Tension Headaches Migraines and Cluster Headaches with Emad Estemalik MD

Podcast Transcript

Nada Youssef: Dr. Emad Estemalik  one of the physicians in the headache section, part of the Center for Neurological Restoration at the Cleveland Clinic.

I've seen two neurologist through the Cleveland Clinic, I had Botox once, therapy and many different medications, what is the next step to do?

We see a lot of patients that come that have had migraines for years, that have had headaches for years. It is very important often to dig deep into the history and see if there is anything else that could be contributing to the frequency of this headache. Typically we look for things like overusing certain over the counter pain killers. Migrainers for instance who tend to use too much over the counter pain killers or any sort of pain killer are at risk of developing more and more headaches, that's something to look for. Underlying sleep disorders for instance.

We know that sleep deprivation or sleep issues can also contribute to a high frequency of headaches. It's very important also to screen for psychiatric symptoms. Is there a depression, is there anxiety? Again, these needs to be addressed as well. When patients have a high frequency of headaches the challenge is finding the right preventive strategy for these patients and that can vary. It could be medication, it could be different approaches, it could be procedures like Botox. So it would be important again to get a thorough history and to find out if there's anything else that has been addressed.

What should you avoid, food and medications if you have migraines and see black spots?

Dr. Emad Estemalik: That's an excellent question. When we hear black spots or any sort of visual changes with migraines, this is typically what we define as auras. Auras, it's a part of a migraine, not every migrainer gets that, but it can present as black spots, it can present as zigzag lines. Some patients will even describe peripheral vision loss, sensory changes, and this is all part of the migraine cascade.

Typically when it comes to food or diet, what we always recommend is avoiding things with MSG which is monosodium glutamate or nitric oxide. This is crucial. Typically foods that have these things are for instance Chinese food, Doritos, ramen noodles, aged cheeses, red wine for instance is also an offender, too much caffeine. There's a big list that we usually look at. Again, and I just mentioned that in the first question also as a migrainer for her, it would also be important to avoid too much over the counter pain killers so these auras and the migraines don't increase in frequency.

A simple, over the counter strategy to reduce these auras or the black spots would be to take daily magnesium for instance. A dose of magnesium of 400 to 500 mg can protect against these auras. We often advice patients actually to also take an extra magnesium when these black spots or these auras occur. There's one simple strategy where you don't need a prescription for that. Now, with magnesium, you always watch out for side effects like diarrhea, but typically a lot of patients report benefit from just doing that.

Nada Youssef: Great information, thank you. We have Michael. How can you tell the difference between a migraine and a severe sinus headache?

Dr. Emad Estemalik: Again, this is also a good question. When we talk about sinus headaches and we've seen a few studies that actually look in retrospect of what patient used to describe or say, I used to have sinus headaches. Sinus headaches are often migraines that were undiagnosed. It doesn't mention that sinus issues don't cause headaches, you can actually have sinusitis or sinus problems that give you a headache, but it's very important to determine are these headaches just related to sinuses or are they migraines that presenting like sinus problems. Migraines can present with frontal pressure or some autonomic symptoms like runny nose, or nausea, or light or sound sensitive which patients sometimes get when they have sinus issues.

Typically with sinus infections, and this is something primary care physician see a lot or ENT physician see a lot, there are some other symptoms that makes that distinct, postnasal discharge, fever, so there are signs of a sinus infections. It is important to understand that often migraines are labeled as sinus headaches when they're actually migraines. It is always important to address these headaches just as a migraine and find the right strategy for it.

Nada Youssef: Great, excellent. I have Steve. How long should you go with a headache before going to the hospital?

Dr. Emad Estemalik: Again, that's also a good question. Typically, we see that often that patients end up in emergency room because of headaches. We advise our patients not to go to the emergency room, the patients that we have seen, unless there is something out of the ordinary or something neurologic that is concerning. If somebody is already established for instance with us or a physician, there are simple measures that they can contact their healthcare provider for and they will receive for instance a simple steroid pack or a Medrol pak. There are certain medications we can send to try to break a headache cycle.

