clusters - Padda Institute Center for Interventional Pain Management

Migraine Headache: Our position on five medical treatment options that patients with migraines should avoid

Headache is among the principal reasons for physician visits and a common cause of emergency department visits. The costs of tests and treatments for headache are not insubstantial, and when unwarranted, they needlessly expose patients to potential harm. In a recent study of the treatments and procedures that contribute most to the $13 billion dollar annual cost of outpatient neurology visits, migraine alone was the diagnostic category with the second highest costs. For example, using data from the National Ambulatory Medical Care Survey, CT scans ordered at neurology visits (many of which were probably done to evaluate headache) resulted in costs of roughly $358 million dollars.

Five tests and procedures associated with low-value care in headache medicine according to the American Headache Society (AHS).  Listed are five things that “physicians and patients should question” in order to make “wise decisions about the most appropriate care based on the individual situation.”

 

[box] (1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache [/box]

(1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

In clinical practice, it is common to encounter patients with headache who have undergone multiple imaging procedures. These often involve exposure to ionizing radiation. The reasons for these repeated and unnecessary scans are not well understood, but probably include physician fear of missing a dangerous cause of headache and a desire to allay patient anxiety over possible missed abnormalities, especially when treatment is unsuccessful. In some cases, duplicate scans may be ordered because the physician is unaware of previous testing. The risk of unneeded testing may be especially high in the emergency department, where physicians are unfamiliar with the patient and fear missing serious causes of headache.

In ordering diagnostic tests, though, the possible adverse effects of testing must be balanced against the likely benefits to the patient. In particular, the potential adverse health effects of radiation exposure should be taken into consideration when ordering diagnostic testing for headache. In many situations, it is very unlikely that a repeat imaging study of the head will identify any abnormality that will alter management. The radiation risks of CT scanning are not negligible. Younger people are at higher risk of radiation adverse effects than older people.

Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in migraine. However, not all severe headaches are migraine. To avoid missing patients with more serious headaches, a migraine diagnosis should be made after a clinical history and an examination that documents the absence of any neurologic findings, such as papilledema.

The key element is a change in headache symptomology or a new diagnosis of severe headache.

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

When neuroimaging is needed for the evaluation of headache, good quality evidence supports the view that MRI is more sensitive than CT scanning to detect most serious underlying causes of headache. The exception is settings in which acute intracranial bleeding is suspected. A Canadian government health technology assessment group recently reviewed the evidence and cost-effectiveness of the use of CT and MRI scanning for the evaluation of patients with headache. The researchers found that when performed for the indication of headache, the diagnostic yield of CT scans was 2%, while that of MRI scans was 5%. Because MRI was better at detecting abnormalities, the cost per abnormal finding of CT scans was $2409 compared with $957 for MRI.

When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage, acute stroke, or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions, and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure that may elevate the risk of later cancers, while there are no known biologic risks from MRI.

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

The idea of a surgical “solution” to migraine is inherently attractive to patients. Interest in surgical approaches to migraine has been motivated by serendipitous improvement in headaches noted in patients who have undergone various plastic surgery “forehead rejuvenation” procedures. These procedures are based on the premise that contraction of facial or other muscles impinges on peripheral branches of the trigeminal nerve.

The procedures involved are often referred to collectively as “migraine deactivation surgery,” although a variety of surgical sites and procedures are involved. These include resection of the corrugator supercilii muscle with the placement of fat grafts in the site, “temporal release” procedures involving dissection of the glabellar area, transection of the zygomatical temporal branch of the trigeminal nerve, and resection of the semispinalis capitus muscle with placement of fat grafts in the area with the aim of reducing pressure on the occipital nerve. Finally, some surgeons also perform nasal septoplasty or otherwise attempt to address possible intranasal trigger points.

