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The Neurotransmitters: Clinical Neurology Education
Headache with Dr. Aniket Natekar
Join Dr. Aniket Natekar, a neurologist and headache specialist, for an enlightening discussion on the stigmas and complexities surrounding headache disorders.
Navigating the world of migraine treatment can be as bewildering as the condition itself. Dr. Natekar lends his expertise, revealing how a well-considered medication regimen and lifestyle changes can transform patient outcomes.
We also examine the latest advancements in acute migraine treatments, including CGRP inhibitors and triptan prescription practices, providing a comprehensive look at the options available. Completing our journey, we reflect on the language we use in headache medicine and the diverse, fulfilling career paths within this subspecialty.
Find Dr. Aniket Natekar on X at @Natekar_MD
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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.
Hello and welcome back to The Neurotransmitters. We're happy you could join us today. I'm very happy to welcome Dr Aniket Natekar. I know I mispronounced that. Would you care to correct me?
Aniket Natekar:Sure it's pronounced Aniket Natekar.
Michael Kentris:Thank you so much and I apologize. Another fellow neurologist joining us today and headache specialist to boot. Thank you again, and I am very happy to have you.
Aniket Natekar:Thank you for having me. It's a pleasure and I always enjoy trying to give back in terms of education and providing knowledge to the general public and or neurologists or anyone else who's just interested.
Michael Kentris:Awesome, Awesome. I was really grateful that you reached out to me on X slash Twitter, which is how I meet a lot of folks these days. I think it's a great way to keep in touch in the neurology community and the medical community at large. One of the reasons I was so happy was that I've seen some of your other podcasts in the past where you've done some interviews and you do a great job educating about headache. Obviously, for those who are in medicine and for those who aren't, headache is pretty universal. It's one of the most common, if not the most common, neurologic disorder that's out in the general population.
Aniket Natekar:Yeah, people tend to not pay as much attention to it or let me try to reword that as they don't give it the same importance that they may other diseases For a lot of people. They tend to pay more attention to epilepsy, stroke, als, parkinson's disease, things with physical manifestations.
Michael Kentris:Right. Yeah, it's not a sexy diagnosis, right.
Aniket Natekar:Exactly. A lot of times there's a stigma associated with it. Companies, big organizations, even insurance companies, will try their best not to cover it, not to give people time off work or not to try to provide any form of accommodations because there's no physical manifestations of the disease. In some cases, people also think they're faking it.
Michael Kentris:Right, yeah, it's one of those things. It's like the most invisible of our invisible disorders.
Aniket Natekar:Exactly. People don't understand in some cases that migraine is a disease just like several other headache disorders. People don't necessarily give it the same weight as they would high blood pressure or high cholesterol. Those are equally important disease processes that we obviously need to treat and do our best to prevent. But when someone has migraine, we should also treat that the same as we would if they had high blood pressure or high cholesterol.
Michael Kentris:Absolutely, I think. Starting out, would you care to differentiate a little bit for those who may be less familiar when we say headache versus when we say migraine. How would someone differentiate between the two if they were evaluating someone?
Aniket Natekar:Great question. In the headache world we don't really separate out something as a regular headache versus migraine, because in reality there's no such thing as a regular headache. I've had a headache twice in my life, once when I was 11 with the flu, the second time after I hit my head on a car door. Outside of that, I've never had a headache. Don't know what it's like. I've never endured it personally. That's why I try to avoid saying regular headache with our patients and in general. Migraine tends to be the second most common type of headache disorder. Tension type headache is actually the most common. Migraine is just the most well-known. It's the one that is experienced by a lot of individuals and tends to drive a lot of the media attention when we think of headache. There's several headache disorders. I like to think of headache as an umbrella term. Within that you have multiple disorders, such as migraine, tension type headache, any of the trigeminal autonomic cephalology or a new daily persistent headache, et cetera.
Michael Kentris:In my experience and from what I've read in the past, a lot of times tension headache or your mild ache, so to speak, but it doesn't usually get bad enough for most people to seek medical attention. I'm a little jealous of your lack of headaches throughout your life. I get some muscular and tension type headaches when I'm on call and I'm sleep deprived or overcaffeinated all the typical types of triggers. I'll take some ibuprofen or acetaminophen or something like that, and I'm usually fine. That happens maybe once every month or six weeks or so, but I've never seen a doctor about it, because obviously I'm a terrible patient. What are our main things when we are looking at a migraine In terms of asking questions, evaluating someone? What do we need to look for? What do we need to ask about to get better assessments for these patients?
Aniket Natekar:Oh yeah, no problem at all. When you think of migraine, first thing is first, there's something called the international classification for headache disorders, ichd, and they're on version three right now. Anyone who's interested in trying to diagnose someone with a headache, you can look up ICHD3.org. Within that are the classification criteria for all of the major headache disorders Migraine, tension type headache, cluster headache, sunked pseudo cervical, genetic headache, tension type headache, as we said. But when it comes to migraine, someone needs to have at least five attacks in their life of which the headache has lasted anywhere between four to 72 hours. Then, in addition to that, there's a third type, which is where they need to have at least two of, I believe, four criteria. One, it has to be unilateral. Two, it tends to be pulsating.
Aniket Natekar:So I describe it to my patients as they can hear their heartbeat in their head or does it feel like the heart is beating inside their head? It tends to be moderate or severe pain. Then they typically notice that it's worse with physical activity. We're not talking triathlon level exercise. This is routine physical activity, things that they would normally do in their daily life. Then during the attack, they need to have either nausea and or vomiting, or photophobia and phonophobia, what those two are meaning sensitivity to light and sensitivity to sex. You need both of those. Then you could also have nausea and or vomiting. With all of these, you can diagnose someone with migraine. It is important to know that if someone's headache is only three hours, or if it's more than 72 hours, does that mean that they don't have migraine? No, it could still mean that they have migraine. It's just that in order to have an official diagnosis, you need diagnostic criteria that can be objective, but if someone's at 3.78 hours, I would still treat them as if they had migraine. If they had all of the other characteristics.
Michael Kentris:How do different auras wrap into the diagnostic evaluation there?
