Cheryl Martin (Host): We've all probably had at least one in our lifetime, a headache. We don't always know why, but we know it's inconvenient and can be painful. Dr. Dwayne Brown is here to answer our pressing questions about headaches; what causes them, the different types, the best ways to treat them. And when it's time to see the doctor. Dr. Brown is the Director of the Comprehensive Headache Center at Capital Institute for Neurosciences This is the Health Headlines podcast series from Capital Health. I'm Cheryl Martin. Dr. Brown, thanks for coming on.

Dwayne Brown, DO, PhD: Thank you for having me.

Host: So let's get started. What are the different types of headaches and how common are they?

Dwayne Brown, DO, PhD: So there's several different headache conditions, and they're divided into two groups, so primary and secondary headache conditions. So primary headache conditions are those that are not due to any underlying medical conditions. There's several of them. The more common ones that we see in clinic are migraine headaches, tension headaches, and cluster headaches.

And then secondary headache condition, as a name suggests, are those headaches that are due to another underlying condition. So this could be due to a infection, so perhaps sinusitis or meningitis. Is it vascular in origin? So does a patient have a subarachnoid hemorrhage from a ruptured aneurysm, headache from a stroke? Or is it just inflammation of the temporal artery? Specifically we should be conscious of this in patients over the age of 50.

Or is it a headache due to high blood pressure? You can also get headaches from head and neck trauma, so perhaps a concussion or whiplash, headaches from just overusing certain medications like opioids or withdrawal from let's say caffeine. You can also get headaches from brain tumor, or just a ophthalmic cause perhaps glaucoma. And then finally dental. So does a patient have TMJ? So there's several different, secondary headache conditions out there.

Host: So when we have a headache, we most of the time don't know what caused it then and why we're having it.

Dwayne Brown, DO, PhD: Correct. Yes. So that's why it's important to have a team of hopefully neurologists who are, trained in headache medicine who can solicit a really good history, oftentimes the history is what's telling.

Host: So when should you see a doctor about a headache? Because let's say if you get one once every couple of months, once a year, how do you know when you should go to the doctor?

Dwayne Brown, DO, PhD: I mean, the simple answer is if you have a headache that's disabling, that's interfering with your quality of life, it's worthwhile seeing a doctor about this. But there are red flags that I oftentimes, look out for or suggest that patients seek immediate medical attention. So if the patient has a sudden thunderclap headache. Definitely that warrants immediate action, that could be due to an underlying bleed. If there's headache with fever and neck stiffness, this could be suggesting, possible meningitis, headache with weight loss and night sweats could imply that there's an underlying malignancy that's causing this. New headaches over the age of 50 is somewhat concerning for possible giant cell arteritis.

So if there's anything that's somewhat concerning, definitely worthwhile reaching out to your healthcare provider.

Host: Now, talk about migraine headaches because that's one that we hear the most about. And how is that one different from other headache conditions?

Dwayne Brown, DO, PhD: So migraine is one of the primary headache condition and the reason why it's more commonly seen, it's because it's more severe in terms of how it presents. So it is oftentimes described as a unilateral headache, meaning it's one-sided, but it can switch sides. And importantly, in younger patients, it can be bilateral, which is both sides.

Typically it's described as pulsating or throbbing in quality, and the patient has to have light sensitivity and noise sensitivity or nausea to make the diagnosis. But most importantly, it should last between three hours to three days if untreated. It can last more than three days though. And when that happens, we call that status migrainosis.

In my experience, that typically happens if the patient waited too long to take their migraine medication and then they end up in that state. And when this happens, it's really hard to treat. So these are the patients that end up going to the emergency room for perhaps a migraine cocktail, which includes fluids and rein rather and steroids to name a few.

Host: So an over-the-counter product doesn't necessarily work for migraines.

Dwayne Brown, DO, PhD: Over-the-counter products can be effective as an abortive regimen. So typically when it comes to what you prescribe, it depends on the frequency. The recommendation from the American Headache Society is that if the headache is happening in less than four days per month, a simple analgesic like an over-the-counter will be fine, or you can start thinking of Triptans or some of the new agents that we call the G pens.

But if you're having headaches more than four days per month, then it's time to start talking about preventive agents. So these are meds that you take either daily, monthly, and we do have some that are quarterly.

Host: You mentioned when I asked you about headaches, that some are as a result of some medical conditions that are underlying, but what are also some common causes of headaches that may not be because of a medical condition?

Dwayne Brown, DO, PhD: Sure. Sure. So those would be the primary headache conditions, which are migraine, cluster, tension headache. In fact, tension headache is the most common headache condition. The reason why we don't often see patients with those is because they're more mild to moderate in terms of how they present, and patients are often able to take over-the-counter medications for those.

