Author: Priyanka Chaudry

The following brief review is written specifically for those patients who have chronic headache resulting in the frequent use of pain medication.  Studies show that up to 4% of the American population suffers from headache more than 15 days per month.1 Most of those individuals have a daily or almost daily headache syndrome.  Further reports indicate that as many as 80% pf those patients with chronic daily or almost daily headaches may use pain medication on a daily or almost daily basis.2

Although previous terms such as analgesic rebound headache, drug induced headache, and transformed migraine have been previously used to describe headache associated with sustained medication exposure, the revised International Headache Society Classification Criteria has classified these headaches under the term Medication Overuse Headache (MOH).3    Under the International Headache Society guidelines, MOH is headache that occurs >15 days per month, is associated with the frequent intake of pain medications, and resolves after the discontinuation of the medication.  The clinical syndrome of MOH becomes a self sustaining, rhythmic, headache medication cycle characterized by the daily or almost daily headache in association with the daily or almost daily use of analgesics.

MOH can occur as a result of the overuse of simple over the counter pain medications (Aspirin, Excedrin, Advil. Aleve, Tylenol, BC Powders, etc.) and/or as a result of prescription pain medications (Fiorinal and other Butalbitals, Darvon, Ultram, Stadol Nasal Spray, etc.), including narcotics (Vicodin and other Hydrocodones, Codeine, Percodan, Percocet, etc.) and triptans (Imitrex, Zomig, Maxalt, Relpax, Axert, Amerge, Frova, Treximet, etc.).4   In summary, Medication Overuse Headache can be facilitated by virtually any agent used for symptomatic relief of headache.  Headache associated with the medication overuse is one of the more common causes of Chronic Daily Headache in patients who present to specialized headache clinics in North America.5,6

As the science of Medication Overuse Headache has become better understood, it also became recognized that medication overuse may make headaches refractory to preventive (prophylactic) therapy.7   This means that not only will analgesic overuse in headache patients lead to worsening of the headache rather than relief, but that pain medication overuse also appears to interfere with the therapeutic benefit of standard usually effective pharmacological and nonpharmacological treatment regimens, specifically prophylactic or preventive headache medications.  Thus, the use of preventive medications does not result in the expected improvement until discontinuance and withdrawal of the daily or almost daily analgesics are accomplished. The earlier terminology of Analgesic Rebound Headache which historically had been widely used to describe Medication Overuse Headache implies that the headache was caused by withdrawal from analgesics. However, the term “rebound” was originally intended to explain the increased headache frequency observed with medication overuse. Thus, the overuse of pain medication may actually result in important changes within the brain which perpetuate the recurrent headache. One might infer that the medication used to prevent today’s headache actually causes tomorrow’s headache.

The syndrome of headaches caused by medication overuse is not a drug withdrawal. The condition is not indicative of drug addiction. Instead, Medication Overuse Headache is a condition which appears to affect different parts of the Central Nervous System (CNS). These CNS changes may directly suppress certain pain receptors within the brain and may actually down-regulate or even diminish the number of anti-pain receptors in the brain. There may also be biochemical changes which take place within the brain tissue. Research has shown that important substances within the brain such as serotonin, glutamate, calcitonin gene related peptide (CGRP), nitric oxide, and others, play an important role in the mechanism of migraine and therefore, would likely be involved in Medication Overuse Headache. These substances are known as neurotransmitters and may be instrumental in the production of increased pain when analgesics are stopped. Headaches such as migraine appear to develop through a cascade of events that take place within the brain during a migraine attack. An alteration of these events’ secondary to chronic use of analgesics may underlie the development of chronic headache.

