Cleveland_Clinic_Host: Millions of people suffer headaches severe enough to seek medical care. Most people start with their primary care physician, and find relief from common prescription pain relievers. When a headache persists despite treatment with medications such as non-steroidal anti-inflammatory drugs like ibuprofen or prescription pain relievers, it may be time to visit a headache specialist.
According to the National Headache Foundation, over 45 million Americans suffer from chronic, recurring headaches and of these, 28 million suffer from migraines. Headaches are the most common cause of absenteeism from work and school. Migraine sufferers lose more than 157 million work and school days annually because of headache pain.
The Headache and Pain Program, within the Cleveland Clinic Neurological Center for Pain, is dedicated to the diagnosis and management of headache disorders, facial pain syndromes and associated disorders. The Program commonly treats patients with both primary headaches and secondary headaches. The Program sees more than 7,000 headache patients a year in the outpatient clinic and offers a wide variety of medical treatments including a specialized infusion service to provide urgent, outpatient care to patients who would otherwise need to visit an emergency room.
Our speaker today, Steven J. Krause, PhD, is a clinical psychologist in the Departments of Psychiatry, Psychology and Neurological Center for Pain at Cleveland Clinic since 2006. Dr. Krause specializes in pain management; he directs IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headaches), an outpatient treatment program for the rehabilitation of chronic headache patients.
Dr. Krause has a BS in psychology and mathematics from Loyola University of Chicago and a MS and PhD in clinical psychology from Saint Louis University in St. Louis, Missouri, and an MBA from the University of Wisconsin - Madison. He was a fellow in clinical psychology at the Langley Porter Psychiatric Institute at the University of California, San Francisco and a post-doctoral fellow at the University Pain Control Center in the Department of Anesthesia at University of Cincinnati Medical School.
Welcome to our Online Health Chat with Dr. Steven Krause. We are thrilled to have him here today for this chat. Let’s begin with the questions.
Understanding Headaches and Migraines
Simi2: What is headache or migraine? What causes it, and how can I treat it?
Speaker_-_Dr__Steven_Krause: Headaches are simply the term used to describe significant pain or discomfort in the head and face area. There are many types of headaches, each with its own cause and appropriate treatment. The first step in headache care is to determine if the patient has a “primary” headache, not caused by another illness or injury, versus a “secondary” headache, caused by some other disorder. Migraines are the most common type of primary headache, resulting from a complex process of neurological and vascular activity in the brain. Many different treatments are appropriate for headaches, including medications, injections, physical therapy, psychological counseling, and lifestyle changes, depending on the exact type of headache.
Centeraisle: How do you know if you are having a migraine or some other type of headache? Does it make a difference in treatment if you know?
Speaker_-_Dr__Steven_Krause: There are many other headaches besides migraine. Nearly everybody has had a mild tension-type headache, although migraine is the most common type of severe headache. Different headache types are distinguished from each other on the basis of their characteristic patterns, including factors such as age of first headache, family history, location in the head, headache frequency and severity, associated symptoms, and response to treatment. For example, a female patient who experiences severe headaches around the time of menses but not otherwise, typically on the right or left side of her head but not both, beginning around the age of 13, accompanied by nausea or vomiting, made worse by eating chocolate, resolving with sleep, with a history of similar headaches in her family is probably having a menstrual migraine.
Conversely, a woman with a history of less severe but more frequent headache, centered in the back of her head but spreading to her neck and forehead, with equal pain on both right and left sides, unrelated to menses and diet, without nausea or vomiting, and relieved by a hot shower is probably experiencing a tension-type headache. Other types of headaches have their own characteristic patterns. A skilled headache physician, most often but not always a neurologist, can help you examine the pattern of your own headaches to arrive at the correct diagnosis.
It matters a great deal to know what type of headache you have. Medications that work well for some headache types can be completely ineffective or even harmful in others. Lifestyle changes that reduce one type of headache will have no effect on another. The first step in planning effective treatment is to clearly understand what you're treating, and to choose interventions known to work for that particular problem.
Lisel: What is an aura?