Host: Okay, so how are headaches and migraines evaluated and diagnosed?

Dwayne Brown, DO, PhD: So for simple migraine, it's a clinical diagnosis. So if the patient, again, meets what we call the ICHD3 guidelines, so that is the International Classification of Headache Disorders. So to meet the criteria, they have to have at least five events that has light sensitivity, noise sensitivity, or nausea lasting between three hours to three days, and of moderate to severe intensity, then that is a migraine.

So they just have simple migraine features with no concerns for secondary cause then just you start a medication depending on how frequently they're getting it. We consider imaging when there's other red flags. So if I have a patient in clinic and they're telling me that they're having headaches, that's waking them up in the mornings.

Then there's a concern for could this patient have an underlying tumor, that may be causing this. There are certain headaches that are positional. So if I have a patient that's telling you that they're having this headache that gets worse with coughing, sneezing, pooping, then you may want to consider imaging to rule out a CSF leak. So it just depends on the story that the patient is giving you. 

Host: And what about treatment and management once a patient has been diagnosed?

Dwayne Brown, DO, PhD: So we've come a long way when it comes to treatment for different headache conditions, specifically migraine. I would say prior to 2018, most of the meds that we had on the market were medications that were used off-label for migraine that belonged to other classes of medications. So this includes some anti-seizure meds, some anti-hypertensive class of medications and some antidepressant medications. However, since 2018 onwards, we now have a new group of medications that works on the CGRP pathway. CGRP stands for calcitonin gene related peptides. So some will bind into the actual molecule or the ligand and some will bind into the actual receptors.

Essentially, again, if I have a patient that's coming to me with more than four headaches per month, I would typically start one of these medications, and then if they're only getting less than four per month, or it could be two headaches that are very disabling, then I would start both a preventive as well as an abortive regimen.

Host: Dr. Brown, what are the benefits of going to a Comprehensive Headache Center like Capital Health's for treatment? 

Dwayne Brown, DO, PhD: Most people can get their headaches treated at just their primary care doctor's or just a general neurologist. But one of the advantages of being seen at a comprehensive headache center is that you have more of a specialized treatment. So you have experts who are well versed when it comes to diagnosis because that's always key.

At Capital Health, we have two fellowship trained headache specialists, myself and Dr. Day, who are both UCNS certified Headache Medicine Certified. The other advantage is that we offer more of a multidisciplinary approach. So we work very closely with physical therapy, neuropsychology, neurosurgery, pain medicine, as well as sleep medicine. You have access to more advanced therapies. So we offer Botox injections for migraine, nerve blocks, spina palatine ganglion blocks to name a few. And then the approach is always individualized. So we treat every patient differently, as we should. So sometimes the approach could just be cognitive behavioral therapy, biofeedback, or working on lifestyle changes.

Host: I'm glad you brought up lifestyle changes because that's my next question. Are there any lifestyle changes that people can make to reduce their risk of experiencing headaches or migraines?

Dwayne Brown, DO, PhD: Certainly, and the lifestyle changes are equally important as taking medications, but the common ones that I stress to my patients includes good sleep hygiene. So we always recommend at least eight hours of sleep nightly. Hydration is key. So lots and lots of water. Being active doesn't mean going to the gym, but cardiovascular exercise, maybe 30 minutes for three days a week is important.

Also, eating frequently throughout the day, because hunger is a big trigger for headache conditions. There's certain foods that can also trigger headaches, specifically migraine, including chocolate, for some people, dairy, processed foods with MSG, gluten for some people, too much caffeine, too much alcohol. And then believe it or not, the weather can affect patients.

So biometric pressure changes specifically in migrainers can be a big trigger for their migraine.

Host: Anything else you'd like to add about headaches that we didn't cover or something else we need to be aware of?

Dwayne Brown, DO, PhD: I think the most important message I'd like to bring across is that no two people should be treated the same. That there's several different headache conditions, that history is important. Because often if we don't collect the right history, patients are oftentimes misdiagnosed and undertreated. And, we should offer individualized approach to patients when it comes to management of these conditions.

Host: Dr. Dwayne Brown, some great information to know since most of us get headaches. Thanks so much.

Dwayne Brown, DO, PhD: My pleasure.

Host: For more information, visit capitalneuro.org or call 609-537-7300 to schedule an appointment at Capital Institute for Neurosciences. If you found this podcast helpful, please tell others about it and share it on your social media.

Check out our entire podcast library for other topics of interest to you. Thanks for listening to the Health Headlines podcast series from Capital Health.