Search for tag: "headaches"

Interviewer: Can you believe that there's a school actually called Headache School? And if you have headaches, you might want to go to this school. So we're going to talk to Dr. Jared Bartell. He's assistant professor in neurology. He's a doctor, but he's also an expert in headache. He did his fellowship in headache medicine, they call it and today we're going to find out more about the University of Utah Health Headache School, why you have one, what it is, and who can benefit. So Dr. Bartell, thank you for being on the show today. I do appreciate it very much.

Dr. Bartell: Thanks, Scot. Happy to be here.

Interviewer: Yeah. So tell me a little bit briefly, I just I'm curious. So headache medicine is what it's called, that you do. Explain the additional training you've had and what that means?

Dr. Bartell: Yeah. So I finished my neurology residency at the University of Wisconsin. And in neurology, you learn about all aspects of epilepsy, multiple sclerosis, stroke, various things that affect the central nervous system and the peripheral nerves too. But headache is certainly within that and we learn a lot about headache in residency. For those people that want to do more outpatient neurology, headache is really a big part of that.

So I spent this last year doing headache fellowship at University of Utah training with the guys there at the university. I learned about various procedures to use for headache, things like Botox, nerve blocks, the different types of medicines that you can use, both for prevention and for rescue of headaches. The nice thing about headache medicine these days is that there really are a lot of new treatments available within the last even couple of years there have been a number of new medicines that are all fairly expensive right now. Insurance tends to pay for them as long as you've tried a few other medicines first, but it's definitely an exciting time to be in the field as a provider of headache medicine, and it's been a great opportunity for me to help patients as well.

Interviewer: Yeah. That's pretty cool. I know headaches can really be debilitating to some people. It can really just really affect the quality of their life, their ability to enjoy life, their ability to do what they have to do. Headache School. So what is Headache School?

Dr. Bartell: So Headache School is a program that we are offering at the University of Utah, and in collaboration with Danielle Henry Foundation to educate patients and their loved ones about headache in terms of treatment and what causes them and just every aspect of headache.

Interviewer: And it's virtual and online, and you can find back episodes on YouTube. So there are a lot of different kinds of headaches. Why would somebody with a headache want to come to the Headache School or watch some of these videos? Why wouldn't they just say, "Just give me some aspirin. Tell me what it is I need to do to solve my headache"? Why are you finding people who are finding this interesting, and coming and showing up?

Dr. Bartell: So they're really a lot of headaches that . . . So you can think about just little everyday headaches that most people get as being responsive to an over-the-counter medicine like aspirin or ibuprofen or Tylenol. But unfortunately, a lot of people have much more severe headaches that really don't respond to those types of medicines. And that actually can get worse with chronic use of things like aspirin or Tylenol. And it can actually cause something called a rebound headache or a medication overuse headache. For people that have chronic migraine or chronic tension type headache or various other types of even more unusual headaches, those types of over-the-counter medicines aren't as helpful. And so educating patients on the different types of treatments, whether that's medicines or non-medication therapies can be really helpful in treating their headache condition overall.

Interviewer: Talked to one of your colleagues, Dr. Pippitt, and she is an expert with headaches as well. And she says that for the most part, a primary care physician can take care of most people's headaches. So it sounds like Headache School is for somebody who has really struggled and hasn't found that answer to their headache because they do have more of an unusual headache and this gives them access to some experts that might just specialize in that particular type of headache. Is that correct?

Dr. Bartell: Yeah. I think so. I think that's a good way of thinking about it. Most primary care providers are excellent in treating headaches. Sometimes it takes 2, 3, 4, or 5, 10 medicines until you really find the right medication fit for that person's headache. Everybody's headaches are a little bit different. Even if you have migraine, for instance, you can have 10 migraine patients lined up and all of their headaches are a little bit different. And the physiology of their migraine can all be a little bit different such that different medicines work for some people and not for others.

Interviewer: So somebody that might have gone through the process of trying to find some satisfaction or some treatment for their headache really could benefit from Headache School. I'm looking at, man, you've got so many episodes already. Just to cover some of them, the cognitive behavioral therapy treatment for headaches, yoga, for headache and migraine, contraception options in migraine, headache, the basics, acupuncture self-care for a headache, pathophysiology of migraine. Sounds like you cover a lot of ground. And what benefit does this help with somebody then if they hear the lecture? What does that information usually do? How does that impact somebody?

Dr. Bartell: So, in Headache School, we have the benefit of having a number of different speakers coming from different backgrounds talking about their view of what headaches are, how to treat them, we have a pharmacist that has given us several talks, we have multiple different providers that treat patients clinically that have their own medical background to provide. You could do a bunch of your own personal research online, which you might find various blogs and find anecdotal ideas as to what to do and what your headaches are caused by and different things you can try. But really looping into how doctors think about your headaches and how a pharmacist might think and how a psychologist might think about headaches can really be helpful in better managing your headaches.

There have been many years, decades and decades of research into headaches and it's not all intuitive. So you might think that you can treat all of your headaches with Tylenol, you take Tylenol three times a day. And this seems to knock down your headache just a little bit. But as it turns out, somewhat counter-intuitively, that can worsen your headaches. It can cause rebound headaches, it can cause some other problems, it can cause liver problems. Different medicines can do things like that, but it's really helpful just to touch base with the headache medical establishment to know what Western medicine thinks about headaches. We do try to incorporate alternative ideas too, and there are many talks on not just true Western medications and that type of thing, but also these alternative therapies that are available.

Interviewer: I love that you have all sorts of experts. I never really thought of that as an advantage, I just thought, "Well, you go to a doctor." Maybe you go to a doctor who's an expert with headache. But as you said, you've got pharmacists, you've got people like psychiatrists or people that can help teach you a cognitive behavioral therapy, or you have people that know about how exercise impacts headaches. So just a lot of different opinions on how to maybe reduce the impact of your headache or the frequency of your headache. So that's pretty awesome.

It's also pretty awesome too because many people they don't live in Salt Lake City, they don't have access to one of these specialists. They can just make an appointment, but they can go to the Headache School and they can watch the lectures and it sounds like they can interact with that individual. At the end, it's not recorded, they could ask them questions and boy, just really making yourself available.

Dr. Bartell: It's true. We see our clinic, especially now more than ever, patients from all across the region. We see people in Nevada and Wyoming, Montana, Colorado. And this resource especially it's on YouTube, so anyone can see it. You could live in a different country and you have all of the videos available for free at your own pace. One thing that you may not realize is that with YouTube videos, you can actually adjust the speed of them too.

Interviewer: Yeah. It gives you access to these experts. It gives you access to this great expert information. Briefly, I want to hit on the skill building session. So you say you have some skill building sessions. What do those look like on Headache School? I get a lecture, what's the skill building session?

