Migraines

Headache

Headaches are very common and most people have suffered from them at one time or another. There are unfortunately many people who suffer from migraine, cluster or chronic daily or other headaches and associated symptoms. Many patients not only suffer from headaches alone, but find their schedules, activities, professional and personal lives severely compromised. You are not alone, and our cluster headache treatments have allowed many patients to resume more normal lives and have in many instances, effectively arrested their headache cycles with our patented therapies.

We have effectively managed many patients who have serious headache disorders. Some patients consult us following a visit to their primary care or general practice physician, or after seeing a neurologist or other specialist. Many patients have found our cluster headache treatments surprisingly effective even after failing years of cluster headache treatment by multiple physicians and at specialized headache centers.

In general, headaches may be very difficult to treat and we cannot guarantee success. However, we treat every patient with great care and strive to obtain the finest results possible.

Our highest levels of success are with patients suffering from several specific types of headaches. Note that many patients may have more than one headache type.

Migraine headaches will be discussed in more detail further along. We have developed a migraine medication called MYGAINE which is a proprietary treatment which is safe and rapidly and dramatically effective in  about 20-40 % or more of migraine suffers. Typically, MYGAINE is most effective in patients who have several of the following complaints and findings. Firstly, migraine episodes should not be more frequent than 2-3 days weekly. Symptoms should include eye pain or pain behind the eye. Aura may or may not be present prior to headache, and associated symptoms such as nausea, vomiting, photophobia or phonophobia may be present. Patients who have significant visual changes or who have occuloplegic migraines are also excellent candidates for MYGAINE treatment. The patient should not have pain at the base of the back of the head, or feel the headache travelling up the neck to the head, and should not have sinusitis or a history of headache following sinus surgery.  Postconcussion, posttraumatic brain injury, postmeningitis and post stroke headaches typically will not respond well to MYGAINE treatments.

MYGAINE also responds very well as a cluster headache treatment, and the relief is usually dramatic.

In our practice, we have found that many patients who have failed headache and cluster headache treatments elsewhere and who carry the diagnosis of migraine or other headaches actually have headaches that originate in the cervical spine.  We have a fairly robust success rate treating these patients with a variety of interventions including cervical facet procedures, cervical  transforaminal epidural injections and other procedures. Patients with these type of headaches often feel the headache travelling from their posterior neck, or the back of the head to their eyes. We also have a high success rate treating headaches which originate from, or are complicated by ,TMJ disorders or peripheral neuropathies. We have also effectively managed patients with postsurgical or posttraumatic facial pain syndromes.

A very exciting discovery of ours relates to Chronic Daily headaches. Essentially, we have found  that several patients who suffer from these headaches respond to patent pending therapies which alter characteristics of CSF flow dynamics.  Furthermore, patients note that their mental accuity and energy levels markedly increase.

In general  headaches  are subdivided as being primary or secondary headaches.

Secondary headaches are symptoms of underlying medical or other conditions including fever,  meningitis or other infection, medication side effect,  high blood pressure, abnormal intracranial pressure, altitude sickness, endocrine disorders, psychiatric  or emotional conditions, head injury or trauma, stroke, tumors, and  vascular abnormalities including arteriovenous malformation, aneurysm, or  intracranial venous blood clot.

In adults, immediate medical care should be sought for new onset headache or a headache that is explosive or described as the worst headache ever felt, or  if there is associated numbness or weakness of the limbs , face or elsewhere, seizure, confusion , altered or loss of consciousness, fever, stiff neck, increasing severity or different headache pattern or following head trauma.

Most headaches  that are commonly treated are recognized as  primary headaches and these are usually classified as migraine, tension-type headache, trigeminal autonomic cephalgias such as cluster headache, and a miscellaneous group. We also diagnose and treat several types of secondary headaches such as those that are Cervicogenic in origin, arising from spinal degenerative and other pathologies, and several  related to peripheral nerve structures, and have begun treatment for a subset of Chronic Daily Headache which we recognized and call Normotenisve Nonhydrocephalus (NTNH).  We have found that it is not uncommon for a patient to suffer from more than one type of headache, and tailor treatment accordingly. For example, patients may suffer from Arnold Chiari Syndrome and also have Migraine headaches in addition to Chronic Daily Headaches.

