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The Facts about Headaches and Migraines
Dr. Sanjiv Sahoo discusses headaches, migraines, and BayCare's neuroscience services.
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Learn more about Sanjiv Sahoo, MD
Sanjiv Sahoo, MD
Sanjiv Sahoo, MD, is board certified in neurology, clinical neurophysiology, epilepsy and electrodiagnostic medicine. He has served as an attending neurologist since 2004 and was assistant professor of neurology at Virginia Commonwealth University. Dr. Sahoo specializes in epilepsy, neuromuscular diseases, stroke and general neurology. He has extensive experience in EMG, EEG and clinical neurophysiology. Dr. Sahoo is a member of the American Clinical Neurophysiology Society, the American Academy of Neurology and the American Epilepsy Society. He is fluent in Hindi.Learn more about Sanjiv Sahoo, MD
Transcription:
The Facts about Headaches and Migraines
Melanie Cole (Host): Nearly everyone I know has had headache pain at some point in their lives, but if your headache is severe or unusual, you really start to worry. My guest today is Dr. Sanjiv Sahoo. He’s a neurologist with BayCare Health System. Dr. Sahoo, do we know even why we get headaches? Do we know what they are or what causes them?
Dr. Sanjiv Sahoo (Guest): I think that’s an excellent question, but before we can answer that question, we have to understand that headaches come in very many different flavors. There’s very different causes for headaches. The vast majority obviously, especially in the younger population would be migraines, but you always have to make sure the headaches are not coming from a secondary cause. Sometimes somebody might have a tumor. They might have a clot. There may be an infection. There may be other causes for the headache that aren’t apparent, and it’s important to make sure you see a physician to evaluate you to establish there isn’t a secondary cause for the headache. If you have ruled out the secondary causes then the vast majority really have migraines, and that can happen in about 10% of the population, and why people have migraines? That’s an excellent question. I wish we had an answer to that, but part of it is genetics. If you have a first degree relative with headaches, it’s likely that you might suffer them too, and we have some basic understand of why someone has a headache once it’s triggered, and there are many types of triggers for a headache and we can go into details of that later on.
Host: As I said in the intro everybody worries. They get a headache once or twice but if they get it 3 or 4 times and they don’t know if they have migraines, they really start to worry that it is a tumor or something worse. What are the symptoms that you want people to be aware of, red flags, something that changes the picture that would send them to see a provider at the first place?
Dr. Sahoo: Again, that’s an excellent question. I think what we need to pay attention to is the pattern of the headache. If it’s a migraine, you can have a headache that comes and goes, but in between the headaches you recovery completely. If there’s a headache that is gradually progressive and then continues to build up and then stays persistent, then it’s definitely something that needs to be looked into, especially if it’s lasted for more than a week or two. It’s worth getting checked out. Other red flags that are really important to pay attention to is if someone has a fever, if they have neck stiffness, if they get nauseous and start throwing up, if they have any neurological symptoms of deficits such as numbness, tingling, weakness, blurry vision, loss of vision, imbalance, dizziness, all of those signs and symptoms could suggest that maybe there’s something worse than just pain migraines and it’s a good thing to get checked out for those.
Host: How do you diagnose them? People don’t want to have this big battery of tests to find out why they have a headache. What do you do and how do you differentiate that it could be a sinus issue or a toothache or eye issues? How is the testing and diagnosis process? How does that start?
Dr. Sahoo: So I think the very first step is to go to your primary physician and simple reasons for having a headache such as eye strain, glaucoma, sinus pressure headache, tension headache, maybe a toothache, anything that revolves around the neck, neck strain, those are things that primary physicians see on a daily basis. What they will pick up on is something that doesn’t fit the usual symptomatology, that doesn’t fit the usual pattern, and if they try their regular therapies and it doesn’t work or if they don’t reach the conclusion that they were expecting then that’s when they have to send you to the next level and that would be to a neurologist, and once you come to see a neurologist, then they take a background history, they go into details of the characteristics of the headache. They will then evaluate you with an examination. They look for signs and deficits that suggest that there are some things like a structural lesion or another etiology for the headache, and then they can always consider imaging, even if its something simple as a CT scan. If it’s something more worrisome, we can always do an MRI. It depends on how the patients present to you. Sometimes we see unusual cases of cervical dissection, or there can be a tear in the vessel, blood clots in the brain, there can be increased pressure in the spinal fluid and these things will show up on the exam with blurring the discs when you check the fundus on an eye exam. When you see signs of a small pupil on one side versus the other, that’s a sign of Horner syndrome, which can make you consider a cervical dissection. So the neurologist would be able to pick that out and decide if we need to do more imaging such as CT, and MRI, an MR venogram or does that patient need a spinal tap? Are we worried about infection? Are we worried about increased pressure? There’s a condition known as pseudo tumor cerebri where there’s elevated spinal fluid pressure, and no one really knows why someone has that, but something simple as weight gain can cause that. So these are things we look for and address before we end up diagnosing a migraine.
