My Role in the Treatment of Headaches As a neurologist, I am frequently consulted by primary-care physicians for help in the evaluation and management of headaches. My first duty to the patient is deciding if this headache is a primary headache disorder or a secondary headache disorder. Some examples of primary headache disorders are tension headaches, migraines, cluster headaches and chronic daily headaches. These are headaches where there is no permanent damage being done. In these primary headache disorders there are some brain cells that are over-stimulated and some that are under-stimulated. This change in the pattern of how brain cells communicate with each other causes a wide variety of symptoms such as nausea, tingling, dizziness and often pain. Some examples of secondary headaches are those caused by tumors, increased intracranial pressure, autoimmune disorders, strokes, aneurysms, or genetic conditions. In these cases, the headaches are “secondary” to something else. The secondary headache syndromes are treated by addressing the underlying cause, or preventing recurrence of this problem. These treatments may involve some pain control measures, but really they focus on removing the cause of the headache. Luckily, these are the least common types of headaches. The point of all the MRI and CT scans, the blood work, the lumbar punctures and other testing that is done in the investigation of a headache is aimed at identifying a secondary headache syndrome. This testing is important to do for some people, as the last thing you want to do is to treat a brain tumor by just prescribing more Tylenol. Once we are no longer worried that you have a secondary headache syndrome and the diagnosis of a primary headache disorder has been made, the focus then turns to finding the appropriate way to manage the headaches over the long term. If the headaches are infrequent, only once or twice a month, emphasis may be solely on finding a non-toxic appropriate and effective headache medication. If the headaches are more frequent than this, the focus is not on individual headaches but on attempts to reduce the overall frequency. These efforts involve the examination of reasons why the headaches have become more frequent. Here Is a Short List of Common Triggers: • Overuse of headache medications • Exposure to inappropriate headache medications • Insomnia or poor sleep hygiene • Psychological problems • Food triggers • Lack of regular exercise • Social stressors like failing relationships or problems at work • Supplements or prescription medications • Poor posture and other musculoskeletal problems For the patient with frequent severe headaches, it will be important to consider starting a preventative medication that when taken daily may decrease the frequency of their headaches by one half. Once an appropriate medication has been chosen, it must be taken at least two months before the effectiveness can be clearly determined. In the meanwhile, other triggers must be identified. If these triggers are not addressed, it is unlikely that the preventative medication will be helpful.   It is important to realize that for most patients with frequent severe migraines or tension headaches, the benefits received from addressing their headache triggers will be far and away more significant than the effect of any medication I can prescribe.  It is dangerous and unwise to neglect these triggers in the treatment of headaches. Medications are unlikely to be useful if these triggers cannot be addressed. As I tell my patients, I am not a full service pharmacy. I will not continually switch medications in an attempt to find the elusive magic headache medication when the likelihood of finding such a medication is low. Often at this point, the chances of discovering a life threatening side effect or drug interaction is much more likely.   Unfortunately, treating headache pain is not the same as treating a broken ankle. For a broken ankle, it is a mere matter of increasing the dose and one will eventually get relief. Headaches just aren't like that. One cannot just double the dose of medication and get twice the pain relief. Individual headaches are hard to treat. My success in headache treatment rests more in helping prevent future headaches than finding the perfect medication to treat any individual severe headache.   My job primarily is one of education and letting you heal yourself. If I've done my job correctly, you won't need medications or neurologists to help with your headaches. Return to Headaches

My Role in the Treatment of Headaches

As a neurologist, I am frequently consulted by primary-care physicians for help in the evaluation and management of headaches. My first duty to the patient is deciding if this headache is a primary headache disorder or a secondary headache disorder.

Some examples of primary headache disorders are tension headaches, migraines, cluster headaches and chronic daily headaches. These are headaches where there is no permanent damage being done. In these primary headache disorders there are some brain cells that are over-stimulated and some that are under-stimulated. This change in the pattern of how brain cells communicate with each other causes a wide variety of symptoms such as nausea, tingling, dizziness and often pain.

Some examples of secondary headaches are those caused by tumors, increased intracranial pressure, autoimmune disorders, strokes, aneurysms, or genetic conditions. In these cases, the headaches are “secondary” to something else.

The secondary headache syndromes are treated by addressing the underlying cause, or preventing recurrence of this problem. These treatments may involve some pain control measures, but really they focus on removing the cause of the headache. Luckily, these are the least common types of headaches.

The point of all the MRI and CT scans, the blood work, the lumbar punctures and other testing that is done in the investigation of a headache is aimed at identifying a secondary headache syndrome. This testing is important to do for some people, as the last thing you want to do is to treat a brain tumor by just prescribing more Tylenol.

Once we are no longer worried that you have a secondary headache syndrome and the diagnosis of a primary headache disorder has been made, the focus then turns to finding the appropriate way to manage the headaches over the long term. If the headaches are infrequent, only once or twice a month, emphasis may be solely on finding a non-toxic appropriate and effective headache medication. If the headaches are more frequent than this, the focus is not on individual headaches but on attempts to reduce the overall frequency. These efforts involve the examination of reasons why the headaches have become more frequent.

Here Is a Short List of Common Triggers:

•Overuse of headache medications

•Exposure to inappropriate headache medications

•Insomnia or poor sleep hygiene

•Psychological problems

•Food triggers

•Lack of regular exercise

•Social stressors like failing relationships or problems at work

•Supplements or prescription medications

•Poor posture and other musculoskeletal problems

For the patient with frequent severe headaches, it will be important to consider starting a preventative medication that when taken daily may decrease the frequency of their headaches by one half. Once an appropriate medication has been chosen, it must be taken at least two months before the effectiveness can be clearly determined. In the meanwhile, other triggers must be identified. If these triggers are not addressed, it is unlikely that the preventative medication will be helpful.

It is important to realize that for most patients with frequent severe migraines or tension headaches, the benefits received from addressing their headache triggers will be far and away more significant than the effect of any medication I can prescribe.

It is dangerous and unwise to neglect these triggers in the treatment of headaches.   Medications are unlikely to be useful if these triggers cannot be addressed. As I tell my patients, I am not a full service pharmacy.   I will not continually switch medications in an attempt to find the elusive magic headache medication when the likelihood of finding such a medication is low. Often at this point, the chances of discovering a life threatening side effect or drug interaction is much more likely.

Unfortunately, treating headache pain is not the same as treating a broken ankle. For a broken ankle, it is a mere matter of increasing the dose and one will eventually get relief. Headaches just aren't like that. One cannot just double the dose of medication and get twice the pain relief. Individual headaches are hard to treat.  My success in headache treatment rests more in helping prevent future headaches than finding the perfect medication to treat any individual severe headache.

My job primarily is one of education and letting you heal yourself. If I've done my job correctly, you won't need medications or neurologists to help with your headaches.

Return to Headaches