Chief Concern Series: Headache Essentials For Clinicians

We map a practical path from “is this dangerous?” to “what actually helps." We also talk about some specific headache types such as:  IIH, medication overuse, trigeminal neuralgia as well as the rise of CGRP therapies.

• separating primary from secondary headache with SNOOP4
• recognizing thunderclap, GCA, IIH, and low-pressure patterns
• uncovering hidden chronic headache burden and medication overuse
• exam essentials including fundoscopy and neck palpation
• trigeminal neuralgia in MS and targeted MRI protocols
• rescue strategy with effective OTC dosing and triptan timing
• antiemetic choices matched to daily function
• preventives matched to sleep, anxiety, weight, and goals
• carbamazepine and oxcarbazepine for trigeminal neuralgia
• role of acetazolamide and topiramate in pressure states
• CGRP therapies, access hurdles, and practical selection
• empowering patients with education, logs, and portable plans

Chapters

• 0:00 Kicking Off The Headache Series
• 2:44 Primary vs Secondary Headache Framework
• 6:40 Red Flags And The SNOOP4 Checklist
• 13:15 Uncovering Hidden Chronic Headache Burden
• 18:20 Giant Cell Arteritis: History Pearls
• 22:42 Suspecting IIH And Key Risk Factors
• 27:45 Medication Overuse And Rebound Headache
• 33:10 Exam Priorities: Neuro And Neck
• 38:24 Trigeminal Neuralgia In MS And Imaging
• 43:05 Positional Headache: High vs Low Pressure
• 46:52 Rescue Therapy: OTCs, Triptans, Timing
• 53:20 Sleep, Stress, Caffeine, And Nausea Plans

Transcript

Michael Kentris: 0:04

Hello and welcome back to the neurotransmitters. I'm your host, Dr. Michael Kentris, and I am joined by my co-host today, Dr. Galena Geikman. Galena, I uh, you know, I often get called by my primary care colleagues with various concerns. And I know that we have embarked on our series about chief concerns. We're updating our lingo from chief complaints, I have been told. Um, so to that end, we've invited some of our friends and colleagues to talk about some of these things and kind of get more expanded perspectives. So with that said, I'll throw it over to you.

SPEAKER_01: 0:39

Yeah, thanks, Michael, and thanks for welcoming back to co-host on this exciting series. We're super uh excited to get started today, and we're gonna be focusing on headache. And for that, I've invited, I love what you said, like my friend and colleague, uh Dr. Sarah Conway. She is a multiple sclerosis specialist at uh Mass General Brigham and one of our core educators in the neurology clerkship at Harvard Medical School. Sarah, anything else to add to your introduction?

SPEAKER_02: 1:06

I'm also part of the neurohospitalist group.

SPEAKER_01: 1:08

Yeah, well, welcome. We're so excited to have you. So I thought we'd dive right in. You know, headache is a common concern for our patients and is a common concern among our colleagues in terms of what to do when you're faced with this. You know, we hear about these frameworks like red flags, and we hear about, you know, you're reassured potentially if they've had a chronic history. But even if you're not concerned about a red flag, and we'll talk about those, how do you manage these patients? So we're gonna get into all of this today. So, Sarah, you're MS specialist, but how often are you treating headaches for your patients? Do you get asked about this?

SPEAKER_02: 1:45

Yeah, actually, I was just talking about our new class of fellows coming in, and we were discussing how much general neurology we see in our MS clinics and our MS patient population. You know, we have patients who have seizure, and there is a slight increased risk of headache with MS. And so I would say probably at least once a day we're also co-managing someone's headache disorder.

SPEAKER_01: 2:07

So let's start off with imagine you know, you have a new MS patient, maybe you're going through your various systems. It turns out this uh poor, unfortunate, let's say young lady is also have a history of migraines. Tell us how you start with that headache history.

SPEAKER_02: 2:22

Yeah, I would say when I'm taking a headache history, I'm always keeping in the back of my head trying to distinguish if this is a primary headache disorder or a secondary headache disorder. And so primary headache disorder, meaning something like migraine or tension headaches that are the result kind of increased pain sensitivity in the brain, but not due to an underlying disease or medical condition. And so some of the questions I'll ask is going to be to try to get at that primary versus secondary headache difference. And then just to define it, secondary headaches are caused by some underlying medical issue, brain tumor, stroke, um, blood clot, et cetera. Um so I I think the most important thing that I start with when I'm asking someone about their headaches is the onset of the headache. Um so if this is something very acute in onset or something more slow and progressive. Um and I think that's helpful in general when we approach neurologic signs and symptoms. So when thinking of something that's hyper-acute, meaning onset to peak in seconds to minute, you have to think of something vascular. So if someone is telling me they have the worst headache of their life that comes on in a couple seconds, I'm very worried about something called a thunderclap headache, um, which which is most concerning for a subarachnoid hemorrhage or a burst aneurysm. And that that would prompt ER evaluation.

SPEAKER_01: 3:48

That makes sense to divide it into that kind of category. I mean, if this person is coming in, you definitely want to right away know within the first couple seconds whether you're dealing with an emergency and maybe have to redirect from your MS, you know, annual visit to uh referral to the emergency room. But let's say the timing is a little bit less concerning. It's so, you know, no, it's uh just uh get regular headaches. Maybe they are getting more frequent and uh they describe kind of a baseline that's changing. So how do you think about that more? Let's say uh that the headache is coming on over a couple of minutes, maybe lasting a few hours. And what other questions do you want to ask to characterize it?

