We treat common and uncommon headaches
and try to share our expertise with you

Burning Mouth Syndrome This is defined as a burning pain affecting the mouth or tongue, occurring daily for at least 2 hours a day, over more than 3 months, for which a medical or dental cause cannot be found. It tends to be chronic and disabling. It can affect up to 18% of postmenopausal women. The pain is described as burning, tender, tingling, hot, scalding, numbing, and the anterior tongue is the site most affected. In two-thirds of patients, it is termed “primary,” meaning there is no defined cause. Possible causes in the other third include Sjögren’s syndrome, an autoimmune disorder; iron or zinc deficiency; badly fitting dentures; toothpaste that contains sodium lauryl sulfate; oral candidiasis; smoking; acid reflux; B12 deficiency; perhaps alcohol. Anxiety and depression are common in these patients. They may also have a sensation that their mouth is dry even though the amount of saliva they make is normal. In Sjögren’s syndrome, the saliva production is indeed reduced. Some patients report that eating reduces pain. Treatment is difficult, and studies are inconsistent. Most patients have tried antianxiety drugs, antidepressants, antiepileptic drugs, supplements. There are reports of topical clonazepam, a benzodiazepine, being helpful. Cognitive therapy may help as…

Hypnic Headache is also called “alarm clock” headache in that it wakes patients out of sleep, usually at a consistent time each night. A new report shows that the average age of headache onset is 62 years and that 8 out of 10 patients were women. About 60% also had migraine. In two-thirds of patients, the headache was bilateral, severe in intensity, and sharp in quality. Taking caffeine at bedtime as well as at the time of awakening led to a complete response in about 30% of patients and a moderate response in another 30%. Lithium, used most commonly in bipolar illness, led to a complete response in 70% and a moderate response in 20%. Lithium seems to work for other disorders such as cluster headache, which often awakens patients from sleep and is cyclical, varying with the seasons and with the circadian sleep cycle. About a third of patients also noted that physical activity / exercising immediately upon awakening with the headache reduced the intensity.

We know that people with migraine are hypersensitive and hypervigilant to painful stimuli. Unlike most adults, they are unable to inhibit pain sensation by shifting their attention away from the pain. These observations have been confirmed in new studies that show that migraineurs have abnormal relationships between the cortical thickness of regions that participate in pain processing and pain thresholds. These findings indicate that along with use of medications, techniques such as cognitive behavioral therapy may be useful by helping patients learn to distract or reorient their attention in the moment of pain. This study by Todd Schwedt, MD, was presented at the 67th Annual Meeting of the American Academy of Neurology.

Children with migraine often come up against barriers, the most important being their parents. Children have a right not to suffer when treatment is available, but frequently, parents are resistant to have their child use prescribed medication. Children further tend to downplay the impact of the pain on their lives and families. Migraine is common in childhood and adolescence. Before puberty, boys are affected more commonly than girls. The same medications used in adults, mainly triptans, are appropriate. Maxalt and Axert are FDA approved for children and teens, but all triptans work and are well tolerated. Preventatives can include the supplement butterbur or prescribed medications similar to those used in adults with migraine. Evidence supports use of Depakote, Topamax, beta-blockers. Depakote is reasonable in children and young teens. It comes in sprinkles for those who cannot swallow pills. Topamax is a good choice for obese teens with caution that higher doses may cause cognitive symptoms. Cyproheptadine has been used for years by pediatricians with little supporting evidence. We are a Children’s Headache Center, recognized by the National Headache Foundation.

Education is the most important measure. Short-acting drugs such as butalbital and most opioids are of higher risk for habituation than longer-acting drugs such as ibuprofen or naproxen. The first step is to stop the medication. Generally, this can be done abruptly. Pick a long weekend so withdrawal headache, which is common though temporary, is better tolerated. Start a preventative if the patient is not already on one. If the drug is butalbital or opioids, use a triptan during the withdrawal. There are several choices for rescue medications. I favor indomethacin in combination with metoclopramide and a steroid dose pack if that fails.

Non-modifiable risk factors are older age, female gender, Caucasian ethnicity, low educational level, low socioeconomic status, and genetic factors. Modifiable risk factors are obesity, snoring, head or neck injury, comorbid depression, stressful life events or major life changes. Only about 25% of patients achieved remission, specifically moving from more than 15 headache days a month to less than 10 headache days a month, over a period of 2 years. The most important factor that favors obtaining remission is a lower baseline of headache frequency. Recognizing risk factors leads to behavioral modifications such as weight loss, checking for sleep apnea, treating anxiety and depression. Using effective abortive therapy, mainly triptans and treating each headache early, is also helpful.

