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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