Online Health Chat with Dr. Stewart J. Tepper

June 10, 2011


Cleveland_Clinic_Host: According to the National Headache Foundation, more than 40 million Americans suffer from chronic, recurring headaches; and of these, 29 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.

Cleveland Clinic’s Neurological Center for Pain is dedicated to the diagnosis and management of headache disorders, facial pain syndromes, and associated disorders, and commonly treats patients with both primary and secondary headaches. The center treats thousands of headache patients each year 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.

Dr. Stewart J. Tepper, Professor of Medicine (Neurology) at Cleveland Clinic's Lerner College of Medicine and Director of Research for the Neurological Center for Pain, is board-certified in Headache Medicine and Neurology. He was Director of The New England Center for Headache in Stamford, Connecticut prior to joining Cleveland Clinic in March of 2008.

After earning his medical degree from Cornell University, he took his neurology residency at Harvard University. He is an Associate Editor for the journal Headache. He is a professional reviewer for more than 20 journals, including Cephalalgia and Neurology, and has published more than 200 peer-reviewed manuscripts, editorials, and books.

Dr. Tepper has been Director of the Headache Therapy course from 2009-2011 for the American Academy of Neurology and is currently Co-Director of the autumn meeting of the American Headache Society (AHS). He serves on the education committees of AHSand belongs to multiple societies, including AHS, IHS, American Academy of Neurology, and National Headache Foundation. He has participated in more than 200 clinical research studies.

He lectures nationally and internationally on all aspects of headache medicine. His interests are in patient care and education, research in the causes and treatments of headaches, and in patient outcomes.

To make an appointment with Dr. Stewart J. Tepper or any of the headache specialists from Cleveland Clinic’s Neurological Center for Pain, please call 216.636.5860 or toll-free at 866.588.2264. You can also visit us online at

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Stewart J. Tepper. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


twist_and_shout: What are the most common headache triggers?

Dr__Stewart_J__Tepper: Stress and let-down from stress, alcohol, skipping a meal, nitrates, menses, weather changes, bright light or strobes, exertion, exposure to smoke, high altitude, crossing time zones, plane rides, strong odors, and alteration of sleep.

tipper03: How often are headaches a sign of something worse? How would you know the difference?

Dr__Stewart_J__Tepper: We use a set of warning signs to alert us when something may be more than just a headache. These include, but are not limited to, an underlying medical illness such as an autoimmune disease, chronic infection, or cancer; an abnormal neurologic examination; a sudden onset of headaches or onset with age; and a change in pattern of headaches. These warning signs can be discussed with your physician.

jag655: Is there any treatment for cluster headaches that is effective?

Dr__Stewart_J__Tepper: There are preventive, acute, and what are referred to as transitional therapies for cluster headaches. Only certain acute medications, such as subcutaneous sumatriptan and DHE (dihydroergotamine mesylate), have FDAapproval. Last year, the American Academy of Neurology published guidelines and ratings on all of the cluster medications, so treatment is usually very effective. A headache medicine specialist or a neurologist with a special interest in headache is often necessary to get optimal cluster treatment.


AndyB: Can migraine cause a fever?

Dr__Stewart_J__Tepper: It is rare, but it can occur. However, a careful look for other causes of headache and fever is in order.

sunnyday: If I have migraines, will my two daughters have them as well.

Dr__Stewart_J__Tepper: There is a high likelihood for inherited migraine, especially in females with migraine. This is especially true if your daughters have motion sickness, unfortunately.

look_away: My friend said that she gets a migraine every day. Is this possible? Is there anything that can be done? She said that nothing works.

Dr__Stewart_J__Tepper: Chronic Migraine is defined as headache at least 15 days per month, at least four hours per day, at least eight days of which reach migraine level. Continuous Chronic Migraine occurs, that is headache that never stops, and Chronic Migraine affects 2 percent of the general population.

Race222: How young can children begin to get migraine headaches, and can children get stress headaches?

Dr__Stewart_J__Tepper: Children can get migraine as toddlers. Stress is a common trigger of migraine in everyone, including kids.

Arizona50: I had a history of migraine auras occurring about once every 8 to 12 months. I had two atrial fibrillation ablations and two more similar procedures to place a pulmonary vein stent within a year at Cleveland Clinic. After each procedure, I had repeated auras, one after another, while in the hospital overnight. Six months following, the aura frequency increased and persisted at two to three times a day. Is there an explanation for this change? I did not add or change medications during this time. I am now treating the migraines with 50mg Toprol a day and having success.

Dr__Stewart_J__Tepper: There is an association between patent foramen ovale, cardiac emboli, and aura, so perhaps the procedures are related. Beta blockers such as Toprol (metoprolol) are a good option.

flowerpot: If you have a migraine with associated numbness (in arms/hands), does this signify something more serious?

