Living With Headaches and Migraines with Dr. Emad Estemalik

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and we're here with Dr. Emad Estemalik. Dr. Estemalik is a headache specialist in the Center for Neurological Restoration, and section head for headache and facial pain here at Cleveland Clinic, and today we are talking about headaches. Thank you so much for coming in today.

Dr. Estemalik:   Thanks for having me. Happy to be here.

Nada Youssef:   Sure thing. And please remember, this is for informational purposes only, and is not intended to replace your own physician advice. Before we jump in the topic, I'm going to ask you some questions off topic to get to know you better.

Dr. Estemalik:   Yeah.

Nada Youssef:   All right. How many languages do you speak?

Dr. Estemalik:   I grew up in Egypt, so my first language is Arabic, of course, but born and raised for my first six years of life in Germany, so German was my second language. Of course, I was taught English at school, so that became my third language. By middle school we took French at school, so that was my fourth language. And then, when I came to the U.S. and met my wife who is of Mexican heritage, so I learned Spanish.

Nada Youssef:   Wow.

Dr. Estemalik:   So, by now, five languages.

Nada Youssef:   Wow, proficient in like all of them?

Dr. Estemalik:   Well, I think my French is kind of going to an area of the brain that I can't get anymore.

Nada Youssef:   Retrieve it anymore, yeah.

Dr. Estemalik:   Spanish I'm getting much better, but still, very efficient in both German and Arabic, and of course, English.

Nada Youssef:   That's amazing. Good for you. How about the best food you've ever had?

Dr. Estemalik:   I've got to go with Middle Eastern food, since also some of the healthiest foods, so I would say [shish tawook 00:02:11] and tabouleh, would be my favorites.

Nada Youssef:   Oh, that sounds delicious, yes.

Dr. Estemalik:   Yeah.

Nada Youssef:   All right. And what about best concert you've ever been to?

Dr. Estemalik:   That's a good question. Probably going back in time, growing up in Egypt. It was 2006, just a year before I moved to the U.S. Shakira was doing a Middle East tour, and she came to Egypt, and she held one of her conferences by the pyramids, and one of the most magnificent concerts I've ever been at.

Nada Youssef:   Wow. Lights up and everything.

Dr. Estemalik:   Lights everywhere. They lit the pyramids. For anyone who's ever been to they pyramids, really, they host a lot of concerts by the pyramids. Pink Floyd was actually just there. It's unbelievable. So, Shakira by the pyramids, that's something I'll never forget.

Nada Youssef:   That sounds amazing.

Dr. Estemalik:   Yeah.

Nada Youssef:   That sounds amazing. Thank you. Thank you for that. Okay, so let's go back into topic. According to the International Headache Society, there are over 150 headache categories. For practical purposes, let's just talk about the most common or primary ones during this podcast. But first, I want to ask you, who suffers more frequently from migraine headaches? Would it be man or women?

Dr. Estemalik:   It is actually women, and we know the data, and if we go by prevalence, 20% of women, roughly, have migraines versus 6 to 8% of men. So, definitely, women tend to be more affected than men.

Nada Youssef:   Why is that?

Dr. Estemalik:   Basically, it comes down to the hormonal factor, and it tends to be really the fluctuation of hormones that play a huge role in migraines. That's why women, mainly during child-bearing age, anywhere from, by the time they start their menstrual cycle till menopause, it is the time they have the vast majority of their migraines. Usually they do improve after menopause, because then you have a steady level of hormones, so it is the hormonal component.

Nada Youssef:   You said 20% of women get migraines?

Dr. Estemalik:   20%. Yeah. 20% of women have migraines. Less than 10%, somewhere between 6 and 8% are men, so definitely double the amount.

Nada Youssef:   Wow. That's huge. Yeah. I would like to talk a little bit about the most common types of headaches, and what they're called, where they're located, how long they last, all kinds of stuff. So, first of all, most common one is tension headache?

Dr. Estemalik:   Absolutely.

Nada Youssef:   What is a tension headache?

