Sinus Headache

2. Menstrual Migraine

3. Olfactory hallucinations and headache

4. Shaking arm and headache

5. Traumatic Brain Injury and head pain

6. Cluster headache and suicide thinking



Headaches are a common experience and not all headaches are created equal. This type of headache is more common than diabetes and asthma combined. Less than half of all patients receive adequate evaluation or treatment.


Migraine headache refers to a specific type of recurrent attack of discomfort in the head, eyes, sinus area, neck etc that is not due to a serious systemic illness or from an aneurysm, arterial malformation or inflammation, infection of the brain, seizure or stroke.


Migraine sufferers may have a warning that the headache is coming on before the pain begins or may experience nausea, sensitivity to light, noise, odors, see jagged lines or sparkles along with or separate from pain. Headaches are usually similar but may vary in pain or length of discomfort. Pain, whether "ice pick or burning or throbbing" is not a predictable localizer of where the problem is in the brain.


Medical experts that study migraine believe that there are "triggers" that disrupt our biorhythm and begin a cascade of changes that cause both nerve inflammation and blood vessal swelling.


There is no one universal best treatment for headaches with the exception of not getting the "next one". Advances in science have allowed doctors to treat this condition in most cases quickly and safely. Using a combination of medication that affects serotonin receptors ( triptan class) along with medication to reduce seizure like brain irritability ( anti-convulsants) can reduce migraine headaches by more than 50%. Often we treat headaches ourselves with OTC pills, sleep, cold compresses or lying down in a dark, quiet room. We can do better with good health and proper medical treatment to reduce the suffering from this condition.


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1. Migraine masquerading as a Sinus headache.


T came to me with a long history of headaches but they had recently gotten worse after an inner tube from a water park fell on her head. She told me they were very painful involving her entire top part of her head and caused dizziness with nausea. She did get partial relief with pain medication . When she added the triptan class of medication with a blood pressure pill she got near total relief.


To her surprise, she continued to experience discomfort in the sinus area and behind her eyes. Despite no "gunky" yellow nasal discharge, sinus tenderness or fever she still took over the counter sinus pills. She had convinced herself that she even needed antibiotics. This combination of pills never relieved her headaches.


On her last visit we discussed the path of the 5th cranial nerve; when  inflamed this nerve causes pain sensitive tissues in the face and sinus area to ache in a manner that can masquerade as a sinus infection. She stopped her sinus pill approach and used her triptan class of medication more often to experience relief of her headache.


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2. Menstrual Migraines


C  came to me after her birth control pills were adjusted following her last pregnancy. She complained of feeling overwhelmed in the last part of each month since her child was born with headaches and fatigue. Her doctor had adjusted her estrogen to a lower level knowing that estrogen can exacerbate headaches. She still complained.


After a thorough history, I learned that during her entire pregnancy she was headache free. For several years before and now, several months after the pregnancy, she felt nausea, and irritable ten days before her menstrual period. Her health was excellent and blood tests and brain images were normal.


She was concerned that daily prescription medication would be too much so we used the calendar to determine the next cycle. She started on an SSRI class of medication two weeks before her period and added the triptan class of medication at the time of her period. This approach has worked excellently for the past 3 cycles.


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3. Headaches or Seizures in a child


J is a junior high school student with a good family and does well in school. Last winter, in class he complained he felt sick when the teacher observed him to stare unresponsively with a glazed look. The emergency room exam, including a CT of the brain to look for a stroke, was normal but an EEG done later was suspicious for a seizure.


J came to me with several more of these brief events but also reported that he heard people call his name and smelled popcorn when no one or no popcorn was cooking. He always experienced a severe headache afterwards.


Several other EEG�s were normal but he continued to observe headaches, dizziness and nausea despite some relief with the triptan class of medication. I added medication for epilepsy and noticed that this was very helpful to eliminate headaches for 3 months.. His mother has restricted his play with other children because she fears he will have a great big seizure, fall and hurt himself. J has become more depressed.


Does he have seizures or does he have a complicated migraine? Fortunately, the EEG�s are normal and he can take the same medication for each condition since some anticonvulsants help migraine and epilepsy.


We are now involving J and his mom in counseling. He does not need a pill for depression, just better understanding of his migraine and less restrictions by mom.


