Chief Concern Series: Headache Essentials For Clinicians

Hello, and welcome back to the neurotransmitters. I'm your host, Dr. Michael Kentress, and I am joined by my co-host today, Dr. Galina Geigman. Galina, I often get called by my primary care colleagues with various concerns, and I know that we have embarked on our series about chief concerns. We're updating our lingo from chief complaints. I have been told. So to that end, we've invited some of our friends and colleagues to talk about some of these things and kind of get more expanded perspectives. So with that said, I'll throw it over to you. Yeah, thanks, Michael, and thanks for welcoming back to co-host on this exciting series. We're super excited to get started today, and we're going to be focusing on headache. And for that, I've invited, I love what you said, like my friend and colleague, Dr. Sarah Conway. She is a multiple sclerosis specialist at Mass General Brigham, and one of our core educators in the neurology clerkship at Harvard Medical School. Sarah, anything else to add to your introduction? I'm also part of the Neural Hospitalist Group. Yeah, well, welcome. We're so excited to have you. So I thought we'd dive right in. You know, headache is a common concern for our patients, and is a common concern among our colleagues in terms of what to do when you're faced with this. You know, we hear about these frameworks like red flags, when we hear about, you know, you're reassured potentially if they've had a chronic history, but even if you're not concerned about a red flag, and we'll talk about those, how do you manage these patients? So we're going to get into all of this today. So Sarah, you're a mass specialist, but how often are you treating headaches for your patients? Do you get asked about this? Yeah, actually, I was just talking about our new class of fellows coming in, and we were discussing how much general neurology we see in our MS clinics and our MS patient population. You know, we have patients who have seizure, and there is an slight increased risk of headache with MS. And so I would say probably at least once a day we're also co-managing someone's headache disorder. So let's start off with, imagine, you know, you have a new MS patient. Maybe you're going through your systems. It turns out this poor unfortunate, let's say, young lady is also have a history of migraines. Tell us how you start with that headache history. Yeah, I would say when I'm taking a headache history, I'm always keeping in the back of my head, trying to distinguish if this is a primary headache disorder or a secondary headache disorder. And so primary headache disorder, meaning something like migraine or tension headaches that are the result kind of increased pain sensitivity in the brain, but not due to an underlying disease or medical condition. And so some of the questions I'll ask is it going to be to try to get at that primary versus secondary headache difference. And then just to define it, secondary headaches are caused by some underlying medical issue, brain tumor stroke, blood clot, et cetera. And so I think the most important thing that I start with when I'm asking someone about their headaches is the onset of the headache. So if this is something very acute in onset or something more slow and progressive. And I think that's helpful in general when we approach neurologic signs and symptoms. So when thinking of something that's hyperacute, meaning onset to peak in seconds to minute, you have to think of something vascular. So if someone is telling me they have the worst headache of their life that comes on in a couple of seconds, I'm very worried about something called a thunder clap headache, which is most concerning for a subarachno and hemorrhidra burst aneurysm. And that would prompt ER evaluation that makes sense to divide it into that kind of category. I mean, if this person is coming in, you definitely want to right away know within the first couple seconds whether you're dealing with an emergency and maybe have to redirect from your MSU, you know, annual visit to referral to the emergency room. But let's say the timing is a little bit less concerning. So, you know, no, it's just to get regular headaches, maybe they are getting more frequent and they describe kind of a baseline that's changing. So how do you think about that more? Let's say that the headache is coming on over a couple of minutes, maybe lasting a few hours. And what other questions do you want to ask to characterize it? Yeah, so I'll also still try to look for other red flag symptoms before jumping to some of those primary headache disorders like tension headache in migraine, which I'll honestly tend to be more common. But again, we don't want to miss underlying scary things. So I like to use the snoop for namanic to kind of walk me through some of these questions we're going to ask. And so the the S of snoop forestands for systemic signs. So I'll screen patients and ask them if they've had any associated fevers or night sweats that may underlie an infectious process. Or, you know, if they're of the right age, it's a good screen for giant cell arteritis, which is a do not miss cause of headache, which we typically think of in patients who are over 50 and have systemic signs or symptoms. And then I'll ask about any other associated neurologic signs or symptoms, right? If they're having any tingling or numbness or weakness. Now, in an MS patient, that can be difficult, right? Because they may have underlying baseline underlying MS deficits. But I think again, something that can be helpful in distinguishing is there symptoms associated with the headache or symptoms associated with MS is going to be the time course. So typically MS signs or symptoms come on and last for days, two weeks. And then they can sometimes slowly get better. Sometimes someone is left with baseline deficits, whereas typically symptoms associated with a primary headache disorder will come on, you know, over hours and then tend to linger and typically resolve also over hours to maybe a day or two at most. So I think the time course there is also really helpful. And then so that gets us to, we talked about the S and then the N and then we talked about, oh, for onset, you know, being asking about how quickly the headache comes on. And then other things to be worried about as if again, as the age, so older age and onset. So if someone is over 50 and they have a new type of headache, that also is concerning for me. You have to get a headache history, right? So you can ask them if they've had a headaches when they were younger because many people will have, you know, have been told that they have migraines as a child or, you know, as a teen and then you have to figure that out. If there's something new or different about the headaches, they're having now worth, it's just they've come back. I guess going on to that, I often like to ask patients what they mean about the headache. So just because someone told them they have migraine, like you have to delve into that, like what does that actually mean, right? So I'll ask them, tell me about your headache, what is it like? How does it feel? And I think it's important not to necessarily give options at the beginning, right? To try to keep it very open-ending. And did and just hear what they say, right? They do they say it's like squeezing across their head, which may make you