Joey Wahler (Host): They can be debilitating, but they are treatable. So, we're discussing headaches 101, insights from an expert. We'll talk about causes and treatments from tension headaches to migraines. Our guest, Dr. Pooia Fattahi. He's Regional Chair of Neurology for Trinity Health of New England.

This is Transforming Your Health from Trinity Health of New England. Thanks for joining us. I'm Joey Wahler. Hi, Dr. Fattahi. Welcome.

Dr. Pooia Fattahi: Hello. Thank you for having me today.

Host: Great to have you aboard. So first, just how prevalent are headaches for people in the United States and what are the different types?

Dr. Pooia Fattahi: Absolutely. So, headaches is the most common medical complaint, and migraines specifically is the third most common disorder and the seventh highest cause of disability worldwide. More than 90% of patients who present to their primary care doctors for evaluation headaches have a primary headache disorder. And we'll discuss what are different type of headache disorder shortly.

The most important thing is there is a direct and indirect socioeconomic cost of headaches to the society, which is estimated at around $14 billion per year. And about 40% of the population in the world suffers from tension type of headaches. And 10% of them suffer from migraine headaches. Migraines are most commonly between age of 25 to 55, and it occurs in women more than men. And about 3-5% of people in the world suffer from something called chronic daily headaches at any given time. So, different types of headaches.

We have either something called a primary headache, which has no underlying cause, or there is a secondary headache, which is a result of something else causing that. It could be a traction, could be inflammation, or it could be something that is pressing against a structure. The most common primary headaches include migraine headache, tension-type headaches, and cluster headaches. Headaches that are related to let's say infection, vascular disease or trauma are example of some of the more common secondary headaches. And only 1% of patients with brain tumor will have a headache as they still complain. Thankfully, the vast majority of patients who present with the headaches, they do not have anything significant such as a brain tumor.

Host: Let me ask you about a couple of things you mentioned there, Doc. One being that most headaches sufferers are between 25 and 55 years old. What's going on during those ages? Any idea?

Dr. Pooia Fattahi: There's no one common theory of why patients have headaches or what is specifically causing migraine headaches. However, we do know that around this age, patients do suffer from a lot of tensions, either it could be because of work-related or things that they pick up. We don't know exactly why we have such a high number of patients around this age group at this point.

Host: All right. Well, that theory certainly makes sense. How about any information as to why women suffer more from headaches than men do?

Dr. Pooia Fattahi: We do not know that. Is it possible maybe related to hormonal changes? That's always a possibility. But otherwise, at this point, we do not know why that is happening.

Host: Gotcha. So regarding headaches, Doctor, how much does family history play a role here?

Dr. Pooia Fattahi: There is certain studies that show that certain migraine headaches can run in the family. However, most of the headaches are not inherited.

Host: And so, when we talk about migraines, what basically are the differences between those and a regular tension headache?

Dr. Pooia Fattahi: That's right. So as we discussed, migraine headache is the most prevalent disorder in the world and the seventh highest cause of disability worldwide. However, not every headache is a migraine. In order for a headache to qualify for migraine, there are certain criteria that need to be met. One of them, the pain has to be moderate to severe. There should be some sound sensitivity or light sensitivity or even nausea and vomiting. They usually are unilateral, means it's happening on one side of the head. And they could be pulsatile quality, meaning that the headache can come and go as far as the brain. And physical activity will cause aggravation of this headache. So if you have a patient who says, "I have a migraine headache, but I'm able to jog or I'm able to go and exercise," well, that's not really a migraine headache. And the migraine headaches also do not last beyond 72 hours. So if a patient says, I have a migraine headache or a headache that is lasting me a week, that is not a migraine headache. Now, the migraine itself can be divided into episodic or chronic. So if you have more than 15 headaches a month, that's called chronic migraine. If it's less than that, it's called episodic migraine.

Host: So having said all that, when getting a headache of any type, how often is too much? When is it time to see a professional like yourself?

Dr. Pooia Fattahi: That's right. We used to say that if you have more than one headache per week, you need to start some daily medication and be seen by somebody. However, we do know that we have some patients that they may have headaches only happening once or twice a month, but that headache could be disabling. They may not be able to participate in daily activity or with the family events, or maybe they have to take way too many days off from work or from school. So, we always say now that if a headache is impairing your activity, your daily function, it's time to be seen by either a neurologist or a primary care doctor.

Host: Okay. And speaking of being seen, when someone is about to have a first doctor's appointment for a headache, what should they expect, and what should they, if anything, prepare on their end?

Dr. Pooia Fattahi: The best thing is come basically with as much information as you can provide to the physician. So, for example, when we see a patient coming in for migraine, we cover things like how long you've had these headaches, what makes it better, what makes it worse, is there a family history of any headaches? And also, what medications have you tried?

We'll also discuss different things regarding lifestyle. For example, what is the coffee intake? How much water do they drink per day? What's the level of stress? Do they sleep okay? Do they snore when they sleep? And also, we perform a physical exam on them to make sure that there's nothing else that may be provoking this headache.

Host: And speaking of diet, in terms of what we're eating and drinking, what can make a headache better or worse?

Dr. Pooia Fattahi: The diet is variable for each person. Some patients notice that if they have an alcoholic beverage or chocolate, it sets off a headache or some patients are able to pinpoint that there are certain type of foods that will provoke a headache. So, obviously, if we're able to find what is triggering that, it's best to avoid it.