Host: Dr. Sahoo with teens, they get so many headaches, and we all do if we’re really stressed out. When does a parent determine if it’s stress, lack of sleep, all of the other things that teens go through, and what do you advise parents to do about it as far as taking them in versus saying well let’s try some stress modification techniques or get better sleep? For parents this is a confusing situation.
Dr. Sahoo: So that’s – you’ve already raised some very, very important management options. You really stressed on the lifestyle changes and I think parents should really start off with that. Again, the teenage years are a very difficult time. They’re under tremendous stress, tremendous peer pressure. They have a lot to perform and achieve and so they have altered sleep/wake cycles, and so I think the parents should really help them and encourage them to develop a disciplined lifestyle and it’s difficult but you have to eat at the right time because fasting can trigger migraines, you have to eat healthy. You have to have a proper bed regimen. You go to sleep at a certain time, wake up at a certain time. You have to find time to exercise. It’s been shown in studies that 150 minutes of exercise a week, 3 to 5 sessions of 20 minutes a day would basically help achieve that 150 minutes and you can decrease your migraine frequency just on that basis alone. Now in spite of that the teen still has frequent headache, we have to understand that the migraines by themselves is not the issue. Sometimes there’s premonitory phases where you can find symptoms of fatigue, tiredness, you can even have increased micturition frequency and then the post migraine symptoms the exhaustion, the confusion, that all adds up. So even if it lasted a day, you add a day before and the day after, they’re losing 3 days for every single headache. Now some migraines are easy to treat and you can treat them with simple over the counter NSAIDs or nonsteroidal anti-inflammatory drugs like ibuprofen, Tylenol, Excedrin, but if the headaches are frequent and even if they’re responding to the medications, if they have more than 6 headaches that are easy treatable, that’s still too many. If they’re having 3 or 4 headaches or more that are difficult to treat and don’t respond to the regular medications, that’s when the parents should actually consider bringing them to a specialist so that maybe you can try a medication, a prophylactic medication to prevent them from getting so many frequent headaches that seems to be impairing their daily life.
Host: Please speak about some of the newer medications on the market including anti-nausea treatments or even Botox that you’re using. What’s new and exciting in the headache world?
Dr. Sahoo: So for the longest time we’ve had many different types of medications that we use to treat the headache when you have the headache. I talked about the nonsteroidal agents, but there are the triptan classes, the sumatriptan, the almotriptan, the rizatriptan, the eletriptan. There are different types of triptan medications which can abort the headache when you get it. If you use it within the first 15 minutes, it will stop it in its tracks along with some of the following symptoms and those are the things that we have for abortive therapies. There are different types of ways you can use them. They can be in the tablet form, a nasal spray, they can be in the form of an injection where you just have an air puff that goes into the skin. There’s even a powder that can be blown into the nasal mucosa that can also help abort the headache. So aside from abortive therapy, we now have treatment options of prevention of migraines, and we’ve had different classes of medications that you may have come across. There’s a very good medication and it’s topiramate or Topamax, which is highly effective to prevent headache but then we have other older antidepressants such as amitriptyline, nortriptyline. We have some beta-blockers like propranolol, nadolol. We have calcium channel blockers like verapamil and then we have some older anticonvulsants like Depakote, many different options and some over the counter options that most individuals are not aware of like simple magnesium 400 mg, coenzyme Q10 at a dose of 300 mg, riboflavin, just simple things that you can do. The newer agents that are out there – we’ve had Botox which has been quite a few years and you can take Botox injections every three months and that will help decrease the frequency of headaches, but the most recent medication that has come out on the market is a class of drugs known as CGRP antigram. CGRP stands for calcitonin gene related peptide and they have come out with 3 or 4 different medications that target that particular receptor and they’re really very effective and most of them are in the form of injections once a month and they can drop the headache frequency significantly and with very minimal side effects. There’s a new one that we’ve been using in the last year, Aimovig that really has some injection site reactions and constipation, but nothing too worrisome. The other two out there, Emgality and Ajovy are also very well tolerated without really any side effects other than injection site, and so we have really good options nowadays.