Not all patients with episodic migraine require preventive medication. The decision should be based both on disability from headache as well as frequency of headaches. For example, a person with a 2- or 3-day disabling headache once a month, not responding to acute medications, should be on a preventive. On the other hand, a patient with 6 or 8 headaches a month who responds well to acute treatments, does not have increasing frequency or headaches, and has little disability does not need a preventive. About 40% of migraine patients would benefit from preventive therapies, but only about 10% currently receive them. Lifestyle modifications are important. Patients should be counseled to avoid triggers, practice good sleep hygiene, treat stress and depression with medications or behavioral intervention or both. Treating comorbidities such as obesity, hypertension, and chronic neck pain may help. A trial of 2 to 3 months is needed. Preventive treatment need not be life-long. Some patients can taper or stop therapy after 6 months of successful treatment.

CGRP is a neurotransmitter, elevated during attacks of migraine. Injecting CGRP in a migraine patient between attacks reliably triggers an attack. Several monoclonal antibodies targeting CGRP itself or its receptor are in clinical trials. They are given either by subcutaneous injection or intravenous infusion. Results of the trials have been promising. A medication may be available within the next year or two. DHE has been used for many years as an acute treatment. It is available by injection or with a nasal spray, but these delivery routes have issues and are infrequently used. A new device uses an oral inhaler. Phase III trials are completed. Approval by the FDA is on hold because of problems with the delivery device. Ketorolac (Toradol) is an NSAID that is often given by injection in urgent care for a prolonged migraine. It is available in a nasal spray to treat pain short-term, and clinical trials for acute treatment of migraine are ongoing. Rizatriptan (Maxalt) utilizing a thin film strip that dissolves rapidly in the mouth, is being tested. The drug is not absorbed in the mouth but rather through the GI tract. Botox is approved by the FDA for use in adults but not…

Chronic migraine patients often overuse acute medications, and this can lead to medication-overuse headaches. In individual patients, however, it is difficult to determine if medication overuse is the cause of or a response to frequent headaches. Barbiturate-containing analgesics or opioids are very high risk. Triptans and nonsteroidal anti-inflammatory medications such as ibuprofen or naproxen are lower risk. Frequency of more than 10 days a month should be avoided. All patients do not revert from chronic migraine to episodic migraine after medication overuse is stopped. Fifty percent or more can be treated with only simple educational intervention over 18 months. About 40% of “detoxified” patients relapse within the first year after withdrawal.

A transcranial magnetic stimulation device, available by prescription, may be effective in patients with migraine with aura though not in patients with migraine without aura. It should not be used in patients with a history of epilepsy. It is hair dryer sized. A smaller device, developed by the same company, was approved in 2014 for acute treatment of migraine with aura. It is not yet widely available. A Belgian company, Cefaly, makes a transcutaneous supraorbital neurostimulation headband (tSNS). It is designed to be a preventive treatment and to be used 20 minutes a day. About half of the patients respond. It may be helpful as a treatment for acute headache as well though this has not been tested fully.

Botox is injected approximately every 12 weeks. Side effects are few and temporary, and they include droopiness of the eyelids or eyebrows, discomfort for a day or two after the injections, and weakness of neck muscles. Side effects peak at 2 to 4 weeks and improve gradually and are usually gone by 8 weeks. Overall, 70% of patients achieve 50% or fewer headaches a month with Botox. Thirty percent do not improve. Another 30% within the 70% achieve reduction of 75% or more per month of headaches.

Only 50% of patients with migraine have seen a physician. Only two-thirds of patients who have seen a physician have been correctly diagnosed with migraine and prescribed migraine-specific treatments. Mild to moderate headaches may respond to NSAIDs, Tylenol, or Excedrin. If they fail, triptans are the treatment of choice. There are 3 brands and 4 generic preparations, and they are available in oral, nasal, and injectable formulations. A new transdermal delivery system is available. When taken early in the attack, response is much higher. Frequency should be limited to 2 or at most 3 days a week to reduce the risk of medication-overuse headaches (rebound headaches).

Migraine is a primary headache disorder, and the first step in diagnosis is to exclude a secondary headache disorder, i.e., that which is caused by a possibly life-threatening condition. These red flags are sudden onset of headache (thunderclap headache or first-worst headache), age of onset after 50 years, fever, stiff neck. Conversly, signs that point to a primary rather than a secondary headache disorder include a long duration of similar headaches, family history of migraine, and menstrual exacerbation. Response to triptans is not diagnostic of migraine and may be seen in secondary headaches, including subarachnoid hemorrhage and meningitis.