At the Cleveland Clinic's headache department here, we operate an infusion suite for instance where patients with a status migraine, that just means a headache that has not subsided in a few days where patients thought, "Should we go to the emergency room or not?" They can contact us if they're already our patients, we bring them in for one to two days of infusions as an outpatient, and the headaches usually improve dramatically with this kind of approach.

In general, ED visits for headaches are unnecessary unless there is another concern for instance a stroke, or a bleed which would manifest differently than just a headache. Now, we advice all patients and not just the ones who have headaches or not, that if they experience a headache that seems to be very different or what they would call the worst headache of my life, that's something to take seriously and that is a situation where yes, a hospital visit would be appropriate.

Nada Youssef: Great, thank you. I have Leila. Are sharp pains in the head anything to worry about beyond the normal, dull, throbbing headaches?

Dr. Emad Estemalik: Sharp pains in the head are not uncommon. There's an ICHD 3 diagnosis labels that as primary stabbing headaches. These are discreet stabbing sensations that can occur sporadically in the head. However, if this is the first time it occurs this always warrants an evaluation by a headache specialist or a neurologist. Occasionally, stabbing headaches in the head can be a sign of a secondary headache disorder, an aneurysm or other conditions, so this is something that always needs to be worked up before labeling it as a simple primary stabbing headache.

If the right workup has been accomplished by a brain imaging and all, everything comes back normal, this is not uncommon to have these kind of stabbing sensations to the head. In fact, a lot of migraines will have stabbing sensations on top of their migraines as well.

Nada Youssef: We have Cara. Any specific part of the head more worrisome for headaches than others?

Dr. Emad Estemalik: It is not the location of the headache that often worries us, it is what causes a headache to occur, to emerge or to worsen. What we typically look for in terms of determining is this a secondary headache, which means a concerning headache or not, is what brings it on. We call those red flags or things to look out for. If headaches worsen when patients lay down, this is a red flag. If headaches worsen when you cough, you sneeze, when you go to the restroom you strain or you bend down, these signs can be concerning. It is more the triggering factors or what brings the headache on rather than the location. So that is what I would always look for and this is what we often screen.

Nada Youssef: Very good. We have Callie. How much do weather changes affect migraines?

Dr. Emad Estemalik: Again, this is a very good question, and this comes down to the triggering factors for migraines. Weather changes comes on top of that list and what we typically refer to is the barometric changes or the pressure changes with weather. It's not always that it's cold or it's hot that would lead to a headache or a migraine, it's the sudden decrease or change in their barometric pressure. For instance today we're at 68, a few days ago we were close to 80 degrees fahrenheit. It is that sudden drop that can bring these migraines on.

This is one of the factors we often cannot modify, other factors that we can like we already talked about are the diet changes that can affect migraines, the hormonal changes in women with the right oral contraceptives for instance that also has a great impact when that's controlled. Barometric pressure is something we really struggle to kind of get under control.

Nada Youssef: Especially in Cleveland.

Dr. Emad Estemalik: Yes, especially in Cleveland.

Nada Youssef: We have Nora. Is it true that Botox can help your migraines?

Dr. Emad Estemalik: Correct. Botox is an FDA approved procedure, this has been on the market for several years now. It is of great benefit to a migraine patient. It is not our first choice, usually we typically want to try different migraine preventives first before going to Botox. However, when certain drugs or other medications have failed, we will them move to Botox injections. It is a very simple procedure, it's done as an outpatient, it's done every 90 days. There are several muscle groups that we inject. We inject in the front of the head, the corrugator, the procerus, the frontalis muscle. We inject the temporalis on each side of the head, and we inject in the neck and the back of the head. Again, done every 90 days, very safe.

