Severe Head And Neck Pain

Some 37 million Americans have migraines, those brutally painful and often crippling headaches. They can knock a person flat. But no one thought migraines did lasting harm to the brain – until now. A study published in the journal Neurology suggests migraines change brain structure for good, in more than one way. People with migraines with aura had a 68% higher risk of white matter brain lesions (damaged spots) than people without migraines. For people with migraines without aura, that added risk was cut in half (34%). But they too could get lesions in the part of the brain made of nerve fibers. Migraine affects about 10 to 15% of people. It can take a heavy toll on home life, work and social life.

The American Migraine Foundation says migraines cost the United States more than $20 billion a year. Part of that is direct medical costs like doctor visits and medicine. Part is lost work when people miss their jobs. Many headache patients need an organized headache center with many kinds of experts. That is the only way to cover the full range of headache care.

• Patients who need full-scope care because their headaches have many parts.
• Patients who have not responded to medicine and keep needing urgent care, or whose headache keeps getting worse and will not go away.
• Patients who have had many tests and treatments, yet still have no clear diagnosis.
• Patients who go to the emergency room often, have spent too many nights in the hospital, or have overused pain pills, including opiates. This also includes patients treated again and again with shots or IV medicines.

Headache goes back to ancient times. At the dawn of civilization, early headache cures tried to drive out the “demons and evil spirits” that people thought caused headaches. Skulls from as early as the Neolithic period, back to 7000 BC, have man-made holes in them (called trephination). These were likely made for medical reasons, which may have included treating headache. Skulls with trepanation have also been found in Peru, dating back to the thirteenth century. The early Greeks wrote of headache as a serious medical problem. Hippocrates (400 BC) may have been the first to describe the symptoms of migraine.

In his books, Hippocrates wrote about what seems to be the visual aura that can come before a migraine. The word “migraine” itself comes from the Greek word hemicrania (half of the head). Over the centuries, famous people such as Plato, Thomas Willis, Erasmus Darwin (Charles Darwin’s grandfather), and others added to what we know about headache. In more recent times, Dr Harold Wolff played a key role in sorting headaches into types and in how we treat them. In 1948 he published the first edition of his classic book, Wolff’s Headache. Dr Wolff then brought in key scientific ideas that made the study of headache modern. Since then, headache research has exploded, and we understand the condition much better. Science now shows more clearly how some headaches, such as migraine, work inside the body.

This has also led to new drugs made just for migraine, special pain care methods, and in the end, better ways to treat it. Migraines have hit people for centuries and have shaped world history. Many famous people have had severe headaches. Julius Caesar, Napoleon, Ulysses S. Grant and Robert E. Lee all had migraines. So did great painters Vincent Van Gogh, Georges Seurat and Claude Monet. So did famous authors Virginia Woolf, Cervantes (best known for Don Quixote) and Lewis Carroll (Alice’s Adventures in Wonderland). Thomas Jefferson spent six weeks in bed with a migraine. Then, in a burst of hard work, he wrote the Declaration of Independence.

There is even evidence to suggest that at least some of Alice’s Adventures came from the visual auras of Carroll’s own migraines. As Cheshire Cat observed, “One pill makes you smaller; one pill makes you larger, the pills mother gives you do nothing at all”. Writings indicate that Thomas Jefferson’s headaches were so severe that they often kept him from getting through the day.

As he wrote to Martha Jefferson on 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 patients are one of the largest groups seen in a neurology practice. More people see a doctor for headache than for any other single problem. Headache, and migraine most of all, may be thought of as part of being human. Yet it is still missed, misnamed and mistreated. For some people, a headache is a nuisance that comes now and then. For others, it is the sign of a disabling long-term disease. For that second group, headache breaks up the day and drags down their lives. How often headaches strike, how bad they get and what they do to a life varies widely. The causes of headache are different from person to person.

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

• Tension headaches are the most common. They feel like a mild to moderate steady band of pain, tightness, or pressure around the forehead or the back of the head and neck.
• Cervicogenic headaches are a little less common. They come from problems in the neck that send pain up into the head. Most often the source is the cervical facets (small joints in the neck) or the cervical discs. Some studies suggest the trigeminal sympathetic and parasympathetic nerves carry pain from the area of the Occipital Nerve. The link is so close that the Occipital Nerve may be thought of as the “V4” of the trigeminal. Cervicogenic (neck-based) pain can set off Migraine headaches and Cluster headaches.
• Migraine headaches are severe. They bring a throbbing head pain that keeps coming back and can last for hours or even days. Light or sound can make it worse, and most patients must find a dark, quiet room to lie down. The typical aura of migraine shows up in only 25-30% of all cases.

A rare, severe type of migraine that lasts more than 72 hours. It brings intense pain and nausea, and it often lands people in the hospital. Chronic daily headaches strike often, usually more than 15 days per month. They are split into long ones (lasting more than four hours) and short ones (lasting less than four hours).

Most people with chronic daily headaches have the long kind. Medication overuse headaches, sometimes called rebound headaches, happen when people with migraine or tension headaches take too much pain medicine or migraine medicine.