SPEAKER_02: 4:28

Yeah, so I'll I'll also still try to look for other red flag symptoms before jumping to some of those primary headache disorders like tension, headache, and migraine, which I'll honestly tend to be more common, but again, we don't want to miss underlying scary things. So I like to use the snoop for mnemonic to kind of walk me through some of these questions we're gonna ask. And so the the S of Snoop 4 stands for systemic signs. So I'll screen patients and ask them if they've had any associated fevers or night sweats that may um underlie an infectious process, or you know, if they're of the right age, it's a good screen for giant cell arthritis, which is a do-not miss cause of headache, which we typically think of in patients who are over 50 and have systemic signs or symptoms. Um, and then I'll ask about any other associated neurologic signs or symptoms, right? If they're having any tingling or numbness or weakness. Now, in an MS patient, that can be difficult, right? Because they're they may have underlying baseline underlying MS deficits. But I think, again, something that can be helpful in distinguishing is their symptoms associated with a headache or symptoms associated with MS is going to be the time course. So typically MS signs or symptoms come on and last for days to weeks, and then they can sometimes slowly get better. Sometimes someone is left with baseline deficits, whereas typically symptoms associated with a primary headache disorder will come on, you know, over hours and then tend to linger and typically resolve also over hours to maybe a day or two at most. So I think the time course there is also really helpful. And then so that gets us to we talked about the S and then the N, and then we talked about O for onset, you know, being asking about how quickly the headache comes on. And then other things to be worried about is if, again, is the age, so older age and onset. So if someone is over 50 and they have a new type of headache, that also is concerning for me. You have to get a headache history, right? So you can ask them if they've had a headaches when they were younger, because many people will have, you know, or be have been told that they have migraines as a as a child or you know, as a teen, and then you have to figure that out if if there's something new or different about the headaches they're having now, or if it's just they've come back. I guess going on to that, I often like to ask patients what they mean about the headache. So just because someone told them they have migraine, like you have to delve into that. Like what does that actually mean, right? So I'll ask them, tell me about your headache, what is it like? How does it feel? And I think it's important not to necessarily give options at the beginning, right, to try to keep it very open-ending ended and just hear what they say, right? Do they say it's like a squeezing across their head, which may make you think more of a tension headache? Or do they say it's throbbing on one side of my head, which could point more towards migraine? Or maybe they say they just don't really know. It's just like a dull ache all the time. And and then you can kind of delve in and give them some options. But I think it's important to hear hear what they have to say. And then and another piece of that is uh we can talk about some migraine cut treating a little bit, but many people are told they have migraines, and maybe it wasn't actually a migraine. People sometimes just use that interchangeably, I find, with a general headache. And it's important because the treatment can be slightly different.

Michael Kentris: 7:36

Yeah. You know, you bring up like a really good point as far as like the the new or changed headache thing. And I find when I'm working with like students or residents that they'll get like a you know very thorough like you know, time, onset, severity, character, description of the current headache. Then I ask them, like, well, it depends. Like, are we seeing them in the office or is it in the hospital? Well, like, why why are they here now? You know? And a lot of times, like, well, is this headache different? And that's that to me, that's one of the most reassuring things. Like, this is the same headache they've had for 20 years, like, all right. That right off the gate like rules out like a lot, to me at least, a lot of the more dangerous stuff that I would have to worry about.

SPEAKER_02: 8:14

Yeah, and I think to that point, we'll also ask patients if it's if it's a newer type of headache or different, right? That that raises red flags, or if it's a similar type of headache, but it's occurring a lot more frequently, or with new associated neurologic signs or symptoms, or any of those other things we've talked about. Um thus far, that would also make me at least want to maybe get an image to make sure we're not missing something else going on.

SPEAKER_01: 8:38

It's interesting to hear that, you know, you both had this experience of the patient being really kind of articulate about what they what they have and and maybe how it's changed. I've actually found sometimes I kind of call it like the like reverse headache history, which is in some people who've had chronic headache, they may not actually, in a way, acknowledge the number of headaches that they have. You know, they may say, I only have, you know, the bad migraines twice a month. And you start to kind of pick at that history and you realize they're referring to a bad migraine as an episode that's maybe lasting 48 hours, they're in bed, they have the lights off, but they're actually reporting, you know, a milder headache, though one that probably someone without a headache syndrome wouldn't, you know, think was normal, uh, that's happening more often in the week, maybe three to four times, maybe requiring some board of medicine. Do you either of you have kind of tricks up your sleeves for how to actually like tease out this, you know, more chronic headache history for those who maybe dismiss symptoms what they they experience very often?

SPEAKER_02: 9:43

Yeah, it can be difficult. And I I've definitely had cases like that. I I sometimes will ask patients, well, how often are you taking a medication for to treat your headache, right? Like Tylenol or ibuprofen. And sometimes they're like, oh, I'm taking it like multiple times a day because I I constantly have a background headache. Oh, and then I have my rescue medication, like a tryptan. And I only take that once or twice a week. And that's that can sometimes be helpful to get at what do they consider their really bad ones and what is just their day-to-day headache?

Michael Kentris: 10:13

As you said, like the reverse question, it's not enough not to ask how many days do you have a headache, but how many days in a month do you not have a headache? Uh which can be, I think, very revealing also. And it's like, oh, never, never.

SPEAKER_01: 10:26

There's just better days. Yeah. Exactly.

Michael Kentris: 10:28

Where do we want to go from here, Galena?

SPEAKER_01: 10:30

Well, I really liked the mention of GCA as a can't miss. So I'm wondering, Sarah, if we could delve a little bit more into that because some of that information is gathered on history. So let's say you have that suspicion maybe because of the older age of the person and the new onset. What might you do in that case just on history to see if you can kind of increase your suspicion or increase your reassurance against that?

unknown: 10:59

Yeah.

SPEAKER_02: 10:59

So for giant cell arteritis, this typical screening questions I'll ask again is are they having any systemic symptoms like fevers, chills, night sweats, any visual changes? And I tend to leave that question very broad and just hear what they say because giant cell arteritis can cause lots of different visual problems, visual loss being the most concerning one, but sometimes there's other funny things it can do to the cranial nerves or strokes or things like that that can cause diplopia. So I'll just ask like any visual changes. And then I'll you also want to screen for jaw cloudication. And I find this one actually the trickiest because sometimes patients can also have TMJ or jaw issues themselves. So I'll I will also try to leave that open and ask if they've noticed any differences when they're chewing, or just ask like how how in general are they doing when if they were to chew something difficult like a piece of steak and hear what they say. And if if they're like, oh, I've had this for 20 years and oh yeah, I see my dentist and they think it's TMJ, that's reassuring. Or they might say, oh no, this is new. Like I've just noticed this over the past couple of weeks. Every time I try to chew something, it really hurts. I would be more concerned about that. But I find if you ask people, like, especially in their older many people will say, Oh, yeah, actually, I do have some pain when I'm chewing. So I find it kind of a tricky question, actually.

