S1 Episode 46: Suffering From Headaches?

The COVID crisis is causing many more people to call their doctors with headache complaints. When is it time to stop self diagnosing your headache and to see a headache specialist? Dr. Louise Klebanoff, a leading neurologist and headache expert, explains why the right diagnosis can make all the difference in conquering most headaches. Hear about lifestyle changes and a range of medical approaches from nutraceuticals to Botox, plus the promising new CGRP therapy for migraines. 

Dr. Philip Stieg: Almost 80% of us will experience a tension headache in our lives. 28 million Americans experience migraine headaches, which can be a chronic disabling medical condition. Nearly 50% of migraine sufferers have such severe symptoms that they can’t perform their daily activities. And in many cases require bedrest. In the current COVID environment of anxiety and fear, many more people are experiencing headaches. I’m extremely pleased to have one of the country’s leading experts in the diagnosis, treatment and management of headaches, including migraines, Dr. Louise Klebanoff. Dr. Klebanoff is Chief of General Neurology and Vice Chair of Operations for the Department of Neurology at Weill Cornell Medicine, Louise. welcome.

Dr. Louise Klebanoff:  Thank you so much. I’m happy to be here.

Dr. Stieg: One of the things that I always find surprising is patients that come in to me say, Oh yeah, I’ve had migraines for years and they’d never really seen a doctor. They kind of self-diagnose themselves. And then the other side, and the flip side of it is the patient that never goes to the doctor and they seem to be afraid of going and getting a diagnosis. What’s the difference in why does that happen?

Dr. Klebanoff: I think both are really common. I think headaches are common, patients take over the counter medications. I think they’re often poo-pooed by other doctors and don’t get a real good diagnosis or history. And I think some patients are fearful that they’re going to be diagnosed with a serious medical condition and hence they avoid evaluation.

Dr. Stieg: Have you found that to be particularly true during this COVID crisis? People aren’t coming in?

Dr. Klebanoff: Yeah, I think there’s a mix. We have more patients who are calling with complaints of headache, and we’ve been seeing a lot of tension headache with patients who have COVID or tension-like headache, but patients are fearful of actually coming in for a doctor’s appointment. They’re fearful of being exposed. You know, we’re fortunate here in that we’ve opened the practice very gently, so we don’t have too many patients in at once. We’re taking extreme precautions in terms of distancing and wearing masks and gloves. And we were able to see patients in-person to provide that expertise and the confidence that comes with doing a good neurological exam.

Dr. Stieg: Should people be worried about, you know, the genetics of headaches? You know, mom, dad had headaches. Am I at risk? As I get a little bit older?

Dr. Klebanoff: Certainly migraines run in families. And we often see patients coming in who have multiple family members with headaches. It runs in all the women in the family, for example. There were a few very specific migraine syndromes that have a clearly defined genetic predisposition, and we understand the true gene that’s involved. Most migraines, even if they run in families, we don’t have a specific underlying genetic cause.

Dr. Stieg: What are the most common types of headaches?

Dr. Klebanoff: Most primary headaches, so those are headaches that are not caused by an underlying problem in the brain like a brain tumor or a stroke, et cetera. Most of them are actually muscle tension type headaches. That’s the most common type of headache. The second most common type of headache would be a migraine, and cluster headaches are less common. Cluster headaches are a specific type of headache that are on one side of the head. The pain tends to be in and around the eye. And it’s a very sharp, boring, severe pain. There’s symptoms that come along with the pain. The patients often have tearing from that eye. The eye may droop. The eye may even get a little swollen. They often have nasal congestion or running from that side of the nostril. And patients often feel restless during the headache. They want to move. They need to move around a little bit. These headaches lasts anywhere from 30 minutes to three hours at a time and often come at the same time every day or a couple of times a day in certain seasons of the year. And the seasons vary by patient.

Dr. Stieg:  With either tension headaches or with cluster headaches, aside from medicine, and we’ll get into that in a moment, are there things that we as a patient experiencing them can do?

Dr. Klebanoff: For tension headaches, stress reduction can be helpful. If there’s tension in the jaw or tension in the neck and physical therapy can be helpful. For anybody with headaches, I recommend a certain headache lifestyle. That means consistency in terms of sleep, going to bed the same time every night, waking up the same time every day, eating meals regularly, staying well hydrated and doing a little bit of aerobic activity a few times a week.

Dr. Stieg: Aside from the preventive things that we can do as patients, there, I presume, is good medication for either of these types of headaches.

