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Evo Terra (Host):  I was a fairly rough and tumble kid. I grew up on a farm. I worked in a machine shop and I even did auto repair for many years.  I’m no stranger to hammered thumbs, banged knees and the various cuts, scrapes, bruises and other injuries common amongst those who work not just with their hands but with their whole bodies. But I’m a total wimp when it comes to headaches. The slightest twinge of pain from my head has me running for the medicine cabinet and seeking the sanctuary of a quiet, dark place. That makes me the epitome of sympathetic to those who suffer far greater than I. So, it's opportune that I’m speaking with Dr. Sarita Said-Said, Neurologist and Neuromuscular Medicine Specialist with Palouse Neurology, because I have questions.

This is the Health Podcast, the show by Pullman Regional Hospital. I’m Evo Terra. Before we begin, Dr. Said-Said, can you give us sort of headaches 101 and perhaps share some relevant demographic information we might need to be aware of?

Sarita Said-Said, MD (Guest):  So, headaches or pain anywhere in the head are amongst the most common neurological symptoms and reasons for consultation in a neurology practice. And according to the World Health Organization, almost half of the adult population has experienced a headache at least once in the last year. And according to the Global Burden of Disease Studied that was updated 2013; migraine was found to be the sixth highest cause worldwide of years lost due to disability and headaches disorders in general were third.

Host:  Wow, that’s a lot more than I was thinking. Can you talk about some common causes of headaches?

Dr. Said-Said:  We currently do not fully understand what causes most headaches, but we know that there are structures in the head that can signal pain such as the blood vessels in the head and neck, the tissues surrounding the brain such as the meninges and some of the nerves originating from the brain. Also some other structures such as the sinuses, teeth, muscles, joints and the skull. But the brain itself and the skull are not responsible for it.

Host:  So, we know what’s not responsible but what is responsible is still a little bit of a mystery. Ah modern science. Talk to me about the types of headaches that we have.

Dr. Said-Said:  There are over 300 types of headaches. And what we do – we classify them in mainly two groups, the primary and the secondary types of headaches. Primary headaches are those that are not caused by any underlying disease or structural abnormalities and these are benign. On the other hand, the secondary types of headaches those are new headaches that are occurring along with another disorder or disease that is known to be capable of causing these headaches. So, there is an underlying cause which can be an infection, head injuries, bleeds, tumors, er cetera.

And so, there are different headaches in these groups. Primary and secondary.

Host:  So, clearly, with 300 across those two groups, some are much more severe than others. I want to focus in for a moment on one type of headache which I’m sure most of our audience has heard before and those are migraines. What makes a migraine different from some other type of a headache?

Dr. Said-Said:  So, as I mentioned before, there are these primary headaches and secondary headaches. And I want to dwell a little bit more on different headaches that are in these groups so then I can compare them. So, we have the primary headaches, those that don’t have an underlying cause and are benign; migraine headaches are one of them and along with migraines there are other types of headaches such as tension type of headaches that are also one of the most common headaches that are a reason of consult. There are the trigeminal autonomic cephalgia’s that includes the cluster headaches. Those trigeminal neuralgias that people experience. Other headaches like the ice cream headache, the benign caused headaches and other headaches.

They have in common one thing which is there is no underlying disease. And just to expand on the other type of headaches, these are headaches that have an underlying cause such as could be a vascular disorder, could be an infection, could be maybe a trauma to the head among others. So, migraine headaches are classified according to certain criteria and while we have the common belief in a population that all severe headaches are migraines; that’s not true. While migraines are very severe, there are certain features that have to be fulfilled.

Migraines are two to three times more common in women than men. It’s important to bring this up as I could see this in my consultations, most of the time my patients that are complaining of migraines are women. And we believe the migraines are caused by changes in the blood flow of the brain and also nerve cell activity. Usually, a migraine headache has to have the presence of at least two of the following characteristics. And these are; has to be throbbing in quality, unilateral, moderate to severe in intensity and or worse with physical activity. And they have to be present four to 72 hours and they can present nausea and or vomiting or both, sensitivity to light and sound.