Host: So interesting Dr. Sahoo. Give us your best advice for lifestyle modifications. We spoke a little bit about them, but things that are triggers. Things that might set off a headache that you know ahead of time or ways that we can control our stress and thereby control our headaches.
Dr. Sahoo: So again, this is something that I discuss with all my patients, there’s things that you can do something about and there’s things that you can’t do much about but the first thing that I stress is let’s be disciplined. You know, eat, exercise, and sleep. So eat at the right time, try not to miss meals, try not to overhead. Exercise at least 150 minutes a week. Get to sleep on time and then wake up on time. Try to avoid daytime naps if possible. If you have sleep apnea, treat that with a CPAP. Avoid stress. That’s easier said than done, but if you can’t avoid it, try to avoid swings in the stress level. Keeping yourself at a steady state is actually better. I have patients who will suddenly go from a stressful job to a vacation and then they have a headache. So even a stress letdown can cause a headache, so you just have to maintain a steady pace. Obviously, there are environmental triggers that you can control like avoid that odor, certain scent, excessive light, smoke, heat, avoid drinking if that triggers a headache, avoid fasting. And then there’s things that you don’t have control over such as weather changes or hormonal changes and then there’s always the food trigger that you have to watch out for and there’s a few common ones that you can look out for. Not everybody has all the triggers, red wine, teas, coffee, coke, MSG, cured meat, chocolate, even some artificial sweeteners which is aspartame, but again not everybody has these food triggers. You have to maintain a diary and capture the particular food trigger that bothers you and avoid that one; otherwise, you really won’t have much of a lifestyle if you avoid all the good things in your life, so really it’s individually tailored but disciplined and if you can achieve that, I think you can really look for many more headache free days.
Host: Thank you so much Dr. Sahoo for coming on. So many people get headaches, and you really cleared so beautifully up for us those symptoms to watch out for and when it’s important to see your primary care provider and then maybe go on to a specialist. Thank you for the great advice. You’re listening to BayCare HealthChat. For more information, please visit baycare.org, that’s baycare.org. This is Melanie Cole. Thanks so much for tuning in.
The Facts about Headaches and Migraines
Melanie Cole (Host): Nearly everyone I know has had headache pain at some point in their lives, but if your headache is severe or unusual, you really start to worry. My guest today is Dr. Sanjiv Sahoo. He’s a neurologist with BayCare Health System. Dr. Sahoo, do we know even why we get headaches? Do we know what they are or what causes them?
Dr. Sanjiv Sahoo (Guest): I think that’s an excellent question, but before we can answer that question, we have to understand that headaches come in very many different flavors. There’s very different causes for headaches. The vast majority obviously, especially in the younger population would be migraines, but you always have to make sure the headaches are not coming from a secondary cause. Sometimes somebody might have a tumor. They might have a clot. There may be an infection. There may be other causes for the headache that aren’t apparent, and it’s important to make sure you see a physician to evaluate you to establish there isn’t a secondary cause for the headache. If you have ruled out the secondary causes then the vast majority really have migraines, and that can happen in about 10% of the population, and why people have migraines? That’s an excellent question. I wish we had an answer to that, but part of it is genetics. If you have a first degree relative with headaches, it’s likely that you might suffer them too, and we have some basic understand of why someone has a headache once it’s triggered, and there are many types of triggers for a headache and we can go into details of that later on.
Host: As I said in the intro everybody worries. They get a headache once or twice but if they get it 3 or 4 times and they don’t know if they have migraines, they really start to worry that it is a tumor or something worse. What are the symptoms that you want people to be aware of, red flags, something that changes the picture that would send them to see a provider at the first place?