Research has also shown that there are anatomical or physical changes that also occur in the brain as a result of frequent migraine.8 In specific areas of the brain, there appears to be tissue damage or damage to the neurons (brain cells). These changes take place in areas of the brain that are involved in the pain modulating system. One possible implication is that untreated chronic migraine leads to further injury and dysfunction of the brain’s antinociceptive (anti-pain) system. Theoretically, this impairment of the antinociceptive (anti-pain) activity could subsequently result in a permanent feeling of head pain (chronic headaches). It is also possible that the frequent use of pain medications may also play a role in this process. There is concern that eventually these events which may lead to permanent central nervous system changes result in chronic daily headaches. Clinical experience has also shown that, in a specific group of individuals, even stopping the daily or almost daily pain medication does not disrupt the chronic daily headache pattern. Therefore, there may be a population of patients who do not respond to medication withdrawal and who continue to have chronic refractory headaches even when off pain medication. Fortunately, this population of refractory headache patients represents a relatively smaller group of individuals with MOH. The majority of patients with Medication Overuse Headaches, if motivated, have a favorable prognosis for recovery. However, the rehabilitative process takes time. The experience of many Headache Medicine specialists suggests that it may take several months following withdrawal of pain medication before headache improvement is appreciated. In those who persist in having daily headaches even when off frequent pain medication, one possible explanation points to pathophysiological changes within the brain itself.

If one were to summarize the International Headache Society (IHS) criteria for Medication Overuse Headache, the diagnostic criteria would include:

1. Headache present on >15 days/month.
2. Regular use of a medication > 3 months of one or more acute / symptomatic treatment drugs:
3. Ergotamine, triptans, opioids, or combination analgesic medications >10 days a month on a regular basis for >than 3 months.
4. Simple analgesics or any combination of ergotamine, triptans, analgesic opioids >15 days/month on a regular basis for >3 months without overuse of any single class alone.
5. Headache has developed or markedly worsened during medication overuse.

It should be emphasized that although improvement may occur even within a 2-month period following discontinuation of pain medication, there are many headache specialists who agree that it may take up to 6 months (or even longer) for a patient to reach maximum improvement.

Therefore, although the exact cause of Medication Overuse Headache is still within the research phase, the etiology points to a probable complex interaction of biochemical, anatomical, environmental and psychological factors. Consideration of all these issues is important in developing an effective treatment plan. It has been universally agreed, that after the proper diagnosis has been established, effective therapy requires withdrawing from the daily use of pain medication. Clinical experience indicates that medical and behavioral headache treatment has less chance of being successful as long as the patient continues to take daily or almost daily pain medications. The withdrawal of analgesics is frequently difficult and depending on the degree of involvement, must be accomplished under appropriate medical supervision. Patients suffering from medication-induced headache may also exhibit primary or secondary emotional disorders such as depression, low frustration or low tolerance due to the chronic pain. Other patients may exhibit physical and emotional dependency. Some patients may benefit from treatment with behavioral methods including biofeedback, stress management, and cognitive behavioral therapy. There are those in whom psychotherapy and appropriate medical management of associated neuropsychiatric conditions is very helpful. In addition, treatment should also include lifestyle changes, cessation of smoking, a healthy diet, regular eating and sleeping patterns and an exercise program.  Headache triggers must be avoided if recognized.

In any medication withdrawal process, potential withdrawal symptoms including severe headache exacerbation, nausea and vomiting, agitation, restlessness and sleep disturbance may occur.  Depending on the medication the patient is overusing, there may be other neurological and medical issues that should be anticipated and treated if present. Although only rarely observed, in patients who overuse barbiturate-containing headache drugs such as Butalbital, one must caution against the possibility of seizures and hallucinations. If most patients, with appropriate medical supervision, if minor withdrawal symptoms were to occur, they often last on an average of 2 to 10 days. It is likely that almost every headache specialist has encountered patients who have attempted, on their own, to discontinue pain medication and have experienced such escalation of pain that they are reluctant to stop their medications. Other patients simply have a great deal of trepidation about stopping their medications. The discontinuation of pain medication may also be complicated by psychological factors which include medication dependency. Therefore, a transition or bridging regimen is usually recommended. The transitional medications might include alternative safer analgesic control and nonpharmacological support that increases the patient’s ability to work through a potential withdrawal process. The use of “rescue medications” is sometimes necessary during the discontinuation phase of treatment when daily or almost daily analgesics are being withdrawn. It is important that the patient understand that a rescue medication is not appropriate for frequent use.