Speaker_-_Dr__Steven_Krause: An aura is a neurological event that sometimes precedes a migraine headache. During an aura, patients describe wavy lines in their vision, numbness, tingling, blind spots and sometimes weakness in particular muscles. These symptoms are temporary, and leave no lasting damage, although they can be frightening or uncomfortable as they are happening. The aura typically ends when the headache begins, but not always. Most migraine patients do not experience auras, but some do.
newboneman: My grandson, Ethan, is 4 years old. He was diagnosed with hydrocephalus and had a shunt placed at the age of 2 months. He has had 6 revisions since, because of suspected shunt malfunctions and exposed tubing, but most of the suspected shunt malfunctions were associated with headaches and vomiting. He's being seen at Children’s Hospital in Denver. They've done MRI after MRI and CT scan after CT scan, and see nothing changing. He's seen ophthalmologists, who have said that there is some pressure on the optic nerve. He continues to have chronic headaches, often followed by vomiting, and they are currently trying medicine for what is being called chronic headaches. Have you seen this in hydrocephalus patients and do you have any suggestions? Even with the medicine his symptoms continue. We don't know what to do next to try to solve his problem. Thanks for your help.
Speaker_-_Dr__Steven_Krause: Without evaluating your grandson, I am unable to provide specific recommendations. But, the first consideration is whether or not the shunt is currently functioning properly. If not, it could be contributing to the headaches. If the shunt is working, then we need to consider other possible sources of headache and that would require an evaluation with the pediatric neurologist. It is possible that the headaches are not related to the shunt. The headache also may be a long term consequence of his medication, even if the medication is working in the short term.
CiciBaby: Is it possible for one person to have several types of headaches?
Speaker_-_Dr__Steven_Krause: Certainly, and this makes the diagnosis and treatment of the headaches complicated. For example medication overuse headache is very rare in persons who did not first have another form of headache. After all, most people do not use pain medications unless they first had pain!
hessby: Does the character and pattern of migraines remain the same, or do they change over time (in adults) when all other factors (i.e. environmental) remain the same?
Speaker_-_Dr__Steven_Krause: It is unlikely that during their lifespan any adult will have all environmental factors remain the same over time. For example, stress levels, sleep patterns, and diet are variable from one day to the next. For women there are hormonal triggers for migraines, and hormone production varies through a woman's lifetime. The type and degree of hormonal change in life also depends in part on the woman's reproductive history. All these factors can change the character of a person’s headaches, so changes over time are quite common.
Gecko: I am having trouble differentiating between a hemiplegics migraine and a TIA.
Speaker_-_Dr__Steven_Krause: Hemiplegic migraine is a rare form of migraine in which the patient has pain accompanied by symptoms that closely resemble a stroke. Transient Ischemic Attacks (TIA's) result from constriction of blood vessels within the brain from a cause other than migraine, and also present with stroke-like symptoms. These symptoms generally include visual abnormalities such as dark spots, wavy lines, or tunnel vision, and more rarely can include numbness, tingling, temporary paralysis of a limb, difficulties speaking or facial drooping. There's a great deal of overlap between the symptoms of hemiplegic migraine and TIA’s, so it is difficult to differentiate the two illnesses as the attack unfolds. TIA symptoms generally progress rapidly, from no-symptoms to full-symptoms in less than a minute. Hemiplegic migraine symptoms generally take several minutes to fully appear. TIA symptoms are generally more intense. However, there's a good deal of variability around these generalizations, so it can be difficult to judge.
Longer term, hemiplegic migraines generally begin during the teen years, while TIA's are more common in later life. Hemiplegic migraine patients tend to have family members with migraines. Finally, hemiplegic migraines leave no residual damage to the patients, while TIA's can sometimes cause brain damage evident through MRI's and other testing after the attacks. Unfortunately, these factors are clear only in retrospect, so the diagnosis can be tricky.
beachbum: What is a tension-type headache? How is it different from a regular headache?
Speaker_-_Dr__Steven_Krause: Tension-type headaches were once believed to result from excessive muscle tension in the head and neck, but recent studies have cast doubt on this. Nonetheless, patients typically describe a feeling of “pressure” or “tightness” in the head and facial muscles. Unlike migraines, which are frequently, but not always, limited to one side of the head (left or right), tension-type headaches generally range across the entire forehead, and often into the back of the head and neck.
Jayrome: I get severe pain across the bridge of my nose (feels as though I have been with by a baseball bat). Could that be classified as a tension headache? I do have tension headaches, but also experience this pain sporadically.
Speaker_-_Dr__Steven_Krause: What you describe would be an unusual presentation for a tension headache. These generally encompass much of the head, often beginning at the back of the skull.
cnbz19: What is a cluster headache? How is it different from a regular headache?