Dr. Klebanoff: There are. For muscle tension headaches, oftentimes patients just need an over the counter anti-inflammatory like ibuprofen or acetaminophen on occasion. If the headaches are chronic and repetitive, there are certain medications we use on a daily basis that can be helpful to prevent muscle tension headaches. If there’s a lot of tension in the jaw or the neck, physical therapy can be helpful. Stress reduction techniques, biofeedback, acupuncture can all be helpful for muscle tension headache. For cluster, there are both preventive treatments and acute treatments. So for acute treatments, we have medication called triptans that we can use on an injectable basis or by nasal spray that can be helpful for the acute headache. If patients have repeated recurrent cluster headaches, we usually put them on a daily medication for prevention. Verapamil, which is a calcium channel blocker is probably the most commonly prescribed medication for cluster headache prevention.

Dr. Stieg: I always like to give our listeners some hope. If you see 10 patients with tension headaches and 10 patients with cluster headaches, what’s the success rate with either changing lifestyle or with medication?

Dr. Klebanoff: Most, headache, patients can be treated and most headache patients get better. I can’t tell you that, you know, a hundred percent of patients are going to be a hundred percent headache free, but the vast majority of patients, when they’re treated appropriately, will see a significant reduction in the number and the severity of headaches they have. Also resting, having something to drink, maybe having a little caffeine, lying in a dark quiet room, that can also be helpful.

Dr. Stieg: Do you think that stress can worsen, either the quality of a migraine or the frequency of migraines?

Dr. Klebanoff: I think stress doesn’t help many medical conditions, especially conditions that occur with pain. The thing that’s weird about migraine is that some patients get more migraines in the setting of stress. But oftentimes what we see is what we call a letdown headache. So when the stress is finally relieved, that’s when the headaches come. And I see that in my college students who have migraine, who do well while they’re studying and cramming for finals. And as soon as their finals are over and they’re ready to relax and have some fun, that’s when they get socked with a headache,

Dr. Stieg: Yeah, you drink too much coffee. You drink too much tea, too much chocolate. You don’t get enough sleep. You got too much stress. But again, specifically, what are the things that patients with headaches should be thinking about? Like, ooh, maybe drinking 20 cups of coffee a day isn’t good. 

Dr. Klebanoff: Consistent lifestyle is really helpful. So bedtime and wake up time being the same, eating regularly, staying hydrated and exercising. There are certain foods that are pretty typical migraine triggers. So I ask my patients to watch out for those foods, chocolate, nuts, cheese and alcohol tend to be migraine triggers. So I ask my patients not necessarily to eliminate them from their diet, but to watch what happens when they eat those foods. If they eat chocolate every single day and they get headaches once a month, chances are chocolate is not a trigger. But if every time they have a chocolate bar, they get a raging headache, it may be a trigger. The things I recommend my patients to cut out of their diet are artificial sweeteners because they tend to be very common migraine triggers. MSG, the flavor enhancer and nitrites and nitrates in smoked meats. In terms of coffee, usually one to two cups of something caffeinated a day is adequate. What I recommend is that patients are consistent with their caffeine. So if they do one to two cups, most days, that’s okay. I don’t want them doing 10 cups one day and nothing the next cause that probably can trigger a headache.

Dr. Stieg: If a person doesn’t have their migraines treated, can there be a complication? Can they have other medical complications as a result of it?

Dr. Klebanoff: Well, oftentimes migraines when untreated will worsen over time. They become more frequent as the patients get older. If there’s migraine with aura and the aura is very prolonged, very rarely patients can actually develop stroke. I would say the most common medical complication I see from patients who have inadequately treated headaches, that they take too much ibuprofen or aspirin, and they end up with gastritis or ulcers.

Dr. Stieg: The take home message then should be that if you are an individual who suffers from chronic regular headaches, it’s not something you should necessarily try to manage with over-the-counter medications. You should get professional medical help so that you avoid these complications, secondary complications related to using an inappropriate medication.

Dr. Klebanoff: Correct. In addition, patients who have frequent headaches who take over the counter medication can develop this syndrome called an analgesic overuse or a rebound headache. And that’s a daily persistent headache that occurs in the setting of a patient taking too many over the counter analgesics. And sometimes even too many prescription medications. We recommend that patients limit their acute treatment to two, maybe three days a week at most. And if they really need acute medicine, more than that, they need to be on a preventive agent.

Dr. Stieg: If one goes online and you’ll see a number of other forms of therapy, and I’d like you to comment on them, you know, some of the things like hypnotherapy, cognitive, behavioral therapy, acupuncture, these tens units that you can put on, trigger point injections, even Botox for headaches. What are your thoughts about those kinds of things?

