Sarasota Neurology

Living in Florida is difficult for individual who have migraines and other types of headaches. This is because drops in the barometric pressure can trigger a migraine attack. During the hurricane season in Florida, there are many tropical storms, thundershowers and rarely a hurricane (or hurricanes.) There can just be low pressure weather systems sitting over Florida with no actual “bad” weather. It is not so much the rain that triggers the migraine attack as it is the lower barometric pressure. During the recent string of six different tropical storm and hurricane fronts that lasted six weeks, many patients who normal have perfectly good control of their migraines had their worst attacks ever.

It has been studied extensively as to why changes in barometric pressure, temperature and humidity have such a profound triggering effect on migraine but no definite conclusion has been reached. The effects on the outdoor environment by these weather systems, in Florida, have a profound effect on headache suffers. Not only does the change in weather trigger headache attacks but so does the increase in pollen, mold and fungus spores.

Patients will often claim that they have “sinus headaches.” True sinus headaches belong in the same category as chances of winning the lottery: 1 in 14 million. Why? Because true sinus headaches are rare. What patients are actually feeling is a milder form of their migraine headache, triggered by weather, pollen and molds. Migraine headache symptoms include: nasal congestion, sinus pressure, sensitivity to light and nasal drainage. While these are sinus symptoms, they are part of the migraine syndrome, which is a collection of symptoms associated with migraine. Patients frequently will take sinus medications that will help or stop their headache. This, unfortunately, reinforces the mistaken belief that they are suffering from “sinus headaches.” The fact is, is that sinus medications have a similar effect in relieving headaches as do those of the more specific migraine drugs.

In conclusion, more Florida patients suffer from more headache and migraine attacks during hurricane season (June 1 - November 30) than at other times of the year. About fifty percent of migraine suffers find that changes in weather will trigger their headaches. The best thing to do, if you suffer from migraines or recurrent headaches, is to seek out a neurologist headache specialist and get started on preventative headache treatment as well as migraine treatment specific medication to stop an attack. If you do suffer from allergies, there are many medications to help control this as well.

Occipital neuralgia is a commonly missed headache diagnosis. The symptoms for headaches can be quite different. Occipital neuralgia can mimic migraine headaches but do not respond to standard migraine medications. Occipital neuralgia rarely occurs as a headache syndrome by itself. The majority of patients with occipital neuralgia have one or more other types of headache including: migraines, tension headache, rebound headache and cluster headaches. Occipital neuralgia is frequently misdiagnosed as migraine or cluster headaches. Patients with prominent face pain as part of their occipital neuralgia may be incorrectly diagnosed with tic delaroux (trigeminal neuralgia.)

Occipital neuralgia is caused by an irritation of the occipital nerve as is comes through the muscles in the back of the neck. The occipital nerve is formed from branches of the second and third cervical nerve roots. This nerve passes posteriorly up the back of the head, piercing through the muscles of the upper neck. The occipital nerve then curves over the back of the head to the frontal area, stopping at approximately the hair line. This nerve provides pain and sensory information over the back 2/3 of the head. When the nerve becomes irritated from various causes such as strained or tense neck muscles, whiplash injury, neck arthritis or even just sleeping wrong - getting a kink in your neck.

The headache symptoms of occipital neuralgia include upper neck pain, pain at the base of the skull, which may be on one or both sides, and pain traveling up the back up the head as far forward as the forehead. Some patients experience pain behind the eyes or even facial pain. The pain is commonly made worse by laying on your back. The back of the head or scalp can be sore to touch. The head pain can be anywhere from a nagging aching pain to an excruciating migraine headache type of pain, which can be debilitating. The latter type of occipital neuralgia pain is frequently missed and instead treated as a migraine. Most migraine therapies do not work to relieve occipital neuralgia.

Diagnosis of occipital neuralgia is made by careful neurological examination of the patient. Most individuals have normal exams except for exquisite tenderness at the base of the skull, in the area of the occipital nerve. If pressing on this area reproduces the occipital head pain, the diagnosis is made. Treatments can include the use of anti-inflammatory agents such as aspirin, Tylenol, naproxen (Aleve) or ibuprofen (Advil, Motrin.) Ice to the back of the neck and head can provide temporary relief. One of the most effective therapies, which can be curative for occipital neuralgia, is an occipital nerve block. This is a very safe procedure and consists of injecting a mixture of a local anesthetic with a long acting cortisone. This injection is put in the neck muscles just below the skull base, in the area where the occipital nerve pierces through the muscled. The needle is directed away from the spinal cord and is outside the skull so there is no chance of injury to the spinal cord or brain. The anesthetic works immediately and may cause some temporary scalp numbness. The cortisone is long acting - slow release so that it may take a week to be fully effective. Success rates of up to 80% have been reported. In patients with additional types of headaches, it is not uncommon to add an antidepressant to prevent migraines and other similar headaches. The antidepressants are the mainstay therapy in headache treatment and prevention and have nothing to do with their use for treatment of depression. If you think you have occipital neuralgia or have persistent headaches, particularly ones that are always on one side, you should seek out care from a neurologist who is also a headache specialist.