Aniket Natekar:Yeah, great question when it comes to auras. Auras can be visual, they can be sensory, they can be auditory, they can even be smell. You might smell a certain type of fragrance or a scent of some sort. Auras are typically anywhere between five minutes to an hour before the onset of the pain. The ones that we think about the most are visual auras, but they can really, again, be any of the types. It could even be a combination of the two.
Aniket Natekar:Some people have what we call a brainstem aura, so it's not just the visual or the sensory or the smell that they may have, but they may actually develop hemiparesis. They might develop complete numbness on one side. They may develop severe onset of dizziness and true vertigo that is associated with it. They may even have a decreased level of consciousness prior to the pain. Aura tends to be more of a vascular phenomenon. What we think is happening initially in the headache phase is that you get hyperremix. You get a rush of blood followed by shrinkage of the blood vessels. You get less blood going to the brain In the certain part of the brain that's getting less blood. That's where the auras symptoms will start, for example, if you have less blood flow in the occipital lobe. That's what tends to cause the visual auras. If you have it in the olfactory cortex then you know it might be the scent of smell or the lack thereof that can be the aura, and so on and so forth.
Michael Kentris:Excellent and I know obviously there's differences in exam findings when someone is in between attacks versus in the attack itself. But let's say someone's coming in. They're describing the events to you by history. It sounds like migraine. What are the essential things that we need to ask about history-wise, like in terms of mimics, and also things to check on our physical examination to make sure that there aren't any secondary causes of headache lurking in the background?
Aniket Natekar:No, that's a great question. So anyone who comes in for the first time in your visit and they're talking about headache, you want to scream for other things and again I apologize for the coughing, it's just something in the throat. So there's something called Snoop P4, which is a very common mnemonic that us neurologists, particularly headache specialists, try to use. So the S stands for systemic, which means you don't use screen for any sort of malignancy, immunosuppression of any kind, hiv concerns for fever, chills, night sweats, myalgia meaning muscle pain, weight loss, any sort of jaw clodication. The N tends to be neurologic, meaning you look for focal or global neurologic symptoms. This is not limited to but can include behavioral changes, double vision, transient visual changes, ringing in the ear that can be pulsatile, motor weakness, sensory loss, ataxia, which is difficulty with balance.
Aniket Natekar:The first O is you look at the onset. Is it a sudden onset? Meaning did it peak in less than one minute? The other O is for onset based on the age. You see, is this a headache before the age of five or is this a new onset headache after the age of 65?
Aniket Natekar:Then you can look at the Ps. The first one is you want to see is this a pattern change, meaning have you seen an evolution of the headache in any way? Have any of the characteristics changed with time, including has it become a daily headache versus before it was once a month? You want to see is it precipitated by the valsalva maneuver? Have you noticed that it's worse with certain positions, for example sitting up versus lying down or standing?
Aniket Natekar:For the second P, you look at papillodema, meaning do you notice any swelling of the optic nerves which might indicate a component of increased CSF pressure in the head? You look to see if someone is pregnant. Is this a nuance at headache during pregnancy or is this in any way a change of their headache while they're pregnant? Then you want to see is this a phenotype of a rare headache, meaning this would be the last P? Is it one of the trigeminal autonomic cephalalgia? Is this a hypnic headache? Is this an exercise-induced headache? Is it cough-induced? Is it even a sex-induced headache? You screen for all of those and if several of them are flagging positive, then you want to rule out the more emergent causes for headache. It may require them going to the ER, get emergent imaging, further workup. Once you've ruled all of the more emergent, potentially deadly things out, you then can screen for the other primary headache disorders.
Michael Kentris:No, that was a great rundown the Snoop 4, and I think there's even a Snoop 10 out there, but I would be a liar if I said I knew all 10Ps. But yeah, I think it's a great way to approach these patients. Now, before we started recording, we were chatting a bit and we were talking Most of these patients with headaches, with migraines, specifically present first, obviously to their primary care physician. What is the range that a primary care physician, family medicine doctor and internist be comfortable in terms of starting treatment, diagnosing flip that and reverse it diagnosing and treating when should they be like? Maybe I need to get an extra opinion if this isn't responding as expected.
Aniket Natekar:That's a great question. I would say PCPs in general primary care physicians, nurse practitioners, physician assistants they should at least be comfortable with screening. You do the Snoop P4. I'm not expecting PCPs of any kind to read the MRI themselves. They may be reliant more on the radiology report, not a problem. But if you've ruled out the more emergent stuff, then using a simple resource like up-to-date or even ICHD3.org, you can quickly screen. Okay, the patient has all of these. I can diagnose them with migraine. I'm not afraid to Google things in front of my patient all the time.
Aniket Natekar:I encourage other providers and doctors to do the same. After you've Googled, you can even then Google further. What are common medications to treat said condition, particularly a headache type Within migraine? There's three main classes that we look at as the initial treatment options. One would be an anti-seizure met. Typically topioremaid is our first go-to. You could even look at antidepressants, most of the TCA, so amitriptyline or nortriptyline. You could even look at duloxetine or venylophaxine. Then the third is anti-blood pressure, that's both beta blockers as well as ACE inhibitors, arbs. You could think of propanol or Candisartin as the two main amongst the blood pressures.
Aniket Natekar:The other thing I always encourage primary care providers and doctors to do is to look at other comorbid conditions, if any. If, for example, your patient has depression we know depression is not a cause for headache but it contributes to it. It's part of the cycle If there is depression, maybe consider an amitriptyline or duloxetine or venylophaxine or nortriptyline. If there's concern for weight gain to appear or may it has a side effect of weight loss that you can try to take advantage of. If there's any sort of high blood pressure, then yes, propanol or Candisartin can also be helpful in those situations. Typically I tell PCPs try one or two of these.
Aniket Natekar:If your patient is still reporting headache that is not getting better and you've addressed the medications. Also, talk to them about lifestyle. I think we as medical professionals in general don't do enough of a good job screening our patients for lifestyle. I've made it a point in my own clinic to ask them what do you eat for lunch? What do you eat for dinner? What do you eat for breakfast? How much water do you drink? How much caffeine do you drink? Are you eating mostly red meat? Do you eat mostly seafood, fruits and vegetables? Then, more importantly, do you do any form of exercise? Because more often than not, lifestyle plays a huge part in managing headache. I can even begin to tell you how many patients headache or headache disorders. I should say I've gotten better maybe not cured, but better just by modifying lifestyle. Then this is even before the start of medications.
