In this episode of Dr. Talks we host Dr. Prashant Makhija. Dr. Prashant is a practicing Neurologist at the prestigious Wockhardt Hospital, South Mumbai, India. He has qualitative experience in the field of Neurology including its various sub-specialties such as Epilepsy, Sleep Medicine, Stroke, Headache, Movement disorder, Neuromuscular and Neurobehaviour. He was awarded with “Young investigator award” at the 10th World Stroke Congress.

Dr. Prashant covers following aspect of headache with us:

  • What is a headache?
  • Common facts about headache.
  • Primary and Secondary headache.
  • Migraine, which is a primary headache.
  • Case history with respect to a migraine.
  • Danger signs with respect to headaches.
  • Treatment approaches for Primary and Secondary headache.
  • Treatment approach of Migraine.

#Headaches #Migraine #migrainetreatment

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What are headaches? How is a Migraine treated? What are the red flags? Learn to manage your headache better.

A talk with Dr. Prashant Makhija.

Speaker: Mr. Vivek

Hello, this is Vivek. Welcome to Dr. Talks. Here we chat with the best doctors about diseases and conditions they treat. Our guest today is Dr. Prashant Makhija. Dr. Prashant is a practicing Neurologist at the prestigious Wockhardt Hospital, South Mumbai, India. He has qualitative experience in the field of Neurology including its various sub-specialties such as Epilepsy, Sleep Medicine, Stroke, Headache, Movement disorder, Neuromuscular and Neurobehaviour. He also has many publications to his credit in national and international journals and has authored book chapters in Neurology textbooks. He was awarded the “Young investigator award” at the 10th World Stroke Congress. Welcome Dr. Prashant.

Speaker: Dr. Prashant

Hello Vivek. Thank you for inviting me to Dr. Talks.

Speaker: Mr. Vivek

Which health condition are we going to discuss today doctor?

Speaker: Dr. Prashant

Today we will be discussing headaches, a very common symptom amongst patients coming for consultation with a Neurologist and at some point, most of us have had a bad day because of headache.

Speaker: Mr. Vivek

What is Headache?

Speaker: Dr. Prashant

So speaking in layman language, headache is simply a pain located in the head. Whereas if we speak in medical terms, international headache society defines the boundaries within which this pain should be located. So on the sides, if you draw a line which comes from the outer margin of the eyes and goes backwards up to the ears and to the back above the nape of the neck. So it is the pain located in the head within the confines of these boundaries. Headache can be a symptom of underlying neurological or systemic disorder or it can be a primary disorder in itself.

Speaker: Mr. Vivek

Can you share some common facts about headache with us?

Speaker: Dr. Prashant

So headaches are the most prevalent neurological disorders. In fact, it is the most common neurological symptom for which a patient seeks neurologist consultation. If you look at the epidemiological data, it is estimated that nearly 50% of the general population will have headaches during any given year. It is reported that more than 90% of the population will report a lifetime history of headache. headache is in fact, the third leading cause of disability worldwide. If you look at the amount of analgesic consumption headaches account for more than 13,000 tons of aspirin consumption annually worldwide.

Speaker: Mr. Vivek

What are types of headaches ?

Speaker: Dr. Prashant

Headaches are basically classified as Primary and Secondary. The primary headaches, they account for the majority of the cases. Nearly 90% of the cases are primary headaches. wherein there is no underlying structural brain pathology. So if we do a scan in such cases, a CT or MRI of the brain, it comes as normal. These primary headaches they can present as episodic disorder. That is, the headache episodes occur intermittently. It can also present as a chronic disorder when the patient has headaches for a majority of days of a month. That is mostly 15 days a month, and he or she continues to have this way for at least three months. These chronic credits are usually the most disabling primary headaches. The secondary headache, they account for nearly 10% of the cases wherein there is underlying brain pathology, which is responsible for the headaches. And this pathology can be either vascular that is related to diseases of the blood vessels. It can be infective, which is due to infection, either of the covering of the brain or the brain substance or both. Or it can also be because of a space occupying lesion in the brain such as a brain tumor. So these are the common causes of secondary headaches.

Speaker: Mr. Vivek

Can you share more in detail about primary headaches related to migraine in detail?