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4. Seizures then headaches in an adult.


D is a mother of a special needs child and she suffers from obesity, diabetes and undiagnosed ADHD.


Her last seizure sent her to the local hospital six years ago. She continued to have daily headaches that prevented her from relaxing and enjoying things fully. The headaches were painful and associated with vomiting and fatigue. Her local doctor was unable to refer her successfully to a neurologist because with her public aid card, no one volunteered to re-evaluate her headaches or seizures.


After I examined her and reviewed her history I ran an EEG. This was normal. Her headaches were the main concern. Despite the advances in the past decade her daily headaches were treated with OTC pills. These were not successful.


After one week of a new anticonvulsant pill she became headache free. This small change had a very significant improvement in her lifestyle. 


After two months of headache free and no recurrence of seizures I felt comfortable reviewing her childhood history of the learning disorder. She had a mild dyslexia but really suffered from inattentive ADHD. Just as her migraine headaches in adulthood were not evaluated or treated properly, neither was her ADD. I added a low dose of stimulant medication and she has dramatically improved in her attention, organization, weight management and overall state of health.


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5.  Traumatic Brain Injury headaches


S came to my office with the history that five years earlier she was ejected from a motor cycle and fractured her neck. As this healed the real problems began; she developed problems with her short tem memory, problems with her social judgment and suffered chronic daily headaches. She developed depression as she was unable to hold a job and despite being treated with antidepressant medication and pain medication she was very depressed.


S told me after she got well that I was the last hope because she had decided that she would commit suicide if she couldn�t regain hope and relieve her headaches.


We came up with a plan to evaluate her cognitive loss with a university psychologist and add medication to help her memory improve. Though her brain MRI was normal we did a test to view her brain function; SPECT. This revealed massive areas of loss of brain function in the Frontal lobe and Cingulate gyrus.


After her tests we both decided on a treatment plan. This was a new approach because in the past , though she was treated with antidepressant and pain medication, she was never in charge of the treatment plan. This approach allowed S to feel hopeful. She became cooperative in rehabilitation, taking mediation, and seeking out a good Osteopath to help her with manipulation.


Her headache medicines include an SSRI class of antidepressant, a memory pill, a strong sleep medication and an occasional pain medication. Her headaches were complicated by misunderstanding, lack of mutual respect with doctors, failure to correct the structural changes that occurred after the motor vehicle accident and her ongoing adjustment to the personality and attention skills that accompany a brain injury.


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6. Cluster headaches and Anxiety


Mr. Z came to me because he continued to have an erratic response to a  pain medication after trying a long list of medications. His headaches were frighteningly intense. They might awaken him from his sleep or build to the point of  incapacitation during the day. They began with a droopy eyelid, nasal congestion on one side of the face and progressed to the point of overwhelming pain. This is a classic �cluster� headache.


The headaches had progressed over five years,taking a greater and greater part of his lifestyle into their hold, interfering with family and work.  The advise from the other headache doctors was to continue this �opioid� class of medication because it consistently worked.


Mr. Z became increasingly concerned when the pharmaceutical manufacturer changed the delivery of this "slick, lolly-pop" form of medicine to one that was rough and did not deliver the same relief despite a higher dose. This lead him to take more and  get less relief. His treating doctors became concerned he was taking too much so they limited the amount he could receive. He developed Panic symptoms as he feared he would be left without the medicine at an unpredictable time of need. At this point he confided that he would rather be dead than go thru another series of unpredictable and intractable headaches without this medication.


I reviewed his history with his wife, father and treating headache neurologist to determine weather the "cluster" headache was as severe as the patient pointed out or a means to abuse medication. Both the history of this disorder and the history from family reassured me that he was responsible with this medication.


He told me that more than the medicine itself, is his feeling of trust with me that at times of need I am available to listen and provide the prescription. His panic symptoms have gone away. There is more to treating a headache than the right medication.


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Dr. Kohn is a board certified neurologist with additional training in psychiatry and brain imaging. His practice focus is directed to conditions that affect the brain and behavior such as headache, epilepsy, ADHD in adults and children, brain injury and developmental delays due to Autism, Aspergers or Tourette syndrome.



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