Migraine headaches are one of the most common neurological problems seen. There are an estimated 30 million affected American patients. Despite its common occurrence, fifty percent of affected individuals remain untreated. Why are there so many patients with migraine? A new report in Neurology Reviews has shed some light on migraine risk factors and how they progress.

In this study, conducted by neurologist and headache specialist Dr. Richard Lipton, they found that patients with chronic daily headaches were more likely to be female, overweight and depressed. Other risk factors for daily headaches include head injuries and snoring. Patients also contribute to developing daily headaches by overusing analgesics such as aspirin, ibuprofen or acetomenophen containing compounds - particularly those containing caffeine. Prescription medications containing narcotics, barbiturates and caffeine for migraine treatment also increased risk of more headaches. The overuse of all pain relievers results in rebound headaches. The more headaches you have the more medication you take - the more medication you take the more headaches you have. This cycle must be broken by stopping regular analgesic consumption.

Dietary factors play an important role migraine progression. Excessive caffeine or regular soda consumption constitute significantly to increased number of headaches. Major stress events clearly contribute to migraine progression. Obesity, defined by having a Body Mass Index (BMI) of greater than 30 was associated with a five times greater risk of developing chronic daily headache. The triptan medications, such as Imitrex, Maxalt and others, are excellent choices for treating acute migraine attacks. When they are overused, they can put a patient with frequent headaches at risk for progression to chronic daily headaches. In general, individuals with four headache days per month or less, who take any of the above medications, are not at risk for progression of their headaches to daily headache. If you have more that 4 headache days per month or frequently take pain relievers for headaches, you should see a neurologist headache specialist for evaluation and treatment. The first step to improve your quality of life is to pick up the phone and call.

Post-concussion syndrome (PCS) results from injuries to the head. This can range from mild concussions (being struck on the head) to severe head injuries. Not always does the degree of head trauma correlate with the degree and symptoms of PCS. It is estimated that approximately 60-80% of patients suffering a moderate to severe concussion, traumatic brain injury (TBI), will develop PCS. In milder head injuries, PCS will develop up in up to 40-50% of injured individuals. Loss of consciousness is not a requirement for development of PCS. It is not even a requirement that there be a direct head injury. Patients who have sudden jerking movements of the head, particularly in car accidents, with out direct head trauma can suffer from PCS. Risk factors for development of PCS can include lower education level, drug or alcohol abuse, prior head injuries, or preexisting depression or anxiety. The recognition and diagnosis of the symptoms of PCS are important in helping affected patients to return to normal a quickly as possible.

The symptoms of PCS may develop immediately or make take days to several weeks to become apparent. Headaches and dizziness are the most common complaints in patients with PCS. These however are not the only symptoms that can be associated with PCS. Varying degrees of memory loss, concentration difficulty, anxiety, depression, irritability, emotional and behavioral disturbances, insomnia and personality changes. The headaches can vary from mild, dull, generalized headache to severe migraine like headaches. These headaches usually occur daily and can be quite debilitating. Dizziness can be anywhere from lightheadedness to a spinning type of dizziness known as vertigo. Patient can have irritability, anxiety and depression, partly due to the head injury but also from the persistence of their symptoms. Insomnia frequently accompanies these other psychological symptoms. In more severe case, behavioral changes can occur. Patients can become impulsive and irrational in their behavior. Psychological changes are more apparent later in the course of PCS. Decreased ability to concentrate and slowness in mental function can occur, particularly in higher functioning individuals.

Treatment for PCS is primarily time. Many of the symptoms of PCS will clear within days to a few weeks. A typical time for clearing of symptoms is usually 3 months and as much as 6 months. In 10-15% of the cases it can take a year or more for improvement. The earlier the diagnosis is made, generally the better the outcome. Headaches and dizziness complaints most commonly bring the patient to a doctor’s office. Patients may have tension headaches, migraine headaches or a condition known as occipital neuralgia. The latter is an injury to the occipital nerve at the base of the skull. The most effective treatment for this condition is an occipital nerve block. Other headache conditions are treated with the usual preventative migraine medications protocols. As anxiety, irritability and depression are common symptoms of PCS, the antidepressant medications are the most effective treatment for both the headaches and psychological symptoms. Antidepressant medications have been used for decades in controlling migraine and other headache disorders. Over-the-counter analgesics can be used to relieve headache and neck pains. Narcotics should be avoided as they are addictive and do not help the overall patient outcome.  Mayo Clinic has an excellent, comprehensive summary of post-concussion syndrome.