Speaker: Dr. Prashant

Yeah, so primary headaches as I said earlier, they are the ones without any underlying structural cause. The most common types are the tension type headaches, which has been reported to have a lifetime prevalence of nearly 50%. This one usually occurs in relation to stress, lack of sleep. The symptoms in tension type headaches are mostly nonspecific, the patient, he or she may complain of a stretching or tightness around the head and the pain is usually not that severe. There is often an antecedent history of stress in such cases also the symptoms are not as dramatic as in migraine. Migraine is another variety of primary headache and it has been reported to have a prevalence of around 18% it is relatively more common amongst females. There are certain rare types of primary headaches such as Trigeminal autonomic cephalgia. So in these types, apart from the headache of variable duration, patients may also complain of congestion, tearing from the eyes and runny nose. Talking about migraine in particular, it is usually an incapacitating headache, which usually starts from the one side as one sided pulsatile headache, which then progresses to involve the entire head and during an episode of migraine, the patient may also complain of either a sensation of vomiting or they may vomit, intolerance to light / sound and complain of associated giddiness. Some of the patients with migraine prior to the onset of the headache, they may complain of aura. Which is actually a kind of premonition that within the next 15 to 20 minutes, they are likely to have headaches. This aura is usually in the form of blurring of vision, zigzag flashing lights and as soon as the aura subsides the patient usually starts having a crescendo pulsatile headache. An episode of migraine lasts for a minimum of four hours, but in some severe cases this may continue up to three days also. But not all patients with migraine will have aura. Those one without the aura, we call them as common migraine, or migraine without aura. Aura is experienced in roughly 25% of the migraine patients and a particular patient may have both types of episode. Some of these may be accompanied by aura and others without it. Patients who have frequent migraine episodes are also able to identify in some cases certain triggers which can precipitate a migraine episode. Some of the common ones are exposure to bright sunlight, lack of sleep, fasting for a long period , skipping breakfast / lunch, strong perfume smell. Not all individuals will have the same trigger.

Speaker: Mr. Vivek

Are the two migraines different in terms of their severity and the treatments?

Speaker: Dr. Prashant

Patients may have both types of episodes. So severity and treatment does not differ, it is just a different symptomatology. Some patients will have aura, which gives them a warning that they are likely to have headaches within the 15 to 20 minutes. But the severity of symptoms apart from the aura do not vary. Neither does the treatment.

Speaker: Mr. Vivek

Can you share with us any of the recent migraines cases you treated?

Speaker: Dr. Prashant

Okay, so I can share a case of a young lady. She was about 27 years of age. She had come to me with frequent disabling headaches because of the frequent episode. She in fact stopped going to the office and she had taken a break from work. Before she came to me she had consulted several physicians, and she had also been to an eye specialist. She had also undergone multiple brain scans, which were normal. As she didn’t find any relief she started self medicating herself with over the counter analgesic, which we often see in migraine patients. This particular lady over time, she became dependent on these analgesics. And many of the times she was taking multiple analgesics in a day. And when I reviewed her medical history, her headaches were of migraine in nature. But because of the self medication she had developed what we call medication overuse headache, which is a common complication we see particularly in chronic migraine, wherein the painkillers instead of helping the patient, they become part of the problem itself. So I took time to explain to her regarding the condition and I counseled her on the judicious use of painkillers. I then started our therapy for the migraine. And the first time she came for follow-up that was about three weeks and there was a significant noticeable change in the frequency and intensity of headaches. And after about two months of therapy her headaches have completely subsided. After that, I started tapering her medicines. Presently she is free from headaches and is not taking any painkillers. So it is important that patients who have frequent episodes of headache, they must consult a neurologist rather than subject themselves to self medication, which can lead to complications like these, in particular medication overuse headache.

Speaker: Mr. Vivek

Correctly said doctor and at this point, I would just want to share a couple of interesting data points with our listeners. Nearly 1 billion people worldwide suffer from migraine as per World Health Organization. And there is a 2018 documentary movie, Out of My Head, which explores the history and mystery behind migraine. Listeners who are interested can go to the website of Out of My Head or they can find it over IMDB. Now, coming back to our discussion Doctor, what are the danger signs of headache?

Speaker: Dr. Prashant

So, there are certain situations where the patient is experiencing headaches and should seek an urgent consultation. So, I will list some of the important red flags.

First or worst headache of life: If a person experiences a headache for the first time also if the intensity of headache is severe like never experienced previously, he or she must seek immediate consultation from a neurologist.

Onset of headache is sudden : If the headache shoots up immediately then it is another indication that we are possibly dealing with something serious, perhaps a rupture of the blood vessels supplying the brain structures and this demands an urgent attention.

If there are associated neurological symptoms: If the patient is having headaches, and these are accompanied with certain symptoms and signs such as sudden weakness of any limb, double vision, difficulty in walking, then one should seek a consultation with a neurologist to rule out any secondary cause of headache.