Dr__Stewart_J__Tepper: It depends on the situation. Typical aura can occur as one-sided numbness lasting 5 to 60 minutes, followed by the migraine. Two-sided numbness, however, while it can occur in migraine, requires a careful workup for other causes.

think_it_over: I seem to have a sinus headache nearly every day, and over-the-counter medications don’t seem to work. What can give me some relief?

Dr__Stewart_J__Tepper: Most headache medicine specialists believe that chronic "sinus headaches" are usually migraines, and daily headache is usually Chronic Migraine. I would recommend you see a headache medicine specialist or a neurologist.

wait_up: I often have three to four days of headaches. Continuous Tylenol® or ibuprofen does not work. I also have neck pain, neck stiffness, and shoulder pain. What would an effective treatment be?

Dr__Stewart_J__Tepper: These events sound like migraine, and neck pain is very common in migraine. I would recommend you see a headache medicine specialist or a neurologist for optimal treatment.

Migraine Prevention

gramachris: If prescribed a migraine preventive, such as Topamax®, 50 mg twice daily, and the migraines seem to be coming back again almost every day, is it time to increase the dosage?

Dr__Stewart_J__Tepper: In the FDA regulatory trials of Topamax® (topiramate), 200 mg was no more effective than 100 mg, but had more side effects. However, in the open label regulatory extension trial, many patients described improvements with higher doses. There are other reasons why Topamax® could not be working as well, including how often you take your as-needed acute migraine medications, so a discussion with your doctor is indicated at this point.

creative_arts: Someone told me about a study that demonstrated that Chronic Migraine sufferers treated preventively with Topamax® experienced fewer migraines. Do you know anything about this?

Dr__Stewart_J__Tepper: There have been two randomized controlled trials on Topamax® for Chronic Migraine, and it worked in both studies at reducing Chronic Migraine. In one study, it did not work if the patient was in rebound, taking excessive amounts of analgesics; and in the other study, it was 50 percent less effective if the patient was in rebound.

flowerlady: Are there any advances that will help migraine patients to get better "rescue" treatment when they are travelling?

Dr__Stewart_J__Tepper: Many acute medications and preventive medications can help with headaches triggered by travel, and talking with a headache medicine specialist or neurologist may be of use in this regard.


gramachris: The relief medication I am taking now is Relpax®, 40 mg, and it only seems to mildly touch the pain. I am probably taking it too late. Does it make a difference when I take it?

Dr__Stewart_J__Tepper: Yes, taking the Relpax® (eletriptan) early in the attack works better.

isifile: If I've already been put on propranolol, nortriptyline, indomethacin, and now Topamax®, is there really anywhere else to go if Topamax® doesn't work?

Dr__Stewart_J__Tepper: I would recommend you see a headache medicine specialist or a neurologist with a special interest in headache. There are many treatments still open for you, depending on diagnosis and your other conditions.

sunnyday: I've been taking Effexor® and MigreLief for migraines for about six years now. I have been extremely lucky to find medicine that works. Are there any long-term effects I should be worried about with taking these two?

Dr__Stewart_J__Tepper: With respect to the Effexor® (venlafaxine), regular checks of your blood pressure are recommended, as rarely it can raise blood pressure. MigreLief is not an FDA-regulated combination, but long-term use of magnesium, feverfew, and vitamin B2 is generally well-tolerated.

LynnB: What, generally, is a "safe" dose of Imitrex® to take, and how often? In other words, how much is too much?

Dr__Stewart_J__Tepper: The FDA limits Imitrex®(sumatriptan) to a maximum of 200 mg oral tablets per day, or two shots of 6 mg, or two nasal sprays of 20 mg, or one shot of 6 mg and one tablet of 100 mg. We generally recommend limiting use to two days per week to avoid rebound and daily headache.

Nem: Generally, when taking propranolol for migraine-associated vertigo, and seeing small improvements, how long should you stay at that dosage before trying a higher dose?

Dr__Stewart_J__Tepper: This is variable, depending on your current dose, the severity of the symptoms, and other associated treatments underway (for example, vestibular physical therapy). Therefore, consulting with the prescribing doctor will be necessary.

Botox® (botulinum toxin)

marecpa: I've been receiving Botox® treatments for my migraines with great success, reducing my 24/7 headaches to two to three per month. Unfortunately, since my last treatment in March, the last month and a half have been the worst I have suffered since beginning the treatments. Is it possible I'm becoming immune to the Botox®, or perhaps the last treatment was a weak batch?

Dr__Stewart_J__Tepper: It is possible you could be developing neutralizing antibodies to the Botox®, although these have not yet been described in the literature as reducing effectiveness. My guess is that the Botox® will continue to work for your Chronic Migraine, and I would recommend doing your next treatment as usual.

kaysus1973: I had two occipital nerve blocks done at pain management. They really helped. Is there some way to make that improvement long term or permanent?