Dr. Bartell: So we have a number of talks on various issues, things like progressive muscle relaxation, breathing exercise, guided relaxation. As of today, those are the most recent talks, but there are a number of courses that talk about these non-medicine options to treat headaches that you can just do on your own. You could do these multiple times a day, depending on what they are. And they can really help to have some synergy with the rest of the treatment that you're undergoing. It's one thing just to take a pill every day, but it's another thing to change your lifestyle in certain ways to really help to solidify the changes that your brain is undergoing as you're treating these headaches.

Interviewer: Headache school, it sounds like such a great resource and we will put a link to the University of Utah Health Headache School in the description for this particular podcast episode. Dr. Bartell, thank you very much for telling us a little bit more about Headache School. It's a great resource. Appreciate it.

Dr. Bartell: Thanks, Scot. Happy to be here. Appreciate it.

Interviewer: Today, we're going to talk about how you can go into your primary care physician and talk to them about headaches, so you can finally get that relief.

Dr. Karly Pippitt is a primary care physician, but she's also a headache specialist at University of Utah Health, so she understands both the perspective of a primary care physician and a headache expert. So, hopefully, we'll be able to bring those perspectives together to find out how to talk, how to prepare, and other things like that. So the first question is, what kind of barriers do people run into when they're trying to talk to their doctor about headaches?

Dr. Pippitt: I think probably one of the biggest barriers, when talking to primary care, is time, right? I mean, if I go to my primary care doctor, I probably have four or five things that I want sort of checked off my list to get taken care of, and this is just one in a list of a number of things. And what I have learned is that what's really important is you need to make a visit that is dedicated to your headaches. This is a problem that deserves the appropriate amount of time. So you need to go into it with that perspective if your provider doesn't guide you to that already.

Interviewer: I've been fortunate. I know people that have had severe headaches. And when we talk about headaches, are we talking just about headaches in general, or are we talking about migraines? I mean, what type of headache is it generally that people seek help for?

Dr. Pippitt: So most people I would say probably seek care for migraines, but I think one thing I've been very impressed by is how much people don't talk about headaches. And in my role at the Headache Clinic, I'll sometimes ask people questions about their headaches and they'll say, "No one ever asked me that before."

Interviewer: Yeah.

Dr. Pippitt: And it doesn't seem like a particularly earth-shattering question that I've asked them. So I think that's a pretty important thing is that if your headaches, migraines or not, are impacting something in your life, right, like it's keeping you from work, it's keeping you from school, it's keeping you from anything like that, that means you should talk about it.

Interviewer: Yeah. If you kind of take an inventory and you're like, "Yeah, that is kind of an issue." Because we all get just kind of one-off headaches, a lot of people do. And that's not what we're necessarily talking about here, or is it?

Dr. Pippitt: I think it can be. I think if it's not a one-off as much anymore, but like, "Hey, wait a minute, I think that's kind of been every day. And yeah, maybe I can get done what I need to do, but maybe I can't quite focus as well, or maybe I'm a little more irritable at home with my partner, with my family, and I don't really like that." Those are things you should talk to someone about.

Interviewer: All right. So make that appointment with your primary care provider and just make it just about headaches if that's what you want to tackle with your primary care provider. Then what would you recommend that a patient do to start moving towards maybe managing them a little bit better?

Dr. Pippitt: Yeah. So when you go in for that appointment, be ready. So most people who have headaches have more than one type of headache. This is sometimes I think if you don't have headaches or don't have frequent headaches, you don't think about this very much, but go in ready to talk about that. Maybe I have this sort of low-level headache if I don't eat enough that day or if I go a little bit late on a meal or don't stay super well hydrated, but maybe I get a really bad headache if a storm comes in or if I haven't slept very well for a couple of nights in a row. So be ready with sort of all of those different types of headaches and especially coming in with a diary. So I've seen all sorts of different diaries. There are apps for your phone that you can use. You can write these down on a calendar or just on a notepad. But you want to keep track of the frequency. So how frequent are you having headaches? How bad are they? So did you have to go home from work, or were you able to keep doing what you wanted to do that day? How did you sleep the night before? How active had you been? And then what did you take, and did it help or not? These are all important things to just sort of get a bigger picture, because we all think we remember. "Oh, I think I had a couple of headaches last month." But sometimes when you write it down, it can be pretty striking how frequent you might be having headaches.

Interviewer: Yeah. So go in prepared. It's going to take a little time beforehand. How long would you recommend somebody do the diary before then they actually go and talk to their doctor?

Dr. Pippitt: I'd probably say somewhere around six to eight weeks. Some of it depends on how bad your headaches are. So I think if your headaches are really pretty debilitating and you're having to miss work, then you might not want to go for quite that long. But at least a good couple of weeks of volume of extra information so that then you and your provider can look at that together to determine what might be the next appropriate step.

Interviewer: Okay. And you had mentioned that there are some apps out there and they tend to ask the questions that are going to be the most useful in that appointment. Most of them are pretty good, or do you have a recommendation?

Dr. Pippitt: The one that I've used the most is called My Migraine Buddy. It seems to be the most user-friendly. It actually prints out some nice, pretty charts that talk about how frequent, how intense was the pain, and things like that. That's the one I've heard the best reviews from patients.

Interviewer: Yeah. And when a patient comes in with that information to you because, as you mentioned at the top, you're a primary care physician, but you have also taken extreme interest in headaches and have educated yourself to the extent that maybe the common primary care physician has not. Are you kind of struck by when they come in with that information? Does that truly make it easier for the regular primary care physician?

Dr. Pippitt: Oh, absolutely. I mean I think anytime you come to me as a primary care doc and have information about when your last labs were, about your family's medical history that's really detailed, I'm never going to be upset about that. That is like a gift when you walk in the door.

Interviewer: Okay. So the person brings that in, they bring you some great information, and then at that point, you would review it, and you would likely come up with a treatment plan. Are we at that point yet?

Dr. Pippitt: Yeah. Absolutely. And treatment, we usually break down into two big categories. So one is rescue or acute treatment. So if you're having such intense headaches or migraines and whatever you're trying over the counter isn't working, that's sort of step number one, one thing we could treat. And then I think the second aspect of that is prevention. So if you're having really terrible migraines every week, that lasts for two or three days, well, then we should do something to try to reduce that frequency. So talking to them about what the options are, what might make the most sense based on their particular set of circumstances.

Interviewer: So if I'm a person with a headache and I've gone to my primary care physician and I know maybe they've had like a day or two of training, right, and maybe they have educated themselves off and on throughout their practice, how often can a primary care physician that's kind of got that base level of headache knowledge really solve a problem?

Dr. Pippitt: I think we are well equipped to solve the problem. There are a lot of good migraine medicines that have been out there for a while. And I would say before you escalate to a specialty level of care, unless there's something unusual or concerning about your headache in particular, but you should be able to try at least a couple of rescue medications with your primary care provider and at least a couple of prevention medications. I think it's important to always keep in mind there is no magic cure for any of this. There is no snap of my fingers that is going to make this go away. So patience is really important. If you come in with a migraine a week for a year, it's going to take some time to get at that. So being patient and having reasonable expectations about the outcome, I think is important going in.