Speaker_-_Dr__Steven_Krause: Cluster headaches are a specific type of very severe headaches, most commonly observed in middle-aged men. Patients experience many headaches in a short period (a “cluster”), then often have long periods with no headaches at all.
Treatment for cluster headaches is not as well studied as for migraines, but some migraine medications have been used successfully to treat cluster headaches.
cnbz12: How are cluster headaches treated since they are different from migraine treatments?
Speaker_-_Dr__Steven_Krause: Cluster headaches respond to some but not all triptans, and some evidence suggests that injected triptans may be more useful than oral ones. Cluster headaches sometimes respond to oxygen therapy and some patients may be provided with a portable oxygen tank that can be used for when they have an attack.
Consuela: I've spoken to others that have cluster headaches. Heat helps sooth mine while cold helps others. How can these opposites be true?
Speaker_-_Dr__Steven_Krause: There's no evidence that heat or cold will directly change cluster attacks. However, most people tense up when in pain and this tension intensifies their headaches. Heat often helps people relax, and can reduce pain indirectly. Relaxation training will also help. I can't really explain why someone would find cold soothing for a cluster headache (although it often helps migraines), but there's certainly no harm in it.
jazzgirl: Is there a link between migraine and hormones?
Speaker_-_Dr__Steven_Krause: In females, migraines are more common around menses, as the abrupt drop in estrogen that triggers menses also can trigger migraines.
Migraines are generally worse between puberty and menopause, since these estrogen fluctuations generally do not occur in young girls and post-menopausal women.
There do not appear to be any hormonal triggers for migraines in men, although men’s migraines can be triggered by multiple other factors.
fuzzfinder: If you get headaches associated with your menstrual cycle, is there anything you can do to prevent or get rid of them? Or will you have this for the rest of your life?
Speaker_-_Dr__Steven_Krause: Menstrual migraines are treatable using the same techniques as other forms of migraine, including medications, stress management, relaxation training, biofeedback, and lifestyle management. Even if the hormonal triggers do not change, other triggers can be addressed. If your headaches are strongly influenced by hormones, it is possible you will experience improvement or resolution of the headaches when reaching menopause.
Causes or Triggers
Lisel: What can trigger a headache?
Speaker_-_Dr__Steven_Krause: Triggers vary depending on the type of headache, and can include strong lights, noise, smells, emotional stress, disruptions of sleep, certain foods, and anxiety (including anxiety about getting a headache).
For pre-menopausal women, migraines are frequently triggered by the hormonal variations that accompany menses.
GileanBrd: Does weather affect migraines?
Speaker_-_Dr__Steven_Krause: Patients very commonly report that weather influences their headaches, with low barometric pressure and high temperatures reported as triggers. There are few studies on this subject, but research from emergency room settings suggest that severe headaches of several types are more common in high temperatures.
Results are inconsistent regarding the effect of barometric pressure on non-migraine headaches. Surprisingly, recent studies show no effect of barometric pressure on migraine headaches, but there really aren’t enough studies to say for certain.
ww321: What triggers migraines in men?
Speaker_-_Dr__Steven_Krause: Migraine triggers in men are the same as triggers in women, except for the estrogen fluctuations that occur in women. Migraine triggers for both genders include stress, excessive or insufficient sleep, diet, emotional state and frequency of exercise.
Samantha: Are headaches hereditary?
Speaker_-_Dr__Steven_Krause: Migraine headaches are much more common in the relatives of migraine patients than in the relatives of persons without migraines.
The best available evidence suggests that a vulnerability to migraines is inherited, but that the conversion of that vulnerability into actual headache attacks depends on the number and amount of triggers active at any particular moment.
Acute Migraine Treatments
theo: What are acute medications for migraine? What should I take right when I feel I might be getting a migraine?
Speaker_-_Dr__Steven_Krause: The most commonly used medications for acute (during the attack) treatment of migraines are the “triptans,” such as sumatriptan, frovatriptan, almotriptan, zolmitriptan, and others. These are frequently effective in ending a migraine after it has begun.
However, patients should be very careful to use these medications as prescribed by their physician. While helpful at the time they are used, with excessive use these medications can cause a long-term pattern of headaches becoming both more frequent and more severe. This is known as “medication overuse headache” or “rebound headache.”
theo: Are over-the-counter medications for migraine effective?
