What is chronic migraine? The International Headache Society’s International Classification of Headache Disorders, 2nd edition, has defined chronic migraine as 15 or more migraine days a month in someone with no medication overuse that has lasted for three months or more.

A revised version of this diagnostic criteria has been proposed for inclusion in the next edition. These are 15 or more headache days a month, at least 8 of which are migraines, and present for three months or longer. (And without evidence of medication overuse.)

What causes chronic migraine?

Why some people get chronic migraine and some people don’t is not always entirely clear. There is some evidence that chronic migraine may be on a spectrum of headache frequency between episodic migraine (less than 15 days a month) and transformed migraine, which is migraine occurring very frequently, similar to chronic daily headache, but with clear migraine features to the headaches.

Research into why headaches become chronic has shown the following risk factors for headache chronicization. This research did not focus on chronic migraine specifically, but looked at chronic daily headache. Risk factors are:

• History of head or neck trauma
• Female
• Habitual snoring
• Sleep apnea and other sleep disorders
• Obesity
• High caffeine intake
• Smoking
• Coexisting pain disorders
• Overuse of pain medications
• Major life changes (moving, getting married, etc.) were associated with the onset of chronic headache

What Can You Do About Chronic Migraine?

If you have any of the risk factors above, work with your doctor to minimize the ones you can control. However, not everyone with chronic migraine will necessarily have something on this list. It’s best to be certain that you are not overusing abortive migraine medication, and that you are on an effective prevention regimen.

References:

What are Ice Pick Headaches?

Ice pick headaches (called primary stabbing headache now in the International Headache Diagnostic Criteria) are defined as either a single stab or a series of stabs felt in the orbital region (around or behind your eye), temporal area, or parietal area of the head. (The parietal area is behind the temporal area.)  Stabs occur with irregular frequency. On days that they occur, they may occur only once, or may occur many times per day, but with no regularity. Duration of stabs is short, usually a few seconds.

So, what does an ice pick headache feel like? Well, pretty much like it sounds—like an ice pick suddenly jabbing into your head without warning. The pain is often sharp and severe, and most people who have had these headaches are glad they don’t last very long.

Stabbing headache or ice pick headaches can occur as an isolated headache type, but occur more commonly in migraine or cluster headache sufferers. The pain experienced can be very intense, and tends to hit without warning. If you experience tears, redness of the eye, and nasal stuffiness in conjunction with stabbing pains in the temporal region or the orbital region, it is likely that you have a rare headache type known as SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjuctival injection and Tearing), which is one of the Trigeminal Autonomic Cephalgias. Another condition that needs to be ruled out is trigeminal neuralgia, which causes facial pain and can sometimes feel like a jolt in the face.

Headache textbooks tend to be somewhat dismissive of stabbing headache, indicating that reassurance should be offered, since this headache type does not indicate underlying pathology such as a tumor or aneurysm. This, however, is not terribly helpful to the sufferer who is experiencing the sensation of needles, ice picks, spikes, or tiny knives being jabbed into their head on a recurring but unpredictable basis.

Some sufferers of stabbing headaches indicate that they started to experience them in childhood. Most attacks of ice pick headache occur randomly and without warning, although some sufferers have identified emotional or other stressors as triggers. Other than stress, triggers of ice pick headache have not been clearly identified.

Treatment is problematic, since the attacks are so short. In some cases, indomethacin taken preventatively will be helpful, but this is by no means universally so. Some migraine sufferers who also experience ice pick headaches report that the stabbing headaches improve with better control of their migraines. A small case series (three patients) reported benefit for ice pick headache from melatonin. As with many headache types, more information is needed before we more fully understand the underlying causes and can offer a meaningful solution.

References

1. Rozen, TD. Melatonin as treatment for idiopathic stabbing headache. Neurology. 2003; 61:865-866.

2. Raskin, NH, Schwartz, RK. Icepick-like pain. Neurology. 1980 Feb;30(2):203-5.

Did you know that women are more likely to experience headaches than men? While tension-type headaches affect slightly more women than men, migraine is much more likely to affect women, and afflicts three times as many women as men. Why would this be?

The reason is thought to be a combination of genetics and hormones. The World Health Organization has found that migraine is a leading cause of disability in women throughout the world. Despite all we now know about migraines, misinformation persists.

Here are some common myths about why women have migraines.

Twelve Migraine Myths

Because the general public is largely misinformed about this illness, numerous misconceptions about migraine have entered the popular lore. What follows are twelve myths about women and migraine. Once you’re armed with the facts, you can set the record straight when confronted with such troublesome fallacies.

• Myth 1 – Women get more migraines than men do because women are more emotional and easier to upset.

  Fact
  Women experience more migraines than men do as a result of hormonal differences and genetics and their effect on brain biochemicals. The majority of women – however “emotional’ they may be – do not get migraines.

• Myth 2 - Many women bring on migraines to avoid something like sex or work.

  Fact
  Migraine is a disorder of altered physiology. While there may be a subset of women (and men) with subconsciously triggered psychosomatic migraines, the vast majority of migraineurs have no psychological reason for their headaches.