Interviewer: Yeah. That can be important. I know some people personally that they have headache issues and they've gone to their doctor and then they felt like they weren't able to solve it so then they just gave up. So I think kind of realizing that it sounds like it's a process, where maybe a few treatments might need to be tried would be useful. At what point then would you want to consider going to more of a specialized headache care center?

Dr. Pippitt: I think if you've tried a couple of things with your primary care and you're not making any headway, if you'll pardon the pun, I think that's the time to think about talking to someone else. It's an okay thing to ask your primary care provider. Just be forthright and say, "At what point do you usually refer patients to a specialist?" I think most of us have a level of comfort with different medical conditions, like I'm clearly going to take care of a lot of things in my primary care practice that are headaches that some of my partners will not, but they'll take care of some things that I would probably send to a specialist as well. So I think asking your provider when. I think it's important that you've tried something, though. I occasionally will see patients in our Headache Clinic who've never tried anything before. They've never tried a prescription rescue medicine. They've never tried a prescription preventive medication. And while that's particularly lovely for me in the Headache Clinic, I would say it's not a good use of a pretty limited resource, because we're there to really take care of patients who've tried quite a few things and are not making any progress.

Interviewer: So we talked about how to talk to your doctor, your primary care physician about headaches, make that diary. It sounds like have a little bit of patience with them as they work through a few treatment options. Are there some other keys to getting that correct diagnosis and treatment from a primary care provider?

Dr. Pippitt: I think you as the patient are the one who knows your history best. So I think we worry that maybe the right questions aren't being asked. So if there's some symptom or something you're experiencing that you don't know if my hand tingling, before I get a migraine, has anything to do with it, bring it up, pay attention to those things. Really ask the questions when you go in so that you're well informed about your own condition, because that helps your provider make the correct diagnosis.

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Scot: What would you say to any man listening that's suffering from migraines? What would be your one or two sentences?

Dr. Pippitt: Man up and go see your doctor.

Scot: It's a different kind of man-up.

Troy: I like it. I like it.

Scot: Instead of don't be a wuss, just deal with it. It's man up and see your doctor. Get something done about it.

Dr. Pippitt: Yeah, absolutely. You don't have to live this way. There are things to be done about it. And like, this is real. I mean, you know, sometimes I'll tease patients like, yeah, this is all in your head, but there is something we can do about it.

Scot: Dr. Pippitt, thank you very much for joining us today to talk about men and migraine headaches. I want to get into migraines in general, and then also talk about if there are any special considerations for men. Have you met Dr. Troy Madsen, one of our emergency room physicians and cohost of this fine show?

Dr. Pippitt: We have met I think in meetings, but probably never face-to-face.

Scot: Troy, I know you said . . . I didn't know this about Troy, Troy said he suffers from migraines, and I never knew that.

Troy: Yeah. As is often the case on our podcast, I am aiding an example of what not to do. I'm often a bad example. I am a self-diagnosed sufferer of migraines, and it's been, I mean, I had headaches as a child and it's been at least 20 years and it took me forever even being a physician to say these are migraines. And I finally concluded, well, they're probably migraines, so we can talk more about that.

Dr. Pippitt: Well, I think you're going to get at what is exactly the issue is that migraines are traditionally thought of as very much a female disease or a disease that afflicts women, but men really do get migraine as well.

But I think there's . . . you sort of brought up the two things that happen. One, men don't often go to the doctor as much as women do necessarily and so you may not seek treatment. And then, because I think the classic teaching is so often that men don't really get migraines as much as women, you don't get the diagnosis of migraine when in fact you actually meet all the criteria to have a migraine.

Scot: Is that a problem? Is it a problem that Troy's self-diagnosed, or is it a problem that men don't get that diagnosis?

Dr. Pippitt: I would say the biggest issue is that because men don't get a diagnosis and often don't get an accurate diagnosis, then they don't get the correct treatment. So that's really the biggest issue is we're delaying treatment and the best care possible because we're not getting the right diagnosis.

Scot: And then, as a result, men just get these terrible headaches and it just impacts their life and their work and their home relationships. Is that usually what ends up migraines end up impacting, or what is bad about migraines? Luckily, I've never had them.

Dr. Pippitt: I think what's the worst, I mean, as someone else who suffers migraine is, you know, the number of, you know, the time away from work, the time away from activities that you enjoy. Those are really important parameters.

Some people think, "Oh, it's not a migraine if my level of pain isn't severe enough. If I'm not like my aunt or my mom who was, you know, down in bed in a dark room with the lights off. And I can function with my migraine, it just hurts and I can't concentrate super well and I kind of feel like I want to barf." Well, you still have a migraine. It's not a matter of intensity of pain. And I think that's an important thing for people to understand.

Troy: Well, here's where fortune has smiled upon us. As good luck would have it, I have a migraine right now.

Scot: What?

Dr. Pippitt: Perfect.

Troy: I am not joking. It started this morning. I was like, wow, isn't that fortuitous. It started yesterday. I just felt kind of tired yesterday. And I don't know that I really saw it coming on because I had a lot of meetings. I was like, "Oh, I'm just tired because I've had a lot of meetings," and, you know, doing lectures, etc., etc. And then today I started to feel it.

And I typically will feel it. It comes on about once a month. It's kind of like my left side of my face and kind of like the back of my nostril on my left side and then I'll feel it up into my forehead. I feel it really around my left eye, I have trouble focusing and, you know, then I just feel very tired while I'm experiencing this with some nausea. It usually lasts about 48 hours. So I'm looking, I've got a shift tomorrow. I've got a shift on Friday. So maybe by the end of my ER shift on Friday, I'll feel better.

So I guess my question for you, Karly, is number one, am I mistaken in thinking these are migraines and then number two, you know, if yes or no, how do you typically diagnose these, and how does someone know if they're having migraines?

Dr. Pippitt: I would say I think you're spot on, Troy. I think you do have migraines. There's a really great three-item questionnaire that's been validated that if two out of three are positive, your chances are pretty good that you've got a migraine.

So one is, do you have nausea or do you feel sick to your stomach when you have a headache? The other is question two is, do you have sensitivity to light or sound? And then question three is, does the level of pain sort of impact what you need to do? Did it impact did you have to skip work? Did you skip activities for fun? Did it alter your activities because the pain was so bad?

I loved what you said about yesterday maybe it was coming on and you felt a little tired. And headaches definitely and migraines definitely have a prodrome, and if you can recognize some of those symptoms, you can actually sometimes catch your migraine before you even get to the pain level.

I often tell people with, you know, the aura that happens before a migraine, which for most people is visual that they get, you know, something that looks like a heat wave or some shimmers or squiggles in their vision. I tell them they're kind of lucky because they know. Whereas some of us who don't have aura, I think to myself, some days, is this just a headache or is this a migraine?

And I'll tell my patients, that's the answer to your question right there. If you're questioning is this just a regular headache or is this a migraine? Should I go take my migraine-specific medicine? That's the answer to your question. You should just go do it because you're probably right. If you're already thinking that, it probably is going to be a worse headache.

