A ‘Heads Up’ on Migraine & Headache Disorders

Migraine is a neurological disorder affecting one out of ten Americans of all ages. This debilitating condition is responsible for an estimated 157-million lost workdays each year. What is migraine and how is it different from other kinds of headaches? On this episode of Baptist Healthtalk, host Dr. Jonathan Fialkow welcomes neurologist Brad Herskowitz, M.D., of Miami Neuroscience Institute to discuss diagnosing headache disorders and the latest treatments available to provide relief to those who suffer with them.

Transcript

Announcer:

At Baptist Health, South Florida it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the podcast, where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life.  Is it a headache or a migraine? And what can be done to battle the debilitating symptoms, on this episode of Baptist HealthTalk.

Dr. Jonathan Fialkow:

Hello, Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventive cardiologist and lipidologist at the Miami Cardiac and Vascular Institute at Baptist Health, South Florida, as well as chief population health officer at Baptist Health. When we think about public health issues that have serious social and economic consequences, the first thing that comes to mind, probably isn't migraine headaches. Diseases like COVID-19, cancer, heart disease get the most headlines, but when you look at the numbers, migraine is the third most prevalent illness in the world. It's estimated that in the U.S. more than 157 million work days are lost each year by migraines. Headaches in general, are suffered by about one third of our population in various surveys and migraines in particular are suffered by about one out of 10 Americans. And 55% of headache sufferers have missed school or work over three month periods.

Dr. Jonathan Fialkow:

What do we know about migraines? What's the latest information on treating this debilitating disease? To help us learn more about migraines as well as how one can differentiate between a migraine and other common causes of headaches is Dr. Brad Herskowitz. Dr. Herskowitz is a neurologist with the Miami Neuroscience Institute, which is part of Baptist Health. Welcome to the podcast, Brad.

Dr. Brad Herskowitz:

Thank you very much, John, for having me. It's an honor to be here.

Dr. Jonathan Fialkow:

Great. I think we're going to have a really good program here, a lot of information that I think that you'll be able to provide, and let's start by just talking about headaches in general. You know, everyone has experienced headaches. We kind of know what it feels like, but can you talk about the more common causes of headaches that we see in populations? And then we can get more into migraines in specific.

Dr. Brad Herskowitz:

Sure. So there are, the headaches are categorized into primary and secondary headache disorders. So the primary headache disorders, the most common would be migraine. Tension headaches are very common. Headaches related to the neck or cervicogenic, headaches, sinus headaches, and just the garden variety headaches that people get. So there's those types of headaches. And then there's other headaches that we worry about, are headaches associated with more serious things like brain tumors and other things, but we'll stick to the primary headache disorders, most commonly migraine and tension type headaches.

Dr. Jonathan Fialkow:

So we do see a lot of people have headaches and they say, "I'm having a migraine." It might not be a migraine. Let's talk now specifically about migraines. What are the signs and symptoms that one may have or feel that would make you say, "Yes, this sounds like a migraine headache."

Dr. Brad Herskowitz:

And this is an important distinction when I see patients in the office. So they may come in and say, "II have migraines," and you know, or headaches, and you have to categorize their headaches and try to find out are they migraines or not? And migraines have a certain classification criteria. And the headaches, the classic headaches or migraines are usually one sided or unilateral throbbing or pounding. And then there are associated features which are nausea and or vomiting, light and noise sensitivity, sometimes smell sensitivity. So these are the classic features that would categorize someone's headache as a migraine.

Dr. Jonathan Fialkow:

So how would you contrast that? I hear what you're saying and well-stated. What kind of headaches that would make sense, not a migraine. What are the kinds of symptoms that someone would feel that would make you feel clear. Tension headache which is very common in sinus headaches?

Dr. Brad Herskowitz:

So a tension headache is sort of a headache that is more of like a band constricting the head. It's fairly constant pressure like... versus the migraine, which is throbbing. The migraine is often more debilitating, often worse when you exert yourself in any way and a migraine patient may have to lie in a dark room. A tension headache is more of a dull kind of there headache at the end of the day. You know, not terribly bothersome. You can kind of go about your activity. You know, sinus headaches also are, a lot of people confuse sinus headaches with migraines. And I find patients who think they have sinus headaches actually have migraines. So, you know, it's important to... That distinction's important to decipher in patients.

Dr. Jonathan Fialkow:

So you mentioned that the migraine headaches could be more severe than other kinds of headaches. When the headache goes away, does the person feel well? Aren't there circumstances where there's a more debilitating aspect of a migraine? Can you elaborate on that a little bit?

Dr. Brad Herskowitz:

Yes. Well, migraines can often have an aura prior to the headache where they feel the headache coming on, whether it's a visual symptom, whether it's flashes of lights or zigzag lines followed by headache, which can last for hours to days. And then often what we call the post drone, which is after the headache is over, there's this sort of hangover effect or feeling the brain is often heavy and sloshy. They just don't feel normal. And that's a common symptom of migraine auras.