Speaker_-_Dr__Steven_Krause: For mild migraines, over-the-counter medications can be helpful, but they are generally not sufficient to treat moderate to severe migraines. The excessive use of over-the-counter pain medications can also cause medication overuse or “rebound” headache, as described above.
CharlesB: A friend suggested assembling a ‘migraine kit’ so that when I get an attack I have everything that I need in one place. What do you suggest I put in it?
Speaker_-_Dr__Steven_Krause: 1) An appropriately chosen headache rescue medication; 2) Instructions for effective relaxation exercises to be used every day, and more frequently when you have an attack 3) A list of all the frightening thoughts that grab you during the attack (e.g. "This is never going to end.") along with realistic responses to these (e.g. "All my previous attacks eventually ended, so this one will too."), 4) Instructions for stretching exercises that increase flexibility in the head and neck, which counteract the natural tendency to tense up when in pain.
Get #1 from a physician who understands headache and has thoroughly investigated your condition. Get #2 and #3 from a psychologist who understands headaches and how emotions can exacerbate them. Get #4 from a physical therapist. But most of all don't wait until you have an attack to help yourself. Educate yourself and follow through with appropriate lifestyle changes such as stress management, relaxation training, diet changes, good sleep habits, and regular stretching and aerobic exercise. Prevention is much easier than cure, and the best headache is the one you don't get at all.
Ally1: I'm a 39 y.o. female with a chronic sinusitis issue, and for the last year I have hemicrania continua headaches (right sided). I have had recent sinus surgery within last 3 months, but still continue with headache issue. I was on indomethacin 50mg twice daily along with Prilosec 40 mg. Unfortunately, I have experienced GI upset which, I went to see a GI doctor who has scheduled me for an EGD next week. In the mean time I spoke with my Neurologist who recommends I come off the indomethacin, and now I have begun to take Cymbalata® 30mg daily. I am still having break through headaches with facial symptoms, I take Phrenilin® Forte every 6 hours as need for pain. My question is what happens to patients are indomethacin responsive to the headaches and are unable to tolerate the medication? What kind of pharmacology recommendation or are there any other procedures available for these headaches?
Speaker_-_Dr__Steven_Krause: Indomethacin does work well for hemicrania continua, but some individuals are unable to tolerate the GI symptoms. Often migraine headaches are misdiagnosed and treated as a sinus issue.
If your stomach will not tolerate Indomethacin and your physician cannot find another equally effective medication, you may find it useful to consider other non-medical approaches such as biofeedback, relaxation training, etc.
Ally1: I would like to know if you have a patient who is indomethacin responsive for hemicrania continua headaches and is unable to take it due to GI upset what other alternatives are there.
Speaker_-_Dr__Steven_Krause: Indomethacin is a powerful anti-inflammatory medication that will also produce GI upset. You noted earlier trying Prilosec® to treat the GI upset to no avail. A number of other anti-inflammatory medications have been tested with hemicrania continua patients, but unfortunately none have been demonstrated to be effective.
The understanding of hemicrania continua is still in its infancy and additional investigation is needed.
gecko: What is involved in applying for the Botox® program to treat Migraine Headaches?
Speaker_-_Dr__Steven_Krause: Botox® treatment for migraines involves injecting Botox® into one or several locations around the patient's temples. This is frequently, but not always successful in reducing or eliminating headache symptoms. It is generally not considered a first line treatment option because of the expense and because the treatment can produce unwanted effects in other parts of the face..
linda: From what I have read, it seems like fluctuating serotonin levels can play a part in constant headaches. Do you agree with this? If that is the case, do SSRI's work?
Speaker_-_Dr__Steven_Krause: Serotonin levels do seem to be related to headaches which is why some antidepressants are effective as headache preventative. SSRI's particularly are less effective than an older group of anti-depressants called tricyclics (TCA’s). Tricyclics are not often used as a treatment for depression now that SSRI's arrived, but they are still used at lower doses as headache preventatives.
phoebe34: After 1-1.5 years, my meds are no longer effective and I have to change them. Why is this?
Speaker_-_Dr__Steven_Krause: It depends on the medication that you are using. Many pain medications exhibit a property called tolerance in which the same dose becomes less effective over time OR increasing doses are required to maintain the same effectiveness. You may also be experiencing medication over-use headache, a phenomenon where the medication helps in the short run but over time increases the severity and frequency of the headaches. Most patients respond to this by increasing the dose, but this merely exacerbates the medication overuse headache in the long run.
theo: What alternative therapies are used to treat migraine?