Troy: And I wonder too how often you see this, how many men are out there where maybe they're not sure that it's a migraine. They've just dealt with headaches for years. They just said I've had headaches. I went through a process. I remember during med school thinking, "Wow, I need to go to the dentist because this pain came on and it just hurt in my teeth, but I could feel it like up into my sinuses."

And then later I thought, "Well, I'm getting these recurrent sinus infections." It hurts on the left side of my nose and around my sinuses and my face, and maybe I just get these sinus infections and they go away after a couple of days.

How often do you see people that have just struggled either trying to self-diagnose or maybe even going to, you know, specialists who aren't headache specialists and have not had the appropriate diagnosis of migraines?

Dr. Pippitt: Yeah. I think this goes back to that training we got in medical school really like presenting migraines as a disease of women that, you know, when someone comes into the ER, when someone goes into your clinic, this might not be the first thing that you think about. Like, sure, it might be on your differential, but you're not going to move it up the list in one way or another as much as maybe you should.

This is where getting some of the other key features of a migraine history so in particular things like family history. I was talking to a patient of mine the other day. She's got migraines, her mom has migraines, her kiddo, you know, we were talking and she's like, "I don't know. He's kind of been complaining, he had bumped his head. Should I worry?" And we started talking about migraines.

I said, you know, he's only like 9 or 10, but knowing your family history, that may be something that's going to come his way so we should start thinking about it and should start talking about it so that the treatment is there sooner.

I think some of the people we see in the headache clinic have not had anyone ask them those questions about migraine or not had anyone ask questions about a family history for both sexes of patients, men and women. So these are questions we should be asking that is additional helpful information to help you decide is this migraine or is this just a headache?

Scot: If there's somebody listening like Troy that gets them about once a month, but it doesn't seem to like, he seems to just work through it. I mean, should that person seek help or should they just work through it? Would you consider Troy a candidate for some sort of medication or something?

Dr. Pippitt: Help.

Scot: Help. Yeah, that's a good word, "help." I'm a man. I'm going to have a hard time saying that word "help."

Troy: Troy would need to reach out first, which I have not done.

Scot: Do you find that guys just won't admit it? They don't want to admit it. We're tougher than that. We don't get it.

Troy: Maybe that's part of it. And I'm curious that maybe for me, that's been part of it. I've just tried to self-treat with, I'll take, you know, Tylenol every four to six hours and caffeine and that's kind of how I get through it, but yeah, I'm curious if that's what you see, Karly.

Dr. Pippitt: I think what's really hard is that you know, headaches, there's usually nothing that if we were actually meeting each other face to face, Troy, and I looked at you, I couldn't look at you and say like, "Oh, I think you have a headache or it looks like you have a migraine," as opposed to, "Hey, I can see that you have this huge laceration on your arm that needs, you know, stitched up."

So there's I think that's one big problem is that, you know, my level of pain, your level of pain, pain is just such a subjective thing that it's hard for people to say, "Oh, this is bad enough to need something or maybe I'm just not tough enough." So since no one else can see, there is no like definitive blood test or something that it really does come down to the history and asking the questions.

So I think that's one reason that some people don't necessarily get a diagnosis because the questions aren't being asked. They're not thinking sort of more broadly or thinking they're even, this is something that could happen to them.

I would say, Troy though, you definitely could get treatment. You're totally a candidate for it. And when we talk about treatment, we talk about two sort of different arms. One is rescue, which for you, someone who's maybe just getting one migraine a month, I think that would be a very reasonable thing to think about.

So something you'd take, you know, ideally yesterday when you're like, "Oh, I don't know. I feel kind of tired. This might be a migraine," then you would take it then, and hopefully, that could actually minimize your symptoms to more like 24 or even 24 hours or even less time than that.

Now there's nothing wrong with over-the-counter. I just want to be clear about that first of all. So what you're doing isn't incorrect, but I think the question is could something be better?

Troy: And what about for the person who's say experiencing headaches on a weekly basis, or, you know, it's keeping them out of work, say several days a month, what do you recommend for them?

Dr. Pippitt: Yeah, absolutely. That's when we start talking about preventive treatment or something that you take every day to try to prevent migraines. And even then, I mean, you're hitting kind of right at that mark where I'll start to talk to people about it where if it's more than once a week or sometimes, you know, you said your migraines will usually last about 48 hours.

Well, if you were having two of those and you know, those were each two days, that's about four days a month where we'll start to talk about, "Hey, what do you think? Do you think you want to take something every day that might help you prevent it?" It would be a different conversation if you had a medicine that you took for rescue and then you never got a migraine. Then you're probably like, well, I don't really want to take something every day because I already have something when I think it's coming that I take it and I don't ever have symptoms after that.

Scot: What about men and the triggers? So, you know, when migraines I hear triggers mentioned, does it apply to men as well as it does to women, and are there things that somebody could do in their life that could reduce the severity or the longevity of their migraines?

Dr. Pippitt: Absolutely. I mean, I think that's a good question for Troy. You said like, hey, you thought maybe you were just in a bunch of meetings yesterday. Have you ever thought about what some of your triggers might be?

Scot: It's meetings.

Troy: Meetings. Can I get a doctor's note? I want a doctor's note for meeting and night shifts. Night shifts and meetings. I know what my triggers are. It's lack of sleep. It's often, you know, stress, those sorts of things. Yeah, so you're right.

I mean, it does seem to follow a pattern that once a month thing, but then I know if I have a night shift coming up about when it's due, I know that within about, you know, 36 hours of that night shift, I'm going to have a migraine. So I imagine others are in that same boat where it's a similar sort of thing.

Dr. Pippitt: Yes. Sleep is a really big trigger, either not enough or too much or even just what you're describing sort of changing your sleep schedule. That's a huge trigger for most people to get that and to get a migraine.

And then other things, you know, are you staying hydrated? I mean, I know like a call shift was sort of a classic day after for me to get a migraine. Like you've disrupted my sleep, I probably didn't eat very regularly and I didn't stay very well hydrated. That's, you know, sort of like the trifecta there of badness going to happen the next day.

Troy: Well, what's the outlook, you know, for let's say someone like me where you say, "Well, I've got this." Do I just expect this is something I will just continue to have the rest of my life? Can I expect it's going to get worse? It's going to get more frequent or is it going to go away someday?

Dr. Pippitt: The natural course of migraines is they're usually with you for your lifetime, and they will wax and wane in intensity sometimes for reasons that make sense. So if you're in a particularly stressful period of your life like in residency training or something where you don't have as much control of your schedule, well, yeah, I think you would obviously think they would get worse.

For some people, as they, you know, as their career changes, some people they move so there might've been something in the environment that was really making them worse for them. For a lot of women once they go through menopause, sometimes that will make it a little bit better.

So we think about like puberty and menopause in women as sort of being a trigger and then sometimes a bit of a release valve. Men don't necessarily go through menopause unless we want to go down a whole other rabbit hole of manopause but maybe we shouldn't talk about that.