There are few medical conditions like ALS or myasthenia gravis where we wouldn't do Botox, also it is not indicated if the woman is pregnant. Other than these scenarios, it is very safe and it has given a lot of people a lot of relief.

Nada Youssef: Let's go to Jennifer. How would you treat ... I'm going to picture this ...

Dr. Emad Estemalik: Trigeminal neuralgia?

Nada Youssef: Yes, thank you.

Dr. Emad Estemalik: Speaking of trigeminal neuralgia, we operate a very unique service line at the Cleveland Clinic as well that deals with patients with facial pain or trigeminal neuralgia. The unique thing about it is it is a multidisciplinary approach here where patients who will see headache specialist of us and neurosurgeon as well to determine the best approach for this condition.

Trigeminal neuralgia is sort of a disorder that can affect anybody but it mostly affects people in their 50s, 60s or 70s. It is a very serious condition that needs the right workup immediately. In the young patients that develop trigeminal neuralgia we worry about things like multiple sclerosis, in elderly we worry about things like brain tumors since they can present like that as well.

The typically presentation for trigeminal neuralgia, it is on one side of the face, it is usually around the mouth or the side of the cheeks, it is a very classic presentations of stabbing electric-like paroxysmal attacks that can come in clusters. Extremely severe, very severe, it's one of the worst pain complaints we hear about. It is typically aggravated by chewing, eating, teeth brushing or any mechanical movement of the jaw. Again, it is a condition we take very, very seriously, it requires immediate brain imagine, blood work and very aggressive treatment.

It has distinct treatment modalities. Again, there are certain medications that we can use, certain seizure meds, certain skeletal muscle relaxant, antidepressants, and then it has a surgical approach as well. Therefore, we work very closely with our colleagues in neurosurgery because there are some procedures or some surgeries that provide great benefit to these patients. Unfortunately, trigeminal neuralgia is a condition for life so patients will struggle with this usually for many, many years. Our goal is always to delay any surgical intervention as much as possible. Again, it is a condition that if any patient presents with that or any patient has sudden face pain of that nature, they need to speak to a neurologist or a headache specialist right away.

Nada Youssef: Okay, thank you. We have Darlene. My last two MRIs have shown a lot of white matter on the brain, what can this mean?

Dr. Emad Estemalik: This is, again, not uncommon. When patients refer to white areas in the brain, some patients refer to it death spots in the brain as well, the majority of cases with what we call or the correct scientific term is white matter hyperintensities, is not of concern. There are conditions where white matter hyperintensities or white matter spots in the brain can be of concern and this is where we evaluate the brain imagine. If they're in certain areas of the brain, it can be concerning for multiple sclerosis for instance, but again, we make that determination when we look at the brain MRI. But we see a lot of patients with white matter hyperintensities, again, white spots, that are not concerning.

Nada Youssef: Okay, great. We have Connie. I have migraines, my doctor gives me frenelin, one caps-

Dr. Emad Estemalik: Fiorinal.

Nada Youssef: Okay, sorry about that. One capsule a day which is often ineffective in managing the pain especially when it lasts several days. Are there other options?

Dr. Emad Estemalik: First of all, thanks Connie for asking this question. Fiorinal and Fioricet are two drugs that have butalbital, and these are drugs we do not recommend for headache. The reason for that is we looked at these drugs several years ago, it was a study conducted that looked at narcotics Fioricet and Fiorinal, and there was a very strong evidence that the consumption of either narcotics or butalbital containing substance like that put patients at risk of more headaches or more migraines specifically, and we call that medication overuse headache or rebound headaches. We don't recommend either of those for the treatment of any headache disorder.

Typically the way to abort a migraine are two classes of drugs, either with the triptans which are things like sumatriptan, rizatriptan, there's several triptans out there on the market, patients know them as Imitrex, Maxalt, Relpax, et cetera. Then there's the DHE, the Dihydroergotamine and there are different forms that can be used as well to avoid a migraine or a headache. Again, this two are very, very effective, good non steroidal anti inflammatory drugs, things like Cataflam, Aleve or so can also be of benefit, but typically our first choice would be something like a triptan. I would not recommend to use Fiorinal or Fioricet.

