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Melanie Cole, MS (Host): Do you get headaches? For some, it's just an annoyance, but for millions, it's a crippling battle that really can disrupt careers, family, and life. And if you've ever been told it's just a headache, you know that's far from the truth. If you're dealing with debilitating migraines or just want to understand why your head is pounding, you're in the right place because we are diving into migraine triggers, treatments, and talking with experts who are dedicated to helping you find lasting relief.

Welcome to the Health Headlines podcast series with the specialists at Capital Health. I'm Melanie Cole. And joining me today is Dr. Andrew Day. He's a neurologist with Capital Health. Dr. Day, thank you so much for being with us today. So, how common are people that get headaches, and what are the different types of headaches that you see every day?

Dr. Andrew Day: Yeah. Thank you so much for having me. Headaches are extremely common. It is probably the number one chief complaint that brings an individual to a neurologist's office. And there are many different headache disorders, ranging from, you know, the ones that we all know, the tension-type headache, where it's a mild kind of headache that you just pop a few Advil and you're good to go. Maybe you didn't get enough sleep that night. Maybe you got a little bit of a caffeine withdrawal to more debilitating diseases like migraine, where people are sort of debilitated by their headaches or even have to miss work, miss family events. There are things like cluster headache, which is another different type of headache disorder. So, I see the broad range of headache disorders that come through my door.

Melanie Cole, MS: Dr. Day, I guess this is probably the million-dollar question. But do we know what causes these mysterious poundings that happen?

Dr. Andrew Day: We have thoughts about things, but we don't have a clear answer. I'll speak to migraine in particular. There's probably a few different things that are going on here. One is genetic component to it. So, it often runs in families, and so you often have a genetic predisposition. And if you look at sort of what are called genome-wide associated studies, GWAS, there are about 20 to 30 genes that seem to be associated with migraine.

 There also appears to be a hormonal component to it as well. And so, it's much more common in women. But that's for migraine. So, something like cluster headache, it's more common in men, 3:1 ratio.

And so, there are a number of risk factors that can contribute to these headache disorders. But what the true cause of migraine, for example, or cluster headache remains a bit of a mystery.

Melanie Cole, MS: Yeah, it really does. Now, you mentioned cluster headaches, you mentioned migraines. What is a migraine, and how is that different from somebody who gets a headache from, as you say, caffeine withdrawal or maybe a little overindulgence the night before?

Dr. Andrew Day: Absolutely. So, a migraine is defined as a moderate to severe headache. it has to meet a number of these qualities. It doesn't have to meet all of them. But the pain is typically throbbing and pounding. It's often unilateral. It should prevent you from going about your day-to-day, right?

So, it can worsen with your day-to-day activity or with physical exertion. It is also associated with sensitivity to light, sensitivity to sound. So, the migraine sufferer will say, "When the headache is severe, I got to be in a dark, quiet room. No one can talk to me." And it also oftentimes is associated with nausea or vomiting.

Melanie Cole, MS: While we think of that and actually what a migraine is, what about triggers? I know we've mentioned a few briefly in passing here, but are there certain things that you can point to, Dr. Day, that you say, "Okay, this is going to trigger" or "It can trigger a debilitating headache"?

Dr. Andrew Day: I think it's always good to think about, like, what the true origin of migraine is and then triggers, right? So, a lot of triggers aren't necessarily the cause of migraine, but it makes you more likely to suffer a migraine. So, the things that I am always counseling my patients on are things like dehydration, missed meals, lack of sleep, also too much sleep, weather changes.

So, a lot of my patients will come in and tell me that, "I could be a weatherman. I can tell you when the storm is coming in." So when that barometric pressure shift drops, that's when that can trigger a migraine. And into the science a bit, but there's release of one of these neurotransmitters that's heavily involved in migraine, it can increase during that barometric shift.

And then, the other big one for many women is menstrual cycle. So, it is the precipitous drop of estrogen, during the menstrual cycle that is often a trigger for patients.

Melanie Cole, MS: So, Doctor, another million-dollar question, when then do we come see a neurologist? When are headaches something that we say, "Okay, logically I'm guessing this isn't a brain tumor, but I better go see somebody about it"?

Dr. Andrew Day: Absolutely. So, I think this is a good place to just talk a second about when I think about headache, how do I differentiate the scary headaches and the headaches that are not necessarily scary, but still need treatment, right? And so, that comes to this idea of primary versus secondary headache disorders.

So, primary headache disorders are headaches. That is the disease in and of itself. So, that's things like migraine, tension headache, cluster headache. There's even things like occipital neuralgia. There's all these different primary headache disorders.