In fully Comprehensive Multidisciplinary Headache Centers the above considerations and treatment models are designed for outpatient treatment protocols which may include the availability of eadache medicine outpatient infusion centers for the administration of appropriate specific intravenous medications when indicated.  Family support and support from other relationships is also important.   In those few patients who have additional medical comorbidities that may also require treatment, hospitalization for inpatient care may also be appropriate.  Although very few in number, those select headache medicine patients who may require hospitalization, earlier medical literature has defined the efficacy of hospitalization in that patient population. The most frequently quoted reference is from the US Headache Guidelines Consortium, Section on Inpatient Treatment. That excellent comprehensive review was entitled “Inpatient Treatment of Headache: An Evidenced-Based Assessment”11 But again, it is to be emphasized that only a small minority of patients require hospitalization for the effective treatment of Medication Overuse Headaches.

It should be emphasized that patients with Medication Overuse Headaches must accept the realization that several mechanisms appear to play an important role in the production of chronic daily or almost chronic daily headaches. In addition to the disability associated with persistent pain, the pathophysiological, biochemical and behavioral mechanisms may lead to chronic changes within the brain.  In addition, Medication Overuse Headache is considered by many to be a major health problem.  Acute pain medications when overused could also affect other organ systems.  Overuse of various medications may result in chronic kidney failure and gastrointestinal ulcers or even have potential harmful effects on the cardiovascular system if used daily or almost daily.

With appropriate treatment under the supervision of a headache medicine specialist, improvement from headache pain still must occur over the course of time.  The prognosis for a good functional recovery also depends on each patient’s individual clinical situation. In other words, “there is no quick fix”. There is a period of rehabilitation for every patient during which time any psychological and behavioral factors must also be addressed. The overall treatment of Medication Overuse Headache should be considered a rehabilitative model of care with objectives and goals to improve the patient’s quality of life and maximize their functional capacity, while protecting them from the potential long term undesirable side effects following the chronic use of analgesics for headache control.

REFERENCES

1. Scher AL Lipton RB, Stewart W. Risk factors for chronic daily headache. Curr Pain Headache Rep. 2002;6:486‑491.

2. Mathew NT. Transformed migraine. Cephalgia. 1993; 13(suppl 12):78‑83.

3. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia 2004; 24 (suppl 1): 1‑60.

4. Limmroth V, Katsarava Z,  Fritsche G, Przywara S, Diener HC. Features of medication overuse headache following overuse of different acute headache drugs. Neurology 2002; 59 (7): 1011-1014.

5. Mathew NT, Reuveni U, Perez F. Transformed or evolutive migraine. Headache 1987 ; 27: 102‑106.

6. Rapoport AM,. Analgesic rebound headache. Headache 1988 28: 662‑665.

7. Mathew NT,, Kkurman R,‑ Perez F. Drug induced refractory headache‑clinical features and management. Headache 1990; 30: 634‑638.

8. Welch KM, Nagesh V, Aurora SS, Gelman N. Periaqueductal gray matter dysfunction in migraine: cause or the burden of illness? Headache 2001; 41: 629‑637.

9. Headache Classification Committee: Cephalalgia 2006; 26: 742-746.

10. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders. Cephalalgia 2004; 24: 94‑95.

11. Freitag FG, Lake AL, Lipton R, Cady R. Inpatient Treatment of Headache: An Evidenced‑Based Assessment. Headache 2004: 44: 342‑360.

Migraine is a Neurological Condition, best defined as a Neurovascular Disorder.  Migraine is characterized by recurrent attacks of severe headache that may be accompanied by various neurological signs and symptoms.  Migraine is thus not just a headache but an important central nervous system disorder which affects 38 million people in the U.S. Medical studies estimate that about 14% of adults in the U.S. suffer from migraine and that 2-3 million sufferers manifest a chronic form of migraine characterized by chronic daily headaches which are associated with significant quality of life issues, marked disability and other important neurological consequences.

