Search for tag: "headache"

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.

Interviewer: What you eat, what you don't eat, and other lifestyle factors, they play a role in the severity and frequency of migraine headaches. Dr. Karly Pippitt is a headache expert at University of Utah Health. And let's just get into how important are lifestyle and nutrition factors when it comes to migraines.

Dr. Pippitt: I'll often tell patients that medications can only do so much, and so they have to be doing the things that are under their control to help us best control their migraines. And typically, people will have some awareness of some of these because they will have realized these are their triggers.

So sleep is a really big one for people. You want to make sure that you're consistent in your sleep hours, so trying to go to bed around the same time, getting up around the same time, and just getting good sleep quality, if you have something like sleep apnea or another medical condition, that you're getting those treated. A lot of people will have already known that if they didn't sleep very well or if they slept too much, that they happened to get a migraine. So people usually know that that's a big trigger. Some of us don't have good control of our sleep because we're shift workers or something else has happened. And that makes your migraines a little bit worse. So to the best of your ability, if you can control your sleep, that really helps.

Staying hydrated is really huge. We live in a really dry climate, and so making sure that you're drinking water, drinking things that are going to keep you hydrated throughout the day is really important. Again, sometimes people will be like, "Oh, it was a hot day and I was out hiking and then I came home and I had a bad headache." There you go. So making sure that you're staying hydrated.

Being active, right, getting out, doing something. I'm not saying you need to be these crazy Utah individuals who are running ultra marathons and hiking Mount Olympus every weekend. But just go out and walk 20 minutes a couple of times a day, making sure you're doing that and not just being sort of still and sedentary. That's a really important thing with your migraines.

And then you brought up nutrition. So not only what you eat, but I would also say how frequently you eat. We'll typically recommend that patients with migraines or with headaches that you're eating something probably somewhere between every two to four hours. That's something to sort of fiddle with, that works with your body best, but not going for long periods of fasting. That tends to be a trigger for a lot of people. And when you do eat a snack, making sure that you're eating something with a little bit of protein, a little bit of complex carbohydrates, something that's going to kind of sustain you and keep you going, so peanut butter, nuts, dried fruit, yogurt, cheese, something like that.

And then what you eat, it does matter to a certain extent. A lot of people will say that there are certain foods that are a trigger. And you've heard me say that a couple of times now, "What is your trigger for migraines?" It's helpful to look at what you're eating and know what some common triggers are, but don't torture yourself in trying to find what you think is the cause. So some really common triggers, I would say for people, red wines or wines with sulfate. Sometimes alcohol in general, but typically red wines and beer are probably big ones. Chocolate can do it. Processed meat, so things like hot dogs, sausages, that can be a trigger for people. MSG for some people, though I would say the data is a little bit less supportive of that. And then sometimes things like fermented foods can also be a trigger. But everyone is very different. So you may have those and not bother you at all, and other people may be more sensitive.

And also, maybe it's just you had a night that you didn't sleep very well, you were really busy at work and maybe you skipped breakfast. And then when you had lunch, you had a hot dog and a Coke and then later you had a headache. Was it the hot dog? Was it the skipped breakfast? Was it the poor sleep? Yes. It was really probably all of those things that did it.

Interviewer: I was waiting for the answer.

Dr. Pippitt: So I think that's an important thing to think about is that I've heard it described at one of our migraine conferences as the inferno of migraine. And so each of those are a little match, right? So a match that you didn't sleep very well, another little match to some dry kindling that you didn't eat breakfast, and then whatever you ate for lunch and maybe didn't stay hydrated. And all of those are really leading to that inferno that then becomes the migraine.

Interviewer: I like to think of things like that in terms of the cup. So you didn't have your breakfast, you put a little water in that cup, and eventually it just gets so full it runs over. Boom, that's when you have the migraine headache.

Dr. Pippitt: Absolutely.

Interviewer: That's kind of my analogy. It worked for me. But I like the inferno. You had fire. I had water. So you went through a lot of kind of lifestyle things that really all of us should be trying to do to the best of our ability anyway -- staying active, eating healthy, trying to get enough sleep, controlling our alcohol consumption.

Interviewer:When somebody comes in, out of all of those, do you kind of have them start with one above the other? Like what's the biggest bang for my trigger buck?

Dr. Pippitt: Oh, great question. I would say probably sleep. Sleep is a really big trigger for people. And not just not enough sleep, but too much sleep can also be a trigger for you. Most people, when you come in, we talk about those four. And I'll tease people that there's usually one I can pick on them about, right? Like very few of us are like good at all four of those things, so there's usually one. So if there's just one, then that's the one that I'll typically pick on. But sleep and then a close second would probably be either hydration. I don't even know that I'd give you a close second, because I feel like all of those are really common, that we get busy, we don't eat, we get busy, we don't stay hydrated, and we don't exercise.