Michael Kentris:Yeah, anecdotally, let me just grab this. I know we don't record video, but I'm holding up a half gallon water container here. For the last three weeks to support your point I've been drinking one of these a day. I think I've lost like seven pounds over the last month. It's just the small things. You do a little exercise, change your diet and it does make a difference. It's all connected, right?
Aniket Natekar:It is when we think of other cardiovascular conditions, for example, the heart healthy diet is also known as the Mediterranean diet. Another way to look at it is the pescetarian diet. Because I live in Ohio, I coined a jokingly term. I call it the not Ohio diet, because people in Ohio tend to eat a lot of beef, a lot of pork and they'd love drinking Mountain Dew. I tell them instead, eat like you live in California or New York, where they tend to eat more of a Mediterranean diet, see food, fruits and vegetables. You don't tell them eliminate the caffeine. Stick to water.
Aniket Natekar:I can't even begin to tell you how many times I've actually counseled patients on not just the importance of water but how to drink water, how to eliminate any potential tastes of water that they claim there is in more than water. How many people I've counseled on using something like a Brita filter. I actually had to counsel a patient on using a metal water bottle and I helped him calculate out the savings that he would have if he had a reusable water bottle versus buying packs of water per year. I did the math in real time for him, based on how much he spent every week. That's what it took in order to get it. Sometimes it just goes right down to the very basics for our patients that we need to do.
Michael Kentris:Yeah, yeah, you're absolutely right. It's one of those things I've been getting. Maybe it's just me getting older as I close in on 40. Starting to think about why do I have the habits that I have and how are they detrimental to my longevity and my long-term health. I'm not quite to the midlife crisis stage, but I'm trying to head it off at the pass. It is one of those things. I just saw a clip the other day where it was in a second hand but someone said treat your body like a house that you're going to have to live in for the next 70 years. I was like that's really well put, actually.
Aniket Natekar:Yeah, I always try to tell patients it's never too late to make changes, even if you're 40, 50, 60, even 70-year-olds. I tell them, even if you make changes now, your body will thank you later. A common phrase that I use my patient is or with my patients, I should say is we should focus on prevention to prevent treatment later. The older you get, hopefully you don't need blood pressure meds, diabetes meds, cholesterol meds.
Aniket Natekar:Maybe you won't need a cane or a walker for as late as possible, because you've exercised your whole life and strengthened your bones and focused on mental health as well. These are all the keys that I try to emphasize with my patients. A bunch of my colleagues joke I'm the most holistic of the headache specialists because I spend the most time talking about this.
Michael Kentris:Yeah, it really does pay off for a lot of these people. These are universal things for just general health. Especially when we're dealing with a chronic pain type situation, it just adds an extra incentive for someone to try and pursue these changes.
Aniket Natekar:Yeah, more often than not, at least in today's day and age, patients are always looking for medication, medication, medication. Then I try to emphasize to them well, guess what? We may start a medication for headache, but if you make these lifestyle changes and your headache gets better, there's a good chance we may be able to come off of the meds too. Maybe some of your other medications, if they're on any, for example, blood pressure, cholesterol, diabetes could get better as well. I had a patient lose well over 100 pounds. He's now off of his blood pressure meds, his cholesterol meds and his diabetes meds got cut in half. His BCB was saying what caused the change. I told him. My neurologist really told me to cut out the beef and pork and the chips, cookies, candy and switch to seafood, fruits and vegetables.
Michael Kentris:Yeah, and that really made a difference. It is one of those things, I think. In a similar story a few years ago I had a younger guy who was having, like you know, it was more like in your chronic daily headache type situation. But you dig into the story a little bit and you find out he's drinking like two, 12 liters of Mountain Dew a day, which, to your earlier point, it is a very common thing we see in Ohio.
Michael Kentris:I was just like, do you realize how much caffeine that is? And it's like how much water you drink? And he was like none. I was like, oh my God, how have you not had any kidney stones already? But yeah, it's like you go through and it's like you're spending this much money every day on all this, on the soda, and you're drinking this many milligrams of caffeine, that's this many cups of coffee. Like doesn't that sound like a little much? And yeah, it's one of those things where you kind of like you write it out in black and white on a sheet of paper and you tell them, unfortunately, kind of, you know, have that come to come to Jesus moment with them. And tell them like, hey, you're causing yourself a lot of problems here and I do kind of. I don't know if this is the same for you, but a lot of times I counsel them like we can try medications, but if you're living your life like this, they're probably not going to work.
Aniket Natekar:Yeah, I tell the patients, you know, regardless of how good a medication may or may not work at that very moment, there's always a chance that it may stop working later if you continue to maintain bad habits. Now you know, and I always try to tell them lifestyle changes, regardless of what you think, will help you long term. You know, studies have shown regular exercise when it comes to migraine can help reduce the intensity, duration and frequency of headache up to 50%. You know, now, is that a guarantee everyone will get 50%? No, but something about the headache should get better with regular exercise, with better diet, you know, with increased hydration and elimination of several other dietary and lifestyle things that we shouldn't be doing.
Michael Kentris:Right, and I mean to be honest, right when we look at a lot of the medication trials for migraine, a lot of the responder rates are 20 to 50%. Also right, so it's almost like another medication in and of itself.
Aniket Natekar:Yeah, and it's nature's best medication, right? So you know, in plenty of studies have shown the American diet has higher risk or higher rates of diabetes, high blood pressure, heart disease and particularly several types of cancer. You know and the United States is, I believe, per capita the most obese country in the world Ohio is the sixth most overweight state in the country.
Michael Kentris:And it's in the middle in the north. Yeah.
Aniket Natekar:Yet it's up there. So this is where emphasizing the dietary and lifestyle factors now, particularly with primary care providers and doctors, can make a huge impact before they ever reach a specialist.