Dr. Sahoo: Again, that’s an excellent question. I think what we need to pay attention to is the pattern of the headache. If it’s a migraine, you can have a headache that comes and goes, but in between the headaches you recovery completely. If there’s a headache that is gradually progressive and then continues to build up and then stays persistent, then it’s definitely something that needs to be looked into, especially if it’s lasted for more than a week or two. It’s worth getting checked out. Other red flags that are really important to pay attention to is if someone has a fever, if they have neck stiffness, if they get nauseous and start throwing up, if they have any neurological symptoms of deficits such as numbness, tingling, weakness, blurry vision, loss of vision, imbalance, dizziness, all of those signs and symptoms could suggest that maybe there’s something worse than just pain migraines and it’s a good thing to get checked out for those.
Host: How do you diagnose them? People don’t want to have this big battery of tests to find out why they have a headache. What do you do and how do you differentiate that it could be a sinus issue or a toothache or eye issues? How is the testing and diagnosis process? How does that start?
Dr. Sahoo: So I think the very first step is to go to your primary physician and simple reasons for having a headache such as eye strain, glaucoma, sinus pressure headache, tension headache, maybe a toothache, anything that revolves around the neck, neck strain, those are things that primary physicians see on a daily basis. What they will pick up on is something that doesn’t fit the usual symptomatology, that doesn’t fit the usual pattern, and if they try their regular therapies and it doesn’t work or if they don’t reach the conclusion that they were expecting then that’s when they have to send you to the next level and that would be to a neurologist, and once you come to see a neurologist, then they take a background history, they go into details of the characteristics of the headache. They will then evaluate you with an examination. They look for signs and deficits that suggest that there are some things like a structural lesion or another etiology for the headache, and then they can always consider imaging, even if its something simple as a CT scan. If it’s something more worrisome, we can always do an MRI. It depends on how the patients present to you. Sometimes we see unusual cases of cervical dissection, or there can be a tear in the vessel, blood clots in the brain, there can be increased pressure in the spinal fluid and these things will show up on the exam with blurring the discs when you check the fundus on an eye exam. When you see signs of a small pupil on one side versus the other, that’s a sign of Horner syndrome, which can make you consider a cervical dissection. So the neurologist would be able to pick that out and decide if we need to do more imaging such as CT, and MRI, an MR venogram or does that patient need a spinal tap? Are we worried about infection? Are we worried about increased pressure? There’s a condition known as pseudo tumor cerebri where there’s elevated spinal fluid pressure, and no one really knows why someone has that, but something simple as weight gain can cause that. So these are things we look for and address before we end up diagnosing a migraine.
Host: Dr. Sahoo with teens, they get so many headaches, and we all do if we’re really stressed out. When does a parent determine if it’s stress, lack of sleep, all of the other things that teens go through, and what do you advise parents to do about it as far as taking them in versus saying well let’s try some stress modification techniques or get better sleep? For parents this is a confusing situation.
Dr. Sahoo: So that’s – you’ve already raised some very, very important management options. You really stressed on the lifestyle changes and I think parents should really start off with that. Again, the teenage years are a very difficult time. They’re under tremendous stress, tremendous peer pressure. They have a lot to perform and achieve and so they have altered sleep/wake cycles, and so I think the parents should really help them and encourage them to develop a disciplined lifestyle and it’s difficult but you have to eat at the right time because fasting can trigger migraines, you have to eat healthy. You have to have a proper bed regimen. You go to sleep at a certain time, wake up at a certain time. You have to find time to exercise. It’s been shown in studies that 150 minutes of exercise a week, 3 to 5 sessions of 20 minutes a day would basically help achieve that 150 minutes and you can decrease your migraine frequency just on that basis alone. Now in spite of that the teen still has frequent headache, we have to understand that the migraines by themselves is not the issue. Sometimes there’s premonitory phases where you can find symptoms of fatigue, tiredness, you can even have increased micturition frequency and then the post migraine symptoms the exhaustion, the confusion, that all adds up. So even if it lasted a day, you add a day before and the day after, they’re losing 3 days for every single headache. Now some migraines are easy to treat and you can treat them with simple over the counter NSAIDs or nonsteroidal anti-inflammatory drugs like ibuprofen, Tylenol, Excedrin, but if the headaches are frequent and even if they’re responding to the medications, if they have more than 6 headaches that are easy treatable, that’s still too many. If they’re having 3 or 4 headaches or more that are difficult to treat and don’t respond to the regular medications, that’s when the parents should actually consider bringing them to a specialist so that maybe you can try a medication, a prophylactic medication to prevent them from getting so many frequent headaches that seems to be impairing their daily life.
