Dr Rania Habib (Host): Headaches, a medical condition that every person will likely experience at least one time in their lifetime. For most, simple medications like acetaminophen or an anti-inflammatory will alleviate that pain. But what happens to those patients who have unrelenting headaches? Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm your host, Dr. Rania Habib.

My guest today is Dr. Andrea Synowiec, the System Vice Chair for the Department of Neurology and an Associate Professor of Neurology for Drexel University. She is here to share her knowledge on headaches. Welcome, Dr. Synowiec, and thank you so much for joining us today.

Dr Andrea Synowiec: Hi. Thanks for having me. Nice to be here.

Host: When a patient is referred to you with a chief complaint of headaches, what is involved in your workup?

Dr Andrea Synowiec: Well, that's a great place to start, is to talk about the patient coming in who maybe has had no previous medical interventions or evaluations for headache. And we see very, very many patients in this condition. So, the first place to start is almost always a detailed history. And I always like to tell our residents that the majority of the important information about the entire patient encounter when it comes to headache is really the history, you could say, even more than the examination.

So, in addition to the history of how the pain began and the quality of the pain and all of the additional historical details that we're so familiar with getting, the examination is also quite important. So, there's a couple components to an examination that would be pertinent to migraine or to headache in general. One part of the exam that's real important is the musculoskeletal exam and looking at things like the temporomandibular joint, things pertaining to the movement of the head and the neck, muscle tension and tone, any asymmetries that we find. And then, of course, the neurologic examination is always important, typically focused on the cranial nerves. Although a good general neurologic examination is quite important to rule out a secondary headache or the headache that might be coming from some other problem.

Host: So in addition to obtaining signs and symptoms and doing your full physical exam, are there any initial tests that you will typically order for these headache patients?

Dr Andrea Synowiec: This is something that is discussed quite a bit, particularly as it pertains to neurologic imaging. Many patients will benefit from and need some sort of additional neurologic testing, which is typically a CT scan of the head or an MRI of the brain, looking for some sort of a mass lesion or something inflammatory or infiltrative. The key is that the majority of patients who come to be evaluated for headache just have headache, and it's not the symptom of another condition, it's what we call a primary headache disorder. So, trying to find the person who would benefit from imaging can sometimes feel a little bit like searching for a needle in a haystack.

We do have an acronym that can be really helpful to remember the kind of patient that you might consider imaging on. And it's one of these acronyms that I think has expanded with time. So, the acronym is SSNOOPP, but there's a bunch of S's and a bunch of P's. So if you think about you're snooping for the red flags that might help you understand or remember who needs some sort of brain imaging.

The S is for systemic signs. So, that means the patient might have fevers or weight loss or they have an immunodeficiency, or there's something about that patient that makes you wonder if this headache could be part of a larger process. N is for the neuro exam. So if there's a neuro exam that's abnormal or the patient has focal neurologic signs, that patient will often benefit from imaging. O's are the onset of pain. So if it's a sudden abrupt, what we think of as a thunderclap headache, that patient often needs imaging. Or older patients, so anybody who's not had a long-standing history of headaches and now all of a sudden is in their 50s, 60s, 70s, and has the first headache of their life. That P, we really rely on quite a bit. There's a bunch of P's that might make you consider imaging a patient. Papilledema is certainly one that can be a sign of raised intracranial pressure. Pregnancy puts patients at risk for things like cerebral venous sinus thrombosis. Or if the headache is positional or precipitated by valsalva, these are all indications that a patient may need a brain scan.

Host: I love that acronym, SSNOOPPing. I'm going to use that in my future headache patients. What is the most common misdiagnosis that you see in your clinic?

Dr Andrea Synowiec: So most commonly, patients who will come to see a physician with the chief complaint of headache have migraine. And this is one of those diagnoses kind of interestingly that patients often get right on their own. So, most patients who come in and they say, "Hey, Dr. Synowiec, I think that I have migraine." Most of the time they're right, which is good. It kind of jumps from needing to explain to them what the diagnosis is because it's quite a common condition. Interestingly though, I see a lot of patients diagnosed with tension-type headache that actually have migraines. And I'd say in my personal clinic, but also statistically, that's a common misdiagnosis. So, there was an interesting study, it's from several years ago, looking at patients who presented to primary care. And in this group, they present to primary care, their chief complaint is headache. And in that group, 87% of those patients presented and met criteria, full criteria for migraine. And of the remaining small percentage, that 13% left over that didn't meet full criteria for migraine, 11% of the total group had probable migraine, which means there's only just a couple percentage of people who come in with a chief complaint of headache that don't end up having migraine as the appropriate diagnosis.

Host: That is some incredible numbers. So, what would you say why in the primary care physician office are we misdiagnosing migraines?