Then, there are secondary headache disorders. Now, secondary headache disorders, there might be something underlying it. And that's when your mind does go to a brain tumor. So, those are things we think about patients who have neurologic symptoms or whether they have an acute onset of headache. Do they have double vision with their headaches? Vision issues just generally. So, that's sort of the starting place.

The answer is no matter what type of headache disorder, if it's debilitating and frequent, you should be checked out by a neurologist to see, you know, first, what's the cause, and then secondly, what can I do about it and so to get my life back, honestly. Because, like you said in your intro, so many of my headache patients have been told, "Well, it's just a headache. I get headaches. Why don't you just take some Tylenol or Advil?" But they don't understand how debilitating headache disorders can really be for a lot of my patients.

Melanie Cole, MS: Well, it really can affect the quality of life. It's like back pain. If you've never had it, you don't understand how truly debilitating it can be, and those headaches can stop you in your tracks. Now, how do you determine what it is? How do you evaluate it? How do you diagnose that this is a simple headache versus maybe, you know, a migraine? And then, we'll talk about some treatment options.

Dr. Andrew Day: Yeah, absolutely. So, that framework that we just talked about with the primary and secondary headache disorders, that's how I walk into a room. And with so much of medicine, it starts with a good history. So, it's really critical I spend time with the patient getting a sense of what their headache history is, and what are the different clinical scenarios in which they come about.

When did these start, right? So, if a headache started when someone was four or five years old, and they're now coming to see me at 35, the chances that this is a secondary headache disorder are quite low, right? So, my mind is already going into a primary headache disorder.

But if someone comes in with what we call the worst headache of life, a thunderclap headache, that raises the red flags quite a bit. And so, I'm going to be pushing more towards imaging and thinking about what kind of testing do I want to order on this patient. After the good clinical history, the next is a neurologic exam.

So, most primary headache disorders will have a normal neurologic exam, and that's very reassuring to patients that I talk to them, you know, "Listen, everything looks normal," right? If there's something like a space-occupying lesion, if there's, God forbid, brain tumor, the neurologic exam is going to show that, right? So, you're going to have weakness on one side. You're going to have persistent numbness on one side, or you're going to have speech issues, all sorts of different things that can come with a sort of a structural lesion that can cause the headache.

And then, it's about thinking about sort of testing. So, there are different imaging modalities. We'll take a look at your brain with an MRI. We might take a look at your blood vessels with an MRA, and just to make sure that there are no structural reasons that could be causing this headache. And if everything comes back negative, then we're reassured that this is a primary headache disorder, and we will talk about treatment and what we do with that next.

Melanie Cole, MS: So then, let's talk about treatment and what we do with that next. The first thing I'd like to ask you, Dr. Day, what do you tell people that are suffering an acute headache? If that migraine comes on, what can they do in that moment? Because I have heard that too many anti-inflammatories or NSAIDs can exacerbate, after a while, headaches. They don't necessarily take care of the problem in some situations. What do you tell people to do?

Dr. Andrew Day: It's critical that you have a headache-specific acute therapy. And so, most patients are dealing with over-the-counters like Tylenol or Excedrin or, Motrin. And you're right, overusing some of those agents, in particular Excedrin, can be very harmful because it can cause something called medication overuse headache, or sort of we colloquially call it rebound headache, right?

So, if you overuse one of these over-the-counters, your nerves kind of come to expect it. And then, you kind of increase your frequency, and then it's hard to differentiate what's the actual migraine and what is your rebound headache. And so, we talk about taking medications that are effective, and taking them early.

So, two of the standard medications that are out there. One are called triptans, and then the other are the newer agents called gepants. So, triptans have been around since the '90s. They work extremely well. You take it at the onset, and it kind of stops the migraine in its tracks. The drawback of triptans is that they can have some side effects. So, some people feel like they cause palpitations, they can feel tired afterwards, and they also should be avoided if you have things like high blood pressure or history of stroke.

The newer agents, these are the gepants, they work extremely well, and the nice thing is they don't have a lot of side effects. So, that's really the starting point, is let me give you something that's going to stop the migraine in its tracks. And you're not going to lose the day in bed.

Melanie Cole, MS: Well, that's a great action plan to have in advance and to know, that this is something that could happen. Now, are there any game-changers? What's going on in your field and in the field of headaches that's really exciting for newer classes of medications that can help with chronic or, you know, you just spoke about the triptans. So, speak a little bit about any of the other options that are out there these days for people that deal with headaches.

Dr. Andrew Day: Yeah. So, it's a very exciting time in the headache world, and it's one of the reasons why I went into headache, is because there are a lot of new medications out there that have kind of transformed how we manage headache patients.

Just to talk briefly, the other aspect of headache care is something called prevention. So, there is a wide spectrum of disease for migraine in particular. And there are some patients who walk into my office who have one migraine a month, and they just need something that'll work in the moment, and that's when we're talking about triptans or these gepants.