In 2004, Blau described a headache syndrome triggered from wearing hair in a ponytail. It came on when the hair was tied too tightly and it improved within minutes up to an hour after loosening the hair. The pain was believed to arise from traction on scalp muscles, fascia, and tendons. Now comes a report in the journal Headache of March 2015 of 5 women who never experienced headaches prior to wearing the hijab. They had headaches mild to moderate in intensity, generally throbbing but also tension-type. None had features of migraine. The headaches began 30 minutes to 4 hours after donning the hijab. Physicians should keep this in mind when seeing these patients.

These are based on the frequency and duration of attacks. Regarding frequency, less than 15 days a month is episodic, greater than 15 days chronic. Regarding duration, less than 4 hours is short and greater than 4 hours long. Episodic short-duration headaches: Trigeminal autonomic cephalgias, such as cluster, SUNCT, SUNA, hypnic headache, stabbing headaches. Episodic long-duration headaches: Migraine and tension-type headache. Chronic short-duration headaches: Chronic cluster and chronic paroxysmal hemicrania. Chronic long-duration headaches: Chronic migraine, chronic tension-type headache, new daily persistent headache, hemicrania continua. If a headache in this group is unilateral, a trial of indomethacin is indicated, and if effective, the patient has hemicrania continua.

Thirty-six million Americans suffer from migraine. Eighteen percent of women and 6% of men have episodic migraine. One point five percent of women and 0.5% of men have chronic migraine. Prevalence of chronic migraine peaks during midlife, 10 years later than episodic migraine, and is highest is women and in households with low income levels. Prevalence of chronic migraine is 1% to 3%. The World Health Organization rates migraine the fourth most disabling medical disorder among women and the seventh most disabling medical disorder overall worldwide. More than half of people with chronic migraine and a quarter of those with episodic migraine missed more than 5 days of household work over 3 months. One in 3 with chronic migraine is depressed.

Diagnostic Criteria For Migraine Without Aura At least 5 attacks. Duration 4-72 hours. Two of the following 4 criteria: unilateral, pulsating, moderate to severe intensity, worsening with routine physical activity, especially bending over. At least 1 of the following: nausea and / or vomiting, photophobia and phonophobia. Diagnostic Criteria For Migraine With Aura At least 2 attacks. One or more of the following reversible aura symptoms: visual, sensory, speech and / or language, motor, brainstem, retinal. At least 2 of the following 4: If 2 or more aura symptoms, gradual spread over greater than 5 minutes or occurring in succession. Each aura symptom lasting 5-60 minutes. At least 1 aura symptom is unilateral. The aura is accompanied by or followed within 60 minutes by headache.

Childhood maltreatment is a worldwide problem, leading to many medical and psychiatric conditions in adulthood, especially pain disorders. Headache has been found to be associated with emotional, sexual, and physical abuse in an important research study. In another study, the association with migraine was stronger for emotional abuse than for sexual or physical abuse. These results remain significant after adjusting for depression and anxiety. Similar findings have been seen in other pain conditions, including fibromyalgia, irritable bowel syndrome, interstitial cystitis, and TMJ disorders. These conditions are often called complex persistent pain, are associated with central sensitization of pain receptors, and probably have a shared pathogenesis. Abuse-induced stress during childhood, a time that the brain has plasticity, could lead to psychobiological changes that enhance pain sensitivity. See Neurology 84, January 13, 2015, page 132-140.

It is well known that people with a history of migraine have higher risk of developing posttraumatic migraine after concussion. A report in Athletic Training and Sports Health Care published September 16, 2014, concluded that a history of migraine did not contribute to greater neurocognitive deficits following a concussion in young athletes. The study measured verbal memory, visual memory, motor processing speed, and reaction time.

Triptans (Imitrex and others) are the drugs of choice to treat migraine, whereas opioids (Vicodin, Norco, and others) are not. Opioids are less effective and have risk of habituation and possibly addiction. Non-neurologists gave triptans to about 20% of their patients with a migraine diagnosis, and 36% received opioids. Ten percent of this group of primary care physicians was responsible for two-thirds of the opioid prescriptions. About 10% of patients on opioids generated almost half of the headache encounters and had 7 or more clinic visits in the 2 years of the study. This study, done at the University of Utah, led to increased teaching of residents and primary care physicians with the goal of reducing use of opioids.

Respondents to a survey of about 1000 patients with chronic migraine reported missing family events on a regular basis and felt guilty and sad about how this affected their relationships with their spouses and children. About 75% thought they would be better spouses if they did not have chronic migraine. About two-thirds felt guilty about being angered or annoyed by their partners or children, two-thirds avoided sexual intimacy, and about 60% felt they would be better parents if they did not have chronic migraine. According to Dr Dawn Buse, “The effects of chronic migraine can be devastating and far-reaching.” There are effective treatments for chronic migraine, including preventative drugs and injections of Botox.