Interviewer: Yeah. We get stressed, we drink alcohol.

Dr. Pippitt: Yeah. So just trying to find time to do the right thing.

Interviewer: I'd like to add in too, for any of those things, it's really I think important to keep a diary, because before I got my Fitbit a couple of years ago, I thought, "Oh, I get eight hours of sleep. I go to bed at 10:00 and get up at 6:00." Well, actually, it told a little bit of a different story. I guess I didn't realize I was going to bed at 10:45 or 11:00. I thought I was going to bed at 10:00. So writing that stuff down and like what you eat is the same thing. So I think really be critical.

Dr. Pippitt: Absolutely. And I love all the activity trackers, because I think a lot of us think that we're active. I have on my busiest day of clinic, I remember when I first got my Fitbit, I was like, "You got to be kidding me. I'm only doing 3,000 or 4,000 steps. Like I'm exhausted when I come home." And it's interesting how different trackers will then talk about how much you stand, how much you moved. Like maybe you didn't take that many steps, but you were up and moving around. And I was like, "Okay. Either that just made me feel better because I was actually a little more active even if it wasn't just from like a step standpoint." But I think that is useful feedback and information for you to act on.

Interviewer: What about posture? Does posture trigger migraines? I know for me, if I sit all day at work, which sometimes, again, I try to get up every 10 minutes every hour. But if I sit all day, I'll start to notice headaches creeping in around 4:00 or 5:00 in the afternoon.

Dr. Pippitt: Yeah. Posture can definitely lead to more headaches, maybe a little bit more tension headaches and tension headaches can then lead to migraine headaches. So you're doing the right thing by standing up every 10 minutes or so. Making sure your setup is good so that you're not hunched over. I definitely have a tendency, even though I have a pretty good setup, to hunch a little bit more, especially as I keep looking into a camera screen, that tends to curl my shoulders a little bit. So standing up, stretching, like bringing your arms above your head, sort of stretching out your pecs is really what you're looking for. So if you've got one of those exercise balls, rolling that onto your shoulders and just letting your arms fall open. We often think about, "Okay. What can I do for my neck?" But we don't realize that as we're hunching forward, you're actually shortening your pec muscles. So opening those up or going to a corner of a room and putting your hand on each of the wall and almost doing a little push-up against the wall to stretch out those areas is huge.

Interviewer: Some great advice to look to try to reduce the severity. Now, do these things reduce both the severity and frequency of headaches, or do they tend to impact one or the other?

Dr. Pippitt: They could do both, to be quite honest. Maybe not as much the like intensity of one that you have, but I suppose if you really filled your cup up and just like kept the hose running, that might actually make a difference with the intensity. The goal is really probably more with frequency, I would say.

Interviewer: All right. And is this an alternative to taking medication, or would you recommend, if somebody has migraines, that this is in addition to?

Dr. Pippitt: I would say definitely in addition to. Like I said, medications can only do so much. So even if we had a perfect medication regimen for you and you weren't sleeping, weren't eating, weren't exercising, and didn't stay hydrated, I don't know that those medicines would really do any good for you.

Dr. Pippitt: I'll often tell patients that medications can only do so much, and so they have to be doing the things that are under their control to help us best control their migraines. And typically, people will have some awareness of some of these because they will have realized these are their triggers.

So sleep is a really big one for people. You want to make sure that you're consistent in your sleep hours, so trying to go to bed around the same time, getting up around the same time, and just getting good sleep quality, if you have something like sleep apnea or another medical condition, that you're getting those treated. A lot of people will have already known that if they didn't sleep very well or if they slept too much, that they happened to get a migraine. So people usually know that that's a big trigger. Some of us don't have good control of our sleep because we're shift workers or something else has happened. And that makes your migraines a little bit worse. So to the best of your ability, if you can control your sleep, that really helps.

Staying hydrated is really huge. We live in a really dry climate, and so making sure that you're drinking water, drinking things that are going to keep you hydrated throughout the day is really important. Again, sometimes people will be like, "Oh, it was a hot day and I was out hiking and then I came home and I had a bad headache." There you go. So making sure that you're staying hydrated.

Being active, right, getting out, doing something. I'm not saying you need to be these crazy Utah individuals who are running ultra marathons and hiking Mount Olympus every weekend. But just go out and walk 20 minutes a couple of times a day, making sure you're doing that and not just being sort of still and sedentary. That's a really important thing with your migraines.

And then you brought up nutrition. So not only what you eat, but I would also say how frequently you eat. We'll typically recommend that patients with migraines or with headaches that you're eating something probably somewhere between every two to four hours. That's something to sort of fiddle with, that works with your body best, but not going for long periods of fasting. That tends to be a trigger for a lot of people. And when you do eat a snack, making sure that you're eating something with a little bit of protein, a little bit of complex carbohydrates, something that's going to kind of sustain you and keep you going, so peanut butter, nuts, dried fruit, yogurt, cheese, something like that.

