Prakash Chandran: To some, migraines are no big deal, an occasional nuisance brought on by a lack of sleep, dehydration or stress. And sometimes you can take Tylenol to get some rest and get back on top of the world the next day. But for others, migraines can become a debilitating and chronic cause of pain, and finding a remedy might not be so simple.

Host: We're going to talk about it today with Victoria Steinkoenig. She's a neurology advanced practice registered nurse at Carle BroMenn Medical Center.

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Host: This is Expert Insights with the Carle Foundation Hospital. My name is Prakash Chandran. So Victoria, thank you so much for joining us today. I truly appreciate your time. I wanted to get started with the basics. What exactly are migraines and how are they different from regular headaches?

Victoria Steinkoenig: Yes. Thank you, Prakash, for having me. Headaches are considered one of the most common types of pain and one of the most frequent causes of presentations to clinics and even hospitals. And it really has the effect on people where it really can decrease their quality of life. So, we take headaches very seriously. There are over 150 different types of headaches. So really to explain to you what a migraine is, I'd like to take a step back and go over how we come up with the diagnosis of migraine. There's so many different types of headaches, over 150 types. And basically what we do is we divide those two types of headaches into two categories, a primary headache versus a secondary headache.

And as clinicians, it is our job to say, "Why is this patient having a headache?" And so, the first and foremost is we want to know are we dealing with a primary headache or a secondary headache? Now, a primary headache is a clinical diagnosis, meaning it isn't caused by any different medical conditions. It's a primary headache. It's the primary problem. Secondary headache is a symptom of another health issue. So us in the neurology world, we're trying to figure out what's causing the headache and making sure we're not masking anything that could be going on in the body.

And so when you look at a headache, about 90% of headaches fall under three categories. And typically, those are migraine headaches, tension headaches and cluster headaches. So out of those three, we can discuss migraines specifically because this is the most prevalent that we're seeing and what a lot of people struggle with on a daily basis. So, migraine is not just a bad headache, it's actually a disabling neurological disease. And there's many different symptoms and different treatment approaches based on how the patient presents and what kinds of problems they're having.

So typically with a migraine, the pain could be moderate to severe, often intense. Some people say that they have headaches on one side of the head or both. But typically, it's going to be on one side. It can be in the front, in the back. And some patients can get a headache behind their eyes, even their cheeks. The type of pain that migraines usually present with is a throbbing, pounding, pulsating sensation and usually will get worse with physical activity or any movement. And a lot of people do associate with their migraines, they have nausea or even to the point where they vomit. And they also may be sensitive to light and sound.

Host: Wow. So, let me make sure that I understand this. You were basically saying there are primary and secondary causes of headaches and like there are, I guess, three different types of headaches. There's the migraine, tension and cluster. And for a migraine, like just for someone to tell the difference between if they're just having a normal headache versus a migraine, you're generally saying it's more severe. There's like throbbing or pulsating. And obviously, there's levels of intensity. Sometimes it can actually cause nausea and vomiting. Is that correct?

Guest: That is correct. And so, there is many different types of primary headaches, but about 90% do fall under that migraine, tension and cluster. And, yes, just exactly what you said, that migraine is going to give you that usually unilateral, severe, throbbing pain that's usually associated with nausea, vomiting, light and sound sensitivity. Exactly.

Host: Okay. And something you said that I've actually never heard before is that a migraine is a neurological disease. For some reason, I've always thought that it was caused by something else or triggered by something else. Can you explain in a little bit more detail about what a neurological disease is, how it is triggered, specifically as it relates to migraines and the most common cause for it?

Guest: Absolutely. So when someone presents with a headache, this can be disabling to them. And once we have ruled out that there is nothing again causing it, like an illness, a secondary headache that we can correct, this migraine or this headache that you're having, it can be debilitating. And it is a neurological disease because we make that diagnosis based on the clinical history that the patient gives us and a close review of imaging. And that's why it's very important to a patient suffering from this, that it's never just, "Oh, you have headaches," it can be debilitating. And that's considered a neurological disease that affects everyone differently.

Host: Yeah, absolutely. And I think this is why you're a neurology advanced practice nurse. This is why it's not just as simple as, for example, asking someone about the symptoms. There's a process to, for example, do scans and do a little bit more thorough investigation as to what is going on. Is that correct?

Guest: Exactly. And so when you look at a neurological disease and looking at headaches in general, there is pathophysiology to this in the brain. This isn't just someone has pain in the head. There's actually a process going on in the brain, and that's what we really classify it as a neurological disease. It's oftentimes just pain, they're having pain or they're having headaches all the time. There's actually pathophysiology that's causing this pain in someone's head that they're having.