In patients who have persistent complaints of memory loss, concentration difficulties, forgetfulness, anxiety and depression, neuropsychological testing followed by counseling can be helpful in patient management and improvement of symptoms. Testing is usually not done for at least 3-6 months following the head injury. This is because so many patients will spontaneously improve over this time period. Once testing is completed, the psychologist can help the patient through counseling to improve their overall well being. Other diagnostic tests may be performed and can include MRI brain studies, EEG or PET scan.

Prognosis for patients with PCS is excellent in the majority of the cases. Most patients are back to their normal baseline within a few weeks, with a few taking as long a 3 months. It is far less common for patients to continue having symptoms beyond this. It is estimated that only about 15% of patients with PCS will have symptoms a year or more. Early treatment by experienced neurologists or other physicians who have training in treatment of concussion, traumatic brain injuries and post-concussion syndrome are important in improving a patient’s quality of life in as short of period of time as possible.

Namenda (memantine) is the newest medication used in the treatment of Alzheimer’s disease. New research has shown that Namenda may be effective in treating patients with both migraine and tension headaches. The study done by John Krusz, PhD, MD showed that some patients with chronic migraines that did not do well with other headache treatments, did well with Namenda therapy. Of the migraine sufferers, there was a 56% drop in the number of migraine attacks. In patients with tension headaches there was a 62% drop in the numbers of attacks. This study was well reviewed on the website, Help for Headaches and Migraines.

Migraine and other headaches are chronic medical conditions that require aggressive preventative treatment. Many therapies have been tried but no cure has been found. Botox treatment has been promoted by the press but no clinical studies have showed that it is superior in migraine treatment than placebo. Having said that, there are certainly patients that have had migraine and headache reduction after Botox therapy.

It is important to note that the use of Namenda, Botox and most other migraine treatments are off-label uses of these and other medications. The majority of medications routinely used in the prevention of migraines are off-label. This is the standard of care in most headache clinics. If you suffer from migraines that prevent you from routine activities or interfere with work, you need to seek out help from a qualified neurologist who specializes in migraine headache treatment.

Migraine is a very common medical condition. Migraine headaches are the second most common cause for work absences secondary only to low back pain. Unfortunately migraine is the most prevalent in the working population age group. Fortunately many new migraine treatments have been developed. The newest migraine medication that has been FDA approved is Treximet. Treximet is a combination medication. It has Imitrex with RT technology in combination with naproxen sodium (the active ingredient in Aleve.) Imitrex was the first drug in the class of triptan medications that are migraine treatment specific. Studies have shown that the Treximet formulation of the two component drugs is more effective in migraine treatment than with either drug alone. Overall, Treximet has about a 10% greater effectiveness in stopping a migraine attack with the first dose, over either of the other migraine drugs, taken alone or together.

There are several other migraine treatment medications including Maxalt, Zomig, Relpax, Frova, Amerge and Axert. All of these medications are “designer drugs” formulated specifically to treat an acute migraine attack. The most important step for any patient who suffers from headaches is to get in to see a headache specialist. Migraine and headache treatment has become a specialized area in neurology. Neurologists who treat migraine, cluster and other headache disorders take a different approach to treatment of headaches and improving the patient’s quality of life. For additional information on migraine and headache treatment click here.

Cluster headaches are the most excruciatingly painful type of headaches. They are very different than your “average” migraine. Typical migraine headaches most commonly affect women. In contrast, cluster headaches are seen predominately in males. These headaches occur in groups, which may be daily for weeks to months. Rarely they continue for years. As compared to a migraine which may last 4-12 hours, cluster headaches are short lived, generally less than one hour. The character of cluster headache is different. These severe pain attacks occur on the same side of the head for every attack. They tend to be localized to the front of the head and around the eye on the affected side. Cluster headache is a syndrome with a constellation of various symptoms which can include eye redness, drooping eyelid, tearing, nasal congestion, facial sweating and flushing. It is important to note that these symptoms all occur on the same side as the headache attack.

In contrast to migraine suffers, who would rather lay down in a quiet dark room, individuals affected with a cluster attack are up pacing around, banging their head and generally cannot sit still. In my office it is not uncommon to hear the saying, “If I had a gun, I’d shoot myself because the pain would be less.” If a patient with headaches says this, the diagnosis is almost certainly cluster headache. This threat should not be taken lightly as unfortunately the incidence of suicide in cluster headache sufferers is higher than the general population. Because of the severity of these headaches, they must be treated aggressively from the time they start. A cluster headache patient may go weeks to months or years without an attack. When they do start, they usually become severe within a week or so. A person may have several attacks in a day. During these attacks, they are completely disabled. Alcohol will trigger a cluster attack during a siege but at other times, when the patient is not having headaches, alcoholic beverages have no effect.