SPEAKER_01: 12:10

We're trying to put ourselves in the shoes of our, you know, primary care colleagues or those maybe not necessarily primary care, but let's say primary clinician who's the first to see a patient with this cheap concern. And so what I always hear from folks is they're worried about missing something that isn't just a benign primary headache. And so I think your starting point there, Sarah, makes a lot of sense. Another one that I get a lot of questions about is idiopathic intracranial hypertension. And I can tell you the number of consults that begin with a quote unquote abnormal MRI and MRI suggesting features of IH, you know, please evaluate. So whether the patient comes to you with the MRI or not, what are the things that on history might actually raise your concern for that? You know, how might how might that differ from the typical headache story?

SPEAKER_02: 13:05

Yeah, so IH, idiopathic intracranial hypertension is a disorder where the pressure is too high in the brain. So some of the screening questions I'll ask for that is positionality of the headache, right? So if if patients tell you it's a lot worse when they're lying down, that could be concerning for increased ICP, which for many cause, right? But if you're screening for IIH, that's one thing I'll ask. I'll also ask if they've had any pulsatile tinnitus, if they've had any double vision. So when the pressure is too high, you can get diplopia from stretch on the sixth nerve. So you can ask if they've had noticed any side-by-side images. That's getting at horizontal diplopia. Um and then I'll ask about any transient visual obscuration, so if they've noticed any like dark black dots in their vision. And I find those questions like patients can be pretty definitive. Yes, no. And and that can be helpful to just to to make you even think if you should be worried for IH. The other things I'll ask is it try to get in any underlying risk factors, the biggest one being weight gain. So I'll ask if they've had any significant gain in weight or or pregnancy, for example, which are all, again, kind of the most common risk factors for developing this condition.

Michael Kentris: 14:18

I often find again, not the not the typical case, but I find I'm asking more and more about like multivitamin use in in these kinds of cases as well, uh, just because there's a lot of people don't know what's in them. And so I end up Googling, you know, it's like, oh, my multivite uh thing, and it's like how much vitamin A is in there, or are you using any topical creams that are vitamin A? Although I know that's a debated subject, uh, as like how much systemic effect is there from that, or like the uh you know, like tretinoin and stuff like that. So kind of these vitamin A type things, especially in younger people, you know, just because I've you know it's like a you know squirrel finding a a nut every once in a while. That I I found a couple cases where that was the thing. And sometimes it is in someone who's had like a gastric bypass surgery and they're put on some multivitamin supplements, but there's too much vitamin A in it, and so it ends up like inducing kind of a you know IIH-like syndrome. It's just one of those weird things that I've come across. It's not the not the typical presentation, but it's one of those things when you're hunting around for weird stuff that I tend to ask about.

SPEAKER_02: 15:18

Yeah, I'm reminded I feel like on the board questions that comes up as someone who's eating like seal liver, right? Because that's very high in vitamin A. So that's how I remember it. Um Yeah, I can't say I've seen any cases directly related to vitamin A, but I think it's a really good point, especially as the supplement industry is growing, really, to hone in on that.

SPEAKER_01: 15:38

I think you also bring up the larger point of sort of medication-induced headache. You know, we often think of medicine as helping the headache, but there are some headaches that could be induced by it. Uh we think of like medication overuse headache. I'm also thinking about what subclass, you know, the RCBS reversible chival basic constriction syndrome, where you do want to ask a substance history and a medication use history. Pseudoophedron is a medication that comes to mind where some people might be just using it for their cold, and then suddenly they're coming in with worst headache of life. Sarah, could you comment on medication overuse headache? I think this is something, this is a public service announcement. Tell us, you know, how you think about that and uh how we can counsel our patients about it.

SPEAKER_02: 16:26

Yeah, I mean, I think so medication overuse headache occurs in patients who are taking significant amounts of regular over-the-counter medications. So the most common ones being acetaminophen, NSADS. Um, and the idea is in patients who are taking these most days of the week for multiple weeks that the brain can be kind of overly sensitized to these medications and that actually they can be doing more harm than good. And I think it's a really hard thing to try to explain to patients because they're like, but I have really bad headaches. Like you're telling me to stop, to stop the things that are helping me. But but I do think um patients who are around the clock taking over-the-counter medications to treat headache, it can be actually not productive in the long run. And so I'll counsel them about the the medication overuse headache. And typically, this is getting a little bit into the management, but I'll try to give them something like a short course of steroids or some other medication to try to break the cycle and then tell them to to stop taking them every day. It's not a problem to take a setaminophan or an NSAD a couple times a week, you know, two to three times a week for those really severe headaches. It's mainly, you know, when people are taking them all the time every day, we start to see issues.

Michael Kentris: 17:39

Yeah, I I agree. That's been my experience also. It's even worse when you find that they've been, let's say, you know, not a knock against our ED colleagues. But uh sometimes they get a course of Fioraset or something. And uh I remember I had, this is a number of years back, uh, a lady who'd been on Fioricet for decades, and she's like, I just don't know why my my headaches just never get any better. I'm like, I think I might have a suggestion. And uh it reminded me, I don't know if you guys are uh familiar with that scene from The Fellowship of the Ring where uh Billboat like almost grabs the ring back from Frodo there, like turns into a a monster for a second. That's what just happened with this sweet little old lady. Like she just turned straight into like a gremlin and was about to take my head off uh for suggesting cutting back on the fjord set. And it it's one of these things where it's just you wind up in this cycle, and uh sometimes as the specialist seeing this person years down the road, perhaps, it can be really hard to correct that ship.

SPEAKER_02: 18:37

Yeah, you bring up a good point, right? It's not just the over the counter the medications we see. I I have seen it quite often with Fiora set, right? You if you're prescribing that medication, you really need to counsel patients not to take it more than twice a week, right? Like taking it every day in the long run is not not good. Same with tryptans, right? I've seen patients that are like on 30 days per month of a Suma tryptan, that can also lead to rebound headaches and worsening.

Michael Kentris: 19:00

Absolutely. So something since we were talking about IIH a little bit here, or I should say for those who aren't familiar, right, the old name would be like pseudotumor cerebri. We're trying to move away from that. But uh I've found, and I I've read some articles about this over the years as well, is that sometimes when we have, let's say, someone who seems like a typical migraine kind of thing, and again, this is edging into the treatment territory, but you've tried multiple medications, just not responding. Maybe they have some risk factors, inasmuch as maybe like, you know, a young, overweight female, and not classic for IIH, but sometimes I found that these patients with IIH may clinically have like a phenotype of a migraine type presentation. What's been your experience with that? And like how long do you wait before it's like, maybe I should do an LP in this patient?