So, migraines can present with auras which are symptoms that can present before or with the headache. And these are symptoms that people can experience in their vision, sensory abnormalities, speech, language, weakness, and other symptoms that are better characterized when they are evaluated by their physicians.

Host:  So, a lot happening for migraines. We talk about migraines as one thing, but it sounds like they are multiple, different things with that. On a similar line, let’s talk about some warning signs of headaches. How do I know if in fact the headache that I have is something that should cause me to go seek out medical attention?

Dr. Said-Said:  This is a very important point to make in headaches. Not only for the patients but also for primary care physicians who are most of the time the first person that patients encounter or seek help for these complaints. There are a few that are well known to be red flags. One of them is a first new headache that develops after age 50. This is usually a complaint that requires imaging and further evaluation. Also a major pattern change in a pre-existing headache and unusually severe headache or a headache that gets steadily worse, complaints of the worst headache of your life. This is a buzz word in the medical community that many times can warn about the presence of an intracranial bleed. Headaches also that increase with coughing or movement. Headaches that can come up abruptly especially when they wake you up from your sleep. If the headache worsens when you are laying flat, if headaches are accompanied by systemic symptoms such as fever, stiff neck, if they cause confusion or memory problems or any other symptom similar to those can be seen in strokes. Also that’s something that has to trigger immediate medical attention.

There are a few other warning signs that I like to prepare my patients about. These are headaches that occur with a very painful red eye or pain that comes with tenderness near the temples, headaches that happen after trauma and in patients that have cancer, or they have a compromised immune system. These are headaches that also have to be evaluated further.

Host:  Fascinating. What about treatment options? What can we do for headaches?

Dr. Said-Said:  So, the management of headaches is a holistic one. The first thing that we have to do is try to find the cause. As I mentioned before, some of these headaches have a cause and some of them don’t, like the primary headaches. So, if there is an underlying cause, that cause has to be treated. Once that is done or that has been ruled out, testing is obtained or not. Also it’s important to determine if there are triggers that can reproduce the headache. In this case, we recommend avoiding such triggers.

In the case of migraine headaches, there can be triggers such as bright lights, smells, sounds, and also there are known foods such as cured meats, aged cheeses, alcohol, wine, MSG, among other things that can trigger headaches and very well known and many times when patients stop eating one of these foods; they can notice an improvement in their migraine headaches such as maybe having them less frequent or being less intense.

Another point that I like to address with my patients are lifestyle changes. One of them is stress. Stress is a very well known trigger of not only migraine headaches but a lot of other types of headaches. Meditation and relaxation techniques are very useful. Also physical activity and adequate hydration. Our heads, necks and body in general don’t like to be dehydrated. Adequate postures. Some headaches can be produced or reproduced from muscle tension in the area of the neck for example which is one of the most common complaints that I get. And in the case of migraines, it is important to avoid fasting. Snacking is really good for the brain. And also avoid the processed foods as I mentioned before.

So, aside from the triggers, and the lifestyle changes there are also some supplements that have been found to be very helpful in preventing migraine attacks and these are magnesium citrate, vitamin B2 also known as riboflavin and coenzyme Q10. There is literature that has shown that these supplements may bring some benefit in treatment. And a lot of times patients prefer to try this because they want to avoid taking a medication and they feel more comfortable taking a supplement.

Weight management is very important and lastly, medications that can vary. There are many types of medications with different mechanisms of actions that have different indications depending on the type of headache.

Host:  Well let’s wrap up with the conversation about those medications Doctor. What do you recommend and what are the side effects possibly of long-term use?