Nearly 1 in 4 U.S. households includes someone with migraine.  About 5 million Americans experience at least one migraine attack per month while more than 11 million people in the U.S. blame migraines for causing moderate to severe disability.  91% of migraineurs miss work or cannot function normally during a migraine attack. 59% with migraine miss family or social events while another 53% with migraine show some disability requiring reducing activities or even bedrest.  49% of migraineurs indicate that they had to restrict activities for at least one day during a migraine. Probably related to hormonal issues, migraine is more common in women. 70% of all migraine sufferers are women.

In the American Migraine Study 11, conducted in 2001, 92% of women and 89% of men with severe migraine had some headache related disability.  About half of the migraineurs were severely disabled and required bedrest. Because migraine headaches strike most commonly during the more productive working years, the disease state also takes a financial toll.  The World Health Organization (WHO) rates migraine as one of the 19th most common reason for disability.  The average migraine sufferer misses 2 days of work per year.  Others may work during a migraine attack but report much lower productivity.  In a 1998 study, in the U.S. the total costs of disability attributed to migraine was estimated to exceed $13 Billion per year.  In a 2002 study, the cost of decreased productivity related to migraine was $19.6 Billion. While more updated studies are in progress, in the U.S. the overall economic cost related to the burden of migraine is staggering.

Headache as an isolated symptom is best defined as a universal experience.  Headache is one of the most common symptoms in the general population. Headache disorders are among the most common disorders of the central nervous system.   For some, the symptoms of headache may just be an episodic nuisance. For others the headache symptoms may be manifestations of a chronic significant disabling disease.  Yet in others headache may also be the first symptom of a more serious, even life-threatening condition. Headache is therefore also a variable experience. Of the primary headache disorders, migraine, tension-type headache and medication-overuse headache are of public health importance since they are responsible for the high population levels of disability and ill-health.

Migraine headache involves different mechanisms of action within the brain and cranium.  The diagnosis of migraine is usually based upon retrospective patient reporting of their headache characteristics, signs and symptoms.  Most laboratory tests as well as the physical examination are usually normal. In specific migraineurs, neuroimaging may reveal abnormalities on MRI which are related to the migraine syndrome.  While childhood migraine is an important early diagnosis, migraine more often begins in puberty and statistically is most prevalent between the ages of 35 and 45 years. The migraine attack is divided into four potential phases. 1.  The Premonitory Phase (Prodrome). 2. The Aura Phase. 3. The Headache Phase. 4. The Resolution Phase (Postdrome).

The Premonitory Phase (Prodrome):  The Prodrome, which is characteristically a change in mood or behavior may also present with nonspecific poorly characterized feelings that a migraine attack is about to occur.  These premonitory features are quite variable among migraineurs but may be consistent within an individual. The premonitory phenomena may include such things as a feeling of depression, hyperactivity, irritability, food cravings, cognitive dysfunction, diarrhea or constipation and other signs or symptoms involving one’s mental state, neurological state and/or more general perceptions.  A prodrome may occur between 20% to 60% of migraineurs and may be manifested hours to days before the migraine headache.

The Aura Phase:  The migraine aura is the most common migraine syndrome associated with neurological symptoms.  Most symptoms develop over a 5 to 10-minute period. Most auras last less than 30 minutes but may persist to over 60 minutes or more.  The most common auras are visual abnormalities but aura may include sensory or motor phenomena. In some instances, an aura may be even more complex and include language disturbances or brief or sometimes prolonged sensory motor abnormalities.  Auras may vary in their complexity. Migraine aura usually occur within an hour before the migraine headache. Sometimes migraine with aura occurs with little or no headache, especially in people age 50 or older. Migraine aura may also occur off and on during the headache phase of migraine.  Migraine aura is usually related to pathophysiological changes occurring within the central nervous system during a migraine attack.