Headaches in elderly population: Headaches in the more than 50 years of age population should never be ignored, they must be taken seriously and should be thoroughly evaluated for secondary headaches.

Experiencing a progressively worsening headache: If it is worsened by changing the posture in particular bending forwards or if the headache increases on coughing and sneezing then this may be a mark of a secondary headache and request evaluation.

Speaker: Mr. Vivek

What are treatment approaches for primary and secondary headaches?

Speaker: Dr. Prashant

Okay, so first let me talk about secondary headaches. In secondary headaches, treatment would depend on the underlying cause. So, in all patients who are suspected to have a secondary headache, they should be evaluated by a neurologist. These patients will require a CT or MRI scan of the brain depending on the clinical circumstances. They may request specific scanning of the blood vessels which supply the brain or analysis of the brain fluid, which we medically call cerebral spinal fluid, which is an important part of evaluation particularly in those who are suspected to have infection of the brain. If the patient has a headache, because of brain infection, then he or she will require treatment of the same, which will be antibiotics /antivirals. Likewise, a headache which is secondary, due to rupture of the blood vessel, which supplies the brain, will require intervention to seal that rupture and a headache which is due to a brain tumor that may require a neurosurgical intervention. Now treatment of primary headaches would vary based on the syndromic diagnosis. So a patient with tension type headache, apart from the symptomatic painkillers, they will require counseling regarding lifestyle measures, and also treatment of the underlying stress. In migraine, which is another type of primary headache treatment would vary based on the severity and frequency of symptoms. Similarly, for autonomic cephalgias, which are rare types of primary headache, there are certain specific medicines to treat a particular headache disorder, but the key to treatment of primary headaches is proper evaluation by a neurologist. So once a right syndromic diagnosis is reached, appropriate therapy can be initiated under the supervision of a neurologist.

Speaker: Mr. Vivek

What are the treatment approaches for migraine, can you elaborate on it?

Speaker: Dr. Prashant

The treatment of migraine varies based on the severity and frequency of episodes. I usually suggest a three pronged strategy to treat migraine.

Preventive: So migraineurs, particularly those who have frequent episodes are often able to identify triggers and its best to avoid them. Triggers can be environmental triggers and also get from food items such as cheese, pickles, artificial sweeteners, preservatives, dark chocolate and red wine.

Abortive therapy: So as the name suggests, these are painkillers to abort the headache episodes. For patients with mild to moderate episodes, they can usually be managed with over the counter analgesics such as aspirin and paracetamol. If you have prominent nausea during the headache episode, they may require a combination of anti-emetics medication with painkillers. If they have severe migraine episodes, they require certain specific medicines called triptans. And some may also require injections to get rid of the severe headache episodes.

Prophylactic therapy: This is usually recommended for patients with frequent episodes. and the guideline suggests that the person should have at least four to five episodes of disabling headache per month that comes about roughly one per week. So these prophylactic medicines are of different classes. And they’re chosen based on a particular patient profile and their tolerance. It should be consumed daily and they should take for about two to six months. The duration can vary from person to person depending on the severity and frequency and they are to be taken under the supervision of a neurologist. The aim is to reduce the frequency and intensity of episodes, and once the episodes are well controlled, these are usually gradually tapered and can be discontinued.

Finally, I would like to reiterate that the patients who experience frequent headache episodes should consult a neurologist rather than self medicating themselves. And with treatment under the supervision of a neurologist, they can get back to their routine and continue with their daily routine.

Speaker: Mr. Vivek

Dr. Prashant, talking with you was very informative. We learned about headache, primary versus secondary headache and we also have discussed in detail about migraine and its treatment approach. Some of the key points which you highlighted included avoiding the use of over the counter drugs and consulting neurologists at the right time, any important point which we have missed.

Speaker: Dr. Prashant

The issue of medication overuse headache, which is particularly common among patients who have frequent migraine episodes so it is important that they seek consultation from a neurologist. Medication overuse headache significantly complicates the therapy of migraine. Another important point which I would like to highlight once again, the red fags which I listed, so anyone who is experiencing these red flags, they should seek immediate consultation from a neurologist.

Speaker: Mr. Vivek

Dr. Prashant, thank you for taking time out from your busy schedule and talking with Dr. Talks.

Speaker: Dr. Prashant

Thank you Vivek. It was my pleasure to be on Dr. Talks.

Speaker: Mr. Vivek

Dear listeners, please share and spread awareness about headache, their types and warning signals by sharing this talk with Dr. Prashant. Please do not ignore your headache and take required medical help when needed. Cheers till we meet next time.

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