Dr. Estemalik:   Tension-type headache definitely is the most common type. It is typically also a headache that we don't see often in clinic because, again, it's easily manageable, and self-manageable. A lot of primary care physicians take care of headaches, but it is the usual headache that every one of us usually tends to experience. So, it is basically a pressure, it could last anywhere from half an hour to a few hours. Not really severe, people can really go on with their lives. No nausea, no vomiting. Typically, not much light or sound sensitivity. So unlike migraines, it is not debilitating headache, not severe enough. And really patients report, usually periods of time where they have an increased frequency of these headaches when they are under stress or there are other factors playing a role. But definitely tension-type headaches tend to be the most common type of headache that patients experience.

Nada Youssef:   So you said it's the most common, but then, it's the least amount of patients that you see. Is that because over-the-counter medications fixes it?

Dr. Estemalik:   Exactly. Over-the-counter usually work, and it is not severe enough, and it doesn't raise a concern to patients or anybody, when they have that kind of headache to see a physician or any health care provider.

Nada Youssef:   So it's mild. [crosstalk 00:05:29] very mild.

Dr. Estemalik:   Mild. Usually mild to moderate, never hits severe.

Nada Youssef:   All right. Second one, migraines?

Dr. Estemalik:   Second one, migraines, and migraines tend to be the most common type of headache that we typically see in our headache clinic, or even that primary care physicians see. And as a matter of fact, headache tends to be one of the two most common pain complaint that any physician encounters. So together with back pain, these tend to be the two most common pain complaints that providers see. Migraines typically are more severe than tension-type headaches. They last anywhere from a few hours, but they can go a few days, so patients can sometimes go two to three days. Typically, one sided, but can also occur on both sides, so patients usually don't think it is a migraine because it can occur on both sides, but that's not always the case. And then patients have these classic features. They'll get nauseous, they'll want to throw up, sometimes they do, and then significant light and sound sensitivity. A throbbing sensation in the brain, and it is not ... These kind of headaches usually do not just simply respond to over-the-counter meds.

Nada Youssef:   So then they can mess with your quality of life? Driving, things like that.

Dr. Estemalik:   Absolutely. Absolutely. Yeah. So they do ... And really what determines how much it affects someone's quality of life or social activities, is both the frequency of these migraines, how many a patient can get in a month, and also the severity, so how bad it gets. And it can really put people down from doing things, stopping what they're doing, having to be in a dark, quiet room, try to sleep it out. That is when this raises the concern for a migraine.

Nada Youssef:   And then, over-the-counter medication doesn't work on this, so what kind of treatments [crosstalk 00:07:04]?

Dr. Estemalik:   So, typically, over-the-counters don't completely abort such headaches. There are two ways really to manage migraines. A, there are medications that we use to abort these headaches, and patients that get migraines know about this. One of the class of medications that we use are called the triptans. For instance, Sumatriptan, Rizatriptan, there are several drugs and that are family. But then, if patients also have a high frequency, that means they have 10, 15 headache days a month or more of migraines, then typically we discuss with the patient a daily migraine preventive. And we can talk about that in detail a little bit, what kind of preventive strategy we use to reduce the frequency, because some patients will say, "It's not just one migraine a month, or two migraines a month I'm getting. It's 10 to 15. And that can really affect somebody quality of life.

Nada Youssef:   Sure. Sure. What about cluster headache?

Dr. Estemalik:   Cluster headache definitely far less common than migraine and tension-type headache. Typically, we see it more in men, so it doesn't affect women as much. And it is by far one of the most severe headache types in terms of the pain severity. A patient will usually come and the presentation is pretty classic. It's always one sided, around the eye. And patients will complain about significant redness, droopy eye, nasal stuffiness, and really being agitated. Some patients actually use the term suicide headache for that. That is how really severe this headache can be. Now, the good news about cluster headache, it does not occur as frequent as migraine, in terms of year long. Typically, it comes in cycles. And patients will know, okay, I'm hitting my cluster cycle right now. It can happen once a year, once every few years. Can last a few weeks. And then we help the patients during that time, to kind of reduce the duration of the cycle and really abort these attacks early on, with some treatments.

Nada Youssef:   Sure. And then you mentioned droopiness and color ... There's physical changes to your face?

Dr. Estemalik:   Absolutely. We call them, actually, autonomic symptoms, where a teary eye occurs, a red eye. Again, some of these other symptoms, nasal stuffiness, runny nose. And patients now about ... They'll always know this is different from any kind of headache I've had before. And, again, the treatment is different than migraines, but also the underlying reason, or what we call pathogenesis, for this headache is different than migraine as well.