The Headache Phase:  About 60% of headaches in migraine are predominantly unilateral.  A headache can even switch sides during the same attack. But it is important to emphasize that a bilateral headache does not exclude the diagnosis of migraine.  About 40%-45% of migraine patients will present with bilateral headache. 85% of patients with migraine describe a throbbing, pulsating headache which may also be exacerbated by any physical activity or even simple movements of the head.  Therefore, typically, during migraine, the patient does not prefer to move and may desire to lie down without much movement of the head or body. Associated symptoms during the headache phase may include nausea (90% of patients), vomiting (30% of patients), light sensitivity (80% of patients), and sound sensitivity (76% of patients).  Because of light sensitivity (photophobia) and sound sensitivity (Phonophobia), patients with migraine often seek a dark, quiet room during an attack.

Resolution Phase (Postdrome):  Following a migraine attack, the patient may feel tired, fatigued, washed out, irritable, listless and may manifest scalp tenderness and even significant mood changes.  Some individuals may report a feeling of being refreshed or even euphoric. Others may experience depression or malaise. In some individuals, this postdrome, or after affects of the migraine attack, may persist for hours to days.

Migraine is not just a headache but is an extremely incapacitating collection of signs and symptoms which have their origin within the central nervous system and result in dysfunction and disability.  Migraine is a condition involving the brain. Migraine is not a diagnosis of exclusion but a neurological condition defined by specific clinical markers identified by performing a careful and detailed neurological history and physical examination.

Because everyone is unique and migraine symptoms may vary by occurrence and even within attacks, a careful evaluation by an experienced headache medicine specialist is often necessary.  It is important for patients to consult a headache specialist if headache symptoms are disabling, interfere with normal life activities or work, are associated with neurological abnormalities, increase in frequency or severity, or if the patient is not responsive to the usual and customary medical care.  Patients experiencing headaches with migraine features two or more days a week should consider further headache medicine consultation. Pregnant women and nursing mothers would also benefit if their medication management were under the supervision of a headache medicine specialist for treatment of their migraines.

The clinical entity of HEADACHE dates back to ancient times.  As early as the dawn of civilization, primitive headache remedies included procedures aimed at ridding the body of the “demons and evil spirits” that were believed to cause headaches.  As early as the Neolithic period dating back to 7000 BC, skulls have been found bearing man made holes (called trephination) presumably done for medical reasons which may have included the treatment of headache.  Skulls demonstrating trepanation have also been found in Peru dating back to the thirteenth century.  The writings of the early Greeks referred to headache as a serious medical condition.  Hippocrates (400 BC) may have been the first to describe the clinical symptoms of migraine.  In the historical Hippocratic books Hippocrates discussed what appears to have been the visual aura that can precede migraine.  The term “migraine’ itself is derived from the Greek word hemicrania. Throughout history, there have been famous individuals such as Plato, Thomas Willis, Erasmus Darwin (Charles Darwin’s grandfather), and others who have contributed to our understanding of headache. More recent scholars, such as Dr Harold Wolff, played an important role in our classification of different types of headache and their treatment. Following his classic 1948 publication of the first edition of Wolff’s Headache, it was Dr Wolff who introduced important scientific concepts which have served to modernize the study of headache.  Since that publication there has been an explosion in headache research which has resulted in our better understanding of this clinical condition.  There are now scientific mechanisms which more clearly define the pathophysiology of some headaches such as migraine.  This has also led to the development of new migraine specific medications and ultimately more effective treatment opportunities.  Epidemiological studies show that Migraine itself currently affects approximately 38 million Americans.