Host: Please speak about some of the newer medications on the market including anti-nausea treatments or even Botox that you’re using. What’s new and exciting in the headache world?
Dr. Sahoo: So for the longest time we’ve had many different types of medications that we use to treat the headache when you have the headache. I talked about the nonsteroidal agents, but there are the triptan classes, the sumatriptan, the almotriptan, the rizatriptan, the eletriptan. There are different types of triptan medications which can abort the headache when you get it. If you use it within the first 15 minutes, it will stop it in its tracks along with some of the following symptoms and those are the things that we have for abortive therapies. There are different types of ways you can use them. They can be in the tablet form, a nasal spray, they can be in the form of an injection where you just have an air puff that goes into the skin. There’s even a powder that can be blown into the nasal mucosa that can also help abort the headache. So aside from abortive therapy, we now have treatment options of prevention of migraines, and we’ve had different classes of medications that you may have come across. There’s a very good medication and it’s topiramate or Topamax, which is highly effective to prevent headache but then we have other older antidepressants such as amitriptyline, nortriptyline. We have some beta-blockers like propranolol, nadolol. We have calcium channel blockers like verapamil and then we have some older anticonvulsants like Depakote, many different options and some over the counter options that most individuals are not aware of like simple magnesium 400 mg, coenzyme Q10 at a dose of 300 mg, riboflavin, just simple things that you can do. The newer agents that are out there – we’ve had Botox which has been quite a few years and you can take Botox injections every three months and that will help decrease the frequency of headaches, but the most recent medication that has come out on the market is a class of drugs known as CGRP antigram. CGRP stands for calcitonin gene related peptide and they have come out with 3 or 4 different medications that target that particular receptor and they’re really very effective and most of them are in the form of injections once a month and they can drop the headache frequency significantly and with very minimal side effects. There’s a new one that we’ve been using in the last year, Aimovig that really has some injection site reactions and constipation, but nothing too worrisome. The other two out there, Emgality and Ajovy are also very well tolerated without really any side effects other than injection site, and so we have really good options nowadays.
Host: So interesting Dr. Sahoo. Give us your best advice for lifestyle modifications. We spoke a little bit about them, but things that are triggers. Things that might set off a headache that you know ahead of time or ways that we can control our stress and thereby control our headaches.
Dr. Sahoo: So again, this is something that I discuss with all my patients, there’s things that you can do something about and there’s things that you can’t do much about but the first thing that I stress is let’s be disciplined. You know, eat, exercise, and sleep. So eat at the right time, try not to miss meals, try not to overhead. Exercise at least 150 minutes a week. Get to sleep on time and then wake up on time. Try to avoid daytime naps if possible. If you have sleep apnea, treat that with a CPAP. Avoid stress. That’s easier said than done, but if you can’t avoid it, try to avoid swings in the stress level. Keeping yourself at a steady state is actually better. I have patients who will suddenly go from a stressful job to a vacation and then they have a headache. So even a stress letdown can cause a headache, so you just have to maintain a steady pace. Obviously, there are environmental triggers that you can control like avoid that odor, certain scent, excessive light, smoke, heat, avoid drinking if that triggers a headache, avoid fasting. And then there’s things that you don’t have control over such as weather changes or hormonal changes and then there’s always the food trigger that you have to watch out for and there’s a few common ones that you can look out for. Not everybody has all the triggers, red wine, teas, coffee, coke, MSG, cured meat, chocolate, even some artificial sweeteners which is aspartame, but again not everybody has these food triggers. You have to maintain a diary and capture the particular food trigger that bothers you and avoid that one; otherwise, you really won’t have much of a lifestyle if you avoid all the good things in your life, so really it’s individually tailored but disciplined and if you can achieve that, I think you can really look for many more headache free days.
Host: Thank you so much Dr. Sahoo for coming on. So many people get headaches, and you really cleared so beautifully up for us those symptoms to watch out for and when it’s important to see your primary care provider and then maybe go on to a specialist. Thank you for the great advice. You’re listening to BayCare HealthChat. For more information, please visit baycare.org, that’s baycare.org. This is Melanie Cole. Thanks so much for tuning in.