Frequently asked headache & migraine questions
- What is The North Carolina Comprehensive Headache Clinic?
- I just have simple headaches. Can I be seen at the Clinic?
- Nothing has worked for me before. What else can you do?
- Could I have a serious condition that has not been found yet?
- I have migraines that don’t respond to anything. Do you have something different to treat this condition?
- Can rebound headaches prevent other medications from working?
- I keep being told that rebound is my problem, but I don’t think it is. Are you going to say the same thing?
- I’ve already tried that medicine, and had terrible side effects from it and it didn’t work…what can you do for me?
- I tried Botox®, and it didn’t work…what can you do for me?
- I am concerned that my doctor can’t feel exactly where my headache is coming from.
- I am tired of going to doctors. When will this ever end?
- My doctor just told me to lose weight and exercise and stop feeling stress.
- I don’t want to take drugs. Do you use alternative treatments?
- What other conditions do you treat?
- Is it a migraine?
The North Carolina Comprehensive Headache Clinic is an outpatient regional clinic dedicated to headache treatment. Founded in 1993 by Dr. Charles Matthews, the Headache Clinic has had over 30,000 patient visits for the treatment of headache. Our most common source of referrals is successfully treated former patients. Practitioners at the Clinic must be board certified neurologists who specialize in headache, or physician assistants with extensive experience in headache management and education. We are members of the American Academy of Neurology ,the American Council on Headache Education, the American Headache Society, and the National Headache Foundation.
Yes. The earlier something is done to stop the process, the easier it is over your lifetime in terms of personal suffering, time lost from family or job, and medical cost.
Most of our patients feel this way. Many have had previous consultations with neurologists, ENT physicians, dentists, ophthalmologists, and other practitioners before coming here. Often, MRI and other studies have been performed with a negative result, and the patient is left without a clear diagnosis. We are a tertiary headache specialist center. We aggressively seek out new treatments for headache. Some of the newer treatments we provide include recently available medications, Botox®, treatment of the palate by cold laser, and histamine desensitization.In most new therapies available, we are among the most experienced in the country. For example, we have administered over 3000 Botox® treatments.
Very rarely, a careful physical examination will reveal signs of a tumor, aneurysm, infection, toxic, or inflammatory disorder that was not evident on any previous tests. Also rarely, the patient may have any of a number of rare headache syndromes, such as hypnic headache, or hemicrania continua, which only respond to a particular treatment. We also have seen patients who have headaches from an undiscovered potentially serious illness, such as a thyroid disorder, temporal arteritis, vascular obstructions, or sleep apnea. But usually, based on a careful examination, it is evident that such concerns are not the problem, without any need for further tests. And when this is the case, after the initial evaluation, we are able to tell you so.
I have migraines that don’t respond to anything. Do you have something different to treat this condition?
What is most common is a history of migraine beginning some years ago, often running in families. But the diagnosis of migraine is not sufficient. We have to answer the question: why did your particular headache become worse over time? The most common reason for treatment failure is a condition called “rebound headache.” The use of aspirin, Tylenol, or similar over the counter pain medications, more often than three days a week may actually lead to more headaches over time. What happens is similar to trying to use a hearing aid-when you can’t hear, you turn up the volume. And the problem there is that sometimes you get a “squeek” – because you had to turn the hearing aid up high. Like someone with a hearing aid turned up too high, the brain can become abnormally sensitive when pain is chronically blocked with analgesics. When rebound is occurring, preventive medications will not be effective. So in many cases, it isn’t something new that is needed at all. Many primary care physicians and patients are already aware of how OTC pain medications, as well as caffeine addiction, can cause rebound headaches. Unfortunately, many patients have simply been told to “stop your pain pills” – and when they found that they could not, the patient stopped going to the doctor. This is entirely understandable. We find that, until you have something better in place, simply trying to stop pain medications leads to unnecessary suffering.
Yes. Often patients have tried a list of medications while they were having rebound headaches, and “none of them worked”. A careful history may reveal that they were suffering from rebound from either Tylenol or caffeine at the time, which prevented the medications they tried from working. In this instance, the patient had two problems- migraine, and rebound headaches. In order to get well, both problems must be treated at the same time.