think more of attention headache. Or do they say it's throbbing on one side of my head, which could point more towards migraine. Or maybe they say they just don't really know it's just like adult ache all the time. And then you can kind of delve in and give them some options. But I think it's important to hear hear what they have to say. And then another piece of that is we can talk about some migraine cutune a little bit. But many people are told they have migraines and maybe it wasn't actually a migraine. People sometimes just use that interchangeably. I find with a general headache. And it's important because the treatment can be slightly different. Yeah. You know, you bring up like a really good point as far as like the the new or changed headache thing. And I find when I'm working with like students or residents that they'll get like a very thorough, you know, time, onset, severity, character, description of the current headache. Then I ask them like, well, it depends like I've seen them in the office or is it in the hospital? Well, like, why why are they here now? You know, and a lot of times like, well, is this headache different? And that's that to me, that's one of the most reassuring things like this is the same headache they've had for 20 years. Like, all right, that right off the gate, like rules out like a lot to me at least a lot of the more dangerous stuff that I would have to worry about. Yeah. And I think to that point, we'll also ask patients if it's a newer type of headache or different, right? That that raises red flags. Or if it's a similar type of headache, but it's occurring a lot more frequently or with new associated neurologic signs or symptoms or any of those other things we've talked about. Thus far, that would also make me at least want to maybe get an image to make sure we're not missing something else going on. It's interesting to hear that, you know, you both had this experience of the patient being really kind of articulate about what they what they have and maybe how it's changed. I've actually found sometimes I kind of call it like the like reverse headache history, which is in some people who've had chronic headache. They may not actually, in a way, acknowledge the number of headaches that they have, you know, they may say, I only have, you know, the bad migraines twice a month. And you start to kind of pick at that history and you realize they're referring to a bad migraine as an episode that's maybe lasting 48 hours. They're in bed. They have the lights off, but they're actually reporting, you know, a milder headache, though one that probably someone without a headache syndrome wouldn't, you know, think was normal. That's happening more often in the week, maybe three to four times, maybe requiring some board of medicine. Do you either of you have kind of tricks up your sleeves for how to actually call us like tease out this, you know, more chronic headache history for those who maybe dismiss symptoms, what they experience very often. Yeah, it can be difficult. And I definitely had cases like that. I sometimes will ask patients, well, how often are you taking a medication for to treat your headache, right? Like Tylenol or ibuprofen. And sometimes they're like, oh, I'm taking it like multiple times a day because I constantly have a background headache. Oh, and then I have my rescue medication, like a trip tan. And I only take that once or twice a week. And that can sometimes be helpful to get at what do they consider their really bad ones and what is their day-to-day headache. Well, as you said, like the reverse question, it's not not to ask how many days do you have a headache, but how many days in a month do you not have a headache, which can be, I think, very revealing also. And there's like, oh, never, never. There's just better days, yeah, exactly. Where do I want to go from here, Galena? Well, I really liked the mention of GCA as a camp miss. So I'm wondering Sarah, if we could delve a little bit more into that because some of that information is gathered on history. So let's say you have that suspicion maybe because of the old, their age of the person and the new onset, what might you do in that case, just on history to see if you can kind of increase your suspicion or increase your reassurance against that. Yeah. So for Giantsal Arteritis, this typical screening questions I'll ask again, are they having any systemic symptoms like fever, chills, night sweats, any visual changes? And I tend to leave that question very broad and just hear what they say because Giantsal Arteritis can cause lots of different visual problems, visual loss being the most concerning one, but sometimes there's other funny things that can do to the cranial nerves or strokes or things like that that can cause duplicates. I'll just ask like any visual changes. And then you also want to screen for dog clotication. And I find this one actually the trickiest because sometimes patients can also have TMJ or GI issues themselves. I will also try to leave that open and ask if they've noticed any differences when they're chewing or just ask like how in general are they doing when if they were to choose something difficult like a piece of steak and hear what they say. And if they're like, oh, I've had this for 20 years and oh, yeah, I see my dentist and they think it's TMJ that's reassuring. Or they might say, oh, no, this is new. Like I've just noticed this over the past couple of weeks. Every time I try to choose something, it really hurts. I would be more concerned about that. But I find if you ask people like especially in their older, many people will say, oh, yeah, actually I do have some pain when I'm chewing. So I find it kind of a tricky question actually. We're trying to put ourselves in the shoes of our primary care colleagues or those, maybe not necessarily primary care, but it's a primary clinician who's the first to see a patient with this chief concern. And so what I always hear from folks is they're worried about missing something that isn't just a benign primary headache. And so I think your starting point there, Sarah makes a lot of sense. Another one that I get a lot of questions about is idiopathic intracranial hypertension. And I can tell you the number of consults that begin with that quote unquote abnormal MRI and MRI suggesting features of IH, please evaluate. So whether the patient comes to you with the MRI or not, what are the things that on history might actually raise your concern for that? How might that differ from the typical headache story? Yeah, so IH, idiopathic intracranial hypertension is a disorder where the pressure is too high in the brain. So some of the screening questions I'll ask for that is positionality of the headache, right? So if patients tell you it's a lot worse when they're lying down, that could be concerning for increased ICP, which for many cause, right? But if you're screening for IH, that's one thing I'll ask. I'll also ask if they've had any pulsatile tinnitus, if they've had any double vision. So when the pressure is too high, you can get diplopia from stretch on the six nerve. So you can ask if they've noticed any side-by-side images that's getting at horizontal diplopia. And then I'll ask about any transient visual observations. So if they've noticed any like dark black dots in their vision. And I find those questions like patients can be pretty