Migraine has played an influential role throughout world history.  There have been many famous and accomplished individuals who have suffered from migraine.  Examples of just a few include Julius Caesar, Napoleon, Thomas Jefferson, Ulysses S. Grant, and Robert E. Lee.  Great painters such as Vincent Van Gogh, George Seurat, and Claude Monet had migraine.  The famous authors Virginia Woolf, Cervantes (best known for Don Quixote) and Lewis Carroll (Alice’ Adventures in Wonderland) had migraine. There is even evidence to suggest that at least some of Alice’s Adventures were based on Carroll’s personal migraine visual aura perceptions. As Cheshire Cat observed, “One pill makes you smaller; one pill makes you larger, the pills mother gives you do nothing at all”.  There has been literature which indicates that Thomas Jefferson’s headaches were so severe and debilitating that they often interfered with his ability to function.  As he wrote to Martha Jefferson in February 18, 1784, “Having to my habitual ill health…. lately added an attack of my periodical headache; I am obliged to avoid reading, writing, and almost thinking”.  In March 1807, while still President, Jefferson wrote “…Indeed, I have but little moment in the morning in which I can either read, write, or think, being obliged to be shut up in a dark room from early in the forenoon till night, with a periodical headache”.

Headache sufferers constitute one of the largest groups of patients within a neurological practice.  More patients who visit doctors complain of headache than any other single ailment. Headache and migraine in particular, may be considered as a universal human condition which continues to be under diagnosed, misdiagnosed and/or mistreated.  Whereas in some individuals, headache may be an occasional episodic, sometimes nuisance, for others the symptoms of headache may be a manifestation of a disabling chronic disease.  In the latter group, headache disrupts daily routines and impairs quality of life.  The frequency, severity, and even life consequences of headache sufferers vary widely.  The causes of headache are different in different individuals.  The treatment needs of patients who have occasional mild headaches are significantly different from those patients whose attacks are frequent and completely disabling.  Headache remains one of the most common health issues which challenge physicians and other health professionals.  The symptoms of head pain are a frequent cause of human suffering and disability.  For many patients with headache, consultation and headache management under the direction of an expert headache medical specialist is necessary to provide the entire spectrum of headache management.  Specialized headache care by a headache doctor are for patients in whom comprehensive services are essential to address the multifunctional components of their headaches.

A daily Headache Diary is one of the most important tools in managing headache pain and frequency, tracking the characteristics of an individual patient’s headache history, and assisting patients in defining headache triggers.  Headache Diaries improve treatment by identifying the response to abortive and prophylactic medications and overall help your physician plan your treatment protocol.

By using a Headache Diary, patterns can be identified from the diary which may also help in defining the specific headache diagnosis.  As an example, a diary is extremely important in the treatment of menstrual migraine where short term prophylactic medications could be initiated prior to the onset of headache and maintained for several days to abort the headache.

There are numbers of options available for keeping a headache diary.  Some are as follows:

iPhone and Android APPS such as iHeadache, Migraine Buddy, and Migraine Diary are available

There are computer based diaries as Migraine Diary available

In addition, well known printed diaries are to be found on the National Headache Foundation and American Headache Society websites

Whatever option is used, it is important to maintain the diary to help your physician achieve maximum headache control.

Living well with migraines is a first line of defense to help headache patients achieve better headache control and improve quality of life. There are a number of lifestyle factors that may have influence in managing headaches.  Some of these factors, for individual patients, may be as important as many of the medical or other therapeutic approaches employed for headache control.   This brief discussion will focus upon those lifestyle changes that may positively influence headache frequency in patients with migraine.

SLEEP:

The human body does not function well when it is sleep deprived.  In the 21st Century this has become a common problem for many.  The literature suggests that teenagers require a minimum of 9 hours of sleep for proper restorative function.  Adults require 71/2 hours. During healthy restorative sleep the brain goes through a series of stages of sleep from very light to very deep sleep and include the active dream stages of sleep as occur during REM (Rapid Eye Movement).  Many medications, including “sleep medications” which are referred to as “ hypnotics” may disrupt these healthy stages of sleep. Alcohol, nicotine and caffeine are notorious for being disruptive to quality sleep.

If possible, it is best for patients with migraine to attempt going to bed approximately the same time each night and plan to awaken as the same time each morning.  In those susceptible migraineurs sleeping in on days off and on vacations may disrupt the brain’s inherent sleep-wake rhythms and contribute to migraine headaches. Thus, over sleeping or under sleeping could be a trigger for migraine occurrence.  Brief daytime naps are not an issue if they do not cause headaches or contribute to insomnia.