And then what you eat, it does matter to a certain extent. A lot of people will say that there are certain foods that are a trigger. And you've heard me say that a couple of times now, "What is your trigger for migraines?" It's helpful to look at what you're eating and know what some common triggers are, but don't torture yourself in trying to find what you think is the cause. So some really common triggers, I would say for people, red wines or wines with sulfate. Sometimes alcohol in general, but typically red wines and beer are probably big ones. Chocolate can do it. Processed meat, so things like hot dogs, sausages, that can be a trigger for people. MSG for some people, though I would say the data is a little bit less supportive of that. And then sometimes things like fermented foods can also be a trigger. But everyone is very different. So you may have those and not bother you at all, and other people may be more sensitive.

And also, maybe it's just you had a night that you didn't sleep very well, you were really busy at work and maybe you skipped breakfast. And then when you had lunch, you had a hot dog and a Coke and then later you had a headache. Was it the hot dog? Was it the skipped breakfast? Was it the poor sleep? Yes. It was really probably all of those things that did it.

Interviewer: I was waiting for the answer.

Dr. Pippitt: So I think that's an important thing to think about is that I've heard it described at one of our migraine conferences as the inferno of migraine. And so each of those are a little match, right? So a match that you didn't sleep very well, another little match to some dry kindling that you didn't eat breakfast, and then whatever you ate for lunch and maybe didn't stay hydrated. And all of those are really leading to that inferno that then becomes the migraine.

Interviewer: I like to think of things like that in terms of the cup. So you didn't have your breakfast, you put a little water in that cup, and eventually it just gets so full it runs over. Boom, that's when you have the migraine headache.

Dr. Pippitt: Absolutely.

Interviewer: That's kind of my analogy. It worked for me. But I like the inferno. You had fire. I had water. So you went through a lot of kind of lifestyle things that really all of us should be trying to do to the best of our ability anyway -- staying active, eating healthy, trying to get enough sleep, controlling our alcohol consumption. When somebody comes in, out of all of those, do you kind of have them start with one above the other? Like what's the biggest bang for my trigger buck?

Dr. Pippitt: Oh, great question. I would say probably sleep. Sleep is a really big trigger for people. And not just not enough sleep, but too much sleep can also be a trigger for you. Most people, when you come in, we talk about those four. And I'll tease people that there's usually one I can pick on them about, right? Like very few of us are like good at all four of those things, so there's usually one. So if there's just one, then that's the one that I'll typically pick on. But sleep and then a close second would probably be either hydration. I don't even know that I'd give you a close second, because I feel like all of those are really common, that we get busy, we don't eat, we get busy, we don't stay hydrated, and we don't exercise.

Interviewer: Yeah. We get stressed, we drink alcohol.

Dr. Pippitt: Yeah. So just trying to find time to do the right thing.

Interviewer: I'd like to add in too, for any of those things, it's really I think important to keep a diary, because before I got my Fitbit a couple of years ago, I thought, "Oh, I get eight hours of sleep. I go to bed at 10:00 and get up at 6:00." Well, actually, it told a little bit of a different story. I guess I didn't realize I was going to bed at 10:45 or 11:00. I thought I was going to bed at 10:00. So writing that stuff down and like what you eat is the same thing. So I think really be critical.

Dr. Pippitt: Absolutely. And I love all the activity trackers, because I think a lot of us think that we're active. I have on my busiest day of clinic, I remember when I first got my Fitbit, I was like, "You got to be kidding me. I'm only doing 3,000 or 4,000 steps. Like I'm exhausted when I come home." And it's interesting how different trackers will then talk about how much you stand, how much you moved. Like maybe you didn't take that many steps, but you were up and moving around. And I was like, "Okay. Either that just made me feel better because I was actually a little more active even if it wasn't just from like a step standpoint." But I think that is useful feedback and information for you to act on.

Interviewer: What about posture? Does posture trigger migraines? I know for me, if I sit all day at work, which sometimes, again, I try to get up every 10 minutes every hour. But if I sit all day, I'll start to notice headaches creeping in around 4:00 or 5:00 in the afternoon.

Dr. Pippitt: Yeah. Posture can definitely lead to more headaches, maybe a little bit more tension headaches and tension headaches can then lead to migraine headaches. So you're doing the right thing by standing up every 10 minutes or so. Making sure your setup is good so that you're not hunched over. I definitely have a tendency, even though I have a pretty good setup, to hunch a little bit more, especially as I keep looking into a camera screen, that tends to curl my shoulders a little bit. So standing up, stretching, like bringing your arms above your head, sort of stretching out your pecs is really what you're looking for. So if you've got one of those exercise balls, rolling that onto your shoulders and just letting your arms fall open. We often think about, "Okay. What can I do for my neck?" But we don't realize that as we're hunching forward, you're actually shortening your pec muscles. So opening those up or going to a corner of a room and putting your hand on each of the wall and almost doing a little push-up against the wall to stretch out those areas is huge.