definitive. Yes, no. And that can be helpful to just to to make you even think if you should be worried for IH. The other things I'll ask is it try to get in any underlying risk factors, the biggest one being weight gain. So I'll ask if they've had any significant gain in weight or pregnancy, for example, which are all again, kind of the most common risk factors for developing this condition. I often find again, not the not the typical case, but I find I'm asking more and more about like multivitamin use in in these kinds of cases as well. I was just because there's a lot of people don't know what's in them. And so I end up googling, you know, it's like my multivite thing and it's like how much of vitamin A is in there or are using any topical creams that are vitamin A. Although I know that's a debated subject, it's like how much systemic effect is there from that or like the, you know, like treadmill and stuff like that. So kind of these vitamin A type things, especially in younger people, you know, just because I've, you know, it's like a, you know, squirrel, fine, and not every once in a while that I found a couple cases where that was the thing. And sometimes it is in someone who's had like a gastric bypass surgery and they're put on some multivitamin supplements, but there's too much vitamin A in it. And so it ends up like inducing kind of a, you know, I age like syndrome. It's just one of those weird things that I've come across. It's not the typical presentation, but it's one of those things when you're hunting around for weird stuff that I tend to ask about. Yeah, I'm reminded. I feel like on the board questions that comes up as someone who's eating like seal liver, right? Because that's very high in vitamin A. So that's how I remember. Yeah, I can't say I've seen any cases directly related to vitamin A, but I think it's a really good point, especially as the supplement industry is growing really to hone in on that. I think you also bring up the larger point of sort of medication-induced headache. You know, we often think of medicine as helping the headache, but there are some headaches that could be induced by it. I think of like medication overuse headache. I'm also thinking about what subclass, you know, the RCBS, reverse rosary-row-based constriction syndrome, where you do want to ask a substance history and a medication use history due to a fadrine is a medication that comes to mind, where some people might be just using it for their cold, and then suddenly they're coming in with worst headache of life. Sarah, could you comment on medication overuse headache? I think this is something, this is a public service that else would tell us, you know, how you think about that, and how we can counsel our patients about it. Yeah, I mean, I think so medication overuse headache occurs in patients who are taking significant amounts of regular over-the-counter medication. So the most common ones being a set of minifin, NSADS, and the idea is in patients who are taking these most days of the week for multiple weeks that the brain can be kind of overly sensitized to these medications and that actually they can be doing more harm than good. And I think it's a really hard thing to try to explain to patients because they're like, "But I have really bad headaches, like you're telling me to stop to stop the things that are helping me," but I do think patients who are around the clock taking over-the-counter medications to treat headache, it can be actually not productive in the long run. And so I'll counsel them about the medication overuse headache and typically, this is getting a little bit into the management, but I'll try to give them something like a short course of steroids or some other medication to try to break the cycle and then tell them to to stop taking them every day. It's not a problem to take a set of minifin or an NSADS a couple times a week, you know, two to three times a week for those really severe headaches. It's mainly, you know, when people are taking them all the time every day, we start to see issues. Yeah, I agree. That's been my experience also. It's even worse when you find that they've been, let's say, you know, not a knock against our ED colleagues, but sometimes they get a course of your set or something and I remember I had, this is a number of years back, a lady who'd been on fewer set for decades. And she's like, "I just don't know why my headaches just never get any better." I'm like, "I think I might have a suggestion." And it reminded me, I don't know, you guys are familiar with that scene from the fellowship of the ring where Bill Vogue almost grabs the ring back from Frodo there, like turns into a monster for a second. That's what this happened with a sweet little lady. Like she just turned straight into like a gremlin and was about to take my head off for suggesting, cutting back on the fewer set. And it's one of these things where it's just, you wind up in this cycle. And sometimes as the specialist seeing this person years down the road perhaps, it can be really hard to correct that ship. Yeah, you bring up a good point rate. It's not just the over the count of the medications we see. I have seen it quite often with fewer set, right? If you're prescribing that medication, you really need to counsel patients not to take it more than twice a week, right? Like taking it every day in the long run is not good. Same with triptans, right? I've seen patients that are like on 30 days per month of a suma triptana can also lead to rebound headaches and worsening. Absolutely. So something, since we are talking about I age a little bit here, or I should say for those who are familiar, right? The old old name would be like pseudo tumor cerebrine. We're trying to move away from that. But I've found, and I've read some articles about this over the years as well, is that sometimes when we have, let's say someone who seems like a typical migraine kind of thing. And again, this is edging into the treatment territory, but you've tried multiple medications just not responding. Maybe they have some risk factors in as much as maybe like, you know, a young overweight female and not classic for I.I.H. But sometimes I found that these patients with I.I.H. may clinically have like a phenotype of a migraine type presentation. What's been your experience with that? And like, how long do you wait before it's like, maybe I should do an L.P. in this patient? Well, I think it raises an even larger point that patients with secondary headache disorders can also have primary headache disorders like migraine and worsen due to their secondary headache disorder. And so I.H. is probably the most common one we run into that patients can have headaches from their I.H. But then they also can have migraines on top of that. And so how long do I wait? I mean, I think my, my threshold is if I'm worried about it, I'll at least discuss doing a lumbar puncture with the patient. Most patients like really, I find want to avoid that at all costs. But I try to read your patients that it can also, yes, it's not the most comfortable thing, but really the actual procedure is just a couple minutes and it can be really, really helpful. And it's not like something that necessarily would have to be done all the time. So I would have a low threshold to recommend a lumbar puncture if I'm really having trouble sorting it out, especially if I try, you