From the onset of the cluster attack, these patients need intensive, aggressive therapy. In contrast to migraines where you have time to adjust medications, a cluster sufferer needs multiple, maximum treatment therapies started at the onset of a cluster. This can include oxygen for inhalation therapy. This will frequently abort an attack. The mainstay of therapy is prevention. Several different medications can be used to control cluster attacks from even occurring. These medications may include Prednisone, Depakote, Topamax, lithium, Verapamil, Lyrica, Sansert or Methergine. Not every medication works for every patient. It is important to see a headache specialist familiar with the aggressive treatment of cluster headaches. To relieve an acute attack, Imitrex injections work well. Although not designed to be used on a daily basis, some patients go outside of the prescribing guidelines to treat their clusters due to the severity of the pain. I instruct my patients that when they feel a cluster attack starting, they need to call for an immediate appointment so that we can get them started on aggressive maximum therapy as soon as possible. Patients suffering from cluster headaches should be under the care of a headache and migraine specialist due to the unique nature and treatment requirements of this disabling condition.

Botox is a potent neurotoxin that causes muscle paralysis by blocking the release of the neurotransmitter, acetylcholine, from the nerves that control muscles. When given under controlled clinical applications, this medication can have a dramatically beneficial effect in relieving muscle spasm due to certain conditions such as cervical dystonia, blepharospasm, hemifacial spasm and limb dystonia. Over the past several years the media has reported that Botox can relieve migraines. These claims are based on random reports of individuals who may have gotten some benefit. The manufacturer of Botox, Allergan, has conducted several nationwide studies on the use of Botox for headaches, none of which have shown a statistically significant difference over placebo. Sandra Leong writes in Natural Headache Remedies a summary about the use of Botox in the treatment of various headache disorders. She notes that one theory on how Botox works for migraine is by relieving the muscle tension. It should be noted however that physiologic studies have not shown an overall increase in muscle spasm around the head in patients suffering from acute headache attacks. It is also important to note that the placebo effect in headache studies is as high has 35%.

In a summary of the studies done by Allergan for headaches, Medical News Today lists the previous and ongoing studies that the company is conducting to analyze the potential benefits of Botox in the treatment of migraine and other headache disorders. Personally, having participated in several of these Botox trials, I would agree with the study results that there was no distinct clinical benefit from Botox over placebo. It is important to note however that these were randomized, double blind placebo studies where neither I or the patient knew if they were getting Botox or placebo saline injections. I base my conclusions on reading the final study reports. At the Florida Headache & Movement Disorder Center, we carefully screen patients with head and neck pain for the possibility of benefiting from Botox therapy. Only very few patients actually meet my criteria for using Botox for migraine treatment. Even with this careful selection of patients, our results are about 50% success rate, slightly higher that the placebo effect rate. The patients that benefit the most from Botox treatment most commonly have a high degree of muscle spasm in their neck and head, associated with but separate from their actual headaches. There have been reports by other respected headache specialists, in non-controlled trials, that Botox may effective for some patients with migraine.

In conclusion, Botox has not been shown to have a major therapeutic advantage in the treatment of otherwise intractable migraine and headache disorders. The “media hype” is without scientific basis to back up the claims cited in many reports. If you have recurrent headaches, your best bet it to be evaluated and treated by a board certified headache specialist.

It is estimated that migraine and other headache disorders affect 30-40 million Americans. The unfortunate fact is that only 50% of these individuals seek out treatment. It is one of the leading causes of missed time from work and social functions. Untreated migraines can have a devastating effect on affected individuals’ quality of life. Migraine is one of the leading causes of temporary total disability in the U.S. work force. This is an unfortunate statistic which could be dramatically improved with earlier recognition and more aggressive treatment of migraines and other disabling types of headache. The main features of the migraine syndrome are recurrent moderate to severe headaches that interfere with activity. Associated migraine symptoms include light and noise sensitivity, nausea, occasionally vomiting and sinus congestion. Most so called “sinus headaches” are actually migraines and have nothing to do with sinus problems whatsoever. Cluster headaches are the most severe form of headache. While considered a type of vascular headache, they are put in a different category to be differentiated from migraines. This is by the International Headache Society classification of all headache disorders.

Patients experiencing a migraine attack prefer to lay down in a quiet dark room with an ice pack on their head or neck. There are excellent, non-narcotic medications that can be used to abort a migraine attack. Migraine treatments to stop an acute attack include the triptan medications such as Imitrex, Maxalt, Zomig, Relpax, Frova, Axert and Amerge. There are other medications that can be used to prevent migraines from occurring. Topamax and Depakote have FDA approval for migraine prevention. The first step is for the patient to schedule an appointment with a headache and migraine specialist.