Michael Kentris:Absolutely no, that's well said. So you know even talking a lot about kind of some holistic options. Now you know we're both neurologists. So obviously you know we both did neurology residency but then you decided to go and pursue a headache fellowship. So when people are looking at, you know, a general neurologist versus a headache specialist, what are the extra things that a headache specialist can bring to the table? What kind of additional options do they have in addition to, obviously, their experience?
Aniket Natekar:No, yeah, great question. So when it comes to you know a primary care provider and doctors sending to a general neurologist, you know general neurologists typically are familiar with any of the medications from those three classes that we had mentioned earlier, and potentially now with the new CGRP inhibitors that are coming out, they may or may not be aware of those as well. They may or may not have some comfort with them as well. Headache specialists in general, not only are we comfortable with the three primary headache classes or the three primary classes of medications, we're very comfortable with the CGRP inhibitors. You know we're comfortable with procedures like nerve blocks, trigger point injections within the head, neck and shoulders.
Aniket Natekar:You know Botox for migraine, which of course a lot of general neurologists also do. But then, depending on where you do your headache medicine fellowship, you may have additional expertise where you admit a patient for a few days to receive a regimen of medications, whether it be a short stay unit or you know some sort of infusion program and if you happen to be at one of those very few tertiary care centers, you may even admit a patient for ketamine or lidocaine or both as infusions for a five day protocol to try to break the headache and improve their headache.
Michael Kentris:Excellent, yeah, because again that's another thing we were talking about Like know those things are done, but not something I have done and you know probably me being a little squishy not something I would feel comfortable doing without studying up a little bit more about it and, as we also said, probably not something my nursing managers would be happy with me for trying to do either. So, yes, it definitely takes a lot of infrastructure to kind of build those things. But the other thing was headache specialties or headache fellowships in general. You know, neurology is not the only road to that. Right, we can see sometimes internal medicine physicians or family medicine physicians. I don't know if there are other specialties beyond those three that can sometimes enter anesthesia perhaps. Yeah, but in your, again, in your sole opinion, is the difference in sort of different perspectives? You know, I know there's obviously a convergence to a degree, but there's probably some difference in approaches.
Aniket Natekar:Yes, so you can see all sorts of primary specialties that then do fellowship and headache. You alluded to several of them. You know primary care of pediatrics, internal medicine and family. You can get anesthesia For eye train for fellowship. At Jefferson there was even a dentist who did the headache medicine fellowship and because he obviously works within the mouth area he can do Botox and several of the muscles for patients who may have TMJ. So you have them. You have ophthalmologists, because a lot of times neuroophthalmologists in particular tend to overlap with migraine. So you can have some ophthalmologists to do the fellowship. You have interventional pain specialists, from whatever background come. I've seen ENTs do headache because you know a lot of times patients will come in with ear pain or jaw pain as a primary thing for ENT or sinus pressure, thinking it's a sinus headache. But in reality there's no such thing as a sinus headache unless it's due to a primary infection or obstruction and you know it ends up being migraine or other headache disorders. So I've seen ENT docs also do the headache fellowship.
Michael Kentris:Interesting and, again, any significant like. Do each of these kind of sub-specialties tend to focus a little bit on certain types of headache in terms of their future practice, or how does that shake out in the wash at the end of the day?
Aniket Natekar:But that's a great question. So if you did neurology, I think you tend to focus on all of the headache disorders. If you're primary care, you may tend to focus more on things related to depression or in how it contributes to headache. You know, weight gain, weight loss, as well as the other medical conditions like high blood pressure, high cholesterol, things like that and if you're ENT, you may tend to focus more on the sinus slash, facial region.
Aniket Natekar:If you happen to be dentistry of any kind, then you know you tend to focus more on the jaw and how it contributes to headache. But each of the specialists and sub-specialists, at that point when you do headache fellowship, the important thing is they get the knowledge of all of the different headache disorders. So, even though they want to focus on one type because the fellowship tends to be standardized across the country regardless of your primary specialty that you came in with, you're taught about all of the headache disorders, so you should be able to, in theory, treat all of them equally.
Michael Kentris:You know, that makes complete sense. Yeah, and the couple I forgot about OPTHO and ENT, and let alone dentistry, as potential players in that space. But that all makes sense, right? There's a lot of people working in the head and neck, not just us, huh.
Aniket Natekar:Yes, exactly.
Michael Kentris:And that kind of brings me back around a little bit. You know, I know we talked a little bit at the beginning about kind of like invisible disorders and about migraine. This is something I've seen campaigns online for in the past. But people talking about how migraine isn't just headache, where people talk about kind of the pre-migraine and the post-migraine kind of symptoms as well, how does that factor into your care of a patient?
Aniket Natekar:Yeah, no, that's a great question. So migraine comes as like three main phases. So you know, you have your produral, which are the symptoms and or feelings that people have before the onset of the actual headache. You have the ictal period, which is the pain itself, and then you have the postural and within the ictal period you can have the aura or no aura. So prodrome can be anywhere, even up to a week or even two weeks prior to the onset of the headache.
Aniket Natekar:You could have yawning fatigue, cognitive fog, which is a term that we tend to use for people who feel like their clarity has been affected. You know myalgias, visual disturbances, all sorts of stuff and then you have the ictal period, which is the actual headache, and then you have the post-drome, which is the same thing as the pre or the yeah, the prodrome. So the post-drome can still have yawning fatigue, cognitive issues, nausea and vomiting can last several days after the headache has resolved, and that tends to be a common phenomenon as well. So even if you think that the headache is only one or two days, the whole aspect of the headache episode can be up to seven days, some people 14 days. So those are also things to think about. You know, some of my patients will tell me they'll notice their headache is going to be coming on because the pressure is changing outside. So they can tell when it's going to rain, because pressure changes affects their headache as well.
Michael Kentris:Fascinating. Now I know that there are, there's some grading scales out there. Midas is the one that I'm familiar with, but I know there's others as well where they kind of talk about, you know, quantifying disability, because obviously in neurology in particular, why we have a lot of disorders that can inhibit people's ability to work or in a living, and so sometimes trying to get work accommodations or other things of that nature can be challenging. You know, especially when we start getting insurance into the mix in the United States, we have to a lot of times justify why we're recommending what we're recommending. In what way do kind of these, these prodromal, post-dromal types of symptoms, help to obtain maybe some type of leeway, work accommodations, things of that nature, at least in your experience?