know, for example, a migraine medication and it's not working or they're developing any other visual symptoms or any of those other symptoms we talked about, like post-atial tinnitus, I'll say, I think we just really need to do this. And then if the pressure is normal, you can be reassured. We've been talking about history and I thought maybe we can shift gears a little bit and talk about the physical exam. So does the exam matter for a patient, a headache patient? And let's kind of put ourselves in the clinic setting. So not the acute new onset headache, but kind of in the clinic setting. What do you want on exam when you think about seeing these patients? I think it's really helpful to have a baseline exam in anyone coming in with a headache. It's not necessarily something you have to repeat the whole thing every time you see patients. And I do think actually, if the first exam is normal, many headache patients can be managed doing telehealth visits. But on the first exam, so that some things I will focus on is a good cranial nerve exam. So again, making sure there's no signs of double vision or cranial nerve issue that could be related to increased pressure, a pupil exam. We'll do a fundoscopic exam looking for papillagema. Again, that would be make you worried that the pressure is too high. And then I'll do a basic screening exam making sure there's no other weakness, unilateral sensory findings, hyper-reflexion, anything that might point to a structural ideology. Curious. Because like you said earlier, right? Sometimes there's another problem kind of setting off maybe an underlying primary headache disorder. Obviously, as neurologist, we are biased towards a neurologic exam. What role do you think like a musculoskeletal exam for say like the head, neck, things like that plays a role as far as like, you know, cervic adgenic pain drivers or tender points. Yeah, I think that's super helpful to do. And often patients will tell you, like, you could ask them to point where it hurts the most right. And if they're kind of pointing in their traps or behind their neck, you can see if you can reproduce that tenderness. And that can definitely be helpful if you're thinking about is this coming from musculoskeletal issues in the neck like a cervic adgenic headache or not. Right? Some patients don't have it. And then you could say, okay, well, maybe we need to move away from treatment of that and really focus on more of a migraine or tension headache or whatever, whatever else it could be. Exactly. Something that I found, I was just going to say like, you know, I know sometimes like you were saying, like the distribution of the headache, I find, especially in some of my older patients who maybe have some some arthritis or things like that, there maybe tends to be a little bit more tendency, like not out and out occipital neuralgia, but a neuralgia-esque neuralgia form, if you will, type of pattern to their headache, whether that's like on the typical like back of the head occipital neuralgia or even sometimes like if maybe like you said earlier, like a TMJ type thing where maybe they have more like over their aricula temporal. And I find some gym just like tapping around on their head a little bit can sometimes reveal some useful diagnostic insights, not always, but it's one of those things where if the the headaches like really side locked, that can be I think a useful thing to just you know, push on their head a little bit see if it radiates and if it points us in a certain direction. Sarah and I both trained at Mass General Brigham under the legacy of Dr. Martin Samuels and he used to say that if a patient comes in with the headache, you better touch their head at some point, you're also going to leave and say the doctor didn't examine me. And I know it's neurologist, we sometimes, you know, laugh at that and I think it's said in just because we know potentially they're not be, you know, more of a, you know, a superficial exam in this case. But I do find that helpful, I part of it, you know, the tapping around I think is part of building a little bit of therapeutic rapport and making sure that the patient knows the question is being attended to. But I do think as you're tapping around there, they might find some sensitive spots. I think the one exception I've seen is for patients where the presentation is likely to be more acute, but could be subacute new onset headache. And in the case of cerebral venous sinus thrombosis, Dr. Samuels used to teach and I have used this examinuver and it has proven true every time, which is you'd say with one finger, can you point to where the headache is originating or where the pain is and you know, the patient will point exactly to say the, on say like the right occipital and then you get the, you know, CTV and that's exactly where that blood clot is sitting and potentially the transverse sinus on that side. And the idea there is that the dura is integrated and the meninges are, is where the pain is emanating from. And so that's always been a fun kind of maneuver to teach on rounds when we have an admission and to have the students give it a try. That's cool. So something that I find myself when I'm working with trainees, you know, students and residents, family residents, family medicine residents, is I keep bringing up the ICHD3 guidelines more just to kind of help them organize their approach because a lot of times I'll bring up some of these headache disorders that they've never heard of, right? Like we all, you know, everyone knows about cluster, but then we've got the stuff that's kind of on both sides of that timeline, you know, on the very long side, the very short side. And so, so we'll, we'll get some folks in here where it's like cluster-esque, but I'm like, so we start talking about that and maybe this is my own biases, but I kind of think of the ICHD3 almost as our version of the DSM because like the last criteria is always not better, not better account for by another medical syndrome or headaches syndrome. I know these are just guidelines, but I find them useful as far as like kind of organizing my thoughts and also kind of teaching those that way of organizing some of these syndromes to think about the quote-unquote weird headaches and that aren't quite migraine, aren't quite cluster, but in our in our history and exam types of situations is asking about like the automatic features, right? Like the nasal dripping, the tearing, you know, et cetera. Is that something that you routinely ask about or is it only like in certain what would prompt you, I guess, in a history to start asking about some of these less common headache disorders? Yeah, I would say I don't necessarily routinely ask patients about that, but if they're describing something that's, I would say the time course is probably what would make me ask, right? So the trigeminal, autonomic, subtle fallalges, they all have slightly different time courses, and to be honest, I typically will look it up to see what patient fits which criteria because I find it hard to keep track of. But if someone's like, yeah, I have these like short stabby things that are lasting seconds, I'll be like, okay, do you have any tearing or nasal congestion with those or on the other, you know, that could get more of the synced or synum. And then on other side of things, if they're like, yeah, I just had this really difficult headache on