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
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
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
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
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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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