Nada Youssef:   Right. And it's only one sided?

Dr. Estemalik:   Only one sided.

Nada Youssef:   It will never be on two sides.

Dr. Estemalik:   That's the classic thing about cluster headache, it is only one sided. In fact, it hardly shifts side. Patients that have had cluster headaches for many years, and when they get it in cycles, they actually know ... It's usually the right side or the left side.

Nada Youssef:   Wow. Wow. How about new daily?

Dr. Estemalik:   New daily persistent headache is ... And this is not a headache a lot of people are familiar with. It is rare. We do see it. But the classic presentation with new daily persistent headache is that you can get a patient that may have never had a history of headaches before. And then out of the blue, they say, well, I woke up one day ... Or there was something that happened, for instance, like they had a viral illness or something. And then, they're left with this constant, ongoing headache that just doesn't subside. And something very classic a patient says is, I have some degree of daily, 24 hour pain or discomfort in my head. And I get these spikes of pain where it gets worse, and then I'm left, again, with a 24 hour pain. For some it's very hard to comprehend how come, out of the blue, I just have a headache that doesn't go away. We still don't understand the exact pathogenesis of this headache.

              Again, it's rare, so we're fortunate that it doesn't affect too many people. But it is one of these headache types that we always take very seriously in terms of our workup, and what kind of tests we need to run to rule out any secondary causes of headache. Another reason for ... When patients describe, I'm having the worst headache of my life, could be actually a ruptured aneurism. And this is something that would require immediate attention, because often the quicker you can get in with a provider, and that's usually a case where you've got to go to the emergency room, is the quicker we can get a surgical intervention to fix this aneurism. Typically, a ruptured aneurism can present with a severe, severe headache. And it can present with some other neurologic signs as well. A droopy eyelid, sudden weakness in one side of the body, again, facial droop. Again, this is a major concern we often have when we hear the worst headache of my life. Or what we also describe as a thunderclap headache.

Nada Youssef:   Sounds good. And we'll get a little bit more into treatments, but I want to talk about preventable measures for headaches in general.

Dr. Estemalik:   If you talk about preventable measures, there's ... And let's talk about migraines for a minute, because that tends to be the one headache disorder that usually takes the bulk of preventative strategy. First, you have, of course, your typical daily preventives, when a patient says I have more than 15, 20 headache days a month. And this can vary. We use different kind of medication. Daily medication can vary from seizure meds to blood pressure meds to anti depressants. These are 3 classic families of drugs that we use to reduce headache or migraine frequency. Then we get into the procedural aspect. For a few years now the FDA has approved onabotulinumtoxina, or Botox injections for prevention of migraines as well. This is typically a procedure that's done every 90 days. And we usually go to this option when patients have failed ... Or tried already a few of the oral preventives. Then, as of last year, we have 3 drugs on the market that are injectable drugs. This is the newest class or family of drugs that are used now for migraine preventions. They're called the monoclonal antibodies. And these are either monthly or quarterly injections that a patient can administer themselves at home. And it's basically a very simple injection. And it acts on a receptor that we've studied for many years now, it's called the CGRP receptor. And it acts on that receptor in terms of reducing headache or migraine frequency. They've been on the market now ... It's been a life changer for a lot of patients, and we've seen great results with some of these drugs.

Nada Youssef:   With these treatments, it depends on the frequency?

Dr. Estemalik:   Absolutely, yeah.

Nada Youssef:   It depends on just how ...

Dr. Estemalik:   Any preventive strategy always depends on the frequency. You never want to expose any patient to a procedure or a daily medication if they don't need to. And this is always the first discussion we have. There are really guidelines of when we bring up the need for a daily medication. It's just like any other disorder. You take diabetes, when you want to start a daily drug? It's when your blood sugars are high that you need to do something about it. Same with high blood pressure. When migraines or headaches affect somebody quality of life, and a patients says, you know what, half the months or more, I'm having a headache. Simple, abortive medication or over-the-counter medication don't do it. That is one type of prevention that we do. The other type of prevention is also, what kind of lifestyle modification that patient can do. This where we usually have a good lengthy discussion about it. One, of course, is always diet modification. We know there are certain food components or diet components that a patient can follow to reduce headache frequency.