Interviewer: Some great advice to look to try to reduce the severity. Now, do these things reduce both the severity and frequency of headaches, or do they tend to impact one or the other?

Dr. Pippitt: They could do both, to be quite honest. Maybe not as much the like intensity of one that you have, but I suppose if you really filled your cup up and just like kept the hose running, that might actually make a difference with the intensity. The goal is really probably more with frequency, I would say.

Interviewer: All right. And is this an alternative to taking medication, or would you recommend, if somebody has migraines, that this is in addition to?

Dr. Pippitt: I would say definitely in addition to. Like I said, medications can only do so much. So even if we had a perfect medication regimen for you and you weren't sleeping, weren't eating, weren't exercising, and didn't stay hydrated, I don't know that those medicines would really do any good for you.

Interviewer: How do I know if my headache is caused by a mouth-jaw issue? That's next on The Scope.

Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: Dr. Gary Lowder is a practicing dentist and a professor, both at the University of Utah School of Dentistry. He's got 30 years of TMJ experience and he's seen a lot of cases of people coming in with headaches asking, "Is this a mouth-jaw issue?" Headaches are so common nowadays and can be caused by so many different things, how do you know if it's caused by a mouth-jaw issue? Is there any kind of one-tell that you look for?

Dr. Lowder: Well first of all, in my practice I like to know if a patient has been to their physician or their ENT to find out if there's any underlying infection that might be contributing to the headaches. A lot of patients will say that they have migraines, but in fact they're really just severe muscle tension-type headaches.

So what we do is we will often use a technique called Spray and Stretch, where we use a vapocoolant spray on the muscle areas of the face to see if there is a diminishing of the pain. If we can get headache to respond to that kind of a test, then it usually indicates that it could be related more to muscle irritability, muscle tension, or another term is called Trismus, and that gives me encouragement that this is something that can be treated because it's more of a muscle tension-type headache than a true migraine-type headache.

Interviewer: And we're talking about tense muscles in the jaw and the mouth area?

Dr. Lowder: Yes.

Interviewer: Does that cover the neck area as well what you do, or is that different?

Dr. Lowder: It also covers the neck area. A simple test to know why is if you look up toward the ceiling and tap your teeth together, the bite will feel different that if you look down toward the floor and tap your teeth together. And the neck muscles actually determine head position.

If the head position is altered by tension in those muscles, it can alter your bite, which in term can trigger clenching and/or bruxism, and you can either get headaches toward the end of the day or when awakening in the morning. Often morning headaches are due to the fact that the individual is clenching their teeth throughout the night.

Another sign that could help you understand if you're clenching or grinding is look at your teeth in the mirror and see if you see any signs of wear. The canine teeth or the cuspids just to the sides of the incisors, should have nice points on them. If those points are missing and they're flattened, that means that you have been doing some grinding and abrading of your tooth structure and it can be a factor in headaches.

Again, not all headaches are related to teeth and occlusion, but if it's been ruled out that you have migraines or some other systemic reason for a headache, then we need to suspect that maybe the occlusion is a factor.

Interviewer: So what are some common issues that might be causing my headaches? So TMJ would be one of them, grinding your teeth sounds like another. Are there any other ones?

Dr. Lowder: Well, stress is probably the number one culprit. And stress happens for good reasons and negative reasons. For instance, Christmas can be very stressful to some people, and so can birthdays and weddings. And so a promotion at work, increased responsibilities, can cause us to start grinding or clenching our teeth, and that usually can create tension-type headaches over time.

Interviewer: What can I do about it if I have headaches that are being caused by my muscles and my jaws and my mouth?

Dr. Lowder: I'd like to say, "Just take a deep breath and relax," but that doesn't always work. I think it is good though to evaluate the stress in your life, both physical and emotional stress and determine if there's a more healthy way to deal with them. Stress management counseling is a good idea. Considering your daily activities, is there anything that you're doing that puts more strain on the muscles of your neck and shoulders than the body is able to tolerate?

The position you're in, if you're at a computer all day, can make a difference in how those muscles feel, which can in turn, create muscle tension-type headaches. Physical therapy is beneficial in those cases, ice packs, good quality exercises, routines that can help strengthen those muscles are also beneficial.

If you feel like you're clenching or grinding your teeth and doing it habitually or waking up having these symptoms, some form of protective mouth wear can be beneficial. And those are called dental splints or mouth guard that helps to take the stress off of the teeth and distribute it over the plastic, protecting the teeth and relaxing the muscles associated with your jaw.

Interviewer: That's interesting. So a lot of headaches can start from there but it sounds like there's some hope for people if that's where their headaches are starting.