Having chronic recurrent headache pain may contribute to insomnia, just as having insomnia contributes to headaches.  Addressing the issues together may be beneficial and improve overall outcomes.

ORAL INTAKE/DIET:

Everyone is unique but there are categories of foods that are more likely to be triggers for migraine that others. People with migraine vary in their sensitivity to specific foods.  Some foods contain naturally occurring amino acids as tyramine, phenylethylamine and dopamine. These amino acids, even in patients without headaches, may provoke brief significant increases in blood pressure when taken in sufficient amounts.  Specific patients with headache may lack the ability to rapidly metabolize these amino acids which may have prolonged effects on blood vessel tone as a possible cause of headaches. Others may have an inheritable condition in which they are unable to breakdown glutens in the intestines and this disorder has been linked not only to severe gastrointestinal and nutritional problems but also to a number of neurological issues including headache.

Food additives may sensitize some migraineurs to an attack.  The most common of these is MSG (monosodium glutamate) and aspartame (an artificial sweetener).  Both of these compounds are derived from or are transformed to amino acids essential for life. These compounds play a role in the brain as stimulating neurotransmitters (chemical messengers).  When used in excessive amounts they may cause migraine in susceptible individuals. Recent trends with bottled waters (some promoted as being nutritional) contain the B vitamin niacin which in some people promotes excessive dilation of the blood vessels and with this, headache.

Nutritional supplements such as minerals and vitamins are not needed for most people who eat well balanced food choices, including adequate sources of meats, fish, dairy, vegetables and fruits.  Those who have less than optimal diets may need to use multi-vitamin supplements. If there are dietary issues, patients are advised to consult with their primary care physicians for advice and guidance.  In some migraine patients a magnesium supplement may be recommended. Since magnesium deficiency may be within the brain cells and not necessarily within the blood stream, laboratory testing for magnesium deficiency in migraine may result in variable outcomes.  Therefore accurate hematologic testing for magnesium deficiency in migraine may not be a reliable indicator since the deficiency is within the neurons and not systemic. For this reason, in some migraineurs with specific type of migraine, magnesium supplements may be prescribed empirically.

ORAL LIQUID INTAKE:

Children, adolescents, and many adults may be prone to headaches from being relatively dehydrated.  General guidelines suggest that 8 eight ounce glasses of water per day should be consumed by adults.  However most healthy people can stay hydrated by drinking water and other fluids when they feel thirsty.  For some people fewer that eight glasses of water daily may be enough. Physical activities including active play by children and adolescents should be accompanied by an increase in fluid consumption.  Special brands of water or bottled waters in general are not needed.

There is also much individual variation in sensitivity to caffeine and some people do best by completely avoiding caffeine.  But caffeine has become almost ubiquitous in our diets. Part of this may be related to the stimulating effect it has that may counterattack the fatigue that occurs from not getting adequate sleep.  Caffeine is found in coffee, tea, soft drinks, chocolate, energy drinks and many over the counter and some prescription pain relievers. In some individuals, the ingestion of caffeine may precipitate migraine while in others missing a daily dose of caffeine may precipitate the headache.  The following are the amounts of caffeine in different ingested products:

. A typical dose of over the counter medication contains

an average of 130 mg of caffeine

. A medium sized chocolate bar contains 50 mg of caffeine

.  A 12 oz. can of soda may contain between 50-100 mg of caffeine

.  A 6 oz. cup of coffee contains an average of 100 mg of caffeine

.  A 6 oz. cup of tea contains an average of 20-60 mg of caffeine

.  6 oz. of decaffeinated coffee contains an average of 2 mg. of caffeine

There are also a number of foods that can trigger migraines.  If a migraineur identifies a particular food that is associated with their migraines, that food should be eliminated from their diet.  Some examples of different foods that can be triggers for migraine include:

.  Caffeine as above.  It is recommended patients with migraine should

limit their caffeine intake to less than 200 mg of caffeine per day

.  Chocolate

.  Alcohol – Some migraineurs are especially sensitive to wine.  Red wine is notorious as a headache trigger.  This appears to be related to a specific chemical substance in red wine.  White wine, tap beer, and the distilled clear liquors are less likely to provoke a migraine