Nada Youssef:   Let's talk about that.

Dr. Estemalik:   Absolutely. Diet is ... The big thing with migraine diet are usually two things. Monosodium glutamate and nitric oxide. We always tell patients to stay away from these two components. And to watch out for food which has these two. Typical food like that is Chinese food, for instance. Aged cheeses. Red wine. Ramen noodles, for instance. Chocolate. The list goes on. But the first thing I always tell a patient is, you don't have to stop everything. It is basically in moderation. And patients are smart. They know ... They often come and say, "Well, when I eat this, I get a migraine." And it kind of makes sense, that there's certain triggers in a certain food type that can trigger these headaches. Really, we look at the list. We look at what a patient likes to consume or eat, and then we take it from there. Caffeine is always ... Also a big factor. Too much caffeine is actually bad for people with headaches, especially people who have migraines.

Nada Youssef:   How about too little caffeine?

Dr. Estemalik:   Actually, a good amount, which is usually anywhere between a 100 to 150 mg a day, which would equal a tall Starbucks, not a venti, that can actually be protective. Patients will say, when I have my morning coffee ... And we hear that from a lot of people, is that can actually help their migraines. Really, the right amount of caffeine can also be of benefit to patients.

Nada Youssef:   And for those who don't know what ... The tall, because it is confusing, that's a small cup of coffee.

Dr. Estemalik:   That's a small cup of coffee. Once you go into the really large one, you're talking 400 to 500 mg. And that, in itself, is a large amount.

Nada Youssef:   Yeah, I imagine all the sugar that you add on top is not helping your headache?

Dr. Estemalik:   Absolutely. Yeah. Yeah, yeah. No, absolutely not. Then any caffeinated drinks, processed food, we try to tell patients to stay away from as well. Really, it is a good discussion we have and a lot of patients do really well with this kind of lifestyle modification. And I like always to give patients the choice. We can first try what I call a conservative approach, or conservative strategy. And then, if that does it, then great. The less medication the better. But, still, there's some patients ... And we know approximately 2-4% of patients with migraines will go into what's called chronic migraine, hence a preventive medication is needed. But you always want to take it one step at a time. Especially with young patients, where you're trying to avoid daily medication. Or even older patients who may already be on a lot of meds and you don't necessarily want to add more.

Nada Youssef:   Sure. And then, how about dehydration? Sometimes ... I don't get a lot of headaches, but when I do get those tension headaches, I find that water will literally fix the situation.

Dr. Estemalik:   Yeah. Two things. A, the right amount of hydration is crucial in terms of being protective against migraines or headaches. And then also not skipping meals. Really, having your breakfast, lunch, and dinner, and really at right intervals, right amount, is also of great benefit. Again, definitely hydration and the kind of diet regimen they follow.

Nada Youssef:   Now, I read somewhere that increasing magnesium intake would help?

Dr. Estemalik:   Typically, magnesium oxide is one of the over-the-counter medications that we add in terms of reducing migraine frequency. And there are really 3 over-the-counters, that based on our studies, we know can help. Magnesium is one of them, anywhere at 400 to 500 mg. Vitamin B2 can also be very protective, and can reduce migraine frequency as well. And then a third one is coenzyme Q10. [crosstalk 00:18:18]. Coenzyme Q10.

Nada Youssef:   Where do I get that?

Dr. Estemalik:   Coenzyme Q10, you can also get it over-the-counter.

Nada Youssef:   Supplements? Yeah.

Dr. Estemalik:   Yeah. It's one of those supplements, it's great for the heart. So our friends in cardiology love that. Again, over-the-counter, just like Mag and B2. These three usually do ... Can really help. And often patients prefer just to stay on over-the-counter supplements to reduce their headache frequency. And that often works.

Nada Youssef:   And then, one important thing we didn't talk about is sleep.

Dr. Estemalik:   Yes.

Nada Youssef:   Sleep, and then I would think stress and sleep really go hand in hand?