Dr Andrea Synowiec: So, the diagnostic criteria, often are things we don't think about, again, because migraine is so common. It's the kind of thing that we all as physicians are kind of, you know, of the mindset, like, "Oh, it's a migraine," we all know what a migraine looks like. But when you really look at the diagnostic criteria, there are four major criteria and two minor criteria, and the patient has to have two of the four major criteria and one of the minor.

So when we look at the four major criteria, that headache should be throbbing, that's number one. Unilateral, number two. Number three is worsened by routine activity. And number four is at least moderate in severity. And so when we think about the throbbing unilateral headache, it's very easy to identify that patient as having two of those four criteria. But the patients that get missed are the patients who come in with a moderate headache that gets worse with exertion. So, that brings us to the two minor criteria, which are nausea or vomiting, that's one, and then photophonophobia, so light or sound sensitivity is the other. So again, easy to pick out that patient who's got a throbbing unilateral headache, and that patient is nauseated. But that moderate to severe steady headache, that's holocranial, that gets worse with routine activity and they get a little light sensitive, that patient actually meets all the criteria for migraine too. So, it's just important to know that not everybody looks exactly the same.

Host: Absolutely. They're never exactly the way the textbook is, right?

Dr Andrea Synowiec: Man, it would be much easier though.

Host: It certainly would if they would. Could you describe your migraine treatment algorithm?

Dr Andrea Synowiec: We do our best to be patient-focused and patient-driven. I think probably everyone in every field tries to focus on what's important to the patient. In migraine care, that's even more important because migraines won't kill people. You know, a migraine can disable someone pretty easily, but it's not like the patient has an infection. And if they don't do what I say, they're going to be in the hospital in a couple days here. So, we do try to let the patient guide management and most patients who come in are most focused on abortive or acute medication. Sometimes we call that attack medication. So, you can think about that as the patient gets a headache, they need something to take, and they need that thing, whatever it is, whether it's a pill or a device or a treatment plan to be safe, effective, well tolerated and reliable. And we spend a lot of time talking about that because it's really important to patients.

However, there is another component to treatment that sometimes gets missed, and this is preventive therapy. Specifically, when we talk about migraine, the American Headache Society in 2021 put forth a consensus statement helping physicians and other healthcare providers understand who may benefit from migraine prevention. And when we look at migraine overall, not everybody needs prevention. I'll say everybody needs attack therapy of some form, but there are probably more patients who need prevention than typically get offered prevention.

To be precise, as far as the guidelines go, we should start thinking about headache prevention for people who have migraines at least two times a month. Now, two seems like a small number, and it is a small number, unless there is pretty severe disability. So, I think about, for instance, some of my patients, I take care of a couple of patients who are surgeons, and if you have a migraine with a visual aura and you can't see for about 30 minutes unpredictably twice a month, that's quite an occupational hazard if you are in the middle of an operating case and you're now kind of stuck and everybody's waiting for you. So, we really decide about preventive migraine treatment based on the severity of the attacks and a lot of very personal factors that are individualized to the patient.

Host: Could you describe some of those preventive measures?

Dr Andrea Synowiec: We have a wide array of options, specifically focused on migraine prevention that we can use. I think one of the interesting things about neurologic disorders is that the brain is the generator of this disorder. So, certain types of personalities sometimes will go along with certain types of neurologic disorders. And I find just so many patients with migraine, they really have this generalized dislike for any sort of pharmacologic treatment, which it makes sense, right? Like, who wants to take drugs? That's just not probably on anybody's list of things they really wanted to have to talk about today, you know, in their lives. But there are some disorders, I think, where there's not a whole lot of things you can do, aside from give a pharmacologic treatment. And in migraine and in tension headache and a lot of different types of pain disorders, but specifically headache disorders, man, there's great evidence for some things that are very natural, that are really well tolerated. Specifically, we like to start with vitamins, so from an evidence standpoint, there are good randomized controlled trials for magnesium; for riboflavin, which is vitamin B2; for CoQ10, and also for a supplement called butterbur. And I'll just hang a little asterisk on butterbur because there is some toxicity potential with certain types of Butterbur, so we have to be careful with that one. But for patients who don't want to be on a medication and they're willing to use these natural supplements and come in for monitoring, we can see sometimes some really great success.

Host: That's fantastic. Now, we all have had those headaches. And, you know, being a surgeon, it is terrifying when you get one and you just can't work. Describe a little bit about the most common attack medications that you prescribe that are very effective that, you know, we may have to take as a last resort when we're not using those preventive measures.