SPEAKER_02: 19:48

Aaron Powell, I think it raises an even larger point that patients with secondary headache disorders can also have primary headache disorders like migraine, then worsen due to their secondary headache disorder. And so IH is probably the most common one we run into that patients can have headaches from their IH, but then they also can have migraines on top of that. And so how long do I wait? I I mean I think my my threshold is if I'm worried about it, I'll at least discuss doing a lumbar puncture with the patient. Most patients, like, really, I find want to avoid that at all costs. But I try to reassure patients that it can also, yes, it's not the most comfortable thing, but really the actual procedure is just a couple minutes and it can be really, really helpful. And it's not like something that necessarily would have to be done all the time. So I would have a low threshold to recommend a lumbar puncture if I'm really having trouble sorting it out, especially if I try, you know, for example, a migraine medication and it's not working, or they're developing any other visual symptoms or any of those other symptoms we talked about, like pulsatile tinnitus, I'll say, I think we just really need to do this, and then if the pressure is normal, you can be reassured.

SPEAKER_01: 20:55

Makes sense. We've been talking about history, and I thought maybe we can shift gears a little bit and talk about the physical exam. So does the exam matter for a patient, a headache patient? And let's let's kind of put ourselves in the clinic setting, so not the acute nuance at headache, but kind of in the clinic setting. What do you want on exam when you think about seeing these patients?

SPEAKER_02: 21:17

I think it's really helpful to have a baseline exam in anyone coming in with a headache. It's not necessarily something you have to repeat the whole thing every time you see patients. And I do think actually, if the first exam is normal, many headache patients can be managed doing telehealth visits. Um but on the first exam, so th some things I will focus on is a good cranial nerve exam. So again, making sure there's no signs of double vision or a cranial nerve issue that could be related to increased pressure, a pupil exam. I'll do a fundoscopic exam looking for papilledema. Again, that would be make you worry that the pressure is too high. And then I'll do a basic screening exam, making sure there's no other weakness, unilateral sensory findings, hyperreflexia, anything that might point to a structural etiology.

Michael Kentris: 22:10

Curious. Because like you said earlier, right? Sometimes there's another problem kind of setting off maybe an underlying primary headache disorder. Obviously, as neurologists, we are biased towards a neurologic exam. What role do you think like a musculoskeletal exam for, say, like the head, neck, things like that plays a role as far as like cervicogenic pain drivers or tender points, etc.

SPEAKER_02: 22:32

Yeah, I think that's super helpful to do. And often patients will tell you, like they could you could ask them to point where the where it hurts the most, right? And if they're kind of pointing in their traps or behind their neck, you can see if you can reproduce that tenderness, and that can definitely be helpful if you're thinking about is this coming from musculoskeletal issues in the neck, like a cervicogenic headache or not, right? Some patients don't have it, and then you could say, okay, well, maybe we need to move away from from treatment of that and and really focus on an more of a migraine or tension headache or whatever whatever else it could be.

Michael Kentris: 23:06

Something I found. I was just gonna say, like, you know, I know sometimes like you were saying, like the distribution of the headache. I find especially in in some of my older patients who maybe have some some arthritis or things like that, uh, there maybe tends to be a little bit more tendency, like not out and out occipital neuralgia, but a neuralgia-esque neuralgia form, if you will, uh type of pattern to their headache, uh, whether that's like on the typical like back of the head occipital neuralgia, or even sometimes, like if maybe, like you said earlier, like a TMJ type thing, where maybe they have more like over the auriculotemporal. And I find sometimes just like tapping around on their head a little bit can sometimes reveal some some useful diagnostic insights. Not always, but uh but it's one of those things where if the the headache's like really side-locked, that can be, I think, a useful thing to just you know push on their head a little bit, see if it radiates and if it uh points us in a certain direction.

SPEAKER_01: 24:03

Aaron Powell Sarah and I both trained at Mass General Brigham under the legacy of Dr. Martin Samuels, and he used to say that if a patient comes in with a headache, you better touch their head at some point, or else they're gonna leave and say the doctor didn't examine me. And I know as neurologists, we sometimes, you know, laugh at that, and I think it's said in jest because we know potentially they're not be, you know, more of a you know a superficial exam in this case. But I do find that helpful. I part of it, you know, the tapping around, I think is part of building a little bit of therapeutic rapport uh and making sure that the patient knows the question is being attended to. But I do think as you're tapping around there, they might find some sensitive spots. I think the one exception I've seen is uh for patients where the presentation is likely to be more acute, but could be subacute, new onset headache. And in the case of cerebral venous sinus thrombosis, Dr. Samuels used to teach, and I have used this exam maneuver and it has proven true every time, which is he'd say, with one finger, can you point to where the headache is originating or where the pain is? And you know, the patient will point exactly to, say, the on let's say like the right oscopa, and then you get the you know, CTV, and that's exactly where that blood clot is sitting, and potentially the transverse sinus on that side. And the idea there is that the dura is innervated and the meninges um are where the pain is emanating from. And so that's always been a fun kind of maneuver to teach on rounds when we have an admission and to have the students give it a try.

Michael Kentris: 25:37

That's cool. So something that I find myself when I'm working with trainees, you know, students, am residents, family resident, family medicine residents, is uh I keep bringing up the ICHD3 guidelines, uh, more just to kind of help them organize their approach. Because a lot of times I'll I'll bring up some of these headache disorders that they've never heard of, right? Like we all, you know, everyone knows about cluster, but then we've got the stuff that's kind of on both sides of that timeline, you know, on the very long side, the very short side. And so we'll we'll get some folks in here where it's like cluster-esque. But I'm like, uh so we start talking about that, and maybe this is my own biases, but I kind of think of the ICHD3 almost as our version of the DSM, because like the last criteria is always not better, not better accounted for by another medical syndrome or headache syndrome. Um I know these are just guidelines, but I find them useful as far as like kind of organizing my thoughts and also kind of teaching those that way of organizing some of these syndromes to think about the quote-unquote weird headaches that aren't quite migraine, aren't quite cluster. But in our in our history and exam types of situations, is the asking about like the autonomic features, right? Like the nasal dripping, the tearing, you know, et cetera. Is that something that you routinely ask about, or is it only like in certain what would prompt you, I guess, in the history to start asking about some of these less common headache disorders?