Dr. Estemalik:   Yeah. Sleep is one incredibly important element when it comes to headaches. And typically, if there's an underlying, and I like to call it diagnosed or unrecognized sleep disorder, it can have a tremendous effect on the amount of headaches or the frequency of headaches patients get. Really taking a good sleep history, and we do that. We even have some questions that patients ask before they see us that kind of give us an idea if there is an underlying sleep disorder or not. And typically you hear, patients may say, I wake up with a headache. Or I wake up ... And when you hear, I wake up during the night several times, this can already trigger the concern that there may be an underlying sleep disorder. And then, really addressing this issue as well can have also great benefit in terms of reducing headache frequency. Often, these patients will have to undergo a sleep study. And then we get a better idea if there's a sleep condition or not.

Nada Youssef:   And you tend to be more stressful when you have less sleep, and it's a vicious cycle.

Dr. Estemalik:   Absolutely. Stress is one major element that we struggle with a lot because, again, everybody's life is ...

Nada Youssef:   Stressed out, yes.

Dr. Estemalik:   Unique and different. And stress can vary from work, to family, to personal issues. So, again, it's ... And this is where self awareness really plays an important role. What can I do personally to reduce my stress level? Again, we're all very busy, and we're often consumed in our daily activities. But, yes, this is one discussion we often have, about stress. Another important element is, and this is something we always joke about that's something we can't control, and that is the barometric pressure. Especially, like you look at our weather in the past few weeks. It is not uncommon that we go from 70, 80 degrees suddenly to 40 or 50 degrees. It's not really the just hot or cold weather, but it's that sudden ...

Nada Youssef:   Pressure itself.

Dr. Estemalik:   Pressure change. So that ...

Nada Youssef:   It's true, when it rains it can ...

Dr. Estemalik:   Absolutely. Oh, yeah. Yeah.

Nada Youssef:   Cause us to get headaches.

Dr. Estemalik:   Rain can cause that, yeah. I hear that from a lot of patients. Rain. But, then again, really, the drop in temperature or the sudden rise in temperatures plays an incredible role in terms of ...

Nada Youssef:   Sure. And in Cleveland we have tons of that.

Dr. Estemalik:   Yes. Yes. Simply today, we're about to reach 75, 76, and we were just less than 50 48 hours ago. So really, that sudden change does affect people. Does affect people, yeah.

Nada Youssef:   Okay, I want to go back to the cluster headaches. I heard that cluster headaches are more common in smokers?

Dr. Estemalik:   That is true.

Nada Youssef:   Okay. Let's talk a little bit about that. You would think smoking would affect all of it, but why cluster?

Dr. Estemalik:   We don't understand exactly why smoking tends to predispose people with cluster headaches to having the disorder. But if you look at some data that we're familiar with, roughly 80% of patients with cluster do smoke. And there is a genetic predisposition to cluster headache. And there are some studies that show that staying away ... Or stopping smoking actually can reduce the frequency of the cluster cycles that a patient experience. So smoking is one big component. The other component for cluster headache is also alcohol.

Nada Youssef:   Alcohol.

Dr. Estemalik:   Typically, patients with cluster headaches know that the minute they consume any alcoholic beverage, it can trigger a cluster cycle.

Nada Youssef:   Wow.

Dr. Estemalik:   Many of my cluster patients, I'm always very strict about, at least during a cluster cycle, you want to completely stay away from alcohol. Absolutely zero amount of alcohol. That, yeah, these two factors are definitely a big player.

Nada Youssef:   Smoking and alcohol?

Dr. Estemalik:   Yeah.

Nada Youssef:   All right. How about, if I'm getting a really bad headache, sometimes we think it's a life threatening disease. A tumor. How do you know when it's just a headache, a bad headache that's coming and going, or it's something life threatening?

Dr. Estemalik:   This is one of the most common questions, actually, that we get. Typically, if anybody experiences what they call the worst headache of their life, that always raises concern. If somebody has no history of headaches and suddenly gets the worst headache of their life, whether they have associated or other neurological symptoms, whether or not, this should be investigated right away.

Nada Youssef:   Even if it's not consistent?

Dr. Estemalik:   Even if it's not ...

Nada Youssef:   Okay.

Dr. Estemalik:   If it is consistent, it's different. But if it's out of the blue, out of the blue and somebody says, "Well, I just ... This feels different. This was ... I'm not familiar with headaches. I don't get them that often." And then they have the worst headache of their life. This requires the workup right away.

Nada Youssef:   Wow.