Dr. Lowder: There definitely is. It's worth investigating because you don't have to suffer with a headache if it's coming from muscle tension in that area. It's also important to know that in some cases of temporal-mandibular disorder, there is clicking and popping that occurs inside the joints just in front of the ear. If it's non-painful we often do not treat that, it's very common. And if it's non-painful or if it doesn't limit your jaw function, then we don't usually treat it. When it becomes painful then the patient should seek help to try and alleviate the problem as soon as possible so that further breakdown in the form of osteoarthritic remodeling isn't occurring.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at the scoperadio.com.

updated: December 19, 2018
originally published: May 27, 2015

Dr. Miller: When should you see a provider about headaches? I'm here with Susan Baggaley. She's a Nurse Practitioner and this is her 20th year taking care of headaches this month. And Susan is also Vice Chair of the Department of Neurology. Welcome, Susan.

Susan Baggaley: Thank you.

Dr. Miller: I think a lot of folks have headaches and they treat them at home and with different remedies, but when would you suggest a patient might want to go to the doctor, to have their headache evaluated?

Susan Baggaley: Well, the simple answer is when things aren't working at home. So if their over-the-counter medicine seems to be less effective, if they start taking more of it, which can perpetuate a daily headache which we can talk about in a little while, but also when things change about their headache characteristics as well.

Dr. Miller: Quality of headache?

Susan Baggaley: Right. Quality and character, so different from what their baseline headache may be every day if they wake up and it's a little, low ache to wake up in the morning and they're vomiting with the headache, for instance.

Dr. Miller: But what about the folks that have what they consider to be mild, daily headaches? Is there such a thing and is that different than a migraine headache?

Susan Baggaley: Well, it can be. The interesting thing about headache in general, it's genetically predisposed in the population so not all people actually experience headache. In fact, if you look at the statistics, migraine is about 12% of the American population, which is more than asthma and diabetes combined. So it's a very...

Dr. Miller: Huge problem.

Susan Baggaley: common problem. And in fact it's a public health disaster right now. Part of that reason being because people treat it as a pain condition, not a neurologic disease and end up maybe getting opioids to treat, or pain pills to treat it as opposed to a specific pain medicine.

Dr. Miller: So, opioids being narcotics?

Susan Baggaley: Right. Lortab, Percoset, those kinds of medicines can actually contribute to more headache.

Dr. Miller: So do you think a patient who has migraines or what sounds like a migraine should see a physician?

Susan Baggaley: I think so, especially when it's interfering with their quality of life, because a migraine itself isn't based on just level of pain or what people often think isn't a migraine unless they have a visual problem or a spot in their vision that makes it a migraine. Only 8% of people actually get aura, as we call it before the headache comes on.

Dr. Miller: Yeah, the common migraine is obviously more common than classic, where you get the aura.

Susan Baggaley: Correct.

Dr. Miller: Are there Susan Baggaley countdowns for what is a migraine headache versus just a daily tension headache? Or is there even such a thing as a tension headache?

Susan Baggaley: Sure. The migraine headache, if you think about it is one that we always attach to a level of disability for the most part. And the reason being is people who have migraine have a much more sensitive brain. So for instance, if were carsick as a child and your mother told you "Look at the horizon," it tells me as a patient they probably had much more sensitive experience to their environment so smells bother them, sounds bother them, noises bother them, lights bother them. So what happens is that gets revved up in the brain. Then they may have nausea. It gets worse with activity. They generally want to lie down, find a dark room. The pulsing...

Dr. Miller: Not be active?

Susan Baggaley: Correct.

Dr. Miller: They can't keep working. That's why it's such a problem for the work environment.

Susan Baggaley: And if they move it makes it worse. They climb stairs, they make it worse. The pain itself then can be anywhere from mild to severe and so many patients might have mild migraine and don't seek a healthcare provider because it's not interfering enough.

Dr. Miller: What kinds of things should they be telling the practitioner? Should they take a history at home before they go see the practitioner about their headaches, or what should they do?

Susan Baggaley: That's always super-helpful. When did their headaches start? Did they start in childhood and increase - say for young women during their menstrual cycle - did it change with pregnancy? Did it change after somebody got a head injury, even though they never had headaches before that? Family history is incredibly important and oftentimes if a young child has a headache, and a parent of them had headaches, they know that this is probably a migraine. But seeking healthcare advice is providing that history to the healthcare provider to say "I get a headache that makes me sick to my stomach. I miss work. I have to lie down. The Excedrin kind of medication isn't working anymore. What do you have for me?"

Dr. Miller: So, what about environmental triggers? I mean, I know physicians and practitioners generally will talk about the common myth is did you eat chocolate or do you get headaches when you drink red wine? Does that hold up under scrutiny?