I keep being told that rebound is my problem, but I don’t think it is. Are you going to say the same thing?
Some of our patients referred with rebound headaches actually don’t have them. It is increasingly common now for headache patients to have multiple problems which need treatment: a disturbance of sleep, energy, mood, or secondarily acquired neck pain. Some patients are sleeping only a few hours a night, and it is not uncommon to hear that a patient has gained 20 pounds in the last year. Headache is a systemic disease, affecting not only the brain but also the endocrine, circulatory, musculoskeletal, and immune systems, and in treating headache it is most effective to consider the health issues of the whole person. Sleep disturbance, depression, dizziness, and many other symptoms are often best understood as part of the migraine process, and keeping the whole person in mind, with all of these symptoms together, is the key to selecting the effective treatment. That is why, for example in the patient with weight gain, we will often select a medication that causes weight loss. Careful consideration of these other factors not only treats the weight gain, depression, or energy loss, but in our experience clearly leads to the most effective treatment for that patient’s headaches. Selecting a headache medicine should never be a guess or simply going down a list one after the other. With experience, we have learned which of the many available treatments will work for your particular problem, when the whole patient is kept in mind.
I’ve already tried that medicine, and had terrible side effects from it and it didn’t work…what can you do for me?
Many patients feel they have “already tried that medicine”. Medications for headache, if they are required, are best administered by an experienced headache specialist. An example of this is our patient who had previously gained 75 pounds on Elavil, although she had a history of heart disease in her family. Her cholesterol had become very high, and her primary care physician had recommended a blood pressure medicine. Her doctor had once prescribed topiramate (Topamax) for her, which in her particular situation was a good choice. However, she had so many side effects that she had told her doctor “I won’t ever take that medicine again”. We have found that such side effects of Topamax can be corrected by adding sodium bicarbonate for a short period of time. We successfully restarted her Topamax, she had no side effects, and both her headaches and her weight (as well as her cholesterol and blood pressure) returned to normal. Experience with this medication was necessary to prevent side effects and achieve the benefits we expected.
Botox® can be effective for headache. However, it is not effective for weight gain, insomnia, or other health changes that usually accompany chronic headache. Botox® is expensive, and coverage for the indication of headache is limited. and the patient should be selected carefully. When Botox is applied for headache we feel it should be done by a headache specialist. Sometimes triggering areas in the neck must also be treated. It is now evident that repeat applications are sometimes needed to be effective.
An examination for headache cause should focus on the cranial arteries, the muscles of the jaw and neck, the nerves exiting the skull, and the cervical spine. For example, we often have patients squeeze their hands and bear down or lean over while feeling their temporal arteries to see if the headache has a vascular component. When the muscles are examined, each muscle of the head, neck, and jaws can be isolated and tested against resistance to determine whether tightness or injury here is contributing to the headache. It is actually common for patients to have more than one kind of headache, and neither improves until all are treated at once. For example, we often find that patients who have had migraine for years, slowly worsening, have begun to develop tension in the back of their neck as these muscles continually “guard” against pain. Over time, the neck muscles can begin to cause headaches themselves. If this is your problem, you can sometimes demonstrate this to yourself. Try pressing on your forehead, and then against the back of your head. If headache is actually pain referred from the back of the neck, the headache will get much better when pressing on the forehead, and much worse when pressing on the back of the head. In many cases, muscle pain deep under the back of the skull will actually be felt in the face. So-called “cervicogenic” headaches may respond poorly to medication directed at treating migraine. It is often necessary to treat both the migraines and the guarding muscles at the same time before the patient can get well. Failure to diagnose each type of headache, when the patient has more than one type, may be the most common cause of treatment failure we see today.
We often see patients who have been doing well for years with very few or no headaches, but with gradually worsening long term side effects of medications such as weight gain, difficulty concentrating, or loss of sexual functioning. One patient we saw had been on a medication from her previous physician that caused reduced sexual functioning that was affecting her marriage. Such side effects are, in our view, not necessary to treat headache. Understandably, she had stopped medication and relapsed. Once our patients have control of their headaches, we make realistic recommendations that fit in with your life, and that will really make a difference in keeping you out of the doctor’s office in the future.
My doctor advised me to lose weight and exercise and stop feeling stress. Is this really going to stop my headaches?