Dr. Jonathan Fialkow:

So we could definitely see why this can really impact one's quality of life and being able to go to work and various other secondary components of having a migraine.

Dr. Brad Herskowitz:

Absolutely. You know, the unpredictability of migraines as well affects patients. And I fill out a lot of FMLA forms for patients with migraine at the workplace, because they often have to miss time, and they're worried about keeping their jobs. So there's so many features other than just headaches alone.

Dr. Jonathan Fialkow:

Do you diagnose migraine basically on you, an expert, getting a good history of the symptoms? Are there any tests or anything that say, aha, it's a migraine?

Dr. Brad Herskowitz:

It's based on clinical criteria, the patient's symptoms, if they fit the criteria that I discussed earlier, which is the throbbing pounding one sided, headache, nausea, light, and noise sensitivity. That's pretty much a migraine. That's enough for me. I think that any patient who has migraines or headaches, who's never had a brain imaging study such as an MRI of the head should have one, at least once in her lifetime, just to make sure there's nothing else, but there is no imaging study that tells me this is a migraine.

Dr. Jonathan Fialkow:

So it's more when you prove it's not other things, and it meets the criteria for the symptoms, which makes sense.

Dr. Brad Herskowitz:

Correct.

Dr. Jonathan Fialkow:

How about who's at risk for migraines? Are there age groups where it generally starts, it's more likely to start? Are there other components? Is it gender related?

Dr. Brad Herskowitz:

So in society we find that women are three times more affected than men. I think about 18% of the United States females have migraine headaches. So and the age group is generally young, 18 to maybe the forties. So it's kind of that age group, more common in females than males, which is a representative of my practice. And that's what I see. You are more likely to have a migraine if you have a family member with a migraine. So there is some genetic preponderance. However, we don't really, that doesn't come in to clinical practice very much. I don't think about it. I usually ask, but it doesn't necessarily make a difference in how we're going to treat them. We don't get to genetic testing. Maybe some time in the future, this will be clinically relevant. But at this point it's not.

Dr. Jonathan Fialkow:

What about causes of migraines? Can you speak to again what we know scientifically or don't know? And then are there other things that happen to a person, triggers that might bring on a migraine?

Dr. Brad Herskowitz:

Yeah so we don't know why people get migraines. Again, we think there's this genetic component to it, but a lot of patients do not have a family history. Things that can cause migraines in patients, I would say most patients probably don't have triggers, even though we look for them, they don't have them. However, patients that do have triggers and that's something that I do in my office. Every patient who comes in with migraines, they get a headache calendar to record their headaches, the frequency of them, the severity, the duration of them. Then we give them a food trigger list. And I discuss with them to look at these different foods. So common triggers would be stress, would be not sleeping well, not drinking enough fluid, maybe not staying hydrated. And then foods like red wine, certain cheeses, nuts, excessive caffeine, things like that are common triggers that patients find that may be causing their headaches. And it's important because if you limit the triggers, you limit the frequency of headaches.

Dr. Jonathan Fialkow:

So you have had in your clinical experience, when you work with the individual and find out things that for them may trigger it, if they remove or improve that component, you've seen improvement in their migraine.

Dr. Brad Herskowitz:

Absolutely, yes.

Dr. Jonathan Fialkow:

That's good to know. So one of the treatments, as we start talking about options, would be lifestyle modification or again, if you're identifying a food trigger, avoiding those types of things, right?

Dr. Brad Herskowitz:

Correct, John.

Dr. Jonathan Fialkow:

So you've been very articulate in elucidating the kind of symptoms that would separate other kinds of headaches from a migraine and who's at risk. When should someone say it's not just a migraine. I could take an over the counter medicine. When should I seek medical attention?

Dr. Brad Herskowitz:

Right. Well, that's something that I deal with in practice frequently and any neurologist does, is this a worrisome headache? Is this a migraine? Is this something more concerning? Should I get an imaging study? And I think any patient with chronic headaches or chronic migraines whose headache is different, the characteristic is different. the features are different. This is not a migraine. Then I would say that patient needs to be imaged. If it's the... We call it the worst headache of their life, a Thunderclap headache. If they have fever. If they have weakness or visual disturbance, anything like that, that's not of the norm. This patient should have an imaging study of the brain.

Dr. Jonathan Fialkow:

Do you find most people self-refer or they're referred by a family member?

Dr. Brad Herskowitz:

That's a good... I don't, I think there is a component of self referral. And I think that the simple migraine patient will be treated by their internist or primary care physician. When it gets perhaps more complicated or the doctor's uncomfortable, they will refer to a neurologist. So I think it's both. I think it's referral from workplace, from friends, family, and doctors equally.