SPEAKER_02: 27:04

Aaron Powell Yeah, I would say I don't necessarily routinely ask patients about that, but if they're describing something that's I would say the time course is probably what would make me ask, right? So the trigeminal autonomic phalalgias, they all have slightly different time courses. And to be honest, I I typically will look it up to see what patient fits which criteria, because I find it hard to keep track of. But if if someone's like, Yeah, I have these like short, stabby things that are lasting seconds, I'll be like, okay, do you have any tearing or nasal congestion with those? Or on the other, you know, that could get more of the sunked or sunab. And then on the other hand side of things, if they're like, Yeah, I've just had this really difficult headache on one side of my head for like days and days, you know, you can also ask about that. And that made me think of more of like a hemicrania continua pattern.

Michael Kentris: 27:52

Aaron Ross Powell And you know as you said, like the when we tend to think of, or at least, you know, I if I think back to when I was a medical student and we would hear, you know, the like the little test vignettes with uh short-lasting stabbing pain across the face, right? Sunct or soona, right, which the S U, we're not going to give you other short-lasting, unilateral. But uh that's not the answer that most of us think of. We tend to think of like trigeminal neuralgia. So when we're thinking about, say, like like trigeminal neuralgia, which is something I imagine you in the MS clinic see probably a lot more often than the rest of us, what what are the kind of the things that would point you in that direction and what kind of imaging or exam maneuvers would help you kind of suss that out?

SPEAKER_02: 28:35

Aaron Ross Powell Yeah, so for trigeminal neuralgia, I find it's really specific pain um in the trigeminal distribution. So patients will describe most typically like in the V2 or V3, so somewhere in the in the face, these like lancinating pains that are typically provoked by things like chewing, brushing their teeth, cold, even like cold wind, any sort of thing that's that's stimulating the trigeminal nerve. And typically aren't associated otherwise with headache or necessarily any other symptoms. It's just really isolated, lancinating pain to that distribution. And and um getting at our MS patient population after the optic nerve, the fifth cranial nerve is actually the most common cranial nerve involved in MS. So if I'm worried about trigeminal neuralgia, say, and anyone just coming into the office, I do think it's helpful to get an MRI with the protocol to look at the cranial nerves. And it's helpful if you tell the radiologist exactly what you're looking at. Um, so they can do thinner slices through the brainstem and fifth crani, and they can look to see if there's any enhancement in the nerve, which may point you towards more of a demyelinating concern, or if there's any vascular compression on the nerve, because that is another cause of trigeminal neuralgia.

Michael Kentris: 29:52

Points. And I know there's a lot more to talk about that on the management side. Any other things that we should be thinking about history-wise? I know we've done, I think, a pretty thorough overview, but uh, any other final thoughts on that side of things?

SPEAKER_02: 30:06

I think one thing just to be more explicit about, um, and this also goes back to that snoop mnemonic that we hinted at at the beginning, is some of the P's. The one P I like is the positionality of it. So we talked about for people who have high high pressure lying down may worsen it. But there also is an entity called intracranial hypotension, which is due to low pressure. And we're seeing, I think this is an entity that's being recognized more and more. This this is the opposite. It's actually people who have headache, which worsen significantly when they stand up. So they'll be totally fine lying down. And the second you get them up, um, they'll tell you they just have a debilitating headache. And this can be from eatrogenesis, right? Like when we do lumbar punctures on patients, they can then develop a post-lumbar puncture headache, or it can be um more idiopathic if there's a dural leak somewhere. But I would say this is something we're starting to see more, or at least recognize it.

Michael Kentris: 31:04

Yes. So moving on to management, though, I think uh, right, everyone everyone loves diagnosis, at least everyone in neurology does. But uh even more important perhaps to some people is uh what do we do once we figure out what's going on? So again, kind of putting up this vignette of someone who comes in relatively clean slate, hasn't been on any medications. When are we thinking about rescue meds? When are we thinking about prophylactic treatment? And where do we kind of start with those?

SPEAKER_02: 31:35

Yeah, so even before starting with medications, I try to ask patients about other lifestyle triggers, because I think many times that can actually get to the root of the issue. So going over things, basic things like making sure they're drinking enough, eating enough. There are some people that are very sensitive to alcohol and different preservatives in wine, for example. And you can just ask them, like make a note of things over the next couple weeks, uh, and they may find that if they just cut out one of those things, they'll be better. But say they do that and you're still meeting with someone who's having frequent headaches. I I will typically um offer patients a rescue medicine if they're having a severe headache around once a week. If it's I think it depends on the severity. If they're like, oh, I only get a rare migraine once a year, it's still reasonable for them to have a prescription medication. But typically I'll start by asking patients what doses of over-the-counter medications they're taking. Because I'll often hear that someone's like, oh, I have a really bad headache and I took 200 milligrams of ibuprofen. Well, that's really not a decent dose. So I'll make sure if they are if they've tried over-the-counter medications that they're taking a good dose. And so I'll recommend to start for rescue 600, 800 milligrams of ibuprofen um, even with Tylenol. And they can, you know, they can do up to a gram of Tylenol is what I'll say to start for rescue medicines. Um and if that doesn't work, um, then I'll I'll start thinking of other more prescription type medications. So if someone is having uh a migraine, which is one of the most common primary headache disorders, the first thing we'll start with is a tryptan. Um anyone who doesn't have like a vascular disorder, I'd say that's sort of like the big contraindication. And kind of like blood pressure medications, I find you just like pick a tryptan that you get used to, that you're used to prescribing. And so the one I typically start with is the Sumatriptan or Imatrex. But I'm curious if you guys have a different one you pick. That's just the one I've sort of gotten used to.

Michael Kentris: 33:32

You know, I find that uh insurance twists my arm a lot. And uh Sumatriptan is the cheapest, generally. So that is often where I start as well. One thing that I find is that when folks come to me and they've tried Sumatriptan, a lot of times I'm asking, like, well, what dose were you prescribed? Because I find that a lot of people are underdosed on it. So I'm just curious where you guys start.