Troy: I was just going to say it. Yeah, we won't go there.

Scot: There's no such thing, right? Please tell them there's no such thing.

Dr. Pippitt: Podcast for another day, but you know, there isn't maybe as much of an off-ramp in that sense that we think about for, you know, people who are men but I think some of it is just your life sort of changes. As we get towards that age, maybe you're not quite as busy, you're not doing as many night shifts, you've hopefully gotten a little bit wiser and, you know, don't do the things that give you a migraine in the first place if you can help it.

Scot: I have a question about triggers. So alcohol use in men, you know, it can be problematic at time because we have episodes that you can go back and listen to if that's something you're struggling with, but alcohol is a trigger, isn't it? Or is it just wine? So then, of course, you know, the stereotypical men drink beer, women drink wine, alcohol wouldn't be a trigger, or is it?

Dr. Pippitt: Yeah, I would say alcohol definitely is the trigger. Red wine is sort of the classic trigger for a lot of people. And it's either the sulfates or the sulfites I have to double-check, but it's one of those that really tends to be the trigger in red wine. And you can find some red wine that doesn't have that in it, but beer can do it too for people. Other like common foods are things like MSG or chocolate for some people, preserved meats. So things like, you know, salamis, hot dogs.

Scot: Don't say beef jerky, don't say beef jerky.

Dr. Pippitt: Preserved meat. I'll just say preserved meat.

Troy: There's nothing unpreserved about that.

Dr. Pippitt: But if you don't have migraines, then that's not necessarily it. And I'll tell people, you know, sure. Look for your triggers. That can be a helpful thing. Like a headache diary can be a helpful thing for like, you know, just what Troy said. He's clearly figured that out. "Oh, the day after I do a night shift, I'm pretty much guaranteed to get a migraine."

So he already knows kind of where that trigger is, but I also tell people don't torture yourself because you can look at every single thing in your lifetime and you know, in a day or in your headache diary and not come up with a single answer for what is it that gave it to you and that's okay. There may not be one perfect, one little thing.

An analogy I heard at a headache conference was think of it like, you know, you had the one match of you had a night shift and then you had another match that you got dehydrated and then you had another match that maybe there was a whole bunch of smoke in the air and all of those make the inferno that is migraine. So it's not usually if X then Y or sort of one thing and then another

Scot: What about hard liquor? Is that a contributor as well? Is that a possible trigger? Does hard liquor have sulfates in it or is that just really wine?

Dr. Pippitt: I think it's mostly just wine. And I think, again, some of this is just you. If you were going to drink liquor, then maybe you weren't as likely to be drinking water that day, or maybe you're outside with a bunch of friends where it's, you know, you're camping and it's warm and so you get a little dehydrated. So it's kind of that whole picture that goes together.

Troy: Knowing now that maybe I should try a medication like I said, I just try and self-treat. I've found that I just take Tylenol like every four to six hours, I take caffeine. I've tried ginger as well. I've read some stuff about ginger. So I'm kind of trying to max out the over-the-counter stuff without a prescription.

How effective would a prescription be if someone has a migraine, you know, whether they're in my shoes or more frequently whatever the case may be?

Dr. Pippitt: I mean, I would hope that the prescription treatment because it's more targeted is going to be more effective. The key with any rescue medication in migraine is that you take it early. So back to that earlier statement of like, well, do I think this is a migraine or do I think this is just a headache? And just taking it, you can often like ward off something from there.

And with any medicine, you know, like you said, Troy, you've tried a bunch of different over-the-counter medicines. Yeah. You may find one that works better. Like Tylenol may work better for you. Excedrin may work better for Scot if he suddenly got diagnosed with migraines or any of those things. So you have to decide what's going to work best for you and it probably is going to be a matter of trial and error before we find the right one.

Even in prescription medicines, there's a whole bunch that are in the same class that we use for rescue. Typically, the triptans is the first place we start, but sometimes, you know, I personally went through a couple of triptans before I found the one that seems to work the best for my migraine rescue treatment.

Scot: Other than the treatments Troy mentioned, are there other over-the-counter things or more natural things that a person could do?

Dr. Pippitt: I liked that you brought up ginger, Troy. Like I said, in the criteria for, you know, if you have a migraine, one of them is nausea. We know that people who have migraine have gut stasis, meaning that your things just aren't moving through your GI tract like they're supposed to, which is why most people feel nausea with migraine. So treating the nausea can be a really important component.

And for some people, if you can treat the nausea alone and ginger has some pretty good data about helping with nausea, that can sometimes be enough to get you over the hump that maybe you don't need your caffeine or, you know, your Tylenol, your Excedrin, your whatever else you need to do.

Scot: So Troy, are you going to go get a prescription? You're going to get a diagnosis and a prescription or you're going to just . . .

Troy: You're going to get me to commit, aren't you?

Scot: Well, no, I'm just wondering, like, you know, are you?

Troy: I struggle with it. Like I feel, and maybe that's maybe that's my problem because I feel like, "Hey, I'm able to function." I get by. Like I said, I've been dealing with this now for about eight hours today and I think I've found a combination that seems to work for me, that I'm able to get through shifts and I'm able to kind of get by.

But again, you know, maybe I do need to look into that and having something more definitive and that's more effective. So it's not like when this hits, I'm like, wait, okay, here we go. Forty-eight hours, power through it. So I'm not dealing with that. So it's a good discussion for me to have for sure.

Dr. Pippitt: I think that's what makes it hard when you feel like you can work through it. You're doing okay. You're maybe not doing the best that you could be, but when it's been this way for so long, sometimes it's hard to realize how bad it actually is.

Troy: That's true.

Dr. Pippitt: Because it's still two days that you're taking medicines for two days, you know, and that just sort of gets you to like limp along to get there. But, you know, don't be afraid to bring it up because I think what we found is that if men aren't really getting the diagnosis, so if you go in and you feel sort of silly because they're like, "Well, dude you have a headache. Why are you coming in to see me?" And then I think you can very much ask the question. Well, could this be a migraine?

Troy: And where's the best place to go? I've got my primary care physician. I actually have an appointment with him coming up in I think a few weeks. Is that the best person to talk to about this? Or should I, you know, come and see you or see a headache specialist or what do you typically recommend to people?

Dr. Pippitt: I would say absolutely start with your primary care. This is a bread-and-butter diagnosis of migraine. So it's making that diagnosis initially. So if they can make that diagnosis, then you can get better treatment.

Some of this too is like you said, people just don't really bring it up. Like if this podcast hadn't have happened, you might not have brought it up next week at your appointment even though you had a migraine just the week before, because you know, it's not happening every day. It's just once a month, you can get through it. It doesn't seem that important.

So make sure you bring it up with your primary care and then they can help you decide, you know, do we need to have another appointment to discuss this further because maybe you went in for your physical and other things where they're like, hey, this is really important. Let's make another appointment to talk about your headaches. Because I think headaches too often get put on the back burner and we don't give it the due, the time that it really needs to give it the proper treatment.