The second sort of component of migraine care is preventative care, and those are patients, the American Headache Society put out guidelines that if you're having four migraine days a month, you know, that's one migraine day a week. Migraine is an unpredictable disease. You never know when it's going to happen. It might be during your kid's baseball game, and now you can't go to your kid's baseball game. Or for some of my students, it might be during an exam, and all of a sudden you can't perform to your best of ability because you're suffering from a migraine. And so, that's when you start talking about daily medications, or there are injectables, or there are even procedures that we can do that can really transform a patient's life.

And so, some of the newer things, there has been what we call in the headache world a CGRP revolution. Bear with me a little bit, but CGRP is a calcitonin gene-related peptide. It's a mouthful, but it's a neurotransmitter that's heavily involved in migraine. We found it gets massively released during an attack. And if we block it from working, we can get a really good handle on patient's migraine. And so in the last seven or eight years, there's been this explosion of new medications, about eight to 10 agents that are targeting that neurotransmitter. And so, there are injectables called monoclonal antibodies that block CGRP, and there are those gepants I was speaking about earlier that also block CGRP. And they come in preventative forms and acute therapy forms, and they have really transformed migraine care for many of my patients. Patients who are suffering from 15, 20 headache days a month have gone down to two or three a month. And it's just been really encouraging to see.

Melanie Cole, MS: Wow. It really is an exciting time in your field. And Dr. Day, tell us about some of the benefits of going to a comprehensive headache center like Capital Health for treatment and the multidisciplinary team that helps.

Dr. Andrew Day: Yeah. I think it's critical to get ideal headache care, is to go to a headache center like we have here at Capital Health. Because we spend a good amount of time getting to know your history, and really try to tailor the right, treatment modalities for you. And so, I think, because of all these new advances in the headache world, it really is good to go to someone who has been trained in headache medicine, right? So, I completed a fellowship in headache medicine for a year after my training and residency to really familiarize myself with the subtleties and challenges of headache care.

And so, I think, I am well-versed with all of these new treatment options, well-versed in different injections that we do. So, we do Botox for migraine. We can do nerve blocks where we sort of inject local numbing medication into the different nerves that are involved in migraine. This multidisciplinary approach can really revolutionize someone's care.

And I can't say enough about how debilitating migraine can be, right? It's the second leading cause of disability in the country. I have patients who have had to stop working because of how debilitating their migraine is. And, unfortunately, there's a lot of stigma with migraine. And so, a lot of patients will get brushed off by different providers being like, "Oh, it's just a headache. Here, take some Advil, take some Tylenol, and you'll be fine." Not understanding that, you know, this patient has 20 migraine days in a month.

And so, coming to a headache center where we understand the disease, where we really can tailor your treatment, can really just be a game-changer and sort of give patients their life back. And that's really my goal.

Melanie Cole, MS: Well, that was beautifully said. And I'd love to give you a chance for a final thought here. Best advice, Dr. Day, for people who suffer from headaches, whether it's lifestyle changes that can reduce some of those triggers or prevention. Give us your best advice here.

Dr. Andrew Day: There are definitely a number of things that you can do to help with your headaches. The common sense things that we are all told that we kind of all wish we were better at, are even more important for migraine sufferers. So, making sure you have a regular sleep schedule, getting enough sleep each day, making sure you're staying hydrated throughout the day, making sure you are eating throughout the day, not missing meals, not skipping that breakfast as you run out the door. And also, exercise. Exercise is extremely important for your brain health.

I don't necessarily think there is a strict migraine diet that will cure migraine, but I just counsel my patients to eat well, eat whole foods, avoid the ultraprocessed foods, that could be bad for your overall health, bad for your brain health, and bad for your migraine.

And I would say the other thing is to seek out care. Like I said, there is a lot of stigma with migraine. There is a lot of hesitancy even on patients' parts to come to a neurologist. I have had patients who are in their 50s who say, "I just thought it was normal to live with headaches all the time." And then, we get them on treatment and they're like, "Oh my gosh, why didn't I do this sooner?"

I would encourage patients to seek out neurologic care, especially if you're having multiple debilitating headache days a month. You know, that is not normal, and there are a lot of great treatment options with minimal side effects that can really transform your life.

Melanie Cole, MS: Thank you so much, Dr. Day, for joining us today and sharing your incredible expertise. That was just an awesome episode and a great discussion. Such great information. Thank you again. And for more information, you can visit capitalneuro.org. We'd like to invite our audience to download, subscribe, rate, and review Health Headlines on Apple Podcasts, Spotify, iHeart, and Pandora.

Thank you so much for joining us on this episode of the Health Headlines podcast series with the specialists at Capital Health. I'm Melanie Cole.