.  Foods containing sulfates which is a type of preservative

.  Raw onions

.  Monosodium Glutamate and Aspartame as discussed above

.  Oranges, grapefruit and other citrus fruits

.  Nitrates and nitrites which are added to foods as preservatives

EXERCISE:

Aerobic exercise for 20 minutes four times a week may exert significant benefits on the brain’s pain regulating system and with that reduce the severity of headaches.  Hoverer, some individuals may experience the onset of or worsening of headache related to exercise. While it is important to determine that there is no serious underlying cause for this, it may be a matter of the form of exercise one does.  High impact aerobics, running and weight lifting are the forms most likely to contribute to or cause headache. In those with sensitivity to these forms of activity, other exercises as swimming or bicycling may be a better alternative.

STRESS:

In these times it would be truly an exceptional person who does not experience stress.  There are many different definitions of emotional stress. But common within all the different definitions of stress are the physical, emotional and psychological strain secondary to the precipitating factors.  Stress as a condition or feeling is a state experienced when a person perceives that the demands exceed the personal and social resources that the individual is able to mobilize. Stress as an emotional and pathophysiological state can trigger the body’s response resulting in the release of different hormones, including adrenalin and cortisol.  Tachycardia, alterations in the digestive system, shunting of blood flow to major muscle groups and changing of the various other autonomic system functions are just a few of the physiological changes that can occur as a byproduct of stress. Stress can also be a trigger for migraine. Between 50% and 70% of people with migraine can connect their symptoms to situations induced by a stressful event or even daily stress.  Migraine may occur with either the buildup or the let down from a significant stressful situation. Thus, stress management with appropriate behavioral cognitive therapy in tandem with behavior modification training are also important mechanisms in the control and management of both episodic and chronic migraine.

Migraine can be different from person to person or even from one migraine to the next.  This brief review is focused upon “triggers”, a tern healthcare provider’s use for those internal or external factors that can precipitate a migraine in susceptible individuals.  Migraine triggers might be different from one person to another but common migraine triggers are factors to consider in developing a migraine prevention plan.

Nerve blocks are performed on nerves that supply the sensation to various parts of the scalp. They are often used to treat different types of headaches, including cluster headaches, migraines, and other types of head pain. They consist of a local anesthetic (usually bupivacaine, a long-acting anesthetic); sometimes a corticosteroid is also incorporated, particularly for cluster headache treatment. Their actions are two-fold: (1) the anesthetic effect, where the skin supplied by the nerve becomes numb and (2) the analgesic effect (pain relief). These two factors are independent of each other.

Nerve blocks probably work for pain because they modulate the signals transmitted by the nerves into the brain. The nerves that are injected for a headache are part of the trigeminal nerve system or the upper cervical nerves, and they connect directly into structures in the brain stem that participate in the generation of pain.

There are several types of nerve blocks including occipital-greater and lesser; supraorbital and auriculotemporal.

Our center also offers Sphenopalatine nerve blocks. Sphenopalatine Ganglion (SPG) is the group of nerves behind the nose and sinus area near the throat and is covered by a thin layer of connective tissue and mucous membrane.  It is the largest group of nerves outside the area of the brain cavity.

The SPG plays a crucial role as a center to dispatch signals as a part of the autonomic nervous system.  The SPG receives sensory inputs from other nerve centers in the body. The nerve fibers coming from the base of the brain pass through another nerve center that directly connects to the SPG and is directly connected to a branch of the facial nerve.

We use specialized FDA cleared, flexible catheters. The procedure involves placing a very thin plastic tube into the nose to insert numbing medication in and around the SPG. These procedures are not painful and less invasive than the injection technique.

As a comprehensive headache center, we perform various nerve blocks. The procedures are done in the office and take only a few minutes to complete.

Your headache specialist can determine which will be the appropriate procedure based on your history and nature of a headache.