Maggie McKay (Host): We usually don't give headaches a second thought until we have one and we can't even see straight or think. Joining me is Neurologist and Headache Specialist, Dr. Heather Moury, here at St. Clair Health to discuss how to deal with and maybe even prevent headaches and migraines.

 Welcome to Curating Care, a podcast brought to you by St. Clair Health, expert care from people who care. I'm Maggie McKay. It's great to have you here, Dr. Moury.

Heather Moury, DO, AQH: Thank you for having me.

Host: Could you share a bit about your journey in neurology? What inspired you to specialize in this field?

Heather Moury, DO, AQH: Sure, so neurology has always been interesting to me. I majored in neuroscience in my undergraduate education at the University of Pittsburgh. During medical school, I thought I was going to be a pediatrician. And it really wasn't until I started my rotations that I discovered my true passion was neurology.

I was really loving how taking care of patients is like solving a complex puzzle or a mystery. And I like that we can use our medical knowledge to localize the pathways in the brain that are involved in each of our patients conditions. When I started neurology residency, I already had a strong interest for headache medicine, as I have headaches myself.

I continued my training after residency in a fellowship of clinical neurophysiology, which enhanced my training in EEGs, which we use to diagnose seizure disorders, and EMGs, which we use to diagnose nerve and muscle disorders. But it wasn't too long in my early career as a general neurologist, that I really learned I love treating headache patients.

We have the ability to resolve migraine and headache pain with just medications and non-invasive procedures. And the satisfaction of being able to help people stop suffering from those painful symptoms motivated me even more to continue my training. I ended up starting with the Certificate of Added Qualification in Headache Medicine from the National Headache Foundation.

And later I completed a post master's course in the Advanced Headache Diagnosis and Management at Thomas Jefferson University. So this really validated my level of expertise in headache diagnosis and treatment. And I'm now Board Certified in Neurology, Clinical Neurophysiology, and Headache Medicine.

Host: Wow. That's commitment. What do you find most rewarding about your career?

Heather Moury, DO, AQH: I love that we can really improve a patient's quality of life with just medications and procedures, almost immediately or just even shortly after treatments. Oftentimes, neurologic diseases are chronic and we really can't make much improvement in patients lives with our current medications.

But, headache treatments allow us to resolve pain, improve impairment, almost immediately. And as a migraineur myself, I really understand the severe disabling symptoms and disability. When I was younger, I actually ended up in an emergency room due to a severe migraine. I remember not being able to open my eyes and feeling as if I couldn't even function.

So it was really amazing how quickly everything resolved when they gave me medication. I could see clearly again. I could function normally again. And so I think this really has motivated me to really want to treat migraine, as I understand it myself.

Host: Yeah. Wow. I didn't know it could be so severe that you have to go in and get it treated. But, when it comes to headaches and migraines, about 90 percent of people in the US experience headaches. And at some point 15 percent deal with severe headaches each year. So can you explain the different types of headaches and what distinguishes them from each other?

Heather Moury, DO, AQH: Sure, there's a long list of so many headaches, and I could honestly go on for hours, but the most common type of headache is a tension headache, which is described as a dull pain in the distribution of a band around your head. It's estimated to affect about two in three adults in the U.S. And it's pretty typically mild, but, and responds to over the counter treatment.

But occasionally, it can become a daily headache that requires further medication. We also have, obviously, migraine, which is not just a bad headache, but it consists of pounding or throbbing sensation with moderate to severe pain. Patients experience sensitivity to light, sound, smell, nausea, and even vomit at times.

The head pain can get worse with movement, with any physical activity, and about 25 to 30 percent of patients can have an aura, which often is a warning sign and precedes the pain. It's a sensory disturbance that patient can experience vision changes, speech disturbances, dizziness, numbness, or weakness.

Another group of headache disorders are referred to as trigeminal autonomic cephalgias. These headaches are predominantly one sided with associated autonomic features like redness of the eye, tearing, nasal congestion, and a cluster headache is actually the most painful of all headaches. It's a real severe pain behind one eye. Patients have restlessness, agitation, but luckily over the last decade, further specific medications and devices have been approved to treat this, such as galcanezumab, which is a CGRP monoclonal antibody, and then the non-invasive vagal nerve stimulator has now been out on the market as well. But all of these headaches I just discussed are primary headache disorders.

We also have many secondary headache disorders, which is when a headache is caused by a certain condition. So, for example, headaches can be caused by high blood pressure, infections of the head and neck, trauma or abnormalities of the vessels of the brain. So our job is really to distinguish if your headache could be caused by one of these concerning conditions.

And we often will recommend lab work, images of the brain, lumbar punctures, or even eye exams to help us rule those concerning conditions out.

Host: What are some common misconceptions about headaches that you encounter in your practice?

Heather Moury, DO, AQH: Most patients assume they have sinus headache when they have a runny nose, watery eyes, and a headache. In actuality, many studies have shown that these symptoms are caused by a migraine attack. Migraines can cause nasal congestion, and a runny nose due to the activation of nerves that supply the sinuses.

A true sinus headache is actually rare and it's caused by a virus or a bacterial sinus infection. So symptoms of a sinus headache would be pressure behind the eyes, a stuffy nose, facial pain, changes in smell or fever. And oftentimes people believe that weather changes give them a sinus headache, but in truth it's just the weather changing, and it's a common trigger for migraine.

Host: Are there any specific triggers for headaches that patients often overlook or underestimate?