Dr. Estemalik:   If you look at a lot of data, typically, headache alone, and this is something we always assure patients with, headache alone is not the sign of a brain tumor. Unless it is ... Manifests with other symptoms. That could raise the concern. Or if it takes different features. And let me go through that. Typically, brain tumors present mainly with things like seizures, cognitive changes, sudden numbness, sudden weakness in one side of their body.

Nada Youssef:   Vision issues?

Dr. Estemalik:   Vision changes. And then, headache can be a hallmark as well. But headache alone wouldn't be the factor that raises concern.

Nada Youssef:   The go-to symptom for a brain tumor.

Dr. Estemalik:   Now, when? When would it be? If the headache takes features like it's mostly present in the morning, with significant nausea or vomiting. So something that would raise the concern for what we call increased intercranial pressure. If a patient says this headache is new, it worsens when I cough, mainly, or what I lay down. That also raises the concern. If a headache is locked primarily one side with vision changes, that can raise a concern. Typically, again, just your regular headaches, here and there, shouldn't raise the concern of a brain tumor.

Nada Youssef:   Sure. Sure. This is very good to know, and hopefully nobody ever has to go through that, but ...

Dr. Estemalik:   Yeah, absolutely.

Nada Youssef:   I read about, I believe, a rare type of headache is that thunderclap headache?

Dr. Estemalik:   Yeah.

Nada Youssef:   What is that [crosstalk 00:24:45]?

Dr. Estemalik:   Thunderclap headache, it is a headache that we take very seriously. The best way to describe it is a sudden explosion. Or sudden excruciating pain that occurs in the head, anywhere from a few seconds to a few minutes. And it is so severe that it can bring somebody to tears. Such headaches, to us, always require every kind of work up that is needed, to rule out any secondary cause. It goes from labs to the appropriate brain imaging to look at the brain in general, at the brain vessels. Because there are secondary causes that can cause a thunderclap headache. A condition like RCVS, for instance, reversible cerebral vascular constriction syndrome. Something like a subarachnoid hemorrhage. Something like a pituitary apoplexy. So there are a lot of secondary causes that can give you a thunderclap headache. This is one of the headache disorders that always require immediate workup as well.

Nada Youssef:   Okay. So that is the worst headache of your life. Yes, that would be ...

Dr. Estemalik:   Yes. Thunderclap headache would ... You're absolutely right. It would in the category of, I just had the worst headache of my life.

Nada Youssef:   Sure, sure. I read a lot of information about headaches in preparation for this. I read a cell phone headache, is that a thing? I mean, it sounds like it would be [crosstalk 00:26:11].

Dr. Estemalik:   Again, there's a lot of literature that talks about cell phones and smart phones being a reason for headache. But the data is not really consistent yet. Now we know that with frequent cell phone users, smart phone use, you are really exposed to a lot of electromagnetic waves. So there are some hypotheses that it can affect the blood brain barrier, for instance. That it can alter brain chemicals. But to really determine accurately the effect of phones or sitting in front of a screen, you've got to look deeper in terms of, okay, what am I ... What are the other circumstances. Am I just on the phone because I'm running some errands or I'm talking to someone, or I'm understand significant stress being on the phone? There are many elements here. Again, we're all exposed to electromagnetic waves wherever we are. Now, of course, putting a smart phone or a phone on your ear, a lot of times can have an effect. But, again, we don't have, yet, enough information to really make that determination.

Nada Youssef:   Okay. And speaking of electronics, sometimes when I binge watch my shows on TV, I find myself getting a headache and nauseous, watching TV for too long. What is that?

Dr. Estemalik:   Again, the best way to actually talk about this, would be really to think about how do we react when we're sitting in front of the TV. We're really tensed. We're really focused. So there is a lot of eye straining.

Nada Youssef:   A lot of eating.

Dr. Estemalik:   There is a lot of ... Sometimes eating. Again, there's some sort of inner physiologic changes when we're excited about watching a show.

Nada Youssef:   We need to look at other factors?

Dr. Estemalik:   Yeah. But what's interesting is, if somebody is predisposed to migraines or headaches, then, again, it could be absolutely an important element when you watch too much TV. Migrainers, a big trigger for them is noise and sound. Sorry, noise and light. So that can be a factor. So if somebody's predisposed to migraines and they're sitting in front a screen with bright lights and loud sounds, it could trigger their migraines as well. So if you're predisposed to having migraines or frequent headaches, then yes, sitting in front of a TV for a long time can be ... Can induce the headaches.