SPEAKER_02: 33:53

Aaron Powell Yeah, I I start around 50, but I know some people will actually start at 100, some of our headache colleagues. And I think the other big key with tryptans is to ask when they're taking them, because many patients will take them too late, but they really need to take them at headache answer or onset to have full efficacy. Aaron Ross Powell And you can also talk about mode of administration for tryptans, right? The oral ones take the longest to have effect. There's nasal, some of them have nasal formulations, some are subcutaneous, and really those subcutaneous and the nasal ones are going to work faster. So some patients may you don't necessarily have to give up on a tryptan if they fail failed an oral one. You can look at trying a different formulation, perhaps.

Michael Kentris: 34:30

I I have one patient who's she she was on the brand name Immatrex back when it came out, you know, 30, 40 years ago with the injection. Lives and dies by it. That's that's all she wants.

SPEAKER_01: 34:43

I just wanted to jump onto the bandwagon of you know patient education around the treatment plan because I think headache management is uh as many things in neurology and many chronic conditions, there's such a big self-management component. So really empowering them to understand what the medicines are for and how they work and how to they best work for them. I find that that's something that I'm always working on with the patient. I also think that your point, Sarah, about the lifestyle factors, there's a huge education component there too, right? So the regular hydration. I also talk to all my headache patients about sleep and how their sleep is going. And that's often a target for me for headache management. I feel like I routinely order sleep studies if people haven't had their potential culprit sleep apnea, you know, diagnosed. So I find that that is often an outcome for my new patients with headache. And then the other thing I'll talk a lot about is stress and just uh to help them understand that that's gonna be a potential precipitant for some of my patients, especially those who have more of a vestibular component. It'll they'll describe interesting triggers like actually um jet lag or like flying or being on boats or being on long trips. So we start to paint a picture to help them understand what might be triggers for them and when they should be prepared and have their little rescue packs. And the last thing I'll say when I prescribe the trip channels, I always say, you know, put these in whatever bag you carry with you because they're only as helpful as if they're within reach in 30 minutes. And that's been an issue. Some of my patients where I have one um who has a stash at work and a stash at home and was at the gym and a headache started coming on, and she's like, no, because she knew she wouldn't be home for about two or three hours and ended up in a bad bout. But kind of, you know, that education can go a long way so that they know how to use the medicines for themselves.

Michael Kentris: 36:40

Absolutely. And I always feel about like we all know stress is such a big trigger in sleep deprivation. Sometimes, like, you get maybe a new parent with young kids at home or someone who is working crazy hours, like 12-hour shifts or things. You know, think of like all of our residents and students. And it's like uh I always feel like a a a bit of a useless uh advisor if I say, have you considered trying to reduce your stress? It's like, yeah, that'd be great. Not feasible right now, though. But yeah, it's it is one of those things where I think we all feel that like, oh, you know, I could be in so much better health if I slept regularly and drank enough water every day. I think we're all guilty of that uh in our modern society. But it is very true.

SPEAKER_01: 37:21

Aaron Ross Powell Totally true. And I don't know that the idea of the education is more around reducing it, although that's always great as able, but more that that can be a trigger for the worsening. I can't this may be cutting too close to home, but I can't tell you the number of uh residents whose migraines get out of control when they enter our residency sleep wake on cycle, and unfortunately can be a trigger for worsening about what had been a stable, stably managed condition.

SPEAKER_02: 37:48

I was gonna say getting at caffeine, right? That's also a big trigger, like lack of caffeine. And it also can be a helpful abortive treatment, right? So you can tell patients. Many people have figured this out themselves, but you know, go get a iced coffee from Dunkin' Donuts that has some hydration, perhaps, and then also caffeine, um, and take your tryptan or whatever else you want to take, etotyol, ibuprofen in that that can be helpful. Or you can get, you can know, you can get that at a local pharmacy like Excedrin, for example, has that has a little bit of caffeine in it. That can be helpful.

Michael Kentris: 38:19

I've definitely done the ibuprofen with an espresso chaser uh for headaches before for myself.

SPEAKER_01: 38:25

And you mentioned, Sarah, low pressure headache and caffeine is one of the best treatments for that specifically as well.

SPEAKER_02: 38:33

Yeah, and then the other thing I'll often ask about is the nausea component, right? Because metaclopermide or regland, that can be very helpful for both headache and nausea. You just have to warn people that there's very rare likelihood they could develop a dystonic reaction to it. So I always just tell patients so they don't freak out or end in the ER.

Michael Kentris: 38:53

Aaron Powell Do you ever counsel them to take like Benadryl if they do develop any of the I do, yeah. I do. Yeah.

SPEAKER_02: 38:58

Yeah. I'll tell them right, like their neck feels really tight, just take a benadryl and then give me a call.

Michael Kentris: 39:03

Yeah. Sometimes I find, and again, right, this kind of goes into the the realities of a lot of our patients where they can't necessarily take uh one of the sedating anti-nause medications for the rescue meds because they have to like keep working or drive home or whatever. And I know, right, we we know on Dancitron is not necessarily as effective as a lot of the other anti-ometics like uh like fennergin or composine or reglan. And so a lot of times I'm asking patients, like, where are your headaches happening a lot? If you were taking something that makes you drowsy, is that going to be a deal breaker? And um, so sometimes I end up going with a medication that I know is probably going to be less effective just because the side effects aren't really manageable in their like day to day life.

SPEAKER_02: 39:47

Aaron Powell Yeah, totally. And I find that actually kind of the opposite happens when someone goes into the ER, right? They like want to make the patient sleep. So they'll give often a sedating anti nausea medicine, plus sometimes even IV Benadryl, sometimes. you know, part of our cocktail and then patients do ultimately feel better, though maybe a bit sleepy.

Michael Kentris: 40:07

Yeah. Yeah. I was I had one headache attending who would always say, like, you know, you can't have a headache if you're asleep, which I technically true, but uh not a great long-term solution necessarily.

SPEAKER_01: 40:17

Fair. I think paying attention to side effects is key. It's kind of how I make a decision about a prophylactic agent as well. Um especially because a prophylactic agent is something they'll be committing to day to day. So let's um maybe shift there, Sarah, for whom would you consider a preventative medication, that kind of more chronic treatment? And then how do you what's your what are your go-tos? How do you escalate that and and how do you choose if an option for your patient?

