Migraine and other headache conditions are a common cause of pain. Migraine headaches are the leading cause of temporary disability in the work force. Fortunately, there are many medications that can be used to prevent and treat migraines.

The first therapeutic event which needs to happen is the correct diagnosis of migraine to be made. Patients can have multiple headache types. Headaches which are severe enough to limit activity and are associated with light and sound sensitivity with nausea and sometimes vomiting are most likely migraines. Migraines usually have a pulsating, heartbeat type pain – made worse by movement.

A common type of headache which can mimic migraine is occipital neuralgia. Occipital neuralgia starts at the base of the skull. There the occipital nerve exits the spine and runs up the back of the skull to the forehead. This nerve carries pain fibers. If it becomes irritated, due to trauma, “sleeping wrong” or just routine daily activities; occipital neuralgia headache occurs. The pain can be just as severe as a true migraine. The pain can be on one side, both sides or even isolated to the front of the head. Diagnosis of occipital neuralgia is made by gently pushing at the base of the skull, over the occipital nerve. If this reproduces the headache symptoms, the diagnosis of occipital neuralgia is made. The most effective treatment for occipital neuralgia is a simple injection in the upper neck in the region of the occipital nerve.

Botox was approved by the FDA in 2011 for treatment of intractable migraines. Botox migraine treatment is not for everyone. In order to have insurance or Medicare to pay for Botox, certain criteria must be met. These criteria include:

– 15 headache days a month
– Failed various migraine prevention medications
– AEDs
– Antidepressants
– Certain blood pressure medications
– muscle relaxants
– physical therapy
– migraines must be incapacitating causing missed work or school

All of these criteria must be met before insurance will authorize and pay for Botox therapy for migraines. Once approved, Botox for migraine is a simple, in-office procedure. For experienced migraine doctors, giving Botox for migraine takes about 20 minutes. Botox does not work immediately to relieve intractable migraines. Effects can be felt as soon as two weeks but maximum benefit is at 6 weeks after Botox treatment. Duration of pain relief can be from 6-8 weeks. With repeated Botox treatment for migraine headache, there is a cumulative benefit in many patients. The minimum time in between Botox treatments is 90 days.

For optimum migraine control, affected patients should be treated every 3-4 months. This results in the best migraine control. This in combination with oral medication migraine prevention therapy.

In conclusion, Botox is effective treatment for many headache patients with chronic, intractable migraines. Proper diagnosis and treatment must be given. For insurance to pay for Botox for migraine, specific criteria must be met. If you suffer from persistent, frequent headaches, call Sarasota Neurology today for an appointment. Start improving your quality of life today.


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Migraine headaches are a common medical condition in the United States, affecting approximately 12% of the entire population. It is estimated that there are 35-45 million migraine and headaches sufferers in the U.S.  An unfortunate fact is that only 50% of all headache and migraine patients are medically treated. Individuals with different types of headaches (or migraines) are either undiagnosed or undertreated. In the 21st century, it is not necessary to suffer needlessly from migraine headache – the number one medical cause of temporary, total disability in the United States.

A new migraine medication has been approved by the FDA for use in treatment of acute migraine attacks. This new medication is called Sumavel DosePro.  Sumavel is an injectable form of the well known migraine medication: sumatriptan. Sumatriptan was first released in United States in 1992 as Imitrex injectable and subsequently the tablet form. Imitrex injectable system uses a small needle to administer the medication, sumatriptan. While this was one of the most effective treatments for acute migraine attacks, it did involve a minor needle stick. For patients who did not tolerate the thought of a needle stick, even this excellent therapy was not an option for them. Sumavel overcomes this problem by the use of a unique, needle-free injector system. Sumavel uses pressurized air to administer the medication. This is demonstrated in this video.

Sumavel comes in a self-contained injector kit. There is no need for alcohol swabs or drawing up sumatriptan into a syringe. With Sumavel a migraine patient, experiencing an acute migraine attack, needs only to snap of the safety cap, flip the small injector lever and press the injector firmly against the skin on the lower, outer abdomen or thigh. Pressurized nitrogen (a neutral gas) causes the sumatriptan change into an aerosol form and this is literally pushed through the skin into the subcutaneous tissue. This delivers a full dose of sumatriptan (6 mg) into the patient. Therapeutic effect and migraine relief can occur in as few as ten minutes. When the injector releases the pressurized air, you will hear and feel a pop noise.  There is a slight stinging sensation when the medication is pushed across the skin, but there is no needle involved. The used injector can then be disposed of in any trash receptacle. As there is no needle, special disposal is not necessary. Most insurances cover this new, novel migraine therapy.

Migraine headaches remain a major health problem in the United States. Migraines are a leading cause of missed school and work. For migraine sufferers who have too many headache attacks, this can lead to the risk of losing their job. This is unnecessary as many excellent and effective migraine control therapies are available. If you suffer from migraines, cluster headaches or any type of headache, do yourself a favor – call Sarasota Neurology for an appointment. As a migraine specialist, Dr. Kassicieh can help to improve your quality of life, control your migraines and give you your life back.


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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 – a type of facial pain.)

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. These can all result in occipital neuralgia (also called occipital headache or occipital neuropathy).

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 muscles. 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.


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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.


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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.


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