Nada Youssef:   Sure. Okay. Well, I know we talked a little bit about treatments.

Dr. Estemalik:   Yeah.

Nada Youssef:   Now, I read somewhere as well that most opioid users are headache sufferers.

Dr. Estemalik:   Yes.

Nada Youssef:   I want to talk about that. And then, if there's any natural remedy or coping mechanism that you can talk about that don't include drugs?

Dr. Estemalik:   Yeah. I'm glad you brought up the question about opiates when it comes to headaches, because I want to be very clear about that. There is no role for any kind of opiate to treat any headache disorder. Opiates are not recommended for headaches in general. In fact, some of the studies we know, and they're very clear, really demonstrate that if migrainers use any amount of opiates, they are at risk of developing what we call rebound headaches or medication overuse headaches. Opiates can actually worsen migraines and headaches.

Nada Youssef:   Making it worse.

Dr. Estemalik:   And yes, make it worse. Now, what about natural ways to cope with that? There are many. And a lot of patients do really well with it. Mindfulness is big, and patients do really well understanding their body responses. Relaxation techniques. Biofeedback. Yoga, phenomenal. Again, a lot of these remedies can reduce the stress level, reduce somebody's pain, and reduce headache frequency as well.

Nada Youssef:   So when you say mindfulness, just to be clear, it's mediation ...

Dr. Estemalik:   Mediation.

Nada Youssef:   Maybe going hiking. Forest therapy.

Dr. Estemalik:   Absolutely.

Nada Youssef:   All that good stuff.

Dr. Estemalik:   Yep. But, again, back to opiates, especially that we face an incredible crisis with the opiate use in America right now. Like I can tell you in our center, we rarely use opiates for any headache disorder, unless, really, there are other medical conditions where you're really limited in terms of what you can give patients. But there is no role for opiates when it comes to managing headaches.

Nada Youssef:   Wow. That's very informative. Thank you. Thank you so much.

Dr. Estemalik:   Thank you. Thank you.

Nada Youssef:   Well, we are out of time. But if there's anything else that you want to talk about or tell our viewers?

Dr. Estemalik:   No. Again, thanks for having me, first of all. One thing I would want to add for a lot of patients that do experience headache is really to pay attention to how much over-the-counter painkillers they use as well. Simple ... Since we just talked about rebound and medication overuse headache, if somebody has a history of migraines or they're predisposed to having migraines, they can have actually more headaches if they use too much over-the-counter painkillers. And patients often don't know that. So I'll hear from patients that they've been taking Excedrin Migraine or any over-the-counter medication 3, 4 times a week. And then, they say, well, then over time I started having more headaches. And there's a reason for that. Even just consuming too much over-the-counter painkillers can have an effect as well in increasing somebody's headache frequency?

Nada Youssef:   So what is too much?

Dr. Estemalik:   Too much, usually, our rule is no more than twice a week.

Nada Youssef:   No more than twice a week. Very, very good to know.

Dr. Estemalik:   And that's where the preventive strategy ... We discussed the preventive strategy. When patients say, well, I'm having 3, 4 headache days a week. And that's when we try to find the appropriate preventive strategy to reduce the frequency, and to allow patients not to take too much over-the-counter painkillers.

Nada Youssef:   Sure. Thank you so much, Dr. Estemalik, for joining us today.

Dr. Estemalik:   Thank you. Thanks for having me. Thank you.

Nada Youssef:   And thanks again to all of our listeners and viewers who joined us today. We hope you enjoyed this podcast. For an appointment with a headache specialist or for more information, you can call 216-636-5860 or toll free 866-588-2264. Or you can visit us online at Clevelandclinic.org/headache. And to listen to more of our Health Essentials podcast from our Cleveland Clinic experts, make sure you go to Clevelandclinic.org/hepodcast, or you can subscribe on iTunes. And for more health tips, news, and information from Cleveland Clinic, make sure you follow us on Facebook, Twitter, Instagram, and Snapchat, @ClevelandClinic, just one word. Thank you. See you again next time. This concludes this Cleveland Clinic Health Essentials podcast. Thank you for listening. Join us again soon.