sickness with nausea and vomiting.According to the Migraine Research Foundation, migraines cause “severe recurring, intense, throbbing pain on one side of the head (although in one-third of migraine attacks, both sides are affected). Attacks last between 4 and 72 hours and often are accompanied by one or more of the following: visual disturbances, nausea, vomiting, dizziness, extreme sensitivity Dr. Kiaras to sound, light, touch and smell, and tingling or numbness in the extremities or face. Of course, everyone is different, and symptoms vary by person and sometimes by attack.” Dr. de Leonni notes that the quintessential pathology for migraine is not in the brain, per se, but rather the nerves around the vessels in the scalp. “When they misfire for whatever reason (usually genetics), that’s what causes migraine.” Dr. Carnahan refers to this as a cortical spreading depression — a cascade of inflammation in the nerves. Migraineurs (regular migraine sufferers) often can have tension or even cluster headaches as a subset of their symptoms. The signals of an oncoming migraine differ in each patient, as well.“Visual auras are the most common type of aura (or presaging event) that people get,” says Dr. de Leonni, a migraineur herself.“They may see halos around people or in their peripheral vision, or flashes of light. I’ve had migraines my whole life, and I get an olfactory aura — if I smell Granny Smith apples and there are none around, I know within five minutes I’m going to have A migraine.” Some patients even experience blind spots, or even a temporary loss of vision (as in an ocular migraine). Just to make diagnosis even more confusing, the migraineur can develop the nausea and vomiting first, followed by the pain, sensitivity etc. And to add insult to injury, Dr. de Leonni adds that migraine sufferers have a 4-5 percent increased risk for stroke … and that the relative risk is even higher in younger women.
The first line of treatment for acute migraine is a triptan, a class of medications that include sumatriptan (Imitrex), eletriptan (Relpax) and zolmitriptan (Zomig). Triptans are prescribed for acute use as long as the patient has no history of coronary artery disease, stroke or peripheral artery disease. In addition to pills, many triptans now come in nasal spray, sublingual, subcutaneous and even a patch form, all of which can arrest the pain much faster than it would take a pill to work.
“If a patient has two or three migraines per week, neurologists often will recommend other medications in order to prevent the headaches or to lessen their severity,” says Dr. Carnahan. “These meds are taken every day so the patient doesn’t have to reach for the acute use or rescue remedy, thereby avoiding the rebound headache problem.”
“Blood pressure medications like propranolol (a beta blocker) and verapamil (a calcium channel blocker), are used as migraine preventives, as well as various anti-seizure medications such as depakote and valproic acid (also used to help bipolar patients with manic episodes),” says Dr. de Leonni. “Tricyclics (antidepressants) were used in the ’70s, but because of cardiac side effects we mostly avoid them. They can be used in appropriate patients, however.”
Dr. LaWall says, “If a patient has had more than 15 headache days a month, and eight or more of those days are typical migraine, and that goes on for three months, we often turn to Botox, which — since 2008 — is FDA-approved for chronic migraine. This was discovered via anecdotal information gathered from cosmetic procedure patients who reported a lessening of their migraines following administration of Botox for their frown lines.
“Botox is administered in 31 injections in a band around the head — there is a specific protocol for the location of the injections, but we can give extra in places where they have more pain, so there is the ability to customize treatment. Some of the injections are in the forehead and above the eyebrows, so there’s a cosmetic effect as well — you get a twofer!”
Although it sounds like an enormous amount of medication, each injection is 1/10 of a milliliter (and there are 5 milliliters in a teaspoon).
Insurance will not cover Botox for headache unless it has been documented that the patient has tried two or three other FDA-approved preventive drugs like propranolol, depakote or topamax.