Troy: Okay. I think, you know, Scot and Karly, I think, you got me committed. I'm going to do it.

Scot: All right.

Troy: I will bring it up when I talk to my primary care physician. Karly, it is just a routine sort of thing and it does make sense to say, "Hey yeah, sure. I can power through this." But if you don't need to just power through it, if there are other options, it's worth exploring. And it makes sense to me to, you know, and hopefully, others out there as well who are just in the same boat I'm in to at least bring it up with your primary care physician and look into some other options.

Scot: Hey, Mitch. Did you have anything that you wanted to ask?

Mitch: No. I just, I guess for me, I'm kind of on Karly's side. I don't have migraines, but like the fact that people are like, "Oh, I'll just work through 48 hours of nausea or whatever," that is so bizarre to me. Why are you not going to a doctor? That sounds miserable. Or am I just a baby? Like, I don't know. Maybe I'm just like . . .

Scot: The nausea part to me sounds more miserable than the headache almost, but, you know, there again, I'm a guy who's never had them.

Troy: It is miserable. There's no doubt. It is. I think, you know, for me and probably others, you just have to learn to get by and you kind of just deal with it. And you accept that it's part of your life and you find that it happens in a certain pattern and but yeah, it is miserable.

Dr. Pippitt: So seriously, Troy. I'd love to hear the follow-up on this, that you talk about it, that you get a diagnosis, and that you get treatment. This is the primary care provider in me. I have to know what happens. I like to know the, it's not really the end of the story that makes it sound like something terrible happened but I want to know that you get the right diagnosis and treatment.

Scot: So is the hope that I mean, are you fairly confident, Dr. Pippitt, that he's going to feel better having the recovery medication?

Dr. Pippitt: Yeah. Absolutely. I think it might be a little bit of trial and error to find the right one. I think I probably tried like three with my own provider before I finally found the one that worked best for me, but I'm definitely confident we can . . . Especially this 48 hours nonsense, if we can knock that down, I think that would be huge.

Troy: That would be. Yeah, no, if I can knock that down even if it's, you know, down to 24 hours or something, that's a lot better than looking ahead at the next 48 hours and thinking, "Wow, I've just got to deal with this." So that would be a significant improvement.

Scot: And I can't imagine a world with 100% functioning Troy. I mean, I have a hard enough time keeping up with him when he's got migraines apparently.

Troy: Thanks, Scot.

Dr. Pippitt: Have I just changed the whole podcast now? Oh my goodness. We're not even going to know.

Troy: There's just going to be so much energy, you're not going to know what to do. This is me with a migraine. Without it, it's just going to be like overwhelming. Get ready.

Dr. Pippitt: I see the numbers climbing already.

Troy: Exactly.

Scot: All right. Well, Dr. Pippitt, thank you very much for talking to migraines with us today. We'll follow up with, Troy, here and see how his treatment ends up going. And if you're listening and you suffer from migraines, know that there is help. Dr. Pippitt, thanks for being on the show and thanks for caring about men's health.

All right. So we had to pop the mics back on because after we turned the microphones off talking to the headache expert, Mitch who was quiet the whole time and not only was he quiet the whole time, I actually asked him if he had anything to add and he said then starts talking about, "Oh, I can't believe, Troy, that you're able to function and do this podcast with your headaches because when I get a headache, I tell my partner like shut all the curtains. I'm going to go curl up in a ball." You didn't bring up the fact that you had headaches when we had the headache expert on.

Troy: Thanks, Mitch.

Mitch: I know. I know.

Scot: What's up with . . .

Troy: He just left me out there alone like I'm the weirdo here that gets migraines.

Mitch: I did.

Troy: And you've got headaches too.

Scot: Explain to me your thought process please behind why you didn't jump in.

Mitch: Yeah, no, it totally didn't dawn on me while we were talking because it was just, you know, "Oh, well I get headaches, but they're probably not as bad as Troy's are because he's talking about nausea, he's talking about whatever."

And even as we're talking about how men undervalue their own headaches or that they have to power through, I just, it's the same thing. If I miss sleep or something like that, I'm just . . . I do. I get really bad headaches and I have to like shut my eyes and like disappear for a couple hours. It's not 48 hours, but at the very least, it probably is something I probably should talk to my doctor about at least for Karly . . .

Scot: You think?

Mitch: Yeah, probably.

Troy: And then she made the point too. Again, we didn't have that on there. Like when you look at those criteria she listed, you meet at least a couple of those.

Mitch: I do.

Troy: Yeah. I mean, it's interesting because again, I'm not blaming you because I do the same thing. I see the really bad, bad cases in the ER, people who have severe migraines that come in and they have to get IV medications and they are just completely disabled.

And so that's where I'm coming from. I'm like, "Well, I'm not like that. I'm fine. Look, I have a migraine now and I'm taking care of them so what's my problem? I don't need to get treatment." So I think we all kind of do that where we do hear really bad stories, but maybe, you know, others are out there with headaches that are in your boat as well, that maybe there's some benefit to getting some treatment. I don't know.

Scot: Yeah. I love the fact that you sat there through the whole thing and it wasn't until after the fact that you finally have [inaudible 00:25:42]. It's exactly as Dr. Pippitt was talking about.

Mitch: What were her three things? Nausea, sensitivity to light, and the . . .

Troy: And it affects . . . It gets disabling. Like it affects the sensitivity light or sound, and then it somehow affects your ability to function. Because I mean, it sounds like there you're closing the curtains, you're turning the lights off. I don't know if you have sensitive. Well, it sounds like you do have sensitivity to light if you're closing the curtains.

Mitch: That would be it.

Troy: That would be it.

Scot: It sounds like it's impacting your ability to function.

Mitch: It sure does.

Scot: You have to remove yourself from the world.

Troy: Yeah, it sure does.

Scot: Wow.

Troy: Sure appreciate you letting me fly solo there, Mitch, through that whole thing.

Mitch: All right. You're good.

Troy: Thanks, man.

Scot: I think it's a good lesson though. I think it's a good lesson that even though you were engaged in this show, you know, in a way that a regular listener might not be completely engaged, it still took you a while at the end of the conversation to realize that, you know, maybe this is something I should talk to my primary care provider about. Are you going to do that?

Mitch: Yeah, I'll talk to him next time. I kind of have to now.

Scot: Begrudgingly, he says it. All right. Good episode.

Troy: Good. Well, we can all follow up in a few months. Sounds like, Scot, you still are in the clear, but maybe two of us. One of us for sure has migraines, maybe two of us. Who knows? But we can follow up in a couple months and see how things are going with us.

Scot: Hey, thanks for checking out the podcast. We'll follow up with Troy and Mitch and their journey with migraines. If you suffer from migraines or know somebody that does that would benefit from hearing this episode, please think about who that one person might be and share this episode with them.