Dr Andrea Synowiec: Well, I'll jump to the newest ones. We have some really exciting things going on in migraine care right now. So, there was a new class of drugs that just came out in 2018, 2019, focused on a neuropeptide called CGRP. There are other migraine-specific drugs and we'll talk about those in a minute, but I want to draw attention to this one because a lot of physicians have migraine and a lot of surgeons have migraine. And so, there has been this sense for many people that they've tried everything out there. And the last thing that they tried to try to get a headache to go away, it either didn't work or they just felt so much worse than even the headache was going to make them feel that they've taken matters into their own hands and you just sort of muddle through. And with these newest medications, sometimes we find someone who's never responded to an attack therapy or an acute medication for migraine, and now it's like the light bulb goes on and you have a medication and it just works.

So, those newest medications are the gepants, that's G-E-P-A-N-T. They're CGRP-focused agents, and rimegepant, atogepant. There's a new one that just came out called zavegepant and there's one ubrogepant. So now, there's four gepants, and these are some of the newest medications that we've been using. When we look historically, though, the triptans, which came out in the 1990s, have been the mainstay of migraine therapy for a long time. And so, those are migraine-specific agents focused on serotonin receptors, and those medications for some people have been just a lifeline to migraine attack therapy.

Host: That is fantastic. And so, what makes the gepant group of medications different from the triptans in terms of effectiveness?

Dr Andrea Synowiec: I wouldn't say they're all that different in terms of effectiveness if you look at groups of people. So in the studies, the numbers aren't all that different if you compare acute medication study to acute medication study. But I think our brains are all so unique and It just seems to be true that with any attack medicine, you're going to have a group of people that do great on it and a group of people where it just really does very little for them. And you know, it's interesting with migraine, there's probably a lot of genes behind it. It's a messy bag of maybe a bunch of little disorders that we'll understand more about as time goes on. And so, it's just a totally new target. So, some patients who didn't do well on triptans and tried all of them in the '90s and into the 2000s now try a gepant and it works.

I think the other thing to note is that the side effect profile is pretty different. So, the triptans, some people do great, other people really feel kind of bad. They get allodynia, they get kind of dizzy and nauseated, and the gepants are just pretty classically well tolerated. There's a little bit of nausea for some people with them. But side effect-wise, they're quite different when we look at historically what we've used.

Host: Some cases of headache are straightforward. Others are more challenging. What factors contribute to a patient who may be more challenging or even refractory to treatment?

Dr Andrea Synowiec: Well, chronic migraine patients are more challenging. They have lots of headache days. By definition, at least 15 headache days a month. And so for those patients, it can be quite hard to treat all of the attacks without overusing analgesics. Other factors that can contribute to refractory patients, long list of medication failures. Sometimes it can seem like there's no other options or patients with a poor understanding of their diagnosis or unrealistic treatment expectations. The final group I'd mention are patients who have overlapping additional comorbidities or other overlapping conditions. So, things like musculoskeletal disorders, psychiatric disorders, sleep disorders, autoimmune conditions or concussion, those sorts of things can amplify and sometimes really change an underlying headache disorder, making it hard to treat.

Host: Now as a primary care physician, if we have tried everything we can think of, and the patient still has headaches all the time, what advice do you have for us as the headache expert?

Dr Andrea Synowiec: There are two pearls I can offer. One would be to ask about acute medication use. Patients who have a headache disorder will have episodes of pain and often take medication for them, and sometimes that's medication that's provided. When that occurs, if it's prescribed, we can look at the quantity prescribed and we know how much the patient may have available. There is a lot of over-the-counter medication that patients may find helpful, or maybe not super helpful, but will at least mitigate some symptoms. And it's very, very important that we ask about this.

There is a specific diagnosis called medication overuse headache, that is just remarkably underdiagnosed. It occurs in about 0.5% to 2.5% of the general population. That's not just of people who have headaches, but like the general population of the US. So, it's a lot of people who overuse analgesics. And what that'll do is basically take a headache disorder that the patient maybe had genetically and was doing okay with and is managing just fine and it just amplifies it. And so probably, the commonest thing we see this with is over-the-counter combination analgesics, like Excedrin would be one that most people know the brand name of. And unfortunately, it just can kind of get this ball rolling where the patient gets stuck on Excedrin two, three tabs a couple times a day. If you don't identify that and eliminate that analgesic overuse, it can be very difficult to get the headaches under control.

So, the other thing to consider asking a patient is about lifestyle practices. These are things that we often don't elicit from patients because it takes time to talk these things through, and we all have limited time in an office visit. However, if a patient is not hydrating, if they're not sleeping well, if they can't manage stress, and they've got a lot of just lifestyle factors going on that are limiting their ability to be able to find some downtime, all of these things heighten nervous system, reactiveness. So, I explain this to patients, like we want to be reactive. We want our nervous systems to respond to the environment. But when our nervous systems are really amped up and there's not a lot of sleep, there's a lot of caffeine, there's a lot of stress, they're much more reactive to things that may trigger headaches. So, we need to ask about those things and sometimes provide empathy, support, just basic ideas about how they can get things under control. Other times they may need something like the help of a therapist or a behavioral health expert to give them some ideas about how they can manage their lifestyle.