Host: And when people have it on a consistent basis, let's just talk about like the most common cases that you see, how often are they experiencing a migraine?

Guest: Sure. When someone's having frequent headaches, the first thing that I tell people to do is to work with their doctor or their provider, whoever it is that they're seeing, it could just be their primary care provider, is starting a diary. It's very important to identify if there's any specific triggers. So once you see your primary care provider and they have specifically done neuroimaging, they've looked at some blood work and they're leaning more towards a primary headache that there's not some secondary cause, it's really important to say, "Okay, then what's triggering these headaches or migraines?"

in looking at keeping a diary on a daily basis of when you have the migraine, what was yesterday like? What was the day before like? What was your sleep like? You know, looking at your foods, did you have any red wine, which has been known to trigger a migraine? Did you skip meals? Has there been any weather changes? Looking at your sleep, making sure you're getting adequate sleep. Is your stress under control? There's also hormonal factors, particularly menstruation. Some women see worsening migraines around that time. And then again, just in general, certain foods, it may not just be wine or chocolate, there are some foods that for some people just are triggers for them.

So after you've kept a good diary, it's important to work with your provider on if you've identified any correlation with the triggers. And then once you've identified possibly what's triggering your headache, then we have to work on prevention. And I tell people, you know, it's 2023, people should not be living with debilitating migraines. There's so much out there that people can be doing in working with their providers or their neurologists and working to prevent migraines versus just treat, treat, treat.

Because what we've seen is unfortunately when people are suffering from migraines, they often are taking a lot of over-the-counter medications such as Tylenol, ibuprofen, which are good for an occasional headache. But what we're seeing is if you have these frequency, maybe even a couple, more than two times a week, if you're taking Motrin or Tylenol, you can develop what's called a medication overuse headache. And this really sets patients up for failure in regards to getting control of their headaches because you actually start to get more headaches from a medication overuse headache. And so, what that does is it's actually making the brain more susceptible to central sensitization.

So, basically, what's happening is the pathophysiology of the medication overuse headache, it's really not completely understood, but the headache seems to make the brain become very sensitive when you're constantly administering NSAIDs and Tylenol, which basically can give you a worse headache. And so, we often see this kind of revolving door that just we can't get a hold of the headaches. So, what we often tell patients, if you're having two or more headaches a week, it's really important to work with your provider again on what do we think is causing this and then start to work on prevention strategies to avoid getting a headache.

Host: Yeah, absolutely. And I think another piece of this is that oftentimes people will just kind of continually use those over-the-counter medications as a fix. Even if it's happening more than twice a week, they'll just continually turn to it rather than picking themselves up and going to their primary care physician. So I guess the question is, over time, let's say someone self-medicates over a long period of time, what are the dangers of that besides the medication overuse headache? What are the dangers of just self-medicating and not seeing someone about this?

Guest: Sure, sure. Well, there are dangers of continuously taking over-the-counter medication because like I said, the headaches will just continue. So, it's really, again, not only keeping a diary of any possible triggers. But also looking at the date of attack, what time did the attack happen, what medicine did you take and working with your provider on, "Okay, is it time to discuss possibly putting their patients on something to prevent migraines?" Historically, it was abortive treatment and that was what we did a lot, was we would get the headache and then treat it. But now I tell people, like I said, in 2023, there's so much out there that you can work with your provider in prevention of these types of headaches, whether it be medication or over-the-counter supplements with vitamins and minerals.

Host: Yeah. So, let's talk about that because one of the things that you mentioned is that people turn so much to treat, treat, treat versus prevention. What does prevention look like and how does working with your primary care or an advanced practice nurse like yourself, like how does that go in terms of setting up a prevention regimen?

Guest: Absolutely. So if we can identify any triggers, obviously, we would refrain from putting yourself in those situations where a trigger may occur. But what's really important is keeping your brain healthy and what does that mean? And we have patients that come in the hospital. And so for example, if someone's recovering from a stroke, they say, "How do I make my brain healthy again? How do I rewire my brain so my neurons are constantly synapsing and all of these things?" Our brain is ever-changing. And the way that we do that is actually hydrating our brain. And making sure we're having adequate water intake. Water is so underutilized. And it's interesting when we see our headache patients and we review how much water intake they have, we run into people that don't drink any water. And considering the human body's made up of about 60% water, it's obvious that the cells in our body depend on water to carry out our essential functions. So in saying this, our brain depends on the consumption of water to perform cognitive functions. And so to put it simply without enough water, our brains can't operate to the best of their ability.