The value of this form of “migraine surgery” is still a research question. Observational studies and a small controlled trial suggest possible benefit. However, large multicenter, randomized controlled trials with long-term follow-up are needed to provide accurate estimates of the effectiveness and harms of surgery. Long-term side effects are unknown but potentially a concern

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

Primary recurrent headache disorders (of which migraine, tension-type, and cluster headache are the most common) are conditions of long duration for which such treatment will be used repetitively over many years. Risks and harms that are unimportant in treating a single attack can become important when treatment is used for long periods of time. Once established, medication overuse can be difficult to treat and recidivism is common. Thus, treatments such as triptans or nonsteroidal anti-inflammatory drugs, which are not associated with dependence or sedation, are preferred first-line.  However, there are many clinical situations in which the use of opiates and butalbital is appropriate, including some situations where they are first-line treatments. These include patients for whom triptans or nonsteroidal anti-inflammatory drugs are contraindicated or ineffective.

These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache.  This is not meant to imply that opioid or butalbital medications are always inappropriate treatments for recurrent headache treatments. Rather, it is meant to address the appropriate order in which medication classes should typically be used.

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache

Over-the-counter (OTC) medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, resulting in “medication overuse headache” (MOH). To avoid this, OTC medication should be limited to no more than 2 days per week. In addition to MOH, prolonged overuse of acetaminophen can cause liver damage, while overuse of nonsteroidal anti-inflammatory drugs can lead to gastrointestinal bleeding.

 

 

Severe Head and Neck Pain

Caution:

If you’re having your worst migraine ever or symptoms that are unusual for you or frightening, see a doctor as soon as possible. You need to be sure this IS a Migraine and not something more serious such as a stroke. 

Caution:

Pregnant women should immediately alert their physician as many of the medications used to treat migraines can cause birth defects.

 

 

The goal of the Padda Institute Headache Section is to provide diagnosis and treatment that will help people who experience severe pain regain a better quality of life.  (The treatment needs of patients who have occasional mild headaches are significantly different from those patients whose attacks are frequent and completely disabling.)  If your quality of life is impacted from migraine, chronic head pain, or nerve pain in the face you need a plan of action from a team of highly experienced specialists. We provide a collaborative approach combined with the latest technology resulting in individualized care. Our goal is to provide effective, compassionate care to improve your quality of life.

Headaches are serious

Headache remains one of the most common health issues which challenge physicians and other health professionals, migraine is the 12th most disabling disorder in the United States..  The symptoms of head pain are a frequent cause of human suffering and disability.  According to a World Health Organization analysis, severe Migraine attacks are as disabling as quadriplegia (paralysis of both arms and legs).  Suicide attempts are three times more likely among people who have Migraine with aura than among people who do not have Migraine.  More than 1,400 American women with Migraine with aura die each year from cardiovascular diseases compared to women who do not have Migraine.

Migraines permanently affect your brain

Some 37 million Americans suffer from migraines, those incredibly painful and often debilitating headaches. While they’ve been known to knock a person out, migraines weren’t thought to permanently affect the brain – until now.  A study published in the journal Neurology suggests migraines permanently alter brain structure in multiple ways.  The risk of white matter brain lesions increased 68% for those suffering migraines with aura, compared to non-migraine sufferers. Those who suffered from migraines without aura saw that increased risk cut in half (34%), but they too could get lesions in the part of the brain that is comprised of nerve fibers.  Migraine affects about 10 to 15% of the general population and can cause a substantial personal, occupational and social burden.  According to the American Migraine Foundation, migraines cost the United States more than $20 billion a year in both direct medical expenses like doctor visits and medication and indirectly when employees miss work resulting in lost productivity.

For many patients with headache, an organized, multidisciplinary headache center environment is necessary to provide the entire spectrum of headache management.

 

  • Patients in whom comprehensive services are essential to address the multifunctional components of their headaches.
  • Patients who have not responded to medication and have a history of recurring acute care needs or progressive persistent headache.
  • Patients who have undergone multiple diagnosis and therapeutic interventions yet the diagnosis remains uncertain or questionable.
  • Patients who have had frequent emergency room visits, who have used hospital inpatient services excessively, and who have overused different oral analgesics, including opiates, or who have been treated repeatedly with intramuscular or intravenous medications.