Migraine Headaches

About 12 percent of the U.S. population experiences migraines, which is a type of vascular headache, with women outnumbering men by a 4 to 1 margin. Vascular headaches are often characterized by throbbing and pulsating pain associated with neurogenic inflammation and edema, and activation of nerve fibers that reside within the wall of brain blood vessels .  These blood vessels become leaky, and narrow  temporarily, which decreases the flow of blood and oxygen to parts of the brain. Patients may experience  recurrent attacks of moderate to severe pain  may  last from 4 to 72 hours. Common symptoms include increased sensitivity to light, noise, and odors; and nausea and vomiting. Routine physical activity, movement, or even coughing ,sneezing, or even crying  can worsen the headache pain.  Many people feel exhausted or weak following a migraine but are usually symptom-free between attacks. Factors, which can trigger migraines vary from person to person and include sudden changes in weather or environment, too much or not enough sleep, strong odors or fumes, emotion, stress, overexertion, loud or sudden noises, motion sickness, low blood sugar, skipped meals, tobacco, depression, anxiety, head trauma, hangover, some medications, hormonal changes, and bright or flashing lights. Medication overuse or missed doses may also cause headaches. In some 50 percent of migraine sufferers, foods or ingredients can trigger headaches. These include aspartame, caffeine (or caffeine withdrawal), wine and other types of alcohol, chocolate, aged cheeses, monosodium glutamate, some fruits and nuts, fermented or pickled goods, yeast, and cured or processed meats. Keeping a diet journal will help identify food triggers.  There is evidence that migraines are genetic, with most migraine sufferers having a family history of the disorder. They also frequently occur in people who have other medical conditions. Depression, anxiety, bipolar disorder, sleep disorders, and epilepsy are more common in individuals with migraine than in the general population. Migraine sufferers-in particular those individuals who have pre-migraine symptoms referred to as aura-have a slightly increased risk of having a stroke. Migraine in women often varies  with hormonal changes. The headaches may begin at the start of the first menstrual cycle or during pregnancy. Most women see improvement after menopause, although surgical removal of the ovaries usually worsens migraines. Women with migraine who take oral contraceptives may experience changes in the frequency and severity of attacks, while women who do not suffer from headaches may develop migraines as a side effect of oral contraceptives.

Migraine attacks may be divided into four phases:

1) Premonitory symptoms occur up to 24 hours prior to developing a migraine. These include food cravings, unexplained mood changes (depression or euphoria), uncontrollable yawning, fluid retention, or increased urination.

2) Aura. Some people will see flashing or bright lights or what looks like heat waves immediately prior to or during the migraine, while others may experience muscle weakness or the sensation of being touched or grabbed.

3) Headache. A migraine usually starts gradually and builds in intensity, although it is possible to have migraine without a headache.

4) Postdrome .  Individuals are often exhausted or confused following a migraine. The postdrome period may last up to a day before people feel healthy.

Types of Migraine Headaches. The two major types of migraine are:

Migraine with aura, previously called classic migraine, includes visual disturbances and other neurological symptoms that appear about 10 to 60 minutes before the actual headache and usually last no more than an hour. Individuals may experience visual distortions or may loss of vision  The aura may occur without headache pain, which can strike at any time. Other classic symptoms include trouble speaking; an abnormal sensation, numbness, or muscle weakness on one side of the body; a tingling sensation in the hands or face, and confusion. Nausea, loss of appetite, and increased sensitivity to light, sound, or noise may precede the headache.

Migraine without aura, or common migraine, is the more frequent form of migraine. Symptoms include headache pain that occurs without warning and is usually felt on one side of the head, along with nausea, confusion, blurred vision, mood changes, fatigue, and increased sensitivity to light, sound, or noise.

Other types of  Adult  Migraine Headache include:

Hemiplegic migraine is a rare but severe form of migraine that causes temporary paralysis-sometimes lasting several days-on one side of the body prior to or during a headache. Symptoms such as vertigo, a pricking or stabbing sensation, and problems seeing, speaking, or swallowing may begin prior to the headache pain and usually stop shortly thereafter.

Menstrually-related migraine affects women around the time of their period, although most women with menstrually-related migraine also have migraines at other times of the month. Symptoms may include migraine without aura (which is much more common during menses than migraine with aura), pulsing pain on one side of the head, nausea, vomiting, and increased sensitivity to sound and light.

Ophthalmoplegic migraine an uncommon form of migraine with head pain, along with a droopy eyelid, large pupil, and double vision that may last for weeks, long after the pain is gone.