Host: Patients with chronic pain are often frustrated, and they can experience burnout, as you alluded to, but so can the healthcare provider. Treatment is a team effort. How can the patient and the healthcare provider take care of themselves?

Dr Andrea Synowiec: You know, I love thinking about ways that we can care for ourselves as physicians and clinicians, even as we care for our patients, because really we can only provide the care that's as good as we are providing ourselves. There's so many different ways that patients who have pain get burned out. And sometimes when a new patient comes in, we'll start there and just say, "Really, what is your goal?" Is the goal to find a new treatment? Is the goal to try to relieve the pain a little bit? Is the goal to get pain-free days? Or is your goal just to have me here just in case you get into trouble and things get beyond a pain level that you can manage on your own? So, If we have not elicited the patient's goals, then that misalignment where I think I need to try to make this pain go away and the patient perhaps knows the pain is not going to go away and just wants somebody in their corner, that's going to lead to me inappropriately prescribing and the patient feeling like I'm throwing medications at them that they don't need. So that discussion about goals, I think is key. And it's a good place to start so that everybody starts out on the same page.

With patients, the patient themselves may get sick of trying new things. So, it's a new copay, it's a titration schedule, it's side effects that they may not be willing to navigate through. So, I also like to ask patients where they are in their journey with managing this chronic neurologic disorder. If they're not ready to try a new medication, even though it happened to be their appointment time and they showed up for their appointment, that's fine. It may be the right time at their next visit, or they may just kind of want to hold off. And then, there are other patients who, you know, every time they really need to be moving forward in order to feel like they're proactively managing a difficult situation. So again, making sure the goals are aligned, I think, is important.

The other thing, just looking at physicians and clinicians and how we carry the burden of these chronic disorders with our patients. It's important to also remember that the patient is the one that has the disorder. It's a classic saying, but the patient has the disease and we are there to empathize and support and relieve pain, maybe cure, but sometimes just comfort. And when we remember that we do what we can, we can't do everything and there are going to be people that we can't fix and let ourselves off the hook for that, it can bring that joy back into that patient encounter or interaction. And when we make ourselves responsible for things that we can't control, I think that's where we really can get in trouble with burnout.

Host: Absolutely. And I think one of the key take-home points I took from that is that as a physician, we have to know our limits as well. So if we're treating a patient with chronic pain or chronic headache syndrome or migraine, there may be a point where we have exhausted the treatment options that we feel comfortable with. And in that case, if we wanted to refer a patient to your clinic for evaluation and treatment, how would we do that?

Dr Andrea Synowiec: Thanks for asking. We love to see patients with all types of headache disorders. The easiest way would be to have the patient call 412-DOCTORS, which is the phone number. It's the main intake line and they will get you where you need to be from there.

Host: Your vast knowledge on headaches and passion for treating these patients is evident. Are there any key knowledge take-home points you want to leave with our audience?

Dr Andrea Synowiec: I think remembering that most patients with the chief complaint of headache will ultimately have migraine is very important so that we get the right diagnosis and get started down the right treatment pathway. I also think it's important to remember that not everyone needs imaging and there are ways that we can identify those who may need some imaging to make sure we're not missing some secondary headache process. The third thing would be to look for overuse of analgesics when patients are not responding to care because that can just really foul things up. And in the end, less medication and less pain is almost, you know, everybody welcomes that scenario.

And then, I'll say that's maybe not a takeaway, but something I do say quite a bit, and I will leave it with you because it always hits well with patients. A lot of times when we meet a patient a first time, we'll say, "I know you don't want to be here. You don't want to take medicine. You don't want to have pain. But here you are and you do have pain. And now, we have to talk about how we want to handle it." And it just reminds everybody in the room that this is not a fun thing for the patient, and they may not be happy with any of the treatment options afforded to them at a visit, but at least you can kind of level set that you're on the same team, you can come up with a strategy together, and you can work on it over time.

Host: Thank you so much for joining me today, Dr. Synowiec. That was fascinating to delve deep into the world of headaches.

Dr Andrea Synowiec: Thank you so much.

Host: Thank you for listening to this edition of AHN MedTalks. To learn more or to refer a patient, please call 844-MD-REFER, that's 844-MD-REFER, or visit ahn.org. I'm your host, Dr. Rania Habib, wishing you well.