SPEAKER_02: 40:47

Yeah, so I w would say if someone is having more than two headaches per week that are debilitating, I'll offer them a prophylactic medication. And there's so many now. So I think the the first thing I actually start with is talking about nutraceuticals. I find that something called my relief, which is a combination of magnesium, riboflavin, and fever few, especially for patients who are hesitant to take prescription medications, can be really helpful and it actually has decent evidence. Again, there's many supplements out there, but I think magnesium does have some evidence for headache, acute treatment and prevention. So I'll I'll offer that to most patients off the bat. And then if I feel like you know they've tried that or they um are having really severe headaches and they benefit from a prescription medication, I'll think about them in classes. And so I will think about tricyclic antidepressants, amitryptaline or nortryptaline in patients. Often I I'll use them in people who have trouble sleeping because the big side effect of those is that they're sedating. So if I want to treat someone's headache and get them to sleep, I'll I'll pick one of those. Typically amitaline is what I start with. And if it's someone who's very medication sensitive, I will do even like a really low dose like five or 10 milligrams because I've found that if you give to someone too much amitriptyline, they'll be like they'll feel horrible, they'll feel dizzy, tired, and they'll be like, I'm done with this medication, right? But it actually is quite good for for headache prevention. The other class I think about are beta blockers or calcium channel blockers. And so this is where it's important to look at someone's comorbidities or medication list, right? So if someone is already on mitoprolol for coronary artery disease, you're you're not necessarily going to add another beta blocker on top of that. But if if you have a young person who's otherwise healthy, normal heart rate, normal blood pressure and maybe they run a little bit anxious, you know propranolol could be a great option for them. Again, I warn them that it can make them a little tired or if you know if they're a performance athlete may may reduce their ability to fully exercise we'll run into that once. And then I think kind of the third class of medications I'll use are more of the anti-seizure type medications. So like valproic acid or topiramate can also be quite affected. I would say valproic acid is a little bit more challenging in terms of its side effect profile and also it's extremely teratogenic. So I'll avoid that in any patients of childbearing age. And those ones I'll I'll again think of the side effect profile. So toperamate in particular as one of the few medications that is weight neutral sometimes even leads to weight loss. So for many medications if that's a concern we'll try low dose topiramate or if they have other neuropathic type pain that that medication can work really well. But it can also contribute to cognitive dysfunction. So if you have someone who's very concerned about their cognition, maybe that's not the best choice and you try one of the other ones.

Michael Kentris: 43:38

And you know it's interesting have found that like even with just low doses of topiramate, like sometimes just 50 milligrams at night, maybe even up to 100 milligrams at night, which is not obviously like our seizure dosing by a long stretch, that is sometimes enough for some of these people with chronic migraine and they feel great. They maybe like you said lose five, ten pounds. Everybody's happy headaches are significantly reduced. It's not everybody certainly but you really feel like a rock star when when that does happen.

SPEAKER_02: 44:08

Definitely and I'll say I also will use topiramate if I'm worried someone may have an IH type phenotype. So if I'm if there's a case where I'm really not sure I'll say okay let's just try toramate it will kind of treat both things you know probably migraine better than IH but let's let's see and I've had some patients where they found it helpful again even at low dose like 50 milligrams at night.

SPEAKER_01: 44:37

I think that's a good point right now to just circle back and kind of double down on some of the diagnostics and sort of why it matters to really characterize the headache syndrome correctly because we've mostly been like we I'll make it explicit talking about migraine management, right? So if you're defining or maybe chronic tension type headache or chronic headache, chronic new daily headache, these will probably respond to the types of medications we've been discussing. I think if you're really falling in a different headache bucket like trigeminal neuralgia, we often you know turn first to the anti-seizure medications or if you're falling into something like you're you know persuaded that it may be an RCBS like picture, you might be looking at a barapamil or a calcium channel blocker. So and then just now you mentioned topamaxera for the IH picture, but typically our first line in a pure IIH headache might be turning to acetazolamide and really targeting the CSF production rather than like the secondary pain. So any other comments for your go-tos for some of our other you know headache syndromes and like what what's your mix and max and match approach for these conditions?

SPEAKER_02: 45:47

So I would say from in my perspective when I see trigeminal neuralgia I find these patients tend to respond best to either carbamazepine or oxcarbazepine as opposed to some of the other medications that we mentioned.

Michael Kentris: 46:00

I say that's probably the thing that I come across the most and you know I something I found is that you will get uh some folks in the primary care setting who you know they've they've made the correct diagnosis of trigeminal neuralgia. They've started the carbamazepine but they started at like 100 or 200 milligrams three times a day. And then as you're probably guessing where I'm going, they're on it for a couple weeks, it works okay, then it drops off its ineffectiveness. And you know one of the things I think people forget about is the the autoinduction effect that carbamazepine has on its own metabolism. And so you do have to kind of stay on top of it for the first few weeks there in terms of the titration. I don't know if that's been your experience but I find that fairly often in my patient population.

SPEAKER_02: 46:45

Aaron Ross Powell Yeah and I find patients will self-medicate sometimes they'll be like, oh I took an extra dose or you'll prescribe it three times a day and they'll have a rescue like 50 milligram tablet that they'll have because it does work that well for many patients. And I'd say the bigger side effects we run into at higher doses are hyponatremia and a little bit of dizziness and fatigue. But otherwise it's pretty well tolerated. It just needs the occasional lab monitoring.

Michael Kentris: 47:09

Yeah and I do find when I again this might be too far down the rabbit trail, but I I do find that sometimes uh switching if I run into the hyponatremia, I end up switching to one of the other sodium channel blockers, you know, like a phenytoin if they come in with an exute acute exacerbation or phosphenytoin rather I should say yeah since we aren't in the 1980s. But uh you know even lamotragen or in some cases like a lyrica or gabapentin.