Recognizing the Culprit:
Suffered more by men than women (a 2:1 ratio), cluster headaches are said to be the most painful kind, even referred to in the vernacular as “suicide headaches.” “These usually present on one side of the head near the eye or temple, and patients will exhibit a red eye, tearing, abnormal size of pupil, droopy eyelid or flushing on that side of the face, as well as nasal discharge. The patient (victim?!)Often is restless or agitated and cannot sit still, frequently pacing the floor during attacks. These headaches usually will last only for about an hour, but they come in clusters,” says Dr. LaWall. They can occur from once every other day to eight times a day, averaging two per day over 4-6 weeks then disappearing for 6-12 months, according to the American Headache Society.
“Even before administering any other medication, having the patient breathe in pure oxygen is recommended, says Dr. LaWall.“In 80-90 percent of patients, it works really well.” Dr. Carnahan notes, “Our first-line treatment is breathing 100 percent oxygen through a re-breather mask. That will usually take care of it, but if it doesn’t we’ll administer subcutaneous Imitrex. If that ‘knocks the patient out too much,’ we can try a nasal spray formulation of a different triptan. These non-oral delivery systems get the drug into the patient’s system very quickly, and the headaches may go away before a pill could have a chance to take effect. But oxygen can be a godsend for these patients, as long as there are no smokers in the house so there is no fire hazard.”
Cluster sufferers also may have other kinds of headaches thrown in there, as in migraine syndrome. The neurologist must figure out what the different kinds are (migraine? Tension?) And treat them specifically, as well.
In cases with cluster headaches, a neurologist may prescribe some of the same preventive medications recommended for Migraine sufferers. Avoiding many of the migraine triggers, particularly those in the lifestyle category, may also help to prevent them.
Recognizing the Culprit:
These occur in three-quarters of the general population, but also as a feature in migraine syndrome or cluster headaches.They can range from mild to chronic and disabling, usually are present on both sides of the head and are felt as tightness or pressure sensation. They are not pulsating, don’t worsen with physical activity, and may result in tenderness in the scalp and pain or tightness in the neck. “People with tension headaches can end up in a cycle of rebound headache because of overuse of medications, particularly in cases where the patient has been taking a narcotic or opioid medication on a frequent basis,” warns Dr. Carnahan. “Even with traditional headache remedies, if they’re used too frequently, the body can respond to its absence with even worse headaches.”
For tension headaches, which Dr. Carnahan refers to as the “kinder, gentler” version, traditional over-the-counter pain relievers usually do the job. The drugs most people reach for first are referred to as NSAIDS (or Non-Steroidal Anti-Inflammatory Drugs), such as aspirin (Bayer), ibuprofen (Motrin, Advil), or naproxen sodium (Aleve). Overuse can cause “rebound headaches,” so tread carefully!
If a patient exhibits many tension headaches, he may be placed on preventive medications, such as those used for migraine sufferers.
As with cluster headaches, avoiding the triggers listed under Lifestyle Factors helps lessen the likelihood of an occurrence.Some patients find relief by using deep breathing, a regular meditation practice and massages (to loosen those tight muscles).
When all is said and done, headache treatment and prevention are quality-of-life issues. “Headaches are not perceived as dangerous because they can’t kill you and they’re not contagious, but those of us who do research in the field need to do a better job of educating the public about what we do and how we can help,” asserts Dr. de Leonni. “Headaches contribute to a great deal of missed work days and, in some cases, even disability. By the time headache sufferers arrive at my door, they have seen other physicians and may have been prescribed the wrong medications or wrong dosage of the right one. That’s where we come in and, working with the patient, find the right ones.” TL
“When you talk to patients and get them to reflect over a few weeks to discover their headache patterns, you usually find some kind of a trigger. You just have to convince them it’s worth looking for.” — Mateja de Leonni Stanonik Spindler, M.D., M.A., Ph.D., Neurologist, Vita Medica Institute
“The most common types of headaches come under the heading ‘Primary Headache Disorder,’ and can include migraine, tension, cluster, and several more esoteric varieties.”
John LaWall, M.D., Adult Neurologist and Head, Banner – University Medical Center - South Neurology Residency Program
“It’s our job as neurologists to ask the right questions of our patients because they might not know if a symptom is important or not.” — Louann Carnahan, DO, Adult Neurologist, Center for Neurosciences