There are currently 3 drugs being studied that target CGRP. One drug showed a reduction of 66% compared to a 52% placebo group reduction in migraine days. Sixteen percent were headache-free while none of the placebo patients were. The second drug had a 63% reduction compared to 42% in placebo group. No safety issues were noted. Our center is a site in a research study with a third drug, which is a monoclonal antibody directed against CGRP, a pain transmitter critical in the migraine process.

Our center is a site in a phase IIb trial of a compound named LBR-101. This is a monoclonal antibody directed against calcitonin gene-related peptide (CGRP). Phase I and II trials have been very promising. The medication is given by injection monthly. If CGRP is given by injection in migraineurs, all develop a migraine. If given to non-migraineurs, this does not occur. Further, CGRP in the blood is increased during an attack of migraine. Previous CGRP oral antagonists have all shown efficacy but also possible liver toxicity. Monoclonal antibodies do not have this risk. Inclusion criteria for the trial include at least 8 migraine days a month.

The connection between hallucinogens and cluster headache began in 1998 when a Scottish patient posted on a cluster headache website that he missed his fall cycle of cluster headaches and could connect this only with using LSD recreationally. LSD may work because it contains types of ergot, specifically-ergine and isoergine. Psilocybin may work because it is similar to serotonin. In a study published by Sewell et al in Neurology in 2006 of 53 cluster patients, 21 of whom having chronic cluster headaches, psilocybin completely eliminated attacks in half of these patients. It was not used to treat each headache but rather as a preventative. Possession of psilocybin mushrooms is illegal everywhere, as it is a schedule I drug, but buying the spores, not the mushrooms, is legal in most states. Several vendors operate online. It is illegal to buy the spores in California, Georgia, and Idaho. It is impossible to obtain LSD legally. It possible to alter LSD by bromination, which makes it nonhallucinogenic. A 2010 study published in Cephalalgia reported on 5 patients, 4 of whom with chronic cluster headaches, who were administered brominated LSD, did not hallucinate and whose attacks per week, which ranged from 25 to 40,…

A study by Dr Scott Powers in Cincinnati found that adding biofeedback, relaxation techniques, and stress reduction to amitriptyline therapy reduced the number of migraine days and disability and had a favorable and clinically meaningful impact on children school functioning. According to Dr Lawrence Newman, translating this into clinical practice is a challenge and “treatment specialists will need to find ways to overcome adolescent resistance to behavioral therapy and insurance coverage issues.”

Tension type headaches are termed episodic if less than 15 days a month and chronic if more than 15. Almost everyone has had this type of headache. Think stress, lack of sleep, hangovers, flus. Duration is usually 1-2 hours, unlike migraine which is 4-72 hours. They are bilateral, non-throbbing, moderate in intensity, are not worse with movement such as bending over. Patients self-treat with Tylenol, ibuprofen, naproxen, etc. and do not see a physician. Chronic Tension Headaches are less common but can be disabling. Underlying stressors should be sought. Best treatment options are antidepressants in the TCA or SNRI but not the SSRI class. Examples of TCA’s are Elavil, Pamelor; SNRI’s are Effexor, Cymbalta, and SSRI’s Prozac, Lexapro. Stress management and relaxation techniques may be more effective than medications.

Nummular means coin-shaped (think numismatist-coin collector). These are rare and often difficult to treat. Patients complain of a constant, severe pain, without migraine features, localized to a specific area of the scalp, about the size of a silver dollar. Nothing abnormal can be felt in the scalp and it is not tender. MRI is normal. Perhaps some unrecognized injury to scalp sensory nerves is the cause. Medications are usually ineffective. Injecting local anesthetics, e.g. Marcaine, or BOTOX may help.

A visual aura, consisting of partial loss of vision or scintillating scotoma, precedes the headache in about a quarter of migraineurs. Occasionally people in their 50’s or 60’s, whether or not they have a history of migraine, develop attacks consisting of the aura only. They are often misdiagnosed as having TIA’s or strokes. The attacks are usually infrequent and no treatment is needed. They last about 30 minutes whereas TIA’s last less than 5 minutes.

This a controversial diagnosis mainly because most migraine patients have neck pain during an attack and for some, the pain seems to start in the neck. In fact, there is a “migraine center” in the base of the brain and when activated it stimulates the Trigeminal nerve. This nerve has branches to the posterior cervical muscles as well the surfaces of the brain, sinuses, face and jaw, explaining why some migraineurs believe they have sinus headaches. Patients with true cervicogenic headaches have chronic neck pain and their headaches may be relieved with pressure over the occipital nerves. Treatment options include physical therapy and injecting a local anesthetic in the area of the occipital nerves.