 

 

The History of Headaches

The clinical entity of headache dates back to ancient times.  As early as the dawn of civilization, primitive headache remedies included procedures aimed at ridding the body of the “demons and evil spirits” that were believed to cause headaches.  As early as the Neolithic period dating back to 7000 BC, skulls have been found bearing man made holes (called trephination) presumably done for medical reasons which may have included the treatment of headache.  Skulls demonstrating trepanation have also been found in Peru dating back to the thirteenth century.  The writings of the early Greeks referred to headache as a serious medical condition.

Hippocrates (400 BC) may have been the first to describe the clinical symptoms of migraine.  In the historical Hippocratic books Hippocrates discussed what appears to have been the visual aura that can precede migraine.  The term “migraine’ itself is derived from the Greek word hemicrania. Throughout history, there have been famous individuals such as Plato, Thomas Willis, Erasmus Darwin (Charles Darwin’s grandfather), and others who have contributed to our understanding of headache. More recent scholars, such as Dr Harold Wolff, played an important role in our classification of different types of headache and their treatment. Following his classic 1948 publication of the first edition of Wolff’s Headache, it was Dr Wolff who introduced important scientific concepts which have served to modernize the study of headache.  Since that publication there has been an explosion in headache research which has resulted in our better understanding of this clinical condition.

There are now scientific mechanisms which more clearly define the pathophysiology of some headaches such as migraine.  This has also led to the development of new migraine specific medications, specialized pain management techniques, and ultimately more effective treatment opportunities.

Migraines have affected people for centuries and played an influential role throughout world history. Many famous and accomplished people have experienced severe headaches.  Julius Caesar, Napoleon, Ulysses S. Grant and Robert E. Lee; great painters Vincent Van Gogh, Georges Seurat and Claude Monet,; and famous authors Virginia Woolfe, Cervantes and Lewis Carroll all experienced migraines. Thomas Jefferson wrote the Declaration of Independence during an intense period of productivity after being bedridden for six weeks with a migraine.  The famous authors Virginia Woolf, Cervantes (best known for Don Quixote) and Lewis Carroll (Alice’ Adventures in Wonderland) had migraine. There is even evidence to suggest that at least some of Alice’s Adventures were based on Carroll’s personal migraine visual aura perceptions. As Cheshire Cat observed, “One pill makes you smaller; one pill makes you larger, the pills mother gives you do nothing at all”.  There has been literature which indicates that Thomas Jefferson’s headaches were so severe and debilitating that they often interfered with his ability to function.  As he wrote to Martha Jefferson in February 18, 1784, “Having to my habitual ill health….lately added an attack of my periodical headache; I am obliged to avoid reading, writing, and almost thinking”.  In March 1807, while still President, Jefferson wrote “…Indeed, I have but little moment in the morning in which I can either read, write, or think, being obliged to be shut up in a dark room from early in the forenoon till night, with a periodical headache”.

Headache sufferers constitute one of the largest groups of patients within a neurological practice.  More patients who visit doctors complain of headache than any other single ailment. Headache and migraine in particular, may be considered as a universal human condition which continues to be under diagnosed, misdiagnosed and/or mistreated.  Whereas in some individuals, headache may be an occasional episodic, sometimes nuisance, for others the symptoms of headache may be a manifestation of a disabling chronic disease.  In the latter group, headache disrupts daily routines and impairs quality of life.  The frequency, severity, and even life consequences of headache sufferers vary widely.  The causes of headache are different in different individuals.

 

Range of Disorders:

Each year, millions of Americans suffer from chronic headaches.  There are four main headache types: tension, cervicogenic, migraine and cluster.