When one dose wears off, the next headache hits and another round of medicine is taken. That sets up a vicious cycle: more and more headaches, and more and more pills. Taking Migraine abortive medications (drugs that stop an attack), pain relievers, or switching between them more than two or three days a week can cause medication overuse headache.

Menstrual migraine is a headache tied to the menstrual cycle. It can strike from two days before up to three days after a woman’s period starts. The exact cause is not known, but changes in hormone levels may set it off.

The most likely cause is the drop in estrogen just before the period starts. When women go through menopause naturally, 1/3 get worse Migraines. When women go through menopause after a hysterectomy, 2/3 get 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 brutal one-sided headaches of extreme force. A typical attack lasts from as short as 15 minutes to three hours or more. An attack comes on fast, most often without the warning signs a migraine gives. They bring repeated, short attacks of brutal pain on one side of the head. A cluster headache may come with a red or tearing eye and a stuffy or runny nose. People often mistake them for sinus or migraine headaches. Cluster headaches bring sharp, stabbing pain in or around the eye, temple, forehead or cheeks. We also treat atypical facial pain of all types, including trigeminal neuralgia.

To get the diagnosis right, we take a full medical history and do a thorough neurological exam. At times we order a special MRI of the brain and neck. Or we order blood tests that look for causes of headache, such as hormone levels, vitamin levels, or signs of an overactive immune system. After the evaluation, we go over treatment options. These include medicines, lifestyle changes, pain-relief procedures and alternative therapies. Nearly 30% of patients with tooth pain after dental work actually have a form of trigeminal neuralgia.

Many people need medicine to control their headaches. Avoiding the triggers that start a headache is the most important step. There are two kinds of headache medicine: abortive (stops an attack) and prophylactic (prevents attacks).

Trigger Management

Managing triggers is key to stopping a migraine attack. Migraines don’t just happen; they have triggers. Triggers are the things around you or in you that can set off a migraine. They differ from person to person. Spot them and avoid them, and you may stop a migraine before it starts. Common triggers include changes in weather or air-pressure, bright sunlight or glare, and fluorescent lights. Others are chemical fumes, menstrual cycles, and certain foods, 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 with frequent severe headaches, usually two or more per month. These drugs may be taken until the headaches are under control. In general, we use the lowest dose that works for the shortest time we can. Examples are antidepressants, beta blockers and calcium-channel blockers. Many people on preventive drugs will also need attack-stopping drugs to ease pain and other symptoms.

Abortive Medication Therapy

Attack-stopping drugs can make a migraine and its symptoms less severe and/or shorter. Most of them should be taken as early in an attack as you can. Many people with migraines or other severe headaches can spot the early signs. That lets them act early with the attack-stopping drug. It may spare them a worse, longer attack. These drugs include cerebral vasoconstrictor abortive agents (which narrow blood vessels in the brain) and non-vasoconstrictive abortive agents.

Our team treats many patients each year, and a great many of them get much better. One of our special treatments is peripheral nerve injections. These shots numb the nerves of the scalp to shut off chronic migraine. On average, the shots can give patients weeks to months of relief. In rare cases, our team offers occipital nerve stimulation. A small device is placed by surgery and sends an electric charge to nerves in the back of the scalp. It treats migraine, cluster headache, and other facial pain that does not respond well to other care.

Few other centers offer this treatment. We also offer alternative therapies, with a special focus on nutraceuticals – nutritional supplements – and vitamin therapies that can hold down pain or migraine.

We also offer pain psychology, which uses relaxation and biofeedback to cut migraine. Our clinic uses a special hormone therapy called bioidentical hormone replacement therapy. We track the patient’s hormones and give hormone therapy fitted to that person. It brings the body’s natural cycle back to normal and cuts migraine or head pain tied to hormone problems. We also offer acupuncture.

Sphenopalatine Block

The Sphenopalatine Ganglion Nerve Block (SPG Nerve Block) both prevents attacks and stops them. It may even keep triggers from firing at all. The Sphenopalatine ganglion (SPG) nerve block and the Trigeminal Nerve Block are fast, highly effective, non-invasive treatments for migraines and headaches. They use no pills and no shots. This treatment uses a transnasal catheter (a thin tube placed through the nose) to wipe out the pain safely and without pain. Beyond migraine and headache, the SPG block has relieved many 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 a brutally painful condition of the trigeminal nerve in the face, 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 the ligament that holds the teeth in place. It also feeds the sinuses, eustachian tubes, the muscle that tightens the ear drum (tensor tympani), soft palate, tongue and the lining of the brain. That is why so many problems are tied to jaw function, TMJ and TMD. The trigeminal nerve does a big job in the face. It senses touch, pressure, pain and heat or cold in the jaw, gums, forehead and around the sensitive eye area. It controls feeling in almost the whole face, so pain in this nerve can hit many parts of the face. Many people speculate that most atypical facial pain, most tooth pain, most sinus headache, and most headache from the base of the skull come from the trigeminal nerve firing.