Also, another great way to help out the podcast is to join our Facebook group, become an active community in the Who Cares about Men's Health group at facebook.com/whocaresmenshealth. And thanks for listening and thanks for caring about men's health.

Kids and headaches, it's something I have parents bring their kids in for all the time. When is it time to worry? And when are there simple things you can do at home to make your child feel better?

Whenever kids get frequent headaches, parents often start thinking worst-case scenario. I'm often asked if a child who has frequent headaches needs an MRI to determine if they have a brain tumor or not. Only one in 4,000 children who have frequent headaches will have something in their brain. Ninety-nine percent of the time the headaches are due to more benign causes.

When we see kids with frequent headaches, some of the first questions we ask are to rule in or out that possibility of a brain tumor. Kids with brain tumors have severe headaches often that don't respond to pain medications or rest, or other symptoms, like dizziness, waking them up in the middle of the night with the worst headache of their lives, and vomiting, they're off balance when they're walking, have vision changes, and facial drooping. According to some studies, up to 50% of kids with brain tumors have no headaches at all but have other symptoms that raise big red flags for doctors that there's something wrong, including those vision and balance changes that I just mentioned.

So if it's not a brain tumor, why do some kids get frequent headaches? This shouldn't be shocking, but one of the biggest causes is stress. Many kids are super stressed out these days. They have academic pressure as young as preschool age. Often, there are families struggling with money issues, parents having marriage problems, older kids trying to keep up with what all their other friends are doing, especially in the digital world they live in. Social media puts a lot of pressure on teens that they really aren't able to handle.

Kids pick up on everything going on in their world. I have some patients as young as three suffering from anxiety because of things going on in their home environment. I've seen kids as young as one throw a temper tantrum if they don't get to play on the tablet or phone when they demand to. And I've got patients who are seven or eight, who are coming in for daily headaches because they're being bullied at school and don't want to go. Again, the teenagers stressed out from peer pressure that is only amplified these days with online video games and apps like Instagram and Snapchat.

Some of these kids with headaches do have migraines, but most have tension headaches. If your child is getting frequent headaches, what can you do? First, talk to your child and find out what's bothering them. Do it calmly though and let your child know you're concerned about them and that they're not in trouble no matter what the issue is. This helps them be more honest with you.

Find out if they can see okay. It's pretty common to have frequent headaches because of eye strain and needing glasses. And evaluate just how much screen time they're having. And if it's more than two hours a day, have them back off.

Make sure they're getting good sleep too. Doing meditation before bed and having a consistent bedtime routine will help with this.

If you still can't figure it out, then have them see their pediatrician who can help do a more thorough evaluation and provide some answers specific for your child's headache.

updated: January 13, 2023
originally published: July 22, 2019

Interviewer: Three symptoms that don't seem serious but could be. We'll talk about that next on The Scope.

Announcer: This is, From the Front Lines with emergency room physician Dr. Troy Madsen, on The Scope.

Interviewer: Dr. Troy Madsen's an emergency room physician at University of Utah Health Care. Today, three symptoms that don't seem serious but could be. We're talking about signs that you might have a serious medical condition that a lot of people ignore because we're kind of numb to these things.

What are the big three? Let's start with number three. In no particular order, or is this in order?

Dr. Madsen: This is in no particular order at all.

Interviewer: Okay.

Dr. Madsen: Just the three things I thought of as we talked about this that people often don't take very seriously but when they come in sometimes we can find serious things going on.

First one on the list is headaches. And when we're talking about headaches, I think a lot of us are used to headaches. We work, we get tension headaches, sometimes we just don't feel quite right, a little nauseated. But I oftentimes find that people with headaches just feel like "I've just got to tough it out," just get through it and it will go away.

Interviewer: Right, it's a headache, everybody gets them.

Dr. Madsen: Exactly. And, sometimes headaches are a sign of something very serious going on. A lot of times, the red flags with headaches are, headaches that come on very suddenly, very severe, maybe make you feel more nauseated then maybe you've been with previous headaches, certainly if you're passing out because of headaches. Another interesting thing with headaches that's more serious is if it wakes you up in the morning, like you get a headache and you wake up and this headache is the thing that woke you up.

Interviewer: Okay.

Dr. Madsen: And that's often a sign of something going on in the brain, maybe a brain tumor or something like that that can be a more serious thing. So a reason to, certainly if it's a sudden onset severe headache, get to the ER, if it's a headache that's waking you up in the morning, something to talk to your doctor about, they may want you to come to the ER or get some sort of imaging of your brain to see what's going on there.

Interviewer: And it might not be a bad idea if you just kind of always have headaches to talk to your doctor about it because that's not a fun way to live.

Dr. Madsen: Yeah, you're exactly right. We do see cases like that, too, of people who come in the ER who say "I just get migraines all the time" and they could be on medication to prevent that, to prevent that ER visit and make their life much more comfortable.

Interviewer: All right, number two on three things that don't seem serious but could be.

Dr. Madsen: Yeah, so number two is back pain. And back pain is another one of these things you figure "Tough it out, I get pain in my back, maybe I was doing some lifting, something like that." But one of the really, really serious things with back pain is an aortic aneurysm, or a tear in the aorta. And classically with that, people will have pain that starts in their chest and goes though to their back and it's like a tearing pain, maybe it's down in their abdomen and they feel some pain in their back as well with that.

Interviewer: So upper or lower back it sounds like.

Dr. Madsen: Exactly.

Interviewer: Doesn't have to be just back from where the heart is.

Dr. Madsen: No it doesn't.

Interviewer: Even though it's a heart thing you're describing.

Dr. Madsen: Well it's related to the heart. The aorta is the main vessel that delivers blood from the heart to the body. So yeah, it is related to the heart. The heart is squeezing blood through there, so people sometimes just have just severe back pain with an aortic aneurysm or a tear in the aorta and that's something that's extremely serious, you've got to get to the ER, get that checked out. And typically with that, they just have sudden onset severe pain. That's how they describe it. Just a sudden onset pain feels like a tearing or a ripping sort of pain.

You know with back pain as well, you can have issues like cancer, tumors in the spine, things there that will cause you pain that's often more severe when you're lying down or certain positions. It's a little more rare, but that would be something to see your doctor about. They could get an x-ray of your back, sometimes they'll get an MRI to take a look there and see what's going on.

Interviewer: So if it's something you've lived with for a while, there again, go see a physician because why should you live with that. If it's something that comes on very suddenly, for no real apparent reason, that's the trip to the ER time.

Dr. Madsen: Exactly.

Interviewer: All right. Number one on the list of three symptoms that don't seem serious but could be.

Dr. Madsen: And number one is abdominal pain. And we see lots and lots and lots of people with abdominal pain, and we see lots of people with abdominal pain who don't have anything wrong. But then we see people with abdominal pain who come in and say "I've had this pain in the right lower side of my abdomen for five days now. I just figured it was gas and it would go away." We get a CT scan and they have a ruptured appendicitis. And that's just not good.