  • Tension headaches are the most common and may be described as a mild to moderate constant band-like pain, tightness, or pressure around the forehead or back of the head and neck.

 

  • While cervicogenic headaches are slightly less common and are caused by any number of conditions in the neck, causing referred pain, most often the cervical facets or the cervical discs.  Some studies suggest that the trigeminal sympathetics and parasympathetics mediate pain from the region of the Occipital Nerve, such to the degree that the Occipital Nerve may be considered the “V4” of the trigeminal.  Cervicogenic pain can trigger Migraine headaches and Cluster headaches.

 

  • Migraine headaches are severe headaches that are described as a chronic, throbbing head pain that can cause significant pain for hours or even days.  Symptoms can be so severe that light or sound can cause exacerbation and most patients must find a dark quiet room to lie down.  The typical Aura of Migraines is only present in 25-30% of all cases.

Status Migrainosus: A rare, sustained and severe type of migraine headache, lasting more than 72 hours that is characterized by intense pain and nausea, often leading to hospitalization.

Chronic daily headaches occur frequently, usually more than 15 days per month. Chronic daily headaches are classified as either long duration (lasting more than four hours) and short duration (lasting less than four hours). The majority of people who experience chronic daily headaches have long-duration headaches.

Medication overuse headaches, sometimes called rebound headaches, occur when people who experience migraine or tension headaches take too much analgesic or anti-migraine medication. When the effect of one dose wears off, the next headache occurs and another round of medication is taken. A vicious cycle is created of ever-increasing headaches and more frequent medication use.  Taking Migraine abortive medications, pain relievers, or alternating them more than two or three days a week can cause medication overuse headache.

Menstrual migraine is a headache that occurs during the menstrual cycle. It can occur two days before and up to three days after the beginning of a woman’s period. Although the cause is not explicitly known, menstrual migraine may be triggered by changes in hormone levels. The most likely cause is the fall in estrogen levels that takes place just before the beginning of menses.  When women experience menopause naturally, 1/3 experience worse Migraines. When women experience menopause following a hysterectomy, 2/3 experience worse Migraines.

Studies have shown that 90% of what people think are sinus headaches are really Migraines. A sinus headache is very rare without an infection.

  • Cluster headaches, also known as suicide headaches, are excruciating unilateral headaches of extreme intensity. The duration of the common attack ranges from as short as 15 minutes to three hours or more. The onset of an attack is rapid, and most often without the preliminary signs that are characteristic of a migraine. They are marked by repeated, short-lasting attacks of excruciating, unilateral head pain of short duration.  A cluster headache may be accompanied by redness or tearing of the eye and nasal congestion or runny nose. Often mistaken for sinus or migraine headaches, cluster headaches are characterized by sharp, stabbing pain in or around the eye, temple, forehead or cheeks.
  • Atypical facial pain of all types including trigeminal neuralgia

To assure an accurate diagnosis, we collect an extensive medical history and conduct a comprehensive neurological exam. At times we request a specialized MRI of the brain and neck or blood tests that search for causes of headache including hormone levels, vitamin levels, or markers of an overactive immune system. After the evaluation, treatment options are discussed including medications, lifestyle modification, pain relieving procedures and alternative therapies.  Nearly 30% of patients with dental pain after dental procedures are actually a form of trigeminal neuralgia.

 

Outpatient Treatment

For many people, medication is required to control their headaches. Avoiding the triggers which initiate headache onset is the most important step. There are two categories of headache medication: abortive and prophylactic.

 

  • Trigger Management

Trigger management is key to preventing a migraine attack, migraines don’t just happen; they have triggers.  Trigger factors are those circumstances or influences that can cause a migraine. Trigger factors vary from person to person; if recognized and avoided, a person may prevent a migraine from developing.

Examples of triggers include changes in weather or air-pressure, bright sunlight or glare, fluorescent lights, chemical fumes, menstrual cycles, and certain foods and food products, such as processed meats, red wine, beer, dried fish, fermented cheeses, aspartame and MSG.