Nada Youssef: Okay, good to know, thank you. Jumping over to Kyle. I often get headaches on the left side of my head, when I've gone through massage therapy, the headaches go away. What can I do to prevent those types of headaches?

Dr. Emad Estemalik: Again, I would need more information to really make a determination. One-sided headaches can mean different things, so the question is are the headaches continuous or not? Do they come and go or not? What is the duration of these headaches. When we talk about what we call unilateral or one-sided headaches, there's a distinct family of headache disorders called TACs or the trigeminal autonomic cephalgias, and they have four distinct headaches.

One is called a cluster headache, we see that often in men. A classic for that are headache attacks that comes around certain seasons, they last to 15 to 180 minutes, very severe, very sharp, patients often call them the suicide headache because it's really, really a very severe headache. The three others are something called hemicrania continua. It's a type of a one-sided headache where patients will have pain on one side of their head, 24 hours, it doesn't go away and they get sharp attacks on top of that as well. They'll get a runny nose, they'll get a teary eye on top of that sometimes too.

Then there's a third one called paroxysmal hemicrania similar to hemicrania continua where patients will get shorter attacks but they're pain-free in between. A fourth one in that family which is also one-sided only, it's a rare headache disorder, it's called ... The abbreviation is SUNCT and SUNA. They are short-lasting neuralgiform attacks with conjunctival injections. Patients will have seconds of severe headaches on one side of their head with teary eyes and runny nose. One-sided headaches require an evaluation by a neurologist or a headache specialist just to make sure there's, again, nothing else going on.

Nada Youssef: Sure. I have Bridget, she's asking bat relieving headaches during pregnancy.

Dr. Emad Estemalik: Again, that's a very, very good question as well. Typically, the good news about pregnancy is migraines tend to improve during the second and third trimester. Pregnancy is actually associated with a decrease in headache frequency. The reason for that is the steady level of hormones that you have in pregnancy. Headaches towards the third trimester which was the end of the third trimester should be taken very seriously especially if they're associated with eye issues like blurry visions or edema, because sometimes that can be a sign of a condition called preeclampsia. Our colleagues in the OB section will always screen for that as well.

We ask any pregnant woman not to use any of the migraine abortives that we recommend for patients that are not pregnant. It's often safe to use Tylenol, sometimes NSAIDs can be used with the approval of the obstetrician as well. Typically again, migraines tend to improve in the second or third trimester. If that's not the case, we typically see these patients to make a better evaluations and discuss what more we can do, but we then have to weigh all the options of what classes of medications are we dealing with because again, there are risk factors in pregnancy or any of the drugs.

Nada Youssef: Susan. Can migraines cause you to go partially blind?

Dr. Emad Estemalik: Again, when I talked about auras, again, this can happen, not unheard of. Before a migraine patient can experience ... Like our first patient said black dots, seeing zigzag lines, sometimes patients will have peripheral vision loss, some patients will have a tunnel vision. So yes, that can occur as well. However, if this is the first presentation like that and it has never happened before, this is still something that should be evaluated thoroughly by a neurologist to see if there's anything else that could be causing that as well.

Nada Youssef: Great. I have Samantha. Are any particular types of headaches or symptoms that could be a sign of traumatic brain injury and how do I know I have it after a trauma?

Dr. Emad Estemalik: With traumatic brain injury we often see other symptoms just besides headache, and this is a topic of great interest to us here within the Neurologic Institute as well just because of the impact of TBIs or concussions that it can have. We're seeing a lot of these symptoms in veterans that are coming back, and this again an area of great research.