Dr. Jonathan Fialkow:

Good. You mentioned, we mentioned some of the lifestyle modifications. Take us through a little bit. What else would you recommend to someone? What are the treatments that are available, that you found have an impact and scientific studies show that as benefit?

Dr. Brad Herskowitz:

Right? So as far as the lifestyle modifications, I think it's important to get regular sleep. I think exercise is important, eating well, finding triggers or avoiding things that may cause your headaches, relaxation. There are a new class of medications that are available and new scientific data on the etiology or cause of migraines, which I think has impacted positively the treatment for migraines. And I'll talk a little bit about treatment if you don't mind.

Dr. Jonathan Fialkow:

Please. Absolutely.

Dr. Brad Herskowitz:

Okay. So in general, there's two ways to treat migraines. One is the acute treatment. So when you get a headache, you take a medication and then there's preventative medications to take to prevent the frequency and severity. So as far as the acute treatment of migraines, there's the simple over the counter stuff that people try that work for them. Excedrin, Fioricet, Tylenol, Advil, Advil migraine, those things. And if that works for you great, but a lot of migraine auras, that's not effective.

Dr. Brad Herskowitz:

There are two new medications. And I speak about this new class of migraine medications called the CGRP antagonists, which stands for calcitonin gene related peptide. And that is a peptide that has been found that is released by these nerves called the trigeminal nerves in and around the brain that cause inflammation. And they cause dilation of the blood vessels in the brain, which cause the pounding throbbing headache. And scientists have shown that if you affect the CGRP or limit the activity of the CGRP molecule, that that will limit migraines.

Dr. Brad Herskowitz:

We found that in both acute treatments with two new medications called Ubrelvy and Nurtec. And those are taken at the onset of a headache. And what they do is they antagonize the CGRP molecule and/or receptor not allowing the CGRP to cause this basal dilation or dilation of blood vessels or the inflammation we see, thereby limiting the severity of the migraines and the duration. So those two have been very effective.

Dr. Brad Herskowitz:

And when you talk about the prevention of migraines. And the patients who require prevention are the ones that have a significant frequency, more than two a week. Those medications, there's kind of old school stuff that you know about John, like the beta blockers and calcium channel blockers. I don't, that's not my first line, but those are something that can be effective. Antidepressants can be effective. There's a drug called topiramate or Topamax, which is an antiepileptic, but also FDA approved for migraines, which can be very effective. But this new class of preventative CGRP injections, there's three of them on the market called the Aimovig, Ajovy, and Emgality. And they are injections that people inject every 28 days themselves into the skin. And they have been very effective for patients with episodic migraines, less than 15 days per month.

Dr. Brad Herskowitz:

Also not to be too long winded, but Botox injections are FDA approved for migraine headaches as well. I happen to be an expert injector for Botox and for the company Allergan. And for patients with chronic migraines, meaning headaches, more migraines, more than 15 days per month, meet criteria for Botox injections. And these have been unbelievably effective in a certain population of the chronic migraine aura going from 15 or 20 headaches to none per month, which is remarkable. So these are the different options that patients can discuss with their neurologist, both the acute treatments and the preventative medications for migraine.

Dr. Jonathan Fialkow:

So it's fascinating and encouraging to know we have lots of weapons for the migraine sufferer to improve their quality life limited to migraines. As you said, from simple solutions to more complex. As you evaluate the patient, I would presume you do a detailed, an individualized approach towards what steps you would take to get them under control. And can you, is it varying which medication I think is best? Or when would you go to Botox? Is that how you kind of approach it?

Dr. Brad Herskowitz:

Yeah, I do like any doctor, you do a history and physical. You determine how bad are the headaches? How frequent are they? What have you tried? What do you want to try? And basically I tell my migraine patients, it's trial and error. I'm here for you. You follow up regularly. If A doesn't work, we go to B. There are a lot of different options. I think with any patient you have, you just want to give them hope. You want to provide them with your support that," I will help you. We will get through this. We'll find a medication that helps you." They just need to follow up regularly. And we try different things, whether it's acute treatments, prevention, different types of stuff. Whatever it is, that requires a follow up on the patient's part and my part.

Dr. Jonathan Fialkow:

Great. So let's, let's bring it to a couple of quick things that you mentioned. Again, I really appreciate informing our listeners and me regarding what these advanced treatment options. But you mentioned early on, and again, just for the listener standpoint, and, and again, I'm going to preface it by saying, obviously it's individualized, but alcohol, wine can trigger, you mentioned?

Dr. Brad Herskowitz:

Sure. Wine, red wine is a trigger in some patients.

Dr. Jonathan Fialkow:

Okay. How about caffeine? Good or bad?