one side of my head for like days and days, you know, that you can also ask about that, and that made me think of more of like a hemicrenia continuum of pattern. And, you know, as you said, like, when we tend to think of, or at least, you know, if I think back to when I was a medical student, and we would hear, you know, the, like, the little test vignettes with a short lasting stabbing pain across the face, right, synced or sooner, right, which the SU, we're not going to give you a short lasting unilateral. But that's not the answer that most of us think of. We tend to think of, like, trigeminal neuralgia. So when we're thinking about, say, like, like trigeminal neuralgia, which is something I imagine you in the hemicreniccy, probably a lot more often than the rest of us, what are the kind of the things that would point you in that direction? And what kind of imaging or exam maneuvers would help you kind of suss that out? Yeah, so for trigeminal neuralgia, I find it's really specific pain in the trigeminal distribution. So patients will just scribe, most typically like in the V2 or V3. So somewhere in the, in the face, these, like, lancinating pains that are typically provoked by things like chewing, brushing their teeth cold, even like cold wind, any sort of thing that's that's stimulating the trigeminal nerve. And typically aren't associated otherwise with headache or necessarily any other symptoms. It's just really isolated lancinating pain to that distribution. And getting at RMS patient population after the optic nerve, the fifth cranial nerve is actually the most common cranial nerve involved in MS. So if I'm worried about trigeminal neuralgia, say in anyone just coming into the office, I do think it's helpful to get an MRI with a protocol to look at the cranial nerves. And it's helpful if you tell the radiologist exactly what you're looking at so they can do thinner slices through the brainstem and fifth cranial nerve. And they can look to see if there's any enhancement in the nerve, which may point you towards more of a demilaneating concern, or if there's any vascular compression on the nerve, because that is another cause of trigeminal neuralgia. Points. And I know there's a lot more to talk about that on the management side. Any other things that we should be thinking about history wise? I know we've done, I think, a pretty thorough overview, but any other final thoughts on that side of things? I think one thing just to be more explicit about, and this also goes back to that stuponomic that we hinted at at the beginning is some of the p's, the one p I like is the positionality of it. So we talked about for people who have high pressure lying down may worsen it, but there also is an entity called intracranial hypotension, which is due to low pressure. And we're seeing, I think this is an entity that's being recognized more and more. This is the opposite. It's actually people who have headache, which worsen significantly when they stand up. So they'll be totally fine lying down. And the second you get them up, they'll tell you they just have a debilitating headache. And this can be from eatrogenesis, right? Like when we do a lump of punctures on patients, they can then develop a post-lumbar puncture headache, or it can be more idiopathic if there's a dural leak somewhere. But I would say this is something we're starting to see more, or at least recognize it. Yes. So moving on to management, though, I think, right, everyone, everyone loves diagnosis, at least everyone in neurology does. But even more important, perhaps to some people is what do we do once we figure out what's going on? So again, kind of put it up this this vignette of someone who comes in relatively clean slate, hasn't been on any medications. When are we thinking about rescue meds? When are we thinking about prophylactic treatments? And where do we kind of start with those? Yeah. So even before starting with medications, I try to ask patients about other lifestyle triggers, because I think many times that can actually get to the root of the issue. So going over things, basic things, like making sure they're drinking enough, eating enough. There are some people that are very sensitive to alcohol and different preservatives and wine. For example, you can just ask them, like make a note of things over the next couple weeks. And they may find that if they just cut out one of those things, they'll be better. But say they do that and you're still meeting with someone who's having frequent headaches, I will typically offer patients a rescue medicine if they're having a severe headache around once a week. If it's, I think it depends on the severity. If they're like, oh, I get a rare migraine once a year, it's still reasonable for them to have a prescription medication. But typically, I'll start by asking patients what doses of over-the-counter medications they're taking. Because I'll often hear someone's like, oh, I have a really bad headache and I took 200 milligrams of ibuprofen. Well, that's really not a decent dose. So I'll make sure if they are, if they've tried over-the-counter medications that they're taking a good dose. And so I'll recommend to start for a rescue 600-800 milligrams of ibuprofen, even with Tylenol. And they can, you know, they can do up to a gram of Tylenol is what I'll say to start for rescue medicines. And if that doesn't work, then I'll all start thinking of other more prescription type medications. So if someone is having a migraine, which is one of the most common primary headache disorders, the first thing we'll start with is a triptan. Anyone who doesn't have like a vascular disorder, I would say that's sort of like the big contraindication. And kind of like blood pressure medications, I find you just like pick a triptan that you get used to, that you're used to for skyping. And so the one I typically start with is the sumitriptan or Imitrax. But I'm curious if you guys have a different one you pick. That's just the one I sort of got used to. You know, I find that insurance twists my arm a lot. And sumitriptan is the cheapest generally. So that is often where I start as well. One thing that I find is that when folks come to me and they've tried sumitriptan a lot of times, I'm asking like, well, what dose were you prescribed? Because I find that a lot of people are underdosed on it. So I'm just curious where you guys start. Yeah, I I started around 50, but I know some people will actually started 100 some of our headache colleagues. And I think the other big key with triptan is to ask when they're taking them. Because many patients will take them too late, but they really need to take them at headache cancer or onset to have full efficacy. And you can also talk about mode of administration for triptans, right? The oral ones take the longest have effect. There's nasal, some of them have nasal formulation, some are subcutaneous and really those subcutaneous in the nasal ones are going to work faster. So some patients may say, you don't necessarily have to give up on a triptan if they failed an oral one. You can look at trying a different formulation perhaps. I have one patient who she was on the the brand name imitrex back when it came out, you know, 30, 40 years ago with the injection. Lives and dies by it. That's that's all she wants. I just wanted to jump on to the bandwagon of you know, patient education around the