The most common cause of headache that I've seen in the office that relates to dietary intake is actually lack of enough water intake. So, there are some patients that they barely drink a glass of water a day. And these patients, they do suffer from chronic headaches. And drinking just, let's say, at least half a gallon of water a day, that resolved headaches in the majority of our patients.

Host: Interesting. I did not know that. So, hydration, especially water, is something to keep in mind.

Dr. Pooia Fattahi: Correct.

Host: How about treatment options now? Which ones are available for headaches and how do they differ from those available for migraines?

Dr. Pooia Fattahi: Absolutely. So, we need to figure out, first of all, what type of headache is the patient suffering? Is this a tension headache? Is it a migraine headache? And if it's a tension headache, let's say sometimes there are musculoskeletal pain. So, neck pain can trigger a headache on those patients. And most of my patients, when I see them, I look not only at the neurological examination overall, but also look at their neck. Is there any neck spasm? Is this something that I can optimize? And most of them do end up getting a physical therapy for that. And that does improve the headache somewhat. We always tend to get an MRI just to make sure there's nothing else intracranially that is causing that. But as we discussed before, it's rare for anything abnormal in the brain to cause headaches. But I think it's a good way of excluding anything that is potentially problematic down the road.

Then, we talk about different medications. Are they taking medication that may be setting off these headaches? Or do we need to put on medication to help with the headaches? And then, on the medication side, we start medication that you use it immediately to take care of a headache that is happening right now. It's called abortive therapy. And sometimes we have put patients on medication long term. It's called prophylactic. While the theory of migraine is still not proven, we know that things can play a role in causing or resolving the headaches as we discuss hydration, addressing the stress level, making sure that patients are sleeping well.

We could use different medication in our arsenal to treat the different types of headaches and including at times we have to use something called onobotulinum toxin, which is essentially injections that are given in the neck and in the head that are FDA approved specifically for chronic migraine, which does help majority of the patients.

Host: And when you mention the term prophylactic treatment regarding long-term treatment, what does that involve?

Dr. Pooia Fattahi: Depending on the frequency and depending on the severity, we try different medications, for prophylactic. So, one of them could be a beta blocker, something like metoprolol, Inderal, or we could use medication that are actually made for other things. For example, we have nortriptyline, which is an antidepressant medication, but at low dose, it does wonders for migraine headaches. We have other medications that are anti-seizure. So, when they develop this medication, they develop it for seizure. But over the years, all of a sudden the physicians notice, wait a minute, this medication is also helping for migraines. So, we have specific medications that are developed for other conditions, and some medications that were specifically for migraine, which we're able to utilize and try to help reduce the chance of these headaches to happen and not only reduce the chance of that, but also reduce the intensity or the severity of these headaches down the road.

Host: Gotcha. A couple of other things, doctor. One being, what would you say from your experience the biggest misconception people have is when it comes to headaches or migraines, I know I'm shocked to hear just how prevalent they are.

Dr. Pooia Fattahi: That's right. That's right. So, number one is, you know, a lot of patients think that they're alone in this, right? But as we discussed, it's very common to have these migraine headaches. And another thing that I've noticed is that sometimes it takes 20 to 25 years for some patients to come to our office. When I've talked to them about headaches, they say, "Oh, you know, I've had this for 20, 25 years and I thought it was just me. That's the way I am," and they've been suffering through that, right? So then, we start therapy for these patients. We do some physical therapy. We'll start medications and eventually we get them to a point that they're either headache-free or they're much better than when they came in. And they will tell us, you know, you give me my life back. So, it's one of the things that we notice is that a lot of patients, they resort to, "Okay, this is me. I have a headache and this is my life forever." So, we always encourage patients that," Look, go and see your primary care doctor, come and see a neurologist. And let's see if we can reduce the headaches or eliminate it altogether."

Host: And so, picking up on that in summary here, last question for you, Doc, how rewarding is it for you to have that kind of result? It sounds like you're saying that when people come to you, especially the sooner the better, that the chances are these conditions can be addressed. How does that make you feel when you're able to, as you put it, give them their life back?

Dr. Pooia Fattahi: Oh, I tell you, this is actually one of the best part our work. You know, I've been practicing for over 10, 12 years now in the area. And I do have a lot of patients that we end up using different medication. And now, they end up on onabotulinum toxin, which is, as I said, it's an FDA medication for headaches. And at times, we have a lot of patients book a few times per month for their injections done every three months. And I love those days because the patients come in and they're like, "Doc, I spent two minutes with you in the office for those injections, but I'm happy for three months, you know? And between the two treatments, the headaches are so good that I don't even remember ever feeling this way." So, that's very rewarding for us to know that there are certain things that we could do either with a pill, with a therapy, or with injection that changes quality of life so dramatically for patients that basically they come in every three months and they're just happy to be here.

Host: That's awesome. Great to hear. Well, folks, we trust you're now more familiar with headaches and migraines. Dr. Pooia Fattahi, keep up the great work. A pleasure. Thanks so much again.

Dr. Pooia Fattahi: Thank you very much.

Host: And for more information, please visit trinityhealthofne.org/neuro. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. And thanks again for being part of Transforming Your Health from Trinity Health of New England.