Dr. Brad Herskowitz:

Caffeine? You know, anything in moderation is okay. And you know, if you have patients who are drinking four, five, six cups of coffee or cafecitos, then that can, you want to limit the caffeine and then you can get caffeine withdrawal headaches as well, especially on weekends. because they drink, wake up early, drink coffee during the week. Weekends, they sleep late, they get caffeine withdrawal. So anything in moderation.

Dr. Jonathan Fialkow:

That's actually, it's a great point, I think, for the listeners, because it's something we all do see in clinical practice that during the week people drink caffeine. On the weekend they might have headaches, a little stomach upset, a little restlessness. Actually, they're just withdrawing from the caffeine they have during the week, which is a mild withdrawal but it's real. How about screen time? Is there any relationship to looking at phones or computers now that can trigger migraines and be related to a specific migraines and screen time?

Dr. Brad Herskowitz:

Yeah, I think you need to individualize each patient. Some, and I'd probably say a small percentage of patients have difficulties at home or at the workplace due to screen time. And you have to make efforts via the FMLA form to limit screen time, more breaks. Sometimes there's certain lighting people don't like at the workplace. So each patient is individualized and again, you try and find out what triggers their headaches and have the best you can do to limit those.

Dr. Jonathan Fialkow:

So again, great information. It's wonderful to have you as a resource in our community and in Baptist Health. Last question I have, which again we touched on and then I'll certainly turn over to you if there's any points that you want to bring up that we missed. We did mention tension headaches. The cause of headaches. We talked about stress can trigger migraine. So if you can talk, you mentioned early on what the symptoms of the migraine are, the throbbing, the one sided, the aura. Let's just talk about tension headaches for a little bit, because they are so common and people do tend to attribute. So when you're evaluating a patient, what would make you say, ah, this sounds like a muscle tension headache as opposed to a migraine?

Dr. Brad Herskowitz:

Right? So the tension headaches are completely different than migraines. They are more sort of like you have a headband on, it's almost like just squeezing of the head. It's not a throbbing pounding type of headache, but it's more of a constant dull type headache, less severe. You generally do not have associated features. And these are often towards the end of the day. Someone has a stressful day. I think we've all gotten those tension type headaches. So they're different headaches and sometimes harder to treat. There's no class. There's no medication for just a tension headache.

Dr. Jonathan Fialkow:

Yeah. The tension headaches... Let me put it a different way. Sometimes the tension headaches, you can have soreness of your neck muscles, soreness of the temporal muscles. With migraines, you would not have any particular points of your head or your neck. That would be sore?

Dr. Brad Herskowitz:

Well you can actually, and in the treatment injection paradigm, when we do Botox injections, part of the injections are in the neck. So in the trapezii and the paraspinal, it's just in the neck. So there may be a component. I mean, I think everyone's different. Some people have some neck pain, some don't. So I think you have to individualize it.

Dr. Jonathan Fialkow:

Great. So again, I appreciate this information. Headaches, as we said at the beginning, are very common. We don't want to scare people with relatively infrequent tension headaches, but there does come a point where you do want to get checked out by your doctor and certainly a headache, a migraine expert, neurologist like yourself like we brought up. Any final comments you'd like to make or anything you want to reiterate that we mentioned?

Dr. Brad Herskowitz:

I think one last topic I would address would be medication overuse. Headaches, or we call them a transformed migraine, and this is very common in patients. Migraineurs who are undertreated or not well, not treated sufficiently can take a lot of over the counter medications, whether it's Excedrin Migraine, Advil, Fioricet. And they actually cause more headaches by a withdrawal effect. And we find that a certain percentage of patients who come to the office have this almost chronic daily migraine, where they have a regular migraine that is transformed into this type of chronic headache. And it's because of too much medication and withdrawal of this medication on a regular basis. And so that's something that is also difficult to treat. And you have to treat that along with the migraine.

Dr. Brad Herskowitz:

So I would say, tell anybody out there listening, if you're taking excessive amounts of these medications, more than a couple of days per week, you can do harm to your body. You can make your headaches worse. Go see a neurologist. There's a lot we can do for these patients.

Dr. Jonathan Fialkow:

So we start with lifestyle modification. Try to identify if there's something that's triggering it in your diet. Get enough sleep. Get enough exercise, general, great recommendations. Move on to some mild over the counters if possible. But if they're not really working within a timeframe, make sure you get checked out by a neurologist.

Dr. Brad Herskowitz:

Exactly.

Dr. Jonathan Fialkow:

All right, fantastic. Well, thanks again, Brad. This is most helpful. I always like when I have podcast guests that I learn from as well. To our listeners, again, hopefully you find this as a good resource. As usual, any ideas or thoughts for future topics, please feel free to email us at baptisthealthtalk@baptisthealth.net and stay safe.

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