treatment plan. Because I think headache management is as many things in neurology and many chronic conditions. There's such a big self-management component. So really empowering them to understand what the medicines are for and how they work and how to they best work for them. I find that that's something that I'm always working on with the patient. I also think that your point zero about the lifestyle factors. There's a huge education component there too, right? So the regular hydration. I also talk to all my headache patients about sleep and how their sleep is going. And that's often a target for me for headache management. I feel like I routinely order sleep studies if people haven't had their potential culprit sleep apnea, you know, diagnosed. So I find that that is often an outcome for my new patients with headache. And then the other thing I'll talk a lot about is stress and just to help them understand that that's going to be a potential precipitant for some of my patients, especially those who have more of a vestibular component, it'll describe interesting triggers like actually jet lag or like flying or being on boats or being on trips. So we start to paint a picture to help them understand what might be triggers for them and when they should be prepared and have their little rescue packs. And the last thing I'll say when I prescribe the trip times, I always say, you know, put these in whatever bag you carry with you because they're only as helpful as if they're within reach in 30 minutes. And that's been a issue. Some of my patients where I have one who has a stash at work in a stash at home and was at the gym and a headache started coming on. And she's like, no, because she knew she wouldn't be home for about two or three hours and it up in a bad bout. But kind of, you know, that education can go a long way so that they know how to use the medicines for themselves. No, absolutely. And I always feel that like we all know stress is such a big trigger and sleep deprivation. Sometimes like you get maybe a new parent with young kids at home or someone who is working crazy hours like 12 hours shifts or things, you know, think of like all of our residents and students. And it's like I always feel like a bit of a useless advisor if I was like, have you considered trying to reduce your stress? Of like, yeah, that'd be great. Not feasible right now though. But yeah, it is one of those things where I think we all feel that like, oh, you know, I could be in so much better health if I slept regularly and drank enough water every day. I think we're all guilty of that in our modern society. But it is very true. Totally true. And I don't know that the idea, the education is more around reducing it, although that's always great as able, but more that that can be a trigger for the worsening. I can't, this may be cutting too close to home, but I can't tell you the number of residents whose migraines get out of control when they enter our residency sleep wake on cycle. And unfortunately, it can be a trigger for worsening about what had been a stable, stable managed condition. As I said, getting at caffeine, right, that's also a big trigger like lack of caffeine. And it also can be a helpful abortive treatment, right? So you can tell patients, many people have figured this out themselves, but you know, go get a iced coffee from Dunkin Donuts. It has some hydration, perhaps, and then also caffeine and take your trip tan or whatever else you want to take, you know, dial it all, ibuprofen and that, that can be helpful or you can get, you know, you can get that a local pharmacy, like, et cetera. And for example, has a little bit of caffeine in it that can be helpful. I've definitely done the ibuprofen within espresso chaser for headaches before for myself. And you mentioned Sarah low-pressure headache and caffeine is one of the best treatments for that specifically as well. Yeah, and then the other thing I'll often ask about is the nausea component, right? Because metaclopermide or beglan that can be very helpful for both headache and nausea. You just have to warn people that there's very rare likely how they could develop the dystonic reaction to it. So I always just tell patients so they don't freak out around in the ER. Do you ever counsel them to take like Ben and Drill if they do develop any of the I do. Yeah, I do. Yeah. Yeah. I'll tell them right. Like their neck feels really tight, just take a Ben and Drill and then give me a call. Yeah. Sometimes I find, and again, right, this kind of goes into the, the realities of a lot of our patients where they can't necessarily take one of the sedating anti-naudial medications for the rescue meds because they have to like keep working or drive home or whatever. And I know, right, we know on Dancitron is not necessarily as effective as a lot of the other anti-medics like like Fenergan or composing or reglan. And so a lot of times I'm asking patients like where are your headaches happening? A lot. If you were taking something that makes you drowsy, is that going to be a deal breaker? And so sometimes I end up going with the medication that I know is probably going to be less effective just because the side effects aren't really manageable in their like day-to-day life. Yeah, totally. And I find that actually kind of the opposite happens when someone goes into the ER, right? They like want to make the patient sleep so they'll give often a sedating anti-naudial medicine plus sometimes even IV Benadryl sometimes, you know, part of our cocktail and then patients do ultimately feel better though maybe a bit sleepy. Yeah, I was, I had one headache attending who'd always say, you know, you can't have a headache if you're asleep, which I technically true, but not a great long-term solution necessarily. Particularly too good there. I think paying attention to side effects is key. It's kind of how I make a decision about a prophylactic agent as well, especially because a prophylactic agent is something that we'll be committing to day-to-day. So let's maybe shift there, Sarah, for whom would you consider a preventative medication, that kind of more chronic treatment and then how do you, what's your, what do you go to, how do you escalate that and how do you choose an option for your patient? Yeah, so I would say if someone is having more than two headaches per week that are debilitating, I'll offer them a prophylactic medication and there's so many now. So I think the first thing I actually start with is talking about nutraceuticals. I find that something called migralief, which is a combination of magnesium, riboflavin and fever view, especially for patients who are hesitant to take prescription medications can be really helpful and it actually has decent evidence. Again, there's many supplements out there, but I think magnesium does have some evidence for headache, acute treatment and prevention. So I'll offer that to most patients off the bat and then if I feel like, you know, they've tried that or they are having really severe headaches and they benefit from a prescription medication, I'll think about them in classes and so I will think about tricyclic antidepressants, amitriptyline or nortriptyline in patients, often I will use them in people who have trouble sleeping because the big side effect of those is that they're sedating. So if I want to treat someone's headache and get them to