What to look for. Headache is definitely a sign of a TBI and it is very, very common, but there are other things. Things like behavioral changes, is there depression going on, is there anxiety, is there a mood component, is there problems with cognition, concentration? Is there dizziness associated? Again, it's a wide variety of symptoms, we call that post-concussive syndrome. It goes beyond just having headaches, and this is something again that would require a whole team of physicians to approach because of discreet natures of these symptoms.

Nada Youssef: We have kaye. How do you know if your headache is actually a migraine?

Dr. Emad Estemalik: Again, good question. If we talk about migraines, a lot of patients think migraines only occur on one side, it doesn't have to be. It's one of the criteria that it is one-sided but migraines can occur on both sides. What are typically features for migraine. Throbbing, severe, light and sound sensitivity, nausea, vomiting, and then the duration of the headache. Migraines last anywhere from four to 72 hours. Again, it's the duration, the associated features, and the nature of the headache and the severity.

Again, back to migraine just for our viewers. Migraines are very, very common in women, so 60% to 80% of women, if not 20%, do have migraine disorders. Less common in men so around 6% to 8% of men have migraines.

Nada Youssef: Let's see, I have time for two more questions here. I have Michelle. Can you have nausea as a step one to a migraine and are they linked?

Dr. Emad Estemalik: Yes. Again, nausea and vomiting are very strongly associated with migraines. Very often, nausea medication can also abort not only the nausea but also the migraine on top of that as well. So very, very common that patients will have the associated nausea.

Nada Youssef: Great. I have Zulie. Is the dose of 500 mg aspirin okay to take for headaches?

Dr. Emad Estemalik: It is okay, again, as a migrainer. I hear it from a lot of patients that this dose will work. Again, we advice patients not to overuse any of the over the counter pain killers because of the tendency to develop rebound headaches or medications overuse headaches. As long as they're not being used more than two or three times a week it's absolutely fine to do that. Unless there are contraindications like gastric issues, stomach ulcers or any of these disorders.

Nada Youssef: Before I let you go, is there anything that you would like our viewers to know that maybe we haven't touched at?

Dr. Emad Estemalik: Again, I'm happy we had the chance to answer a lot of these questions. Headache is a very, very common pain disorder, and together with back pain it is ... The two most common pain disorders that neurologists, pain specialist see. We always want our patients to recognize that yes, medication have a role but it often goes beyond medication as well. We're very fortunate at the Cleveland Clinic's headache section to have and we operate a program here for patients that have had a long history of migraines, a long history of headaches where medications have not been the answer. It's called the IMATCH program or the Interdisciplinary Method for Treatment and Assessment of Daily Headaches.

The unique thing about this program is that we not only utilize medications, procedures and infusions, but there's an extensive approach with physical therapy, behavioral therapy, psychotherapy, relaxation techniques, biofeedback. The programs conducted by physicians, psychologist, physical therapist, nurses are involved so it's different types of care providers. It's a three week program and patients will often finish the program realizing that they've improved and they are part of a process where they're functionally going to get better as well. Often patients say, "We feel we've had our life back."

Again, I urge patients to read about this program on our website and kind of learn about it because it's a very, very unique program that we have.

Nada Youssef: Excellent, thank you. Did you see any spike in the patients after the solar eclipse? I've been hearing a lot about headaches after that.

Dr. Emad Estemalik: I heard of a few patients that are having more headaches after the solar eclipse. I know the American Ophthalmology Associations had come up with the recommendations not to look directly into the eclipse. Most of us were working so we didn't have the time for that. But again, we see that spike in headaches this summer, it's been a very interesting summer because of the sudden, again, change in barometric pressure. One day we're 80, one we're in the 60s again. It's been an interesting summer.

Nada Youssef: Yes, it has. Well thank you so much for coming out.

Dr. Emad Estemalik: Thank you very much Nada, thank you.

Nada Youssef: Again, for more health tips and news from Cleveland Clinic, make sure you follow us on Facebook, Instagram, Twitter and now we're also on Snapchat. Cleveland Clinic, one word. Thank you again for watching, I'll see you again.