Aniket Natekar:Yeah. So in my own experience, if patients are able to reliably track their prodrome and their post-drome, you know, or and I forgot to add for post-drome, some people feel euphoric afterwards. They can even have depression afterwards. So it's not like they're actively having a good depression episode if they have an underlying depression or don't. But it can be part of the headache phase as well. But when it comes to people who can reliably track their pro-, post-drome and their prodrome, what I can write is intermittent family medical leave act. So, fmla, you can ask for intermittent leave, which is okay. My patient will have a headache guaranteed in two days once they experience these symptoms. Please accommodate them with either reduced work hours or allow them to have intermittent time off without punishments of any kind, excellent and, let's say, right.
Michael Kentris:We have a patient, you know, they've modified their lifestyle to the best of their ability, made some, made some improvement in their headache frequency and or severity. They're still not there. You know, we've got them on maybe one, we've tried one or two daily prophylactic medications, but what about rescue therapies? How do we approach that? Soup, if you will?
Aniket Natekar:No, that's a great question. So when we think about rescue medications or abortive therapies, that's another way to look at it. First and foremost, you always want to counsel your patients. Any of the abortive medications outside of the CGRP inhibitors will increase your risk of medication overuse headache, also known as rebound headache or medication adaptive headache, if you take it more than two days a week combined together, so that, on my on its own, I also screen my patients for. So if they tell me they have 20 headache days a month, okay.
Aniket Natekar:Do you take an ibuprofen, tylenol, et cetera, or any of the over the counters every single time? Yes, okay, and then you have medication overuse. So that's something to screen for as well. You know now you have to be careful with who you speak to. If you speak to someone by the name of Dr Bill Young, he will tell you that it's called medication adaptive headache and the reason for that is because your brain has adapted to the use of analgesic medications. I personally think that medication overuse headache. There is a negative stigma associated with it, but it is also accurate. So, depending on how you phrase it, you know, you can hopefully avoid that stigma, but that's why I present my patients with all three.
Michael Kentris:I feel like that's the most common headache that you've never heard of. Is that kind of medication overuse, right? I mean, that is part of the problem, right? These things are just sitting on the shelf ibuprofen, Tylenol. It's safe, right, Like we can take it as often as we need it. Maybe not so much in real life, though.
Aniket Natekar:Yes. So you know I always have to counsel my patients. If they are taking more than two days a week combined together, cut it. You know we should treat the medication overuse headache aspect as well. You should always warn your patients Initially. They aren't going to feel worse because you know their brain is used to a certain amount of medications that it's not getting now. Because when you have medication overuse headache or medication adaptive headache, what happens is your brain will change the structure at the molecular level. So you will still try to take something, but the pain is still firing and it's not going to be as effective, and that also prevents preventive and other abortive medications from being as effective. It's kind of like what we alluded to earlier when it came to lifestyle with the caffeine and how that can affect the medication efficacy.
Aniket Natekar:So you know you have to warn your patients. For the first few weeks you're going to feel horrible because you aren't taking these things as much as you used to. However, after a few weeks your brain realizes you're not taking those things and switches back to the way it used to be and I tell them something about. The headache gets better, whether that be how long it lasts, how many days a week. You know the intensity of it. Something should get better. And I even tell them that it's not going to be a drastic drop necessarily. Instead of being 10 out of 10 pain, it may only be 9 out of 10 pain. It may only last 8 hours. It may only last 7.5 hours. Instead of being 20 days a month, it may only go to 19 days a month.
Aniket Natekar:But either way that's an improvement and it gives us a better chance for other things working. So if you've addressed the medication overuse headache aspect and your patients don't have it, then yeah, you can talk about the over the counter analgesics. You know. As long as they're limiting the use and these are effective, there's no harm in it. Your set is a very common one that's prescribed by probably I was going to ask you.
Michael Kentris:You beat me to the punch.
Aniket Natekar:Yes, and that's one that we tend not to recommend, because it's aspirin, acetaminophen, which is also an astallinol, and it has something called butylbitol, which is a barbitur. It's a stronger class than benzodiazepines. You know there's a potential for tolerance with it, potentially addiction too, so you want to try to avoid that. I do have some patients on fear set, but that's only because they only need it once every three months. So if that's the case, I'm fine with it, but it's in rare circumstances.
Michael Kentris:Yeah, I think I was a first year attending a while ago and I had this. She was in her 70s I think and she'd been on fear set like one to two tabs a day for God knows how long decades. And I was talking with her she was like her headaches are getting worse. I'm like, well, I think we probably need to start weaning you off this fear set. And I felt she was this sweet little old lady and if you remember that scene from Lord of the Rings where Bilbo sees the ring all of a sudden and like kind of transforms into this little troll, it was like that, you know, it was like she just transformed in front of my eyes into this like very angry little old lady when I tried to take a fear set away. And it is right, it is addictive and that makes it a really big stumbling block for some people.
Aniket Natekar:Absolutely, and coming off of it can be hard. You know, if you're doing it outpatient, I tell my patients eliminate one tablet every week. If they're on multiple tablets, if it's just one tablet every day, then I make them do every other day and then for one week and then stop it. You know what the goal is to try to avoid withdrawal symptoms.
Aniket Natekar:Sometimes the safest way to do it is to just bring them into the inpatient side, find the equivalent of phenobarbital, give them the phenobarbital in tapering doses over a few days to get them through the withdrawal period safely and then discharge them without the fear set.
Aniket Natekar:But you know in certain cases you can do it outpatient. So I tend to avoid fear set altogether. Then you want to think about the other abortive medications. So you know you could think of triptans, summa triptan, alma triptan, elitriptan, risitriptan, you know zoma triptan, nartriptan, provatriptan there's so many and they come in different formulations. Right, some are injectable, some can be through nasal spray, some can be dissolvable, some are solid tablets, so some can come in IV formulation as well. So you want to think about what probably works best for your patient. Provatriptan is the one that we use primarily for someone with menstrual migraine, for example, because it's half life is very long I think it's at about 26 hours. The next one after that is nartriptan. However, most often the nart insurance companies will not approve either of these medications because they want you to go through the other triptans first.