Heather Moury, DO, AQH: Yes, there are many common triggers. The migraine brain is really sensitive to changes or inconsistencies in daily life. So changes in weather, sleep, eating patterns can cause a migraine exacerbation. The brain really likes consistency, so for example, sleeping a similar pattern every day can sometimes prevent a migraine.

Oftentimes we wake earlier during the week and tend to sleep in on the weekends, and this alone can cause an exacerbation of migraine. Other common triggers can be stress and hormone changes, and these variables can be hard to avoid. But in some cases, there are treatments which can be used preventatively, such as rimegepant, which is a CGRP antagonist, and we can use this around stressors like traveling.

And we also use frovatriptan prior to and during a menstrual cycle to help prevent exacerbation of migraine. Additional factors can be food related as well, such as caffeine, aged cheeses, specifically tyramine, processed meat, like sulfite containing foods, bacon, sausage, MSG, and alcohol, most commonly red wine and beer.

So I would advise you really take caution in restricting all of these possible food triggers for an extended period of time. If we avoid them too much, sometimes it's really not that helpful and it can cause a lot of stress for you. So, in the past, actually, we used to think chocolate was just a common trigger, but our recent studies show that chocolate craving can occur as a prodrome, or the symptoms before you have a migraine.

And when we satisfy that craving, we may be falsely blaming the headache on chocolate.

So I recommend a well balanced, unprocessed diet with small portions throughout the day to prevent those blood sugar drops, which can also exacerbate migraine. And it's also helpful to use a headache diary to monitor lifestyle factors along with diet, which can help you identify those patterns and triggers.

Host: Dr. Moury, could you discuss the role of genetics in predisposing people to certain types of headaches?

Heather Moury, DO, AQH: Sure. So we know that migraines are hereditary. If one or both of your parents have it, there's a 50 to 75 percent chance that you will have it as well. It's important to know that family history as that can often help younger generations get earlier, accurate diagnosis and start treatment. And there are some specific gene markers for migraine, but the most well known is hemiplegic migraine, which is a very rare type of migraine with aura and weakness on one side of the body.

Migraine is still a really complex disorder, and we don't understand all of the genetics behind it, so we still need further studies to understand all the variables.

Host: You touched a little bit on this, Dr. Moury, but how do lifestyle factors like diet, exercise, and stress management impact headache frequency and severity?

Heather Moury, DO, AQH: All of these factors play a huge component in headache management. There's been many studies that show that both headache frequency and severity can be decreased by changing these factors. So I always tell patients, it takes us working as a team, the patient and the provider, to truly treat migraine.

Medications can only take us so far. And as an osteopathic physician, it's very important to me, we have to consider the whole patient, the body, mind, and spirit. And we need to establish good lifestyle factors like having a healthy sleeping pattern, aiming for consistency, a well balanced diet, regular exercise to improve sleep and stress, hydration, and of course stress management itself.

We live in a world of constant stress and pressure, so we really need to sometimes just take a step back and find the best way for our bodies to handle stress, whether that means meditation, praying, or just taking a walk. We need to find what works best for us individually.

Host: And what are some of the latest advancements in headache treatment and management?

Heather Moury, DO, AQH: Well, in the last five to six years, there's been many new medications and devices that are FDA approved for migraine. So it's really a tremendous time for the hope of people with migraine, as we now have these specific specifically designed treatments. Our older medications included antidepressants, blood pressure medications, and anti-seizure medications.

These were not designed specifically to treat migraine, but were just found to be beneficial incidentally. Our new migraine medications target CGRP, which is a protein that's involved in inflammation and pain associated with migraine. And by blocking CGRP from binding to that receptor, it stops that pathway or that cycle of pain.

So, compared to many of our old treatments, these new CGRP medications have much fewer side effects and can be used by people that were unable to take typical migraine medications.

There are also many new neuromodulatory devices that have been approved for the FDA and are shown to be very beneficial in migraine. Devices can help prevent, reduce, and stop headache attacks without the need of medication.

So this is very beneficial for patients who are unable to take medications or need to limit medications. For instance, the CEFALY device is approved for acute and preventative treatment of migraine, and this device places an electrode on the forehead and stimulates the supraorbital nerves, which transmit signals to the brain.

And if you use this regularly, the device can significantly decrease the migraine attacks.

Host: Well, that all sounds encouraging. How do you navigate the use of medications and other treatment options to effectively manage headaches while minimizing the side effects?

Heather Moury, DO, AQH: The first time I meet with a patient, I really want to get to know all about them. I use knowledge about their occupation, their prior medical conditions, and limits of certain medications to make the best decision for treatment. So this may include medications, vitamins, non-invasive procedures like nerve blocks, Botox, infusions, and devices. But my goal is really to find the best treatment that's most beneficial and has the least amount of side effects.  

Host: Dr. Moury, what advice do you have for individuals who experience chronic headaches, but they have not yet looked for medical help?

Heather Moury, DO, AQH: My advice would be to make the appointment today. So often, I hear from patients that they have struggled with severe chronic migraine for years, and now is the time to take the step. We have so many new treatments, procedures, and devices available, and I'm confident that we can find something to make an improvement in your life.

Here at St. Clair Neurology, we have a team of headache specialists, including myself and my fantastic physician assistant, Faith McGrady. We will take the time to get to know you and find the best treatment for you.

Host: Well, thank you so much for sharing your expertise. This has been really educational and we appreciate your time.

Heather Moury, DO, AQH: Thank you.

Host: Again, that's Dr. Heather Moury. To schedule an appointment with Dr. Moury, visit stclair.org or call 412-942-6300. That's 412-942-6300. And if you found this podcast helpful, please share it on your social channels.

And check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Curating Care, a podcast from St. Clair Health.