Retinal migraine is a condition characterized by attacks of visual loss or disturbances in one eye. These attacks, like the more common visual auras, are usually associated with migraine headaches.

Status migrainosus is a rare and severe type of acute migraine in which disabling pain and nausea can last 72 hours or longer. The pain and nausea may be so intense that sufferers need to be hospitalized.

Treatment

Migraine medication is aimed at relieving symptoms and preventing additional attacks. Quick steps to ease symptoms may include napping or resting with eyes closed in a quiet, darkened room; placing a cool cloth or ice pack on the forehead, and drinking lots of fluid, particularly if the migraine is accompanied by vomiting.

We have developed and used a variety of modalities that are quite effective in treating and aborting migraine attacks. We have found that many  diagnosed with migraines  in fact, have Cervicogenic headaches, TMJ disorders, Peripheral Neuropathies and other  pathologies that give rise to migraine or migraine like headaches.

For one migraine subset which affects over 20-40% of Migraineurs, Mygain, a proprietary  and particulary safe and remarkably effective migraine medication is remarkably effective. For these patients, the migraine medication can abort the headache as well as accompanying symptoms within 1-5 minutes. Side effects are minimal and include bad aftertaste. Patients who respond once to Mygain typically always respond to Mygain for the same headache subtype.

Patients who respond well  to Mygain  have attacks 1-2 episodes weekly to monthly,  severe eye pain, nausea, photophobia or phonophobia,  no sinus symptoms and no TMJ or occipital tenderness.  The more severe the pain, the more rapid and dramatic the relief of the headache.

Most patients who present to us have tried a variety of migraine medications including

Triptan drugs increase levels of the neurotransmitter serotonin in the brain. Serotonin causes blood vessels to constrict and lowers the pain threshold. Ergot derivative drugs bind to serotonin receptors on nerve cells and decrease the transmission of pain messages along nerve fibers. Non-prescription analgesics or over-the-counter drugs such as ibuprofen, aspirin, or acetaminophen can ease the pain of less severe migraine headache. Combination analgesics involve a mix of drugs such as acetaminophen plus caffeine and/or a narcotic for migraine that may be resistant to simple analgesics.

Nonsteroidal anti-inflammatory drugs can reduce inflammation and alleviate pain.

Nausea relief drugs can ease queasiness brought on by various types of headache.

Narcotics are prescribed briefly to relieve pain. These drugs should not be used to treat chronic headaches.

Taking these drugs more than three times a week may lead to medication overuse headache (previously called rebound headache), in which the initial headache is relieved temporarily but reappears as the drug wears off. Taking more of the drug to treat the new headache leads to progressively shorter periods of pain relief and results in a pattern of recurrent chronic headache. Headache pain ranges from moderate to severe and may occur with nausea or irritability. It may take weeks for these headaches to end once the drug is stopped.  Mygain may be a useful migraine medication  for some of these patients.

Everyone with migraine needs effective treatment at the time of the headaches. Some people with frequent and severe migraine need preventive migraine medications. In general, prevention should be considered if migraines occur one or more times weekly, or if migraines are less frequent but disabling. Preventive medicines are also recommended for individuals who take symptomatic headache treatment more than three times a week. Physicians will also recommend that a migraine sufferer take one or more preventive migraine medications two to three months to assess drug effectiveness, unless intolerable side effects occur.

Anticonvulsants may be helpful for people with other types of headaches in addition to migraine. Although they were originally developed for treating epilepsy, these drugs increase levels of certain neurotransmitters and dampen pain impulses.

Beta-blockers are drugs for treating high blood pressure that are often effective for migraine medication.

Calcium channel blockers are medications that are also used to treat high blood pressure treatment and help to stabilize blood vessel walls. These drugs appear to work by preventing the blood vessels from either narrowing or widening, which affects blood flow to the brain.

Antidepressants are drugs that work on different chemicals in the brain; their effectiveness as a migraine medication is not directly related to their effect on mood. Antidepressants may be helpful for individuals with other types of headaches because they increase the production of serotonin and may also affect levels of other chemicals, such as norepinephrine and dopamine. The types of antidepressants used for migraine treatment include selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, and tricyclic antidepressants (which are also used to treat tension-type headaches). Natural treatments for migraine include riboflavin (vitamin B2), magnesium, coenzyme Q10, and butterbur.

Non-drug therapy as a migraine medication includes biofeedback and relaxation training, both of which help individuals cope with or control the development of pain and the body's response to stress.