Host: Yeah, that makes a lot of sense. And I read some like ridiculous statistics like 70-80% of Americans are dehydrated in some form just because they're not regimented in the amount of water they're taking in. And that actually has so much to do with a lot of the things that we experience, including migraines. So, it sounds like dehydration is a major culprit for people that have migraines. Is that correct?

Guest: It is a major culprit and often really there's been people that have gone years with headaches and we talk to them about increasing their water intake. And it's amazing to see how much better people feel not only with decreased migraines, also just their cognitive function and feeling not foggy. We get so many complaints of patients saying, "I feel foggy, I have a headache." And that's what we first talk about, is how much water are you drinking and working with your provider to make sure that you're getting things like your thyroid and your vitamin B12 checked. All the things that when patients start to say, "I'm feeling foggy. I'm not as sharp. I sometimes have headaches," and that's where we start, is really digging down on what their daily life is like as well as not skipping meals. It's so important that the body has that constant flow of glucose. And we have patients who don't eat all day, and maybe that's something they do from a religious perspective or just they don't have time to eat. So, we try to work with the patient, what works best for them to make sure that lack of food is not something that's a trigger for them.

Host: Yeah. And also when you establish a baseline of where you currently are in terms of your vitamin and mineral levels, you can do things like take supplements. Like for example, I've heard that you can take things like the omega-3 fish oil supplement and vitamin B12, as you were mentioning. There's all these supplements that you can take that don't require you sitting down for a meal, but that are very good for your brain health. Is that correct?

Guest: Absolutely. And so, I tell my patients it's important to work with your provider in getting vitamin levels checked that you can check just to see where you're at. And it's always important before you start any vitamins and supplements that you review that with your provider. There are a lot of research out there and ongoing research regarding herbal supplementation and prevention of migraines. But again, that's something that I would encourage anyone who would like to seek this as an option to work with your primary care provider or if they refer you to a neurologist.

Host: Okay. Well, this has been a fascinating conversation. I think the thing that I'm taking away here is that migraines are a neurological disease and they don't just take care of themself. Like it's oftentimes a good idea to, first of all, diary when you are having these triggers, so you can not only like be informed yourself, but when you go to see a doctor, they're able to kind of diagnose exactly what you need, whether that be more vitamins and minerals, whether that be more water, they're going to be able to help you. And that medicating yourself over and over can actually cause more headaches, so definitely avoid that. Definitely go in to see one, diary your triggers, and you'll be in a good place, right?

Guest: Absolutely, absolutely. And I do feel that people often are taking ibuprofen and Tylenol and not even thinking about it, but medication overuse headache can just put these patients in this vicious cycle and really not able to ever overcome the headache just because of the overuse.

Host: Victoria, the last question that I wanted to ask that I always like to end with is, you know, you've probably seen thousands of patients that have suffered from migraines, and maybe someone that is listening to this is suffering from chronic migraines. What is one thing that you know to be true that you wish more people knew before they came in to see you?

Victoria Steinkoenig: I love this question because working in the hospital, I see patients come to me as their last resort with severe head pain because they feel like they have exhausted most of their efforts and that's why they're coming to the hospital for their severe head pain. And what I would like people to know is that there is prevention out there. There's so many new medications that our neurogists are prescribing that have been so effective for patients and changing their lives. The fact that they could take a pill to prevent a migraine rather than get the migraine and hoping that it will go away with the abortive treatment. And I want people to know that this isn't something that you have to live with. This is something that it is a neurological condition and it is definitely worth seeing your provider and a possible referral to neurology if needed. And not only to help with the pain, but also make sure that there's nothing more going on, making sure there's not a secondary headache going on, because what if it's a simple fix of a medical condition that was causing the migraine? So again, seeing your provider, making sure that we're dealing with a primary headache and knowing that if you are having more than two to three headaches a week, there are prevention strategies out there, so you don't have to live like that.

Prakash Chandran: Well, Victoria, I think that is the perfect place to end. Thank you so much for your time today.

Victoria Steinkoenig: Thank you very much.

Prakash Chandran: That was Victoria Steinkoenig, a neurology advanced practice registered nurse at Carle BroMenn Medical Center. For more information about connecting with one of our providers, please visit carle.org. That is C-A-R-L-E.org. That wraps this episode of Expert Insights with the Carle Foundation Hospital. My name is Prakash Chandran. Thanks again for listening and stay well.