Susan Baggaley: Sure. We know, actually that there are true physical triggers, environmental triggers. Perfumes, for instance can be a terrible trigger for somebody with migraine. So it's a reason for some people not to go to church and I give them a hall pass for that. So, other times things like foods, so MSG, the aged cheeses, salami, bologna, things like that can actually increase the trigger for headache so one of the goals of a headache diary and treatment is to look and see-do they always get a headache after certain meals or drinks?

Dr. Miller: You mentioned the menstrual migraines and so certainly that's cyclical and women might be able to pick up on that. What about fasting? I've heard fasting might be a cause of migraine headache in some people.

Susan Baggaley: Yes. There's an insulin gene associated with the migraine phenomenon and so oftentimes when you lower your blood sugar it's a trigger to a headache. What we encourage in all of our patients is actually to eat every two hours, some form of lean protein with a carb not just car eating and clearly having to hydrate. As you know, in Utah we're the second driest state. We're at altitude. So other things that already predispose us to be dehydrated or dry is another component to headache and headache management. I always recommend it to my patients that a minimum of 84 ounces of water daily and then we take into consideration how much caffeine they may be drinking, whether hot or cold.

Dr. Miller: Well, talk about caffeine. Is caffeine a trigger of headaches? I've heard in some situations maybe caffeine mitigates migraine.

Susan Baggaley: It can. So, it's a very interesting phenomenon. Many times when people use caffeine as a rescue agent for their headache, it can be helpful because caffeine actually medicines work better. That's why we have drugs like Excedrin Migraine and that actually has caffeine in it, to augment the aspirin and the Tylenol. However, too much caffeine can actually exacerbate the headache because it's a rebound phenomenon. So, too much...

Dr. Miller: It sounds like the Goldilocks phenomenon. Not too much, not too little.

Susan Baggaley: That's true. I tell my patients I'm willing to go between 12 to 20 ounces of caffeine a day and usually not after 3:00 p.m. so that they can enjoy their caffeinated beverage but making sure they're getting plenty of water in addition.

Dr. Miller: Now, what about alcohol? Now obviously if someone overindulges, they're going to have a headache, which is known as a hangover, in the morning. I'm not talking about that. I may be talking about someone who might take just a little bit of wine at a dinner party and then develop a headache.

Susan Baggaley: It's more common, Tom, with red wines, hopsy beers and just in general, some of the other straight liquors. So one of the rules of thumb I tell patients-if you have a drink, make sure you always have at least 12 ounces of water in between or after the first drink before you decide to have a second drink. And again, hydration is key. Certain liquors can be less migraine-ogenic if you will, perpetuate a headache less frequently and soimes that's just be trial and error with the patient, to see. For instance, white wines that are sweeter-Goert's, De Meers, Rieslings tend to be more tolerated in the migraine population. The red wines-merlots, cabernets - tend to be more offensive. So, subtle things like that that maybe a Shiraz may be more tolerated for red wine for a patient, may be a consideration.

I don't tend to have a big, long discussion in my practice about what drink to drink, but I think we should offer those pieces of information to our patients.

Dr. Miller: So what about with chocoholics? Problem?

Susan Baggaley: Dark chocolate, an ounce a day. Enjoy it.

Dr. Miller: So, is there a headache that a patient should pick up on right away and then scurry to the emergency room? Are there certain types of headaches that you've got to get attention to pretty quickly and maybe you could describe that?

Susan Baggaley: Absolutely. We call one headache a thunderclap headache that is probably the biggest risk of a new headache experience for a patient and that is literally what it's called. The feeling that sohing just went kaboom in their brain, this is not...

Dr. Miller: Pretty frightening, pretty frightening.

Susan Baggaley: Yes. And we worry that those could be a bleed in the brain that needs immediate attention.

Dr. Miller: So, sudden onset, very severe headache, go to the emergency room, get evaluated, especially if you haven't had a headache previously, right?

Susan Baggaley: And these can occur in exercise. It can occur with sex. So different types of headache-weightlifter headache, because of that increased pressure in the chest, can be a very scary headache that later can be ruled out as a weightlifter's headache versus a thunderclap.

Dr. Miller: What types of treatment can a patient expect from a provider?

Susan Baggaley: 20 years later, 1993 was the first year that a medication came out that was specific to the treatment of migraine. Prior to that, patients became quite accustomed to getting narcotics. For example Demerol, Percoset and part of that was the only other previous drug that was used to treat migraine were the ergotamine families and that typically induced vomiting. So you already had a patient who felt sick. You gave them a medicine that we were hoping was going to take care of their headache but it made them terribly ill with it. One of the thoughts behind why narcotics or big dose injections of Demerol and other medicines work is it really helps the patient go to sleep and we know that sleep is a recovery mechanism for headache. And that's one of the issues that we talk about in people with chronic daily headache. If they really aren't getting good reset and sleep, like you think about the breaker box in the basement, to reset your brain, you're always starting your day half tanked, if you will, and then triggers come more easily to get more headaches.

Dr. Miller: That's not how we want to treat things today.