Michael Kentris:Right.
Aniket Natekar:So you can try those, but you always have to counsel your patients again about medication, overuse, headache and the potential for it. You could even try some of the anti-nausea meds, so things like prochloroparesine, chlorpromazine or promethazine Metaplochromyte can also be there, but it's not as effective as the other three. So even though these are anti-nausea meds, you can use them as a headache abortive even if they don't have nausea. I tend to find these also very effective in people who have concomitant nausea with their headache because you're treating both things at once. I avoid on Danzatron, which is known as Zofran, because it's not known to be effective for headaches specifically. So I try to use one of these three, but you always want to be careful about dystonic reactions of any kind and if they do, tell them to take a Benadryl to avoid it or to resolve it. And then you also want to think about the risk of Parkinson's disease if they use metaclopramide regularly for several years.
Michael Kentris:There's always something in the back of your head.
Aniket Natekar:So you always have to tell your patients, limit the use no more than two days a week. You have all of these other extra pyramidal side effects and potential long-term risks. But then even outside of that, chlorpromazine, for example, can cause hypotension. So if someone has high blood pressure, that's another added advantage. But if they already have low blood pressure maybe they're not a candidate for it.
Aniket Natekar:Then, after the basic triptans and the anti-nausea meds, you want to think about the CGRP inhibitors. The two that come to mind are the G-pants. So you have Romenjapant, which is known as Nurtag, and then Ubrojapant, which is known as Ubrelv. These are the two. Not only do they at this point not cause medication overuse headache, they're pretty well tolerated, they're very safe and there's very few contraindications, if any. So those would be, I would say, the abortive classes that you really focus on. Lismitedan, which is known as RayVal, is another abortive that you could look into, but that one comes with the caveat of people are not allowed to drive for eight hours afterwards, so it can be very restricting as an abortive agent compared to the other ones. You can also look at DHE I forgot to mention that one which is an Urganz. That one comes as a nasal spray. One of the brands is Trudesa. It also comes as an intramuscular injection that you can do. It's also there in IV4.
Michael Kentris:Gotcha. No, that's a great rundown of some of the options out there, which they can be, with the triptans as a perfect illustration, where you get a dozen nearly medications all in the same class. They all have these little tweaks this way and that Half-lives are different, indications are slightly different, but there's probably a handful that are relatively equivalent in terms of your plain Jane migraine, if you will. Now, something you mentioned that I wanted to explore a little further, things like adhere, the eye rolling with the reglan, so something I see. I do a lot of neurohospitalist type work and a lot of times folks coming into the emergency department for headache, for migraine specifically, will get, as you said, a combination of usually like catarolac, composine sorry, not composine reglan and benadryl and that'll be it. Essentially they get that little one-time blast of medications. If they get better, they go home, if they don't, they usually wind up on my doorstep.
Michael Kentris:So what are your thoughts in terms of the? Let's say we've got someone coming in with they took maybe a dose of Sumit Triptan at home. An appropriately dosed dose I think that's something to maybe comment on as well is what is an appropriate triptan dose? In my experience, they tend to be underdosed for most people and let's say, this person got an appropriate dose. They came into the ED. They got some reglan, got the benadryl, got the toroidal, maybe got a half liter of normal saline fluids. They're still having a headache. If you were to implement a protocol for an ED which I know you mentioned that you're working on that what would you change? What is your best evidence-based practice for this acute treatment of migraine?
Aniket Natekar:No, that's a great question. You know, headache is the fourth leading cause of ER presentations in the country. Studies have shown giving NSAIDs over opiates in the ER actually leads to a faster rate of discharge out of the ER. So something like Catorilac is effective. You know, when it comes to an ER regimen or even an acute short-state unit or observational state unit regimen, it doesn't hurt to use those three medications that you mentioned. They can be effective.
Aniket Natekar:I try to avoid the opiates unless there's some sort of extraneuating circumstance that would or potentially may warrant it. For example some sort of bacterial meningitis which is severely painful. Okay, maybe a couple of doses of opiates wouldn't hurt. Or if they're going through opiate withdrawal, then yes, you obviously want to try to prevent the withdrawal that may be causing the headache. Or if they just have major surgery or major injury to the head, yes, opiates may be indicated in that sense. So you always want to weigh the risks and the benefits of medications. But in addition to what you mentioned, you know you can cycle them every eight hours. So that's something that people do. I tend to only do the Catorilac for six doses because anything more than that increases your risk of gastritis, you know, potentially acute radial injury. So you want to try to limit that.
Aniket Natekar:You can also look at magnesium. So magnesium sulfate 2000 milligrams every 12 hours IV that can be effective in addition to the other ones that you mentioned. You can even look at DHE. If they've already had Sumitriptin, you know DHE has an IV met in formulation. You can do 0.5 or 1 milligrams.
Aniket Natekar:Now, mind you, you shouldn't use it within 24 hours of them having Sumitriptin at home if they used a lot of Sumitriptin. However, on the inpatient side we used to do it every eight hours so you could actually space it eight hours from the Sumitriptin dose if needed. You know Sumitriptin if you were going to use it. It comes as 25, 50 or 100 milligram doses. What we typically tell our patients to do is you take one at the onset of a headache and then you can take another two hours later. No more than two tablets in a day, no more than two days a week. So whether you're at the 25, 50 or 100 milligram dose, no more than two tablets in a day. I've seen some scripts being written as mass 200 milligrams in 24 hours, but then to some patients that means I can take four tablets and I have to tell them no, you can't, it's two tablets.
Michael Kentris:Yeah, have you ever prescribed a 25 milligram tablet for anybody?
Aniket Natekar:Oh yeah, most of my patients I prescribe. I start at 25. First, and with your patient. Okay, if at the lowest dose you can get rid of their headache, then that's even better, because you're minimizing the risk of side effects.
Michael Kentris:Good point, good point. Right, naja can be a big one yeah.
Aniket Natekar:GERD. Some people will get the palpitations or the chest pain at higher doses, so I try to avoid as much of that as I can.