sleep, I'll pick one of those, typically amitriptyline is what I start with and if it's someone who's very medication sensitive, I will do even like a really low dose, like 5 or 10 milligrams because I've found that if you give someone too much amitriptyline, they'll feel horrible, they'll feel dizzy tired and they'll be like, I'm done with this medication, right? But it actually is quite good for for headache prevention. The other class I think about are beta blockers or calcium channel blockers and so this is where it's important to look at someone's comorbidities or medication list, right? So if someone is already on metoprolol for coronary artery disease, you're not necessarily going to add another beta blocker on top of that. But if you have a young person who's otherwise healthy, normal heart rate, normal blood pressure, maybe they run a little bit anxious, you know, proprennalal could be a great option for them. Again, I warn them that it can make them a little tired or, you know, if they're a performance athlete may reduce their ability to fully exercise and run into that once. And then I think kind of the third class of medications I'll use are more of the anti-seuser type medications. So like Valproic Acid or Topiramate can also be quite affected. I think Valproic Acid is a little bit more challenging in terms of its side effect profile and also it's extremely tragic. So I'll avoid that in any patients of child bearing age. And those ones I'll again think of the side effect profile. So Topiramate in particular is one of the few medications that is weight neutral, sometimes even leads to weight loss. So for many medications, if that's a concern, we'll try low dose Topiramate or if they have other neuropathic type pain that that medication can work really well. But it can also contribute to cognitive dysfunctions. If you have someone who's very concerned about their cognition, maybe that's not the best choice in you try one of the other ones. And, you know, it's interesting, have found that like even with just low doses of Topiramate, like sometimes just 50 milligrams at night, maybe even up to 100 milligrams at night, which is not obviously like our seizure dosing by a long stretch. That is sometimes enough for some of these people with the chronic migraine. And they feel great. They maybe, like you said, lose 5, 10 pounds. Everybody's happy. Headaches are significantly reduced. It's not everybody certainly, but you really feel like a rock star when that does happen. Definitely. And I'll say I also will use Topiramate if I'm worried someone may have an IH type phenotype. It does have some efficacy, some carponech in hydrate efficacy like, like diamox, which is what we typically use for IH. So if I'm like, if there's a case where I'm really not sure I'll say, okay, let's just try Topiramate. It will kind of treat both things, you know, probably migraine better than IH. But let's, let's see. I've had some patients where they found it helpful. Again, even at low dose, like 50 milligrams at night. And there was a good point right now to just circle back and kind of double down on some of the diagnostics and sort of why it matters to really characterize the headaches syndrome correctly, because we've mostly been like, we'll make it explicit talking about migraine management, right? So if you were defining, or maybe chronic, tenured type headache or chronic headache, chronic new daily headache, these will probably respond to the types of medications we've been discussing. I think if you're really falling in a different headache bucket, like trigemoral neuralgia, we often, you know, turned first to the anti-seizure medications, or if you're falling into something like your, you know, persuaded that it might be an RCBS-like picture. You might be looking at a rapamil or calcium channel blocker. So, and then just now you mentioned Topamax era for the IH picture, but typically our first line and a pure IH headache might be turning to a cytosolomide and really targeting the CSF production rather than like the secondary pain. So any other comments for your go-to's for some of our other, you know, headache syndromes, and like, what's your Bixen match approach for these conditions? So I say from my perspective when I see trigeminal neuralgia, I find these patients tend to respond best to either carbamazepine or oxcarbazepine, as opposed to some of the other medications that we mentioned. I say, that's probably the thing that I come across the most. And, you know, something I found is that you will get some folks in the primary care setting who, you know, they've made the correct diagnosis of trigeminal neuralgia. They've started the carbamazepine, but they started it like 100 or 200 milligrams three times a day. And then, as you're probably guessing where I'm going, they're on it for a couple of weeks, it works okay, then it drops off its ineffectiveness. And, you know, one of the things I think people forget about is the auto-induction effect that carbamazepine has on its own metabolism. And so, you do have to kind of stay on top of it for the first few weeks there in terms of the titration. I don't know if it's been at your experience, but I find that fairly often in my patient population. Yeah, and I find patients will self-medicate sometimes, they'll go, "Oh, I took an extra dose," or you'll prescribe it three times a day, and they'll have a rescue like 50 milligrams tablet that they'll have because it does work that well for many patients. And I'd say the bigger side effects we run into at higher doses are hyponatremia and a little bit of dizziness and fatigue, but otherwise it's pretty well tolerated. It just needs the occasional lab monitoring. Yeah. And I do find, when I, again, this might be too far down the rabbit trail, but I do find that sometimes switching, if I run into the hyponatremia, I end up switching to one of the other sodium channel blockers, like a Phenetone. If they come in with an acute exacerbation or phosphenetone, rather, I should say, yeah, since we aren't in the 1980s. But even Lemotrogen, or in some cases, like a Lyric or Gavipentin. I'll put a plug in again for patient education, because I think what we're talking about is what's the setting up the expectations for headache management. And I always like to say, we're now beginning a partnership. It's going to be a journey. We'll get there, but it may take trial and error and time. And even prescribing a new medicine, these medicines don't work like the over-the-counter tunnel. It's not going to work in 30 minutes. It's committing to it for a few weeks to give it a real try. So I think setting up expectation that our goals are to make frequency less and the severity less intolerable. So you can have the quality of life and to engage in the functional things you want to do, whether it's working and not having to go into a dark room for multiple days. So I think setting that goal of like we may not get the pain to zero, but we're going to get it better managed. We're going to empower you to have a sense of how you'll manage it yourself. And then I think I always say, and I don't know which medicine will work for you. But fortunately, we have a lot of options. And that's just been my clinical experience. I can't always predict who's going to respond to what. And it's sometimes surprising that a very low dose will work for someone that you get all