Lifestyle changes that reduce or prevent migraine attacks in some individuals include exercising, avoiding food and beverages that trigger headaches, eating regularly scheduled meals with adequate hydration, stopping certain medications, and establishing a consistent sleep schedule. Obesity increases the risk of developing chronic daily headache, so a weight loss program is recommended for obese individuals.

Trigeminal Autonomic Cephalgias

Some primary headaches are characterized by severe pain in or around the eye on one side of the face and autonomic (or involuntary) features on the same side, such as red and teary eye, drooping eyelid, and runny nose. These disorders, called trigeminal autonomic cephalgias (cephalgia meaning head pain), differ in attack duration and frequency, and have episodic and chronic forms. Episodic attacks occur on a daily or near-daily basis for weeks or months with pain-free remissions. Chronic attacks occur on a daily or near-daily basis for a year or more with only brief remissions.

Cluster headache - the most severe form of primary headache-involves sudden, extremely painful headaches that occur in "clusters," usually at the same time of the day and night for several weeks. They strike one side of the head, often behind or around one eye, and may be preceded by a migraine-like aura and nausea. The pain usually peaks 5 to 10 minutes after onset and continues at that intensity for up to 3 hours. The nose and the eye on the affected side of the face may get red, swollen, and teary. Some people will experience restlessness and agitation, changes in heart rate and blood pressure, and sensitivity to light, sound, or smell. Cluster headaches often wake people from sleep.

Cluster headaches generally begin between the ages of 20 and 50 but may start at any age, occur more often in men than in women, and are more common in smokers than in nonsmokers. The attacks are usually less frequent and shorter than migraines. It's common to have 1 to 3 cluster headaches a day with 2 cluster periods a year, separated by months of freedom from symptoms. The cluster periods often appear seasonally, usually in the spring and fall, and may be mistaken for allergies. A small group of people develop a chronic form of the disorder, which is characterized by bouts of headaches that can go on for years with only brief periods (1 month or less) of remission. Cluster headaches occur more often at night than during the day, suggesting they could be caused by irregularities in the body's sleep-wake cycle. Alcohol (especially red wine) and smoking can provoke attacks. Studies show a connection between cluster headache and prior head trauma. An increased familial risk of these headaches suggests that there may be a genetic cause. Standard Treatment options include oxygen therapy-in which pure oxygen is breathed through a mask to reduce blood flow to the brain-and triptan drugs. Certain antipsychotic drugs, calcium-channel blockers, and anticonvulsants can reduce pain severity and frequency of attacks. In extreme cases, electrical stimulation of the occipital nerve, other peripheral nerves or the SPG is very helpful. to prevent nerve signaling or surgical procedures that destroy or cut certain facial nerves may provide relief.

Mygain has proven extremely effective as a cluster headache treatment in many patients, with retreatment sometimes required.

Miscellaneous Primary Headaches

Other headaches that are not caused by other disorders include:

Chronic daily headache refers to a group of headache disorders that occur at least 15 days a month during a 3-month period. In addition to chronic tension-type headache, chronic migraine, and medication overuse headache (discussed above), these headaches include hemicrania continua and new daily persistent headache. Individuals feel constant, mostly moderate pain throughout the day on the sides or top of the head. They may also experience other types of headache. Adolescents and adults may experience chronic daily headaches. In children, stress from school and family activities may contribute to these headaches.

New Daily Persistent Headache (NDPH), previously called chronic benign daily headache, is known for its constant daily pain that ranges from mild to severe. Individuals can often recount the exact date and time that the headache began. Daily headaches can occur for more than 3 months (and sometimes years) without lessening or ending. Symptoms include an abnormal sensitivity to light or sound, nausea, lightheadedness, and a pressing, throbbing, or tightening pain felt on both sides of the head. NDPH occurs more often in women than in men. Most sufferers do not have a prior history of headache. NDPH may occur spontaneously or following infection, medication use, trauma, high spinal fluid pressure, or other condition. The disorder has two forms: one that usually ends on its own within several months and does not require treatment, and a longer-lasting form that is difficult to treat. Muscle relaxants, antidepressants, and anticonvulsants may provide some relief.

We have found that patients with CDH or NDPH who have mildly depressed affect, mild cognitive deficits such as trouble concentrating, and low energy levels have disturbances of CSF flow or volume in the setting of normal pressures, and therapies to this end are promising but in early stages of development.

Credit to NINDS and The NIH for much of the above background information.