SPEAKER_01: 47:35

I'll put a plug in again for patient education because I think what we're talking about is, you know, what's the setting up the expectations for headache management? And I always like to say you know we're now beginning a partnership. It's gonna be a journey like we'll get there but it may take trial and error and time and even prescribing a new medicine, these medicines don't work like the over-the-counter Tylenol you know it's not going to work in 30 minutes. It's committing to it for a few weeks to give it a real try. So I think setting up expectation that our goals are to make frequency less and the severity less and tolerable so you can have you know the quality of life and to engage in the functional things you want to do, whether it's working and you know not having to go into a dark room for multiple days. So I think setting that goal of like we may not get the pain to zero, but we're gonna get it better managed. We're gonna empower you to have a sense of how you'll manage it yourself. And then I think I always say and I don't know which medicine will work for you, but fortunately we have a lot of options and that's just been my clinical experience is it's I can't always predict who's going to respond to what and it's sometimes surprising that a very low dose will work for someone then you get all excited you prescribe that for the next person doesn't work at all. So just sort of being flexible and adaptable as a provider to say like it's not necessarily your failure or their failure, but it's just you know it's got to be something else. Now those are opportunities also in the road forks in the road to reevaluate the diagnosis, you know, potentially if it's really not um having a therapeutic effect, right? The therapy is part of the diagnostic journey. But I just think setting the patient up with it's going to take time but also hopefully with the hope that we have options found to be helpful. And then they'll stick out so stick it out with you until you figure until you find something that works.

SPEAKER_02: 49:23

I think that's super important. And also counseling them just because they tried one medication in a certain class if if that one didn't work doesn't mean the whole class is out, right? There's sometimes just certain medications work best for other people and it's a lot of trial and error and and dose finding but having that partnership with patients can be very helpful. So you you don't feel like you're giving up on them or vice versa.

Michael Kentris: 49:45

Aaron Ross Powell I know we're we're coming up close on our end of time but I know uh I think we would be remiss if we didn't talk about uh kind of the the new kids on the block as it were so you know in the last couple of years the American Headache Society kind of said that they recommend the the CGRP blockers as first-line therapy because of their their efficacy and their, you know, to be frank much more benign side effect profiles compared to a lot of the medications we've been talking about that have been kind of incidentally found to treat headaches, right? They were antidepressants, blood pressure meds, anti-seater drugs. That's like, oh, they also help with headaches. But now we have a class that was designed specifically for for migraines and headache disorders. And I'm curious what's what's your experience with prescribing them and do you have any practice patterns or things that you find most effective with your patients?

SPEAKER_02: 50:36

Yeah I I think it's a tricky question, right? Should you just start with the CTRP or go for some of the older medications first? That was a whole debate at our most recent American Academy of Neurology meeting. I typically don't start with them first, mostly because we tend to run into insurance issues. They require often that patients will fail medication in at least two classes is my experience, right? But then then I even as an MS specialist, I do prescribe these medications. I typically will ask the patients like in terms of figuring out which one do they prefer an injectable or a pill? And that will kind of be my way I figure out which way I'm gonna go. I found that now that there's more injectable medications out there in general people aren't as bothered by giving themselves an injection at home as they used to even just a couple years ago. And and then I'll think about the indication, right? Am I going to use this just for rescue or if I need more of a preventative medication that will help me figure out which CGRP I will use. And as I said before like the one I tend to go to first is nertecker or medipant because that can be used both for rescue and or prevention just depending on the dosing. So if it's dosed every other day you can use it for chronic migraine prevention or if they take it as needed that would be more for an acute indication. And I find that that one in particular is nice because it has both indications.

Michael Kentris: 51:56

Yeah. And like you said I've been having trouble with insurance getting the preventive dose of of Nerdtech approved in my own practice but it may just be my patient population that I'm working with. But yeah, no I think that that's great. And again this isn't I don't think this is evidence based, but maybe this is more expert opinion based at this level of time is they talk about if you have one that's ineffective, like if it's whether it's a receptor blocker or a ligand blocker kind of switching to the opposite side of the mechanism. I haven't, again anecdotally, I haven't noticed a huge amount, but I do find that sometimes just one medication works better than the other for no apparent reason as far as I can determine.

SPEAKER_02: 52:33

I have found that as well.

Michael Kentris: 52:35

Yeah. Any final thoughts, recommendations, things that you would like to see more done for for folks who are getting treated for their headaches in the the primary care setting that you think are missed opportunities?

SPEAKER_02: 52:47

Aaron Ross Powell I think some of the things we've touched on but just to highlight again so I've seen many I've been impressed that many primary care doctors have started prescriptions for various different tryptans and preventatives but I think the biggest thing would be dose finding. So I've seen often they'll start a prescription and then not go up on the dose for a tryptan or or not switch to a different one. So I would just empower people to realize that just because a a specific dose or from relation of a medication doesn't work not not to give up on it and and to increase the dose and then we're always happy to see patients in consultation and and send them back to their primary care.

SPEAKER_01: 53:22

Yeah I I couldn't emphasize that enough Sarah because so many of the patients that come to see us are like the decision was made they need neurology and you know six months go by and there's an opportunity to try just even the first signs that we talked about and hopefully maybe get a little bit of relief for the patient or at least information like hey this is you know medicine to pursuit got some impact let's increase it versus none at all.

Michael Kentris: 53:47

Yeah that's a great point. And it is right I think you see this on the inpatient and the outpatient side you know it's like oh we've we've consulted X specialty I don't need to think about that anymore. But in reality, right, people are out there they're still you know suffering with whatever problems going on. And I mean these are I think it's low-hanging fruit for for improving quality of life and care for for a lot of people.

SPEAKER_01: 54:11

Aaron Ross Powell Sarah thank you so much for joining us on our first episode in the Chief Concern series we started it off on a high with headache and we're excited to continue the conversations but any final words? Thank you all for having me and h hope this helps you treat your headache patients.

Michael Kentris: 54:28

Thanks thank you anything you want to plug before you go any projects you're working on?

SPEAKER_02: 54:33

Well Sarah and I are working on a project to teach the non-neurologist Sarah take it away we are working on lots of different bedside teaching projects to bring neurology to the neuron neurologist and working with various different people across the country to make this even better.

Michael Kentris: 54:50

Awesome. Definitely a needed a needed thing so glad to hear there's lots of good people working on it.

SPEAKER_01: 54:56

All right well thank you everyone for listening uh Galena folks want to find you or reach out to you where should they look they can reach out to me uh by email uh which we can put in the show notes and I'd be happy to answer any questions they had there or if you have other questions and chief concerns you want to hear on the series feel free to reach out to Michael or myself.

Michael Kentris: 55:18

That's right you can always click the link in the show notes and text us as well. And you can also find me via email at contact at the neurotransmitters dot com or you can find our show on X at neuro underscore podcast. Thank you both again and I really appreciate all the insights today.