excited. You prescribe that for the next person. It doesn't work at all. So just sort of being flexible and adaptable as a provider to say like it's not necessarily your failure or their failure. But it's just, you know, it's got to be something else. Now those are opportunities also in the road forks in the road to reevaluate the diagnosis, you know, potentially if it's really not. I'm having a therapeutic effect, right? That therapy is part of the diagnostic journey. But I just think setting the patient up with, it's going to take time, but also hopefully with the hope that we have options found to be helpful. And then they'll stick out, stick it out with you until you figure it until you find something that works. I think that's super important and also counseling them just because they tried one medication in a certain class. If that one didn't work, it doesn't mean the whole class is out right. There's sometimes just certain medications work best for other people. And it's a lot of trial and error and dose finding. But having that partnership with patients can be very helpful. So you don't feel like you're giving up on them or vice versa. I know we're coming up close on our end of time. But I know I think we would be remiss if we didn't talk about kind of the new kids on the block as it were. So, you know, in the last couple of years, the American headache society kind of said that they recommend the CGRP blockers as first-length therapy because of their efficacy and their, you know, to be frank, much more benign side-effect profiles compared to a lot of the medications we've been talking about that have been kind of incidentally found to treat headaches, right? They were antidepressants, blood pressure meds, anti-seater drugs. That's like, oh, they also help with headaches. But now we have a class that was designed specifically for migraines and headache disorders. And I'm curious what's your experience with prescribing them and do you have any practice patterns or things that you find most effective with your patients? Yeah, I think it's a tricky question, right? Should you just start with the CGRP or go for some of the older medications first? That was a whole debate at our most recent American Academy neurology meeting. I typically don't start with them first, mostly because we tend to run into insurance issues. They require often that patients will fail medication in at least two-class as my experience, right? But then I, even as an MS specialist, I do prescribe these medications. I typically will ask the patients, like in terms of figuring out which one do they prefer an injectable or a pill? And that will kind of be my way I figure out which way I'm going to go. I've found that now that there's more injectable medications out there in general, people aren't as bothered by giving themselves an injection at home as they used to, even just a couple years ago. And then I'll think about the indication, right? Am I going to use this just for rescue? Or if I need more of a preventative medication, that will help me figure out which CGRP I will use. And as I said before, like the one I tend to go to first is Nurtek or Mejapant, because that can be used both for rescue and/or prevention, depending on the dosing. So if it's dose to every other day, you can use it for chronic migraine prevention, or if they take it as needed, that would be more for an acute indication. I find that one in particular is nice because it has both indications. Yeah. And like you said, I've been having trouble with insurance, getting the preventive dose of Nurtek approved in my own practice, but it may just be my patient population that I'm working with. But yeah, no, I think that's great. And again, this isn't, I don't think this is evidence-based, but maybe this is more expert opinion-based at this level of time, is that you talk about if you have one that's ineffective, like if it's whether it's a receptor blocker or a ligand blocker, kind of switching to the opposite side of the mechanism. I haven't, again, anecdotally. I haven't noticed a huge amount, but I do find that sometimes just one medication works better than the other for no apparent reason, as far as I can determine. I have found that as well. Yeah. Any final thoughts, recommendations, things that you would like to see more done for folks who are getting treated for their headaches in the primary care setting that you think are missed opportunities? I think some of the things we've touched on, but just to highlight again, so I've seen many, I've been impressed that many primary care doctors have started prescriptions for various different triptans and preventatives, but I think the biggest thing would be dose-finding. So I've seen the open-mill startup prescription and then not go up on the dose for a tripdan or, or not switch to a different one. So I would just empower people to realize it just because a specific dose or from a release of a medication doesn't work, not to give up on it and to increase the dose and then we're always happy to see patients in consultation and send them back to their primary care. Yeah. I couldn't emphasize that enough, Sarah, because so many of the patients that come to see us are like, the decision was made, they need neurology, and you know, six months go by. And there's an opportunity to try just even the first signs that we talked about, and hopefully maybe get a little bit of relief for the patient release information like, hey, this is, you know, medicine to pursue, it's got some impact, let's increase it versus none at all. Yeah, that's a great point. And it is, right? I think you see this on the inpatient and the outpatient side, you know, it's like, we've consulted X specialty. I don't need to think about that anymore, but in reality, right, because people are out there, there's still, you know, suffering with whatever problems going on. And I mean, these are, I think it's low hanging fruit for improving quality of life and care for a lot of people. Sarah, thank you so much for joining us on our first episode in the chief concern series. We started it off on a high with headache, and we're excited to continue the conversations. But any final words, thank you all for having me and hope this helps you treat your headache patients. Thank you. Anything you want to plug before you go? Any projects you're working on? Well, Sarah and I are working on a project to teach the non-neural, just Sarah, take it away. We are working on lots of different bedside teaching projects to bring neurology to the neuron. Neurologists and working with various different people across the country to make this even better. Awesome. Definitely a needed, a needed thing. So go ahead to here. There's lots of good people working on it. All right. Well, thank you, everyone, for listening. Galina, folks want to find you or reach out to you. Where should they look? They can reach out to me by email, which we can put in the show notes. And I'd be happy to answer any questions they had there. Or, if you have other questions and chief concerns you want to hear on this series, feel free to reach out to Michael or myself. That's right. You can always click the link in the show notes and text us as well. And you can also find me via email at [email protected] or you can find our show on x@neural_podcast. Thank you both again, and I really appreciate all the insights today.