Susan Baggaley: Nope. We want to use very specific medications to treat the migraine for what it is. The class of drugs that became available in 1993 were called the Triptans, so many migraines are now actually have become generic but have been known as Zomig or Maxalt or Imitrex and that family of drugs. Most patients can take those drugs with a caveat of history of stroke or high blood pressure that's not managed or cardiac disease, so it's not a free-for-all on who can take those but they have very nice efficiency in treating the headache and getting people back to quality of work and life.

Dr. Miller: That's a remarkable class of drugs and I think it's revolutionized care for the patients with migraines and different migraine-like headaches. So, a patient coming in to a physician's office, what should they expect in treatment of headache?

Susan Baggaley: I think one of the issues is, if we don't have our patients educated that migraine, specifically, is a neurologic disease and not looked at as a pain condition, so what happens in the world of busy clinicians is someone says they have a headache, it's thought to be a pain condition and what do we use for pain? We use pain pills, not necessarily a headache-specific pill. So I think the bigger paradigm shift that we've seen is the change of the expectation that when a patient has a diagnosis of migraine, they get a migraine- specific drug and if they're having more than three to five migraines in a month, they should actually be put on a medication to help prevent the headaches from occurring and lessen the frequency and need for a rescue drug.

Dr. Miller: Perfect. We all know that the addiction to narcotic medications throughout the country is at incredible levels right now. We don't want to see that increase, so I think again, patients going in to see a physician about headaches should not expect to receive narcotics.

Susan Baggaley: I would agree and I think the scary parts about what patients experience when they take a narcotic oftentimes is also that it treats an anxiety. And so when people have pain they get nervous and they take a pain pill. It makes them feel better but it doesn't actually perhaps take the pain away and so they reinforce this feeling of wellness that's not actually curative to the disease or to the episode of headache.

Dr. Miller: Susan, let's talk about a couple of other treatments such as acupuncture of physical therapy or Botox, does that have any role now in the treatment of headaches?

Susan Baggaley: Sure. Let's start with the FDA approved role of Botox. So two years ago it became very clear through clinical trials that Botox did reduce the intensity and frequency of migraines, specifically chronic migraine. We define that as more than 15 days in a month experiencing migrainous symptoms more than four hours a day-light sensitive, sound sensitive, throbbing, sick headaches. So it's a series of 31 injections within one visit's time to see the physician and repeated in three-month intervals. What was seen is that it reduced the intensity and frequency at least by 50% of the pain threshold. It does not take away the necessity, perhaps for other preventive medications on board in conjunction with Botox as well but there have been many patients with great response and actually have been able to get off of many medicines or lessen the doses of medications because of Botox. So, it's very important to be sure if a patient is looking for somebody who provides Botox for migraine that it's with the FDA approved Botox treatment versus just getting a bunch of Botox in your forehead so that you don't have wrinkles but it's not necessarily going to be treating all of the points in the migraine.

Dr. Miller: How about acupuncture?

Susan Baggaley: So, acupuncture can be quite helpful. There are studies that looked at both acupuncture and with nerve blocks and trigger points and what we know is that the patient response rate for just, what we call dry needling, which is acupuncture is still pretty high in comparison to people who are getting drugs injected into their muscles. So it can be helpful. Certainly it's a safer approach in some patient populations that can't take medications either, pregnant women for instance. So I think acupuncture can be helpful. It's usually a complementary approach to the addition of other medications that are on-board. Physical therapy, again, we see people frequently who need to have some postural advisement from a professional to help them understand...

Dr. Miller: Are those the folks that have chronic daily headaches maybe, from the position they hold at work, where they're sitting in a chair?

Susan Baggaley: Right. So their workplace is probably the biggest issue. I think that when they're sitting in a chair and they're slouched over or they forget to sit up, so one of my recommendations to my patients is setting an alarm on the computer. So if they have Microsoft Outlook, once every hour that they have a chime or use their smartphone for an app so they remember from an auditory cue to sit up. If it's a stay-at-home mom or a soccer mom who's driving kids all over every day, I just tell them every time they get to a red light, sit up, posture and then take some deep breaths and carry on. So again, I think the more we become in-tune to the body and the body's response to pain it changes that paradigm as well.

Dr. Miller: Do we have evidence, do we have good evidence that those kinds of things help?

Susan Baggaley: I think I can speak to my clinical experience as far as evidence. There are some studies looking at mindfulness and pain and patient engagement and I think one of the issues that is always at the forefront in a very common disorder is the more a patient is engaged and involved in treating their headache and watching for what are the triggers, they have higher success rates. In many of our patient population these days we see people going to more of a spa medicine experience where, what can I do to be more engaged...

Dr. Miller: To be proactive...

