Interviewer: All right. Let's talk about chronic headaches. Dr. Bartel is an expert in headaches. He did a Fellowship in Headache Medicine, they call it. And for a chronic headache sufferer, man, it can really just impact your life in a lot of negative ways. How do you treat it? That's going to be the question we're going to answer today with Dr. Bartel. So first of all, what do you as a medical provider consider a chronic headache? What makes it chronic?
Dr. Bartel: So there are a lot of different types of chronic headaches. In a general sense, chronic headaches are headaches affecting somebody more than half of the month. So we tend to consider more than 15 headache days per month as a chronic headache.
Interviewer: And chronic headache sufferers, do the headaches last all day? Is it maybe just a half hour every day? What's that kind of look like?
Dr. Bartel: They can. It depends on the type of headache. So oftentimes, for instance, migraine headaches will last for many hours. There are certain types of headaches that do truly never go away, and some people have headaches every waking hour of their day.
Interviewer: So if you're having headaches 15 or more days a month, that is a chronic headache. Do you also look at the intensity of the headache when you're looking at a chronic headache? Is it kind of a balancing act, or is it really just purely how often are you having this headache?
Dr. Bartel: Yeah, certainly the degree of disability that is involved. Even if a headache isn't truly half of the month, we will often consider preventative medicine. If somebody has headaches at least four days out of the month, like once per week, and it's particularly debilitating or it really bothers them, we'll even sometimes try medication then. But oftentimes, we'll reserve at least some of the more involved therapies for people that have chronic migraine.
There's some evidence that there are a lot of medicines that help, a lot of different therapies that help for what we call an episodic headache, less than 15 days out of the month. They can work for both chronic or episodic. But we pay special attention to those that have headaches that are more severe or that are particularly debilitating.
Interviewer: So there's a difference between a chronic and an episodic headache insofar as what causes them and how you would treat them.
Dr. Bartel: Yeah, it's really a continuum. But between tension-type headaches, which are the most common type of headache, migraine headaches that tend to be the most common severe type of headache, there's cluster headache. There can be a chronic cluster headache or episodic cluster headache. In all of these, it really depends on how bad they are, how much this is affecting somebody's life. And we really use that information to help cater the treatment for everybody's different headache condition.
Interviewer: If somebody is genetically predisposed to a headache, are they just going to get them regardless of what kind of lifestyle decisions they're making? Or do those impact as well?
Dr. Bartel: Yeah, not necessarily. Certain things can reduce the likelihood of having chronic headaches. So things like effectively managing your stress. That's easier said than done, of course, but having certain various coping skills to help when you have a really stressful situation come up.
You can manage it by exercise. So for some people, exercise can make their headaches worse, but in general, exercise, when you do it fairly routinely, 5 days a week, 20 to 30 minutes a day, just enough to kind of get your blood flowing, your heart rate up a little bit, causing a little bit of sweating, that can all really help with reducing the likelihood of headaches.
Having good social support. Actually being married or in a committed relationship can actually be protective against headaches also.
Interviewer: Really? Wow.
Dr. Bartel: Yeah, as is it turns out. In general, just having a good social structure, social support system can be helpful for a lot of conditions, but headache is certainly one of them.
Interviewer: I like one problem, one solution. It doesn't sound like headaches are that at all.
Dr. Bartel: Unfortunately not. Yeah, it's not at all a one size fits all type of a condition. There are really so many different types of medicines, so many different types of alternative non-medication therapies that can be helpful. We try to really include the ones that we think are most likely to help each individual person, but we cater it to that person.
Interviewer: So for the person that has a chronic headache, if they wanted to try to treat it before going to a doctor, if they wanted to take a look at a few things to try to do it on their own, are there things that they could try before going to see the doctor? Dr. Bartel: Yeah. I think that trying to make sure that you're drinking plenty of water. You don't want to over-hydrate, but you want to make sure that you're drinking enough water. Getting enough sleep, regular sleep, every night is an important thing. Some people that have shift work jobs, that's difficult, but trying to get a good six to eight hours of sleep every night is really helpful.
Interviewer: Should somebody take a look at their diet? I mean, if they're eating a lot of sugar, for example, can that exacerbate a chronic headache? Dr. Bartel: Yeah, there are a lot of different food triggers for headaches, certainly. In general, there's no one diet that can help with headaches in a general sense, but trying to eat a little bit of protein when you have a headache can sometimes be helpful. Eating smaller meals throughout the day can also be helpful.
There are certain food triggers that can make headaches worse, things like MSG, monosodium glutamate. That's found in really every food these days practically, but also nitrates in certain cured meats, things like that.
Interviewer: So foods from our modern society.
Dr. Bartel: Pretty much, unfortunately. Yeah, there are really a lot of things. Simple carbohydrates can make headaches worse, just a lot of the sugars that we think about. But really, for everyone, it's a little bit different.
Interviewer: So it sounds like take a look at some of your lifestyle things. If some things have changed, like perhaps you're not sleeping as well or maybe you're hitting the candy bowl or the cookies a little bit harder than normal, could be some of those things that have all of a sudden brought on some headaches and a patient could definitely take a look at those and see if their headaches go away. Is there a time when a patient should not try to solve it on their own?
Dr. Bartel: Yeah, there are certain red flags that a doctor might think about to give us pause and want to recommend extra testing or at least more questions. So things like having stiff neck or fevers or just a change in your headache, generally, in the acute sense. So if you've had a certain type of headache for a long time and now all of a sudden there's something a little bit different about it, like you're just feeling kind of sick and you're just not feeling right, that can certainly be a red flag. It could just be worsening of your headache, but it could also be something else that's more threatening.
Having prolonged neurological symptoms with the headaches can be unusual. So it's one thing just to have a little bit of a visual aura before your headaches or numbness or tingling beforehand, but having prolonged symptoms like that isn't typical. It can be normal, but also it would be something to want to know more about from the provider's side.
Having weakness on one side is something that can happen with hemiplegic migraine, but it can also be a sign of other things happening in the brain.
Interviewer: Yeah, like a stroke.
Dr. Bartel: Exactly.
Interviewer: One of the signs of stroke is . . . yeah, wow. Okay.
Dr. Bartel: Having a new headache or kind of a changed headache in people that are a little bit older than age 50, for instance, can be a red flag also. There can be a lot of things that could be caused by, but that might indicate the need for imaging of the head.
Having a really sudden onset severe headache might be a reason to go into the ER for, which wouldn't be a bad idea because there can be bleeding in the brain. There can be a number of things that can cause that type of headache beyond just your standard tension headache or migraine headache.
Interviewer: Dr. Bartel, I don't know, after hearing those red flag headaches, I think I'm just going to go see a doctor and let one of you professionals work through it with me. It just sounds really complicated. It sounds like if I tried to get under the hood of my car and fix it is about the same thing as trying to diagnose a headache as well.
Dr. Bartel: It's difficult. I mean, it certainly can be. I think the main things to think about are if it's just a kind of a mild headache here and there that responds to ibuprofen, that's great. But you really want to be careful to not overuse your own research. If you're having headaches that are happening more often, certainly more than 15 days out of a month, it's probably a good idea to see a primary care provider to start with and then maybe see a neurologist or a headache expert otherwise just to kind of give you some tips and try to sort out what this headache is.