Michael Kentris:No, that's a good point. Anecdotally, I've just had a lot of failures. I don't usually get responses below 50, but maybe I'm not doing a good enough job counseling people.
Aniket Natekar:No, you never know, and it might just be your specific patient population test to respond at 50 or higher. In my case, up to this point, I've gotten away with 25 or even 50 instead of using the higher.
Michael Kentris:Yeah, it's always good I got to go back and review my own practice.
Aniket Natekar:But there's even more meds you can do on the inpatient side.
Michael Kentris:I forgot to say yeah, yeah, lay it on me.
Aniket Natekar:Oh yeah, so something else that we did. We would try one of the anti-nausea meds first, and if after two or three days they're ineffective, despite maximizing doses every eight hours, you can then look into something like haloperidone. Now I know that seems like a very powerful anti-psychotic. People get nervous with it. You obviously want to, you know, preface it with. There should be no sort of contraindications. For example, someone shouldn't have Parkinson's disease if you're going to use haloperidone. You know they shouldn't have had like permanent tartive dyskinesia which could then obviously worsen with haloperidone. They shouldn't have any underlying psychiatric conditions that may be contraindicated with haloperidone. Right, you want to warrant it with that. If none of those are an issue, then yeah, you can do one milligram, three milligrams, five milligrams, even up to 10, I believe, every eight hours. Not only is haloperidone good at treating headache, but it's also good at treating the nausea part too.
Aniket Natekar:So, it's slightly more powerful than what I do is if, after the six doses of the catorlact, it's still been ineffective, you could even try something like methylprednis alone, 125 milligrams every 12 hours, and I typically would do it at 6am and 6pm with food, and you could do that up to six doses. But remember it has to be minimum eight hours from when the NSAID was given, which was catorlact in this case, because you want to avoid the gastric side effects or bleeding risk from that aspect.
Michael Kentris:Well, that makes sense. No, that's especially good it. Does IV valproic acid have any role in your practice?
Aniket Natekar:Yeah, yeah. So IV valproic acid is also a good option. Some people ask me what about levitrastam, known as KEPRA? Some headache docs do it, some don't. There's really no conclusive evidence that levitrastam is effective in headache, but as a last ditch effort it doesn't hurt If, despite everything else, it has been unsuccessful. You could try levitrastam as well.
Michael Kentris:Interesting and something I've seen, or at least heard about, I shouldn't say seen Some people, even for a more non-localized, or I should say non-oxipital, predominant migraine, they'll try oxypetl, nerve blocks or other just numb do your auricular term porals, super orbitals, all these nerve blocks and just try and numb the head. Essentially, is that just a shotgun maneuver? Is there any data to back that up?
Aniket Natekar:So oxypetl, nerve blocks, trigger point injections, like you mentioned, any of the auricular temporal nerve blocks, super orbital, super trochlear and even lesser oxypetl and even third nerve blocks all of these have tremendous evidence behind them for headache. It's not just a last-ditch effort kind of deal. In reality in some cases these might be the primary things you do in conjunction with all of the medications. So there have been times where I've admitted somebody or someone has admitted we're trying all of these medications and I say screw it, let's do nerve blocks and trigger point injections because it may help them with numbing the headache and make the other medications more effective. But in addition to that, if there's a significant musculoskeletal component to their pain, obviously I can't Botox them on the inpatient side.
Aniket Natekar:So this might be an option where we're just numbing up the nerves and loosening up the muscles and hoping that that contributes to some long-lasting pain relief.
Michael Kentris:No, those are good points and I do think a lot of those nerve blocks aren't particularly challenging procedures. I think it's something our ER colleagues and a lot of our hospitalist colleagues as well would probably benefit from knowing how to do. Just because they can. The side effects are very minimal and if you do them properly they're very safe.
Aniket Natekar:Yes, and lidocaine nerve blocks without epinephrine or even safe in pregnancy. So if you have a pregnant patient who comes to the ER with headache. That might be another thing that you can do on the inpatient side or in the ER. That could help alleviate some of the headache symptoms and is just another tool in the arsenal before having to call neurology.
Michael Kentris:Excellent. So we kind of talked a little bit about kind of outpatient management, inpatient management, when to kind of move people along the diagnostic algorithm. Any final thoughts you have about headache in the medical system, big chinks in the armor as far as management of migraine or headache disorders at large.
Aniket Natekar:Yeah, so for one, there's less than 1000 board certified headache specialists in the country. So you're talking about one headache doctor or headache certified doctor for about 80,000 patients who suffer from a headache disorder, mostly migraine that we think of. So you know there's a severe need for people with headache disorders to be treated by someone who has experience and expertise in headache medicine. In addition to that, I try to educate people on a few things. For one, I avoid saying the word migraines. I say the word migraine because migraine is a disease. So if you use the medical term for blood pressure, for example hypertension, if someone's blood pressure is high, you don't say they have hypertension. Or if someone has depression and they actively have a depressive episode, you don't go. They have depressions. So similarly.
Aniket Natekar:I try to teach people we should avoid saying migraines and instead say migraine. I do the same thing for the word headache. I say stop saying headaches, say headache and choose a different word to pluralize, like day is, attacks or episodes. And when you do that it helps you better advocate for yourself and for your own patients.
Michael Kentris:Alright, so you probably have an opinion on this word. Then what's your opinion on the term migraine?
Aniket Natekar:you are oh so even that term. I don't know why people use it. You know what's funny about it is it's very French.
Michael Kentris:I tried googling it before.
Aniket Natekar:No one really knows the true origin of it, unless it is truly French. But my grineur is what I think of and what I think of what.
Aniket Natekar:Americans think of classically, of the French. If you don't like the French as Americans, then why would you use migraineur, right? There's also a negative stigma associated with the term migraineur. People think pain seeking, patient, etc. So I avoid that.
Aniket Natekar:Other things that I avoid I hate the term headache cocktail Because when you look up the true definition of the word cocktail, it's an alcoholic beverage that's composed of spirits mixed with other liquids. So instead I use the term regimen of medications. The other thing is every provider slash doctor has their own regimen, so it's never standardized. So if one ER doc calls me and says, hey, I gave them a headache cocktail, well, what meds did you give? Oh, I gave them a cocktail.