Dr. Said-Said:  So, for the most common headache types seen in a neurology practice which are the tension type of headache and the migraine headaches; there are different medications that are commonly used. And there are different approaches. So, on one side we have the treatments used to abort the headaches. They usually are treated with NSAIDs or nonsteroidal anti-inflammatory drugs which are ibuprofen, naproxen, medications that you can find over-the-counter. Also Tylenol or acetaminophen and caffeine acetaminophen combinations. We also use anti-nausea medications. For the most part, at the beginning I like to start with an anti-nausea medication along with either an NSAID or acetaminophen. In some patients, especially those with migraines; there are other types of medications that include the triptans and ergotamine among other medications to help break the headache when it comes on.

I like to make a point that the use of opioid is not recommended in the treatment of headaches and there is concern that opioids not only can change the perception of pain, but it could also cause rebound headaches. So I tend to recommend away from this option. So, when patients experience six to eight headache days in a month or they have a severe subtypes of headaches or they have three or more disabling headaches a month; at that point, I consider starting a prophylactic or preventative medication. There is an indication for these medications that are to be taken everyday and prevent headaches in the long run.

For the migraine headaches, since we are being talking more about these type of headaches and it’s the most common cause of consultation in the headache realm; there are some medications. The most commonly prescribed are topiramate, beta blockers, there are also tricyclic antidepressants such as amitriptyline which can also treat tension type of headaches and they are very popular. These are usually well tolerated. There are other medications that include [00:13:53] antiepileptics? There are other antidepressants and medications that are used also for nerve type of pain.

Of course the best way to determine which medication is best for anybody is to consult with their physician and there is a long list of treatments that can be tailored best on the side effect profile and also coexisting medical conditions. And of course, not all patients respond or react to medications the same way. With topiramate some of the most common side effects include weight loss, and kidney stones and also some foggy thinking. Most of the time, the foggy thinking results after taking the medication for a few days or a week or so. but for some patients, it becomes a problem and if not tolerated it is indicted to switch to an alternative medication.

For the beta blockers, patients have to monitor for lightheadedness, and since it can affect their blood pressure and their heart rate, they have to be cautious about it but usually it can be very well tolerated and again, everybody responds differently. With the amitriptyline, it can cause sleepiness and some people can gain weight so these are things to watch for.

There is a new class of medication that are the CGRP inhibitors. CGRP stands for calcitonin gene-related peptide and this peptide is involved in pain transmission and the levels increase during a migraine attack. It is also thought that it plays a causative role in the production of the migraine attack. So these medications inhibit the peptide and current literature has shown really good results with a really good side effect profile. Seem to be very well tolerated. But usually for me to recommend this medications, I like to try at least topiramate and beta blockers and if they fail it then I go ahead and try these that are newer.

One important thing is to always avoid polypharmacy which is having many medications at the same time and I try to optimize one medication before I decide to discontinue or to stop it. I would never stop a medication before about three months of treatment before I can consider that a patient has failed it. and medication overuse headaches is also a concern, so I try to screen all of my medications before I prescribe anything just to not do harm.

And I just wanted to lastly mention that there are some nonpharmacological treatments available. These are new technologies that include the transcutaneous supraorbital nerve stimulator and the single post transcranial magnetic stimulation that a lot of times while they can be expensive, patients that have had problems with tolerating medications or that they have required to take more than one find extra relief by using these nonmedication forms of treatment.

Host:  Well Doctor, thank you very much for the detailed conversation on what is clearly a complex problem. That’s Dr. Sarita Said-Said, a Neurologist and Neuromuscular Medicine Specialist with Palouse Neurology who also provides services at Pullman Regional Hospital, Gritman Medical Center and Whitman Hospital and Medical Center. You can get more information about those services at www.palousespecialty.com. Thank you for listening to this episode of the Health Podcast, the show by Pullman Regional Hospital. I am Evo Terra. If you found this episode helpful, please share it on your social channels. And be sure to check our entire library of past episodes which you can find at www.pullmanregional.org.