Dr__Stewart_J__Tepper: Unfortunately, occipital nerve block effects are always temporary. Sometimes, Botox® delivered in the same place can have a more prolonged effect, but none of the injections or blocks is permanent.


ralphallen: Which is the best for treatment of headaches: aspirin, Tylenol®(acetaminophen),or ibuprofen? Is a cold compress a help?

Dr__Stewart_J__Tepper: There are a variety of FDA-approved medications for migraine and many over-the-counter medications for both migraine and tension-type headaches. If you have significant impact from your headaches, a discussion with your doctor is in order.

oh_please: Since I’m on Plavix® and 81 mg aspirin, is it wrong to take a regular aspirin or should I take Extra Strength Tylenol® for a headache?

Dr__Stewart_J__Tepper: You should use only Tylenol®, as long as you have no liver disease and have used it safely in the past, because aspirin at varying doses and Plavix® (clopidogrel) interact. If Tylenol® does not work, you will need to discuss treatment with your doctor.

Race222: A neurologist told me once that I should stay away from caffeine, as it is a trigger, but I thought I saw that some over-the-counter headache medications actually contain caffeine. What are your thoughts?

Dr__Stewart_J__Tepper: Caffeine is a double-edged sword in migraine, and daily use of more than 100 mg is associated with daily headache. Small amounts used occasionally, mixed with aspirin or acetaminophen, seem to help with the effectiveness of those combinations. However, use of caffeine-containing analgesics more than twice weekly can cause rebound and daily headache.

Migraine and Menstruation

Race222: My daughter, age 22, suffers from migraine headaches every month as her period approaches. She wondered, because she cannot control her monthly period, is there anything she can do to prevent the migraine or assist in prevention, such as a vitamin or mineral supplement? She has been given a migraine medication by her college campus physician.

Dr__Stewart_J__Tepper: There are a variety of both preventive and acute medications for menstrual-related migraines, and a discussion with her doctor is in order.

LynnB: My migraines come about two days before menstruation and last about three to four days. I am using Imitrex®, which usually seems to help. My doctor has added daily Inderal to help as well. Can you tell me what causes my migraines and if there is anything "natural" that I can do to help for now and for the future?

Dr__Stewart_J__Tepper: Migraines are an inherited neurological disorder in which a central brain switch turns on at the beginning of the migraine and turns off at the end. Inderal (propranolol) helps inhibit the switch; Imitrex®(sumatriptan) turns off the migraine once it starts. Magnesium can sometimes be helpful in preventing menstrual migraines and is safe and natural. You may wish to speak with your doctor, a headache medicine specialist, or a neurologist about adding daily magnesium to your regimen.

General Questions

caitlynn: Have you found any association between a partially blocked carotid or vertebral artery and increased headaches and/or migraines?

Dr__Stewart_J__Tepper: Vascular disease can increase headaches, but treatment is generally aimed primarily at the vascular disease.

ocsb3: How does Cleveland Clinic’s IMATCH program differ from standard chronic headache treatments?

Dr__Stewart_J__Tepper: IMATCH stands for the Interdisciplinary Method for the Assessment and Treatment of Chronic daily Headache; and at Cleveland Clinic, it is a multidisciplinary, structured, three-week day-hospital program for difficult to treat daily headaches. It includes support from Neurology, Internal Medicine, Psychology, Skilled Nursing, Physical Therapy, and Infusions. There are four other structured multidisciplinary headache programs in the country (in Ann Arbor, Chicago, Los Angeles, and Dallas), but these other programs are inpatient only. At Cleveland Clinic, IMATCH is a day-hospital program, so patients sleep in a motel at night at a discounted rate. Therefore, insurance is more likely to pay. Otherwise, these five programs work about the same, and represent an effective way to help someone overwhelmed by daily headaches.

flowerlady: I live in another state. If I come to Cleveland Clinic, will I have to come back for all my treatment or could a local doctor oversee my treatment with regular visits to Cleveland?

Dr__Stewart_J__Tepper: This depends entirely on your diagnosis.

flowerlady: Would you consider a headache journal to be an essential component to the proper diagnosis of headache/migraine? If so, would you suggest the data that you would want to see in a journal?

Dr__Stewart_J__Tepper: Yes. Keeping a headache diary or calendar is crucial to evaluating headache care.

pack_it_up: Can you talk about occipital nerve stimulator implants for continuous headaches?

Dr__Stewart_J__Tepper: Several companies are studying occipital nerve stimulators for Chronic Migraine, and these studies are underway nationally. We await the results.


Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Stewart J. Tepper is now over. Thank you again Dr. Tepper for taking the time to answer our questions today about headaches.

Dr__Stewart_J__Tepper: Thank you for joining me this afternoon. Remember, headaches are treatable!

More Information

To make an appointment with any of the headache specialists from Cleveland Clinic’s Neurological Center for Pain, please call 216.636.5860 or toll-free at 866.588.2264. You can also visit us online for more information on headaches & migraines.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit MyConsult Online.

This chat occurred on June 10, 2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.