Sometimes we hear lifestyle recommendations that don’t work and are unrealistic. It is important, when making recommendations to change lifestyle, to consider whether such changes will make a significant difference. One patient had been advised 20 years ago to never eat chocolate, her favorite food, and she had not eaten any chocolate in 20 years. In her case, the particular type of headache she had could not be triggered by chocolate. However, she enjoyed exercise, and had a cervicogenic headache, and we advised avoiding lifting weights over her head. Since her family life realistically made her too busy to go to the gym, we recommended putting a home treadmill in front of her TV, and do only 12 minutes a day. She no longer needs medication- or visits to the doctor. A consultation with a headache specialist is indicated when you are considering making long term lifestyle changes to prevent headache.
“I know that stress makes my headaches worse, but I can’t make my husband change.”
Headache is a condition that affects spouse, children, friends, and employment. It is helpful for the spouse to understand the medical basis of headache, and they are welcome at your appointment. A common misunderstanding arises because most people have experienced minor headaches in their life, and they make the mistake that you must be having the same headache. Since most people can continue to function during a headache, they have difficulty understanding why your headaches should cause so much “trouble” for you. In that case, it is helpful to make it clear that the headache you are experiencing is not the same kind of headache that your spouse or employer has experienced. We see patients whose illness is associated with the stress of an unsolvable family conflict. Our job is to assist both you and your family in making practical changes that really benefit all involved. Again, we find that patients with headache have more than one problem- in this case a medical headache syndrome, and a conflict; both must be solved before either gets better. Surprisingly, we find that the role of stress is often less important than the stress that is caused by the medical condition of headache. Everyone has some stress in their lives, and sometimes patients have been told that their headaches are “caused by the stress”. Even when conflict or stress is present, we most often find that the persistent headaches are not explained by the stress and social factors. Everyone has stress, but not everyone has headaches. Sometimes stress may make headaches worse- weather changes often make headaches worse too, but weather usually does not “cause” the headache condition. It just isn’t possible for most of us to eliminate stress in our lives. But usually it isn’t necessary to eliminate stress to effectively treat headaches.
Patients are often concerned that the recommendations of their doctor may be too dependent on the pharmaceutical industry. This is a problem that has been recognized in the New England Journal of Medicine and by the AMA. We understand this erosion of trust. There is a sense that specialists have an excessively narrow view of illness, and reach too quickly for a pharmaceutical product. Some patients are using alternative therapies on their own, ranging from supplements and herbal medications to non medical practitioners. But like any other effective medication or treatments, nontraditional therapies may sometimes help and sometimes harm. We believe there is no clear distinction between what is natural and what is pharmaceutical. We consider and use all treatments that may be effective for headache, and work closely with many alternative practitioners. Over the years, our patients have taught us what works. There are a great range of potential therapies, and often, pills have nothing at all to do with our recommendations.
We expect our patients with a primary headache disorder to have other symptoms. Typically, these include sleep disturbance, fatigue, weight gain, depression, mood swings, anxiety, panic attacks, muscle pain, fibromyalgia, dizziness or vertigo, sleep disorders such as restless leg syndrome, sleep apnea, or loss of libido or sexual functioning, allergic or inflammatory sinus disorders, or neck and back pain. Since all of these problems relate so closely to the primary headache syndrome, we treat the whole patient. It may do the patient little good to reduce the headache when these other symptoms are still present. Many patients who have weight gain also have other cardiac risk factors such as elevated cholesterol, early diabetes, elevated blood pressure, family history of heart disease, or tobacco addiction. Successful treatment of the primary headache problem is expected to improve these other medical disorders. Because one underlying neurochemical problem often underlies all these diverse symptoms, treating all associated medical problems is simpler and is our preference. With your approval, we prefer to keep your primary care physician and specialists involved in what we do at the Headache Clinic.
This simple three-question test, called ID Migraine, can identify patients with migraine with about the same accuracy as widely used screening tests for other illnesses.
- Has a headache limited your activities for a day or more in the last three months?
- Are you nauseated or sick to your stomach when you have a headache?
- Does light bother you when you have a headache?
If you answered “yes” to two of the three questions, there is a strong chance you are suffering from migraines.