  • Preventive or Prophylactic Medication Therapy

Prophylactic drugs are taken daily to prevent headaches. They may be prescribed for people who experience frequent severe headaches, usually two or more per month. These drugs may be taken until a person’s headaches are under control. Generally, the lowest effective dose is used for the shortest period possible. Examples of prophylactic drugs are anti-depressants, beta blocker and calcium-channel blockers.

Many people who take preventive or prophylactic medications will also need to take attack-aborting medications to relieve pain and other symptoms.

  • Abortive Medication Therapy

Attack-aborting medications can relieve the severity and/or the duration of migraine headaches and their related symptoms. In general, most attack-aborting medication should be taken as early as possible in an attack.

Many people who experience migraines or other severe headaches can recognize their early symptoms, allowing them to intervene early with the attack-aborting medication. This may allow them to avoid a more severe, prolonged episode. Attack-aborting medications include cerebral vascoconstrictor abortive agents and non-vasoconstrictive abortive agents.

Specialized Treatment Options for Headache, Migraine and Facial Pain

Our team cares for many patients each year which empowers countless people to achieve substantial improvement. Some of our specialized treatments offered include peripheral nerve injections, which numb the nerves of the scalp to shut off chronic migraine. On average, the injections can give patients weeks to months of benefit. In rare cases, our team provides occipital nerve stimulation by a surgically implanted device that delivers an electric charge to nerves in the back of the scalp to treat migraine, cluster headache, and other types of facial pain that doesn’t respond well to other treatments. This is a treatment few other centers offer.

We also offer a number of alternative therapies with special focus on nutraceuticals – nutritional supplements – and vitamin therapies that have anti-pain or anti-migraine suppressing properties. Also available is pain psychology which uses relaxation strategies and biofeedback to reduce migraine. Our clinic embraces a specialized hormone therapy, called bioidentical hormone replacement therapy. This is where a patient’s hormonal status is monitored and individualized hormonal therapy is provided to normalize the body’s natural cycle and reduce migraine or head pain associated with hormonal dysfunction. We also offer acupuncture.

 

Advanced therapies

  • Spenopalatine Block

The Sphenopalatine Gangion Nerve Block (SPG Nerve Block) is both a  preventative and abortive technique, and may infact prevent trigger activation altogether.

The Sphenopalatine ganglion (SPG) nerve block and the Trigeminal Nerve Block is a fast, highly effective, non-invasive treatment option for migraines and headaches without the use of pills or injections. This treatment uses a unique transnasal catheter to eliminate the pain in a safe and painless way. Aside from migraine and headache, It has been providing successful relief to a variety of painful conditions including trigeminal neuralgia.

Technical:

The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel’s ganglion) is located in the pterygopalatine fossa, posterior to the middle nasal turbinate. It is covered by a 1- to 1.5-mm layer of connective tissue and mucous membrane. This 5-mm triangular structure sends major branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and the superior cervical ganglion. The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by injection.

  • Trigeminal Blockade

Trigeminal neuralgia is an extremely painful condition that affects the trigeminal nerve in the face, which is also called the fifth cranial nerve.  The Trigeminal Nerve is often called the Dentist’s Nerve because it goes to the teeth, jaw muscles, jaw joints (TMJ),and periodontal ligament. Trigeminal innervation of the sinuses, eustacian tubes, tensor of the ear drum (tensor tympani), soft palate, tongue and meninges of the brain explain why there are so many disorders associated with jaw function, TMJ and TMD. The trigeminal nerve plays a very important role in the face, being responsible for sensing touch, pressure, pain and temperature in the jaw, gums, forehead and around the sensitive eye area. Since it controls sensation in almost the entire face, pain in the trigeminal nerve can affect many different parts of the face.  Many people speculate that most atypical facial pain, most dental pain, most sinus induced headache, and most headache originating from the base of the skull results from trigeminal activation.