Susan Baggaley: Rather than just give me another pill. So I think at the end of the day, making sure people are doing the right things like good hydration, healthy eating habits, exercising every day, becoming part of that healthy lifestyle, absolutely it makes a difference.

updated: May 8, 2020
originally published: April 29, 2014

Recording: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Chronic migraines are a mysterious and debilitating illness that affects an estimated 36 million people in the United States. That's a large number of patients who have a chronic illness for which there is no known treatment or cure.
Dr. K.C. Brennan is an assistant professor of neurology at the University of Utah School of Medicine. He's an expert in treating and researching migraines and he's here today to talk to us about migraines. Dr. Brennan, welcome.

Dr. K.C. Brennan: Thank you for having me.

Interviewer: Would you just quickly explain what a migraine is.

Dr. K.C. Brennan: Imagine a pounding headache, throbbing pain, then imagine that normal light hurts your eyes, sound hurts your ears, normal smells and tastes make you feel nauseous, you're completely incapacitated, that's what a migraine is.

Interviewer: What are the common migraine treatments right now and how well do they work?

Dr. K.C. Brennan: The best medications we have are called the triptan drugs, Imitrex, Maxalt, those are the names of these drugs and you see them advertised. There's been no single medication developed to prevent migraine.

Interviewer: How much do we know about these migraines right now, in terms of what causes them?

Dr. K.C. Brennan: We know that migraine is a pain disorder; it's a disorder where your pain system is activated when it shouldn't be activated. But we also know that migraine is an excitable disorder of the brain, it's the brain firing when it shouldn't be firing.
Migraine is also a disorder of plasticity, plasticity is the ability of the brain to change itself and it's what the brain does when it learns. When you see a chronic migraine patient you realize that their brain has learned to produce pain when it's not supposed to. I think that's a very important way of framing the question of migraine.

Interviewer: At the moment though we really don't know why the brain is doing this.

Dr. K.C. Brennan: We know that your genetics contribute a lot, there is your environment, you know, light and sound can trigger migraines, they sort of set the process off. Stress is a huge trigger of migraines, and release from stress, so not just a kid going into exams but that kid after they're done with exams suddenly stress releases and that's when they get their migraines.
Hormones are a very big part of it so two-thirds of people with migraine are women, only one-third are men, why is that? Well we think it's because of female sex hormones. So there's a lot of factors that can trigger or modulate, they can turn the volume knob up or down or start things off. We do not know the ultimate cause and that's probably because there are many ultimate causes.

Interviewer: Do migraines tend to run in families?

Dr. K.C. Brennan: They do tend to run in families.

Interviewer: What's the current state of research in migraines? How much are we learning and what are the big questions that people are looking at?

Dr. K.C. Brennan: I think there's been a real infusion of strength into the migraine field from two fronts, one is that we're now doing imaging in humans with migraine, so we're able to actually look at the brains of people with migraine. The other area where we've really had an infusion of strength is we're looking at migraine as a pain disorder, how pain works in the brain in general and then what makes migraine unique.

Interviewer: Can you just give us a little bit more in depth detail about what you've discovered and what you're hoping eventually to accomplish.

Dr. K.C. Brennan: What we've done recently is try and look at what this event, cortical spreading depression, which is the event that underlies the aura, what it does to the brain that might contribute to the migraine attack because the aura is something painless.

Interviewer: Yeah, and to be clear, when you talk about a spreading depression, the cortical spreading depression, define that if you would, that's a massive firing of?

Dr. K.C. Brennan: Right, it's got an unfortunate name, spreading depression is a massive wave of activity, it's like a tidal wave in the brain and it spreads out and it doesn't respect boundaries in the brain, it just moves out like a ripple in a pond.

Interviewer: And this itself, the aura itself is not, is it the migraine or is it what pre-stages the migraine?

Dr. K.C. Brennan: It's considered part of a migraine attack for people who have migraine with aura. Now there are people who have migraine without aura and there's fertile debate in our field about whether these are different kinds of migraine or whether they're all the same thing.

Interviewer: Where do you see research going and how much more do you think we will know about migraines 10 years from now?

Dr. K.C. Brennan: I'm optimistic we're going to know a huge amount more and I'm optimistic for a number of reasons. We've got tools to study migraine, in the lab and in the clinic that are just wondrous.

Interviewer: Is there some evolutionary reason that this volume knob might have been turned up?

Dr. K.C. Brennan: One line of thought goes, what goes on in migraine is essentially the sickness response. A person with migraine is very much like a person with a bad flu. When you have a bad flu or when you have meningitis or something like that, you know, all the senses hurt. And this is known as the sickness response that there's an inflammatory everything hurts reaction that goes on that incentivizes the person to get somewhere where they can get better, go to a dark room, lie down, heal up.
It seems like that sickness response gets switched on, that sickness volume knob gets turned up in migraine for reasons that don't make sense. The circuitry that creates migraine exists for a reason but it gets overused in migraine and then it entrains itself it becomes this daily miserable thing.

Recording: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.