So there are things in the abdomen that can go very wrong, and it generally happens over time. Typically in the abdomen, it's not something that's going to happen all of the sudden, but if you're having abdominal pain and it's not going away after a few hours, it's progressing, especially on the right side of your abdomen. If you're a typical young, healthy person, the right lower side is your appendix, the right upper side is your gall bladder.

Those are the most common things I see in young healthy people who are just like "I've had abdominal pain before. This will go away." They come in, they have a ruptured appendicitis, or they have a very serious case of cholecystitis, which is an infection of the gall bladder, and they have to go to the operating room to get these things repaired, which they would otherwise but often it's a much more complex case because the infection there is so advanced.

Interviewer: So it sounds like the first two, sudden symptoms. The third one, symptoms that have lasted for a while.

Dr. Madsen: Exactly. Things that came on more gradually and then progressed but people just keep thinking "This will go away" and it's not going away.

Interviewer: That's for the abdominal pain. How many days, if I kind of have a consistent abdominal thing going on, what should my line be, where I'm like "I better go see somebody"? Five days? Is that it, or sooner than that?

Dr. Madsen: I would do sooner than that. With the appendix, with the gallbladder, most things if you got a little bit of food poisoning or some gas in your stomach it's going to get better within six hours. If it's going on beyond that, if you're getting more toward 12 hours with this sort of thing, that's definitely I think a reason to at least see your doctor about it.

Interviewer: And I think it's also interesting too because I know a lot of people from some previous podcasts talk about very sudden abdominal pain like waking up in the middle of the night, sudden abdominal pain. From what you just told me, that doesn't sound like necessarily the thing to worry about. It's if it continues over time.

Dr. Madsen: Well, and again it becomes challenging because I mention that thing to you about the aortic aneurysm, like the back pain, that's also in the stomach that is a sudden thing, so it comes a little bit more challenging.

Interviewer: How do I know if something happens suddenly if I should be concerned? I mean, how do I parse this out?

Dr. Madsen: I think you have to base it on the severity of the pain, how it compares to your previous pain. But these are things where people kind of ease into it, it's like "Oh this isn't so bad. I've got a little pain in the right side of my abdomen. I'm used to having a little bit of abdominal pain." But then they gradually get worse and worse. Maybe some of these other serious things in the abdomen, they come on suddenly, and they're severe.

And so, you base it on the severity, and then those things that aren't so severe, you base it on well, what's it been doing over time, has it just been gradually getting worse, that's a sign often of something more serious.

Interviewer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: You get a crazy severe headache out of nowhere. ER or not? That's next on The Scope.

All right. It's time for ER or Not, where you play along and decide whether or not something that happened is worth going to the emergency room or not. We're with Dr. Troy Madsen. He's an emergency room physician at University of Utah Hospital. Today's ER or Not, you get a crazy severe headache out of nowhere. Just, bam, it hits you. Should I wait a few minutes, or should I think about going to the ER? ER or Not?

Dr. Madsen: I'm going to ask you a little more about this. Have you had a headache like this before?

Interviewer: No. This was just something, never experienced anything like this.

Dr. Madsen: Nothing?

Interviewer: No.

Dr. Madsen: Severe headache?

Interviewer: Yeah.

Dr. Madsen: All of a sudden?

Interviewer: Maybe mild headaches before, but nothing like this. It just all of a sudden, bam.

Dr. Madsen: Did it make you pass out or cause you to feel sick to your stomach?

Interviewer: It did not make me pass out. Caused somebody to feel sick to their stomach, sure.

Dr. Madsen: Okay. Yeah. These are typical questions I'm going to ask someone. Again, I'm imagining you're a family member calling me on the phone telling me, "I've had this severe headache. It just came out of nowhere. I've never had headaches before. Otherwise, feel okay." I'm going to say, "Go to the ER."

Interviewer: Okay. So severe headache out of nowhere, no other symptoms, still go to the ER?

Dr. Madsen: Yes.

Interviewer: Put a little nausea on top of that or passing out, then definitely.

Dr. Madsen: Absolutely.

Interviewer: I'd imagine go to the ER.

Dr. Madsen: Yes, absolutely. These are cases where the big thing I'm worried about is what's called a subarachnoid hemorrhage, which is bleeding in the brain. So you can have an aneurysm. Maybe 1% to 2% of the population, of all of us, just have possibly little brain aneurysms, just something we have and we may not know it. But these individuals that have severe, sudden headaches like this, the big thing I'm worried about is something rupturing with that aneurysm, bleeding out, and that's what's causing the severe headache.

Classically, what will happen is someone will say, "Out of nowhere I had the absolute worst headache of my life." They describe it as a thunderclap headache, just like that thunder just hitting you all of a sudden. Sometimes they may pass out. Sometimes they may feel very nauseated. They may have other symptoms as well with it, if the bleeding is severe, like difficulty speaking or weakness. But really, if you have that severe, sudden onset headache, you need to go to the ER to get that checked out.

Interviewer: So these aneurysms, otherwise completely healthy people could have them?

Dr. Madsen: They might, and that's the thing. It's not something where I'm going to recommend that people just go and say to their doctor, "Hey, I heard this guy say that maybe 1 or 2 out of every 100 people have these aneurysms. I want to get checked for this." Because most people go through their whole lives and it's never an issue. But in some cases, for whatever reason, there may be something about it, either it's large or it's been weakened for some reason, these aneurysms can rupture, and then can cause these severe symptoms.

Interviewer: Are there instances where you could have this sudden severe headache and it is something else? What I want to say first of all, if you do have this go to the ER.

Dr. Madsen: Yes.

Interviewer: But in the interest of not freaking everybody out, could there be other reasons?

Dr. Madsen: Oh, absolutely.

Interviewer: Okay.

Dr. Madsen: Just because you have this doesn't mean you've had a ruptured aneurysm. When studies have looked at it, they've found that about 10% of people who describe these thunderclap headaches, these very severe, sudden headaches, do end up having some sort of bleeding in the brain. That means the other 90% just had it. For whatever reason, it just came on. The big thing I'm thinking about in the ER is ruling out the bad stuff. Oftentimes, that means getting a CT scan of the head to look for any sign of bleeding there, making sure there's no sign of that, and we may have to do some additional tests as well.

But at the end of the day, 90% of the time or more, I'm telling people, "Hey, you had a severe headache. I don't have a great explanation as to why. I may look for other causes as well, but at least we know it's nothing very serious like this."

Interviewer: Then, that buys you some time to maybe look into the other reasons.

Dr. Madsen: Yes, exactly.

Interviewer: But definitely, those thunderclap headaches, go to the emergency room.

Dr. Madsen: Absolutely. Yep. I've seen cases of people who have come in, young, healthy people who have come in and said, "I've had this severe, sudden onset headache." We start the testing. Within 30 minutes they are not responding, because the bleeding has gotten so severe. We're getting the neurosurgeons down there emergently. So one of those things that I don't want to scare you with this, but severe, sudden onset headaches you want to take seriously.

updated: September 23, 2020
originally published: May 13, 2016