Speaker_-_Dr__Steven_Krause: The most common non-medical treatment for headache is relaxation training. Many studies have demonstrated that relaxation training is equally as effective for treatment of migraine as medications. This training takes more time and effort than using a medication, but once learned it is free, can be used whenever the patient wishes, and has no negative side effects.
Exercise has been shown to reduce headache risk and psychotherapy often helps patients learn to identify and manage headache-triggering emotional stress
arthur: What is biofeedback?
Speaker_-_Dr__Steven_Krause: Relaxation training is sometimes accompanied by using electronic equipment to monitor the patient’s physiology as they try to relax, and giving them real-time information about their progress as an aid to learning. This training technique is known as “biofeedback.”
genevieve: Herbal treatments/ supplements like gingko-biloba, do you think they are helpful? Should supplements be used alone or in concert with more traditional treatment or prophylactic medications?
Speaker_-_Dr__Steven_Krause: There is very little research looking at the value of alternative medications or herbal supplements for headaches. As a result it is impossible for me to recommend herbal supplements with any confidence that they will actually help. That said, some patients have reported that they are helpful. The reality is that it has just not been studied sufficiently to offer guidance to patients.
Genevieve: Please comment on the use of vitamin B12 to reduce the frequency of migraines. If it works, how much do you need to take daily?
Speaker_-_Dr__Steven_Krause: There is no evidence that Vitamin B12 is useful in the prevention or treatment of migraine. However, some European studies have indicated that Vitamin B2 (Riboflavin) is useful to prevent migraines. Doses of 400 mg per day taken every day for several months were shown to reduce headache frequency by 50% in half the patients who took it.
Kimmie: Can acupuncture treat migraines? How often would it have to be done to keep them away?
Speaker_-_Dr__Steven_Krause: Acupuncture has been tried as a treatment for migraine headaches, and some small studies indicate that it reduces pain. However, these same studies indicate that "sham acupuncture", in which a needle is inserted minimally and away from the true acupuncture points, was just as effective. It may be that the effects of acupuncture are simply the result of the relaxation that takes place when a patient believes a treatment is going to help. Unfortunately, there do not appear to be sufficiently large, well designed studies to conclusively answer this question.
Diet and Migraines
KitKat: Would you explain how diet can help control headache frequency? Have you heard of a low tyramine diet for headache?
Speaker_-_Dr__Steven_Krause: There are several chemicals occurring naturally in many people's diets that are known to increase the risk of a migraine headache attack. Tyramine is one of these. It is found in chocolate, yellow cheese, yoghurt, and nuts. Each of these can trigger migraines in vulnerable individuals. Other chemicals that can trigger migraines include sodium nitrate (found in processed meats such as ham, bacon, sausage, and some lunch meats), as well as various sulfites, found to various degrees in alcohol, particularly red wine. Migraines can be triggered by multiple factors besides diet, so eliminating these chemicals will not likely solve the problem altogether, but it may help. There is little evidence that diet matters in non-migraine headache types.
Headaches & Cardiovascular Risk of Stroke
niki32: Is there an increased risk of stroke for migraine sufferers?
Speaker_-_Dr__Steven_Krause: Migraine sufferers are slightly more likely to suffer a stroke than are similar individuals without migraine, but their risk of doing so is still quite low. However, this does not necessarily mean that having a migraine increases the risk of stroke during the migraine attack. Stroke risk can be lowered substantially by frequent exercise, proper diet, avoiding smoking, and maintaining normal blood pressure.
Finding a Doctor
betabuddy: What type of doctor should I see to diagnose and treat my headache?
Speaker_-_Dr__Steven_Krause: If your headaches have just begun, start with your family doctor. If your headaches have already been treated, but still cause you significant problems, referral to a headache specialist, typically but not always a neurologist, would be worthwhile. For the most severe cases, involving headaches at least 15 days per month, and creating substantial disruption in mood and/or ordinary life activities such as work, housework, child rearing, social or recreational activities, the problem may require the involvement of a multidisciplinary team including physicians, psychologists, nurses, and physical therapists.
Cleveland_Clinic_Host: I'm sorry to say that our time with headache specialist Dr. Steven Krause is now over. Thank you again Dr. Krause for taking the time to answer our questions about headaches and migraines.
Speaker_-_Dr__Steven_Krause: Thank you so much for having me here today. It was a pleasure!
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This chat occurred on January 8, 2010.
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