Aniket Natekar:No, just tell me the meds that you gave and then they'll tell me two or three, but then their next colleague will have tried something else. So that's why you know I emphasize that I also try to avoid using opiates on the patient side, kind of like what I had mentioned before, unless I feel like they're indicated in certain situations. And the last thing that I always tell people is I avoid the term failed, because we constantly say our patients failed these medications. But if they took them as recommended and as prescribed and the medications didn't work. How did they fail the medications? In reality, the medications failed them.
Michael Kentris:That's a good twist to it. I like that.
Aniket Natekar:Right. So instead I say the medications were unsuccessful. So that's why I avoid saying oh, the patients failed these medications. Because when I think of failed, I think of math test or chemistry test those you absolutely can fail. But if you took the meds as prescribed or as recommended and they didn't work, then how did you fail them? The meds failed you.
Michael Kentris:True, true, yeah, it is one of those things it does create like a subconscious bias to an extent. Now to your point earlier. There are so few headache specialists in the country and, if I recall correctly, there are very often unfilled headache fellowship slots available for those who would be interested. So if we were to speak to the trainees of today and trying to convince them to pursue a career in headache medicine, what would be your elevator pitch? For why is it a good career?
Aniket Natekar:Oh, thank you for asking that question. You're the first one. So what I would say is headache medicine in general is very rewarding, because headache disorders, particularly migraine, is the second leading cause of disability in the world after low back pain, and migraine affects pretty much everybody in every age group. It's also one of the few neurologic disorders where, if there's improvement in the condition, people can return to their baseline level of function. You know, unlike a stroke, parkinson's disease or Alzheimer's disease, where with Parkinson's or Alzheimer's or any of the dementias, there tends to be a progression in the negative direction. With a lot of the headache disorders, if you can get them better, they tend to go backwards, back to where they used to be. So you can have a real impact on people's quality of life. And now, that's not to say don't go into cognitive neurology or movement disorders.
Aniket Natekar:All of those are equally rewarding, but with headache it's nice to see where you can really impact someone's life in a positive manner and they return to baseline and sometimes it's nice to see that. Oh, it's not a guarantee, in five years they may pass away.
Aniket Natekar:But you know there's several years maybe ahead of them. In addition to that, you get all age groups you know, anywhere from children all the way up to the most senior of citizens. So headache affects everybody. It's not like some of the more nuanced neurologic disorders. In addition to that, because it is the second leading cause of disability in the world, there are plenty of career options. It's not like if you went to a big city you would be saturated with the one subspecialty, so there's not as many opportunities for you.
Aniket Natekar:There is an even in smaller cities or towns, there absolutely is even more opportunity for you where you can have a huge impact with not as much of a practice, not to mention about 30% of general neurology is headache. So if almost one third of your general neurology practice which, by the way, there's an even bigger need for general neurology than there is for headache, but if you were to do general neurology, one third of your practice is headache, why not become proficient in that so that you don't have to keep referring to other subspecialists?
Michael Kentris:Excellent points and I've definitely been promoting it as an option for some of my internal medicine and family medicine residents who rotate through me, who one of the things I've talked about on the podcast before is people who haven't had exposure to neurology as a discipline properly in clinical rotations and then they come and do neurology and it's like, oh, this is interesting, but not interesting enough.
Michael Kentris:I want to go back and do four years of residency but I'm like well, you know, as a primary care doctor, headache, super useful skill set and you get that little extra spice of neurology mixed in there and it can be a very rewarding career. I know one of the deficits and I think we see this with a lot of neurology programs is they're so inpatient-heavy these days that we don't get that longitudinal benefit as much, where we see the change in someone's career and lifestyle and all these things where you get someone who's somewhat disabled by their disease and then you get them to a point where they're living an independent life, they're productive, they're doing what they want to do, and that can make all the difference in terms of your career satisfaction.
Aniket Natekar:Oh, absolutely. I can't tell you how many times when I was a resident where patients would come in with migraine, we give them a regimen. You hope that their headache gets better, but then you know they leave into what we call the ether and you never knew what happened versus when I became a headache fellow. I saw them in clinic after they were admitted on the inpatient side and I saw how much that impacted their quality of life and if we got them on an appropriate preventive regimen, then how they were able to continue that impact in a positive way and then how they started advocating for other people as well.
Michael Kentris:Yes, that longitudinal care right, it's something that I know a lot of people, especially medical students, they talk about when they're considering internal and family medicine as career options. But I always like to emphasize like neurology and neurology sub-specialties have a lot of longitudinal care and a lot of times you end up being in some cases especially for younger patients maybe their primary physician to an extent.
Aniket Natekar:Yes, and you know, like you had said, even with PCPs, majority of headache patients will never get past the PCP. So why shouldn't primary care doctors, nurse practitioners, pas and all become more proficient in headache? You know some? I'll give a shout out to my old fellowship program. Jefferson actually does a continuing certification or course for APPs, which is advanced practice providers, general neurologists or anyone else, even primary care doctors, who don't have expertise in headache but want some extra knowledge, where you can do this continuing certification program and you can develop more of an expertise in headache. Now, does that mean you're a headache specialist? No, but it means you have more of an expertise in headache and might make you more comfortable with headache management.
Michael Kentris:Excellent. Always good to have more resources. If people want to find what you've done, reach out to you. Where should they find you on the internet? Where are you living these days?
Aniket Natekar:Great question. So until X burns down, I'm still on X at Nadekar MD. I'm also on Instagram. I was a playoff. My name Anikade Sometimes people used to think Anakin, so at nick underscore Skywalker. You can find me on Facebook Anikade Nadekar. A lot of my profiles tend to be private because they're my personal accounts, so my Twitter handle is probably the best one.
Michael Kentris:All right, and we'll include a link to that in the show notes as well. Thank you again so much for reaching out, for coming on talking to us about headache. I think that's going to help a lot of people.
Aniket Natekar:I hope so, and I'm glad to have done it All right, take care All right, you too Bye.
Michael Kentris:Thanks for watching.