Dr. Klebanoff: Well, that’s a really broad question. So let’s talk about things that we know can be helpful. Cognitive behavioral therapy can be helpful, especially if there’s a lot of anxiety associated with the headaches. We do have a specific neurostimulator units that can be helpful for migraines that stimulate the nerves and seem to be helpful for migraine prevention. The benefit of those types of procedures is that they’re really risk-free, no real side effects and they’re safe in patients who might have medical conditions that make medications undesirable, or for example, if they’re pregnant. Botox is an approved treatment for chronic migraine. So chronic migraine means that the patients have 15 days of headache a month or more 10 of which meet migraine criteria. Botox is given by a series of injections around the scalp and into the upper neck and shoulders — takes about five, 10 minutes. It’s really well tolerated. And about 30% of patients will have the substantial improvement in their migraines after Botox.

Dr. Stieg: Is that asked for more commonly by women?

Dr. Klebanoff: I would say it’s actually a mix. Patients often come in asking for Botox, but many of the patients who ask about Botox don’t actually qualify for Botox. Cause we really only use Botox in patients with chronic migraine. So that’s migraine more than 15 days a month. Just this week, I saw a patient, a woman in her forties who had a long history of headaches dating back to early adolescence, the headaches worsened over time. But she always took over the counter medications, but she was finding she was needing more and more and more over the counter medications. She spoke to her primary care doctor who recommended a change from one over the counter medication to a different one. She saw her eye doctor, who said that she didn’t really need glasses. She went to her ENT who scanned her and said she didn’t have sinus disease.

Dr. Klebanoff: She saw a chiropractor. She tried some physical therapy. She went to her friend’s acupuncturist and she really wasn’t getting better. She came in to see me. She had had at least a 25 year history of episodic headaches that were worsening. When I took the history, it was very clear that these were common migraines, migraines without aura. That she had enough headaches to benefit from a daily medicine for headache prevention. We talked about what our options were. She had gained a little weight over time was feeling a little chubby. One of the medicines we use, Topamax, can often cause a little weight loss. We started with that. I gave her a medication to take when she had an acute headache. We went over lifestyle that we’ve discussed already, previously. She came back to see me in two months and she went down from having 10 headaches a month to having two a month that responded to her medicine. And she was really, really happy. And that’s my goal. My goal is to have my patients manage their headaches as opposed to having the headaches, manage the patients.

Dr. Stieg: I spent a lot of time reading about the nutraceutical industry, things like magnesium, B-2, coenzyme Q 10. Are they effective for the treatment of migraines or any types of headaches?

Dr. Klebanoff: Yes, actually. There have been several studies that show that certain over the counter supplements can be helpful for migraine prevention. Specifically vitamin B-2, Riboflavin, which is well tolerated, but you have to warn patients it’s going to turn their urine, bright yellow. Magnesium, which is a mineral supplement. Magnesium, however, is the active ingredient in milk of magnesia. And if you don’t warn your patients, they’re going to get loose bowel movements, you’re going to get a lot of phone calls. The other one that’s been approved as an herb called butterbur. And that’s also approved for migraine with some pretty good research supporting its use.

Dr. Stieg: And so you can take this and you don’t have to do it under the guidance of a physician? You can just go and get it. And if it works great, if it doesn’t work, move on.

Dr. Klebanoff: Yes. And I will often start my patients who have episodic migraine on supplements in addition to an acute treatment, or even in addition to a daily medicine for headache prevention. I figure why not, they’re well tolerated. And sometimes if the migraines get under control, I could stop their prescription medication and just maintain them on supplements.

Dr. Stieg: I also understand that there are some new clinical trials with some potential therapies coming down the pike. Can you enlighten us on that?

Dr. Klebanoff: Sure. About 18 months ago, a new class of medication was approved for migraine prevention. The medications work on a molecule called CGRP — calcitonin gene related peptide. It’s a big mouthful, which is why we’re just calling them CGRP medications. CGRP seems to be a true cause of migraines. The substance is excreted in the brain when patients are having a migraine. We have medications. Now that work against this molecule. They either grab the molecule, they block the receptor for the molecule, or they do a combination of both things. It is a revolution in migraine therapy because this is our first preventive therapy that’s actually specific for migraine. We have three medications on the market now. All three are given by injection. The injections are subcutaneous just under the skin given once a month. And the medications tend to be very well tolerated.

Dr. Stieg: Dr. Louise Klebanoff thank you so much for spending this time with me. You’ve clarified the diagnosis signs and symptoms for cluster headaches, tension, headaches, and migraine headaches. Most importantly, you’ve given us hope that there is treatment and there are new treatments on the way. Thanks so much for being with us.

Dr. Klebanoff: Thank you.