• Myth 3 – Women who suffer from many migraines probably need to see a psychiatrist or psychologist. They must have some inner conflicts that cause those headaches.

  Fact
  Some women with migraines also suffer form emotional problems, and addressing inner conflicts in therapy can reduce migraine frequency and severity. (However, it will not “cure” the underlying migraine tendency in the brain.) Some experts believe that the neurochemical changes that cause migraine can also cause mental disorders, such as depression.
  
  If a woman who experiences migraines also has an emotional problem, she may need to consult with a mental-health professional. But most women who suffer form migraines don’t need to see a psychiatrist or psychologist; they just need help in averting migraine attacks and managing their pain.

• Myth 4 - Women get migraines because they eat bad things, like chocolate.

  Fact
  Various foods do act as a trigger in about 25% of all migraine sufferers, which means that they don’t precipitate a headache in the majority of migraineurs. Of that 25%, not all women react adversely to chocolate. Some women anecdotally report that chocolate actually makes them feel better. Why? Because chocolate contains a caffeine-like substance, which can help alleviate pain in some individuals. Other foods that often trigger migraines are red wine, aged cheese, and dishes prepared with MSG. (More about food triggers later in this chapter.)

• Myth 5 - If a medication works for one woman’s migraines, then it should work for most other women, too.

  Fact
  Women are not all made form the same mold. A medication or treatment that works for one woman may not work for the next one. There’s a tremendous amount of individual variation in responsiveness to given medications.

• Myth 6 - Women who get migraines are just plain depressed.

  Fact
  A disproportionately high number of women with migraine are clinically depressed; however, treating their depression does not cure their migraine. Does the recurring pain of migraine make women feel depressed because migraine is inherently depressing? Or is there another cause of both depression and migraine? Research actively continues to work toward determining the underlying factors of this relationship. It is known that depression places one at increased risk of developing migraines and migraine increases the risk of becoming depressed. But it’s important to realize that depression is highly treatable.

• Myth 7 - Women who get migraines usually have PMS (pre-menstrual syndrome).

  Fact
  The approach of a woman’s period triggers migraine in many women. But these women do not necessarily also get PMS. For other women, migraines have nothing to do with their menstrual cycle. Some women who do have PMS do not get migraines.

• Myth 8 - People who get migraines take a lot of time off from work.

  Fact
  People with migraines don’t appear to take any more time off from work than people with other chronic ailments. In fact, some people with migraines struggle to stay on the job and actually take less time off than people with other disorders.

• Myth 9 - Women who get “weekend headaches” are avoiding their spouses and families.

  Fact
  Unfortunately for migraineurs, many women experience migraines on weekends. this could be because of a change from high levels of stress to lower stress levels. It may also be due to changes in daily habits, such as sleeping patterns and decreased caffeine intake. But few (if any) women get migraines because they want to avoid their families.

• Myth 10 - Only white women get migraines.

  Fact
  Women of all races suffer form migraines, though the prevalence is higher among Caucasian women. One study showed a 20.4% rate of migraine among Caucasian women, a 16.2% prevalence among African-American women, and a 9.2% prevalence among Asian-American women.

• Myth 11 - If a person tried hard enough, she could shake her headache problem.

  Fact
  It is simply not possible to “will away” your tendency to migraine. Many migraineurs try hard to find their migraine triggers and to control the illness. Although many women never seek medical treatment, they do take over-the-counter medication in an attempt to lessen these debilitating headaches.

  Much can be done to minimize the frequency and severity of migraines. Recent research has yielded new medications and new ideas about migraine. Doctors have made amazing strides in helping people, but we haven’t yet learned to cure people of migraines forever.

• Myth 12 - Women who get migraines are extremely intelligent, high-achieving, nervous people who have a “migraine personality”.

  Fact
  Though migraine sufferers like the “extremely intelligent” part of this stereotype, unfortunately, no study supports this idea. Many of the women I’ve treated were very bright; many were also high achievers. Others were of average aptitude and accomplishment.

  The American Migraine Study and other research demonstrate that people from all walks of life are plagued by migraines. But women who are high achievers are more likely to have medical resources available to them, are more likely to consult a physician, and are more likely to speak out about their illness than their less privileged “sisters”.

  While there is an increase in the incidence of certain psychiatric disorders as concomitant conditions with migraine, it is neither fair nor accurate to describe all women with migraine as having personality abnormalities. Nor is the abnormal personality the cause of the migraines; one must have a predisposition to migraines.

Excerpted from The Women’s Migraine Survival Guide

15259 SE 82^nd Drive, #201B

Clackamas, OR 97015

503-656-9844 | fax 503-656-3120

The Oregon Headache Clinic, located at 15259 SE 82nd Dr, #201B, Clackamas, OR 97015, and founded by Christina Peterson M.D., was established to help patients identify and treat chronic head pain. Dr. Peterson is a physician specializing in neurology for twenty-five years who has treated thousands of patients with headache pain. Dr. Peterson has experienced the pain of migraine herself and has, through her own deep experience and study, developed a thorough understanding of the tools needed to conquer this suffering. This personal experience gives Dr. Peterson a unique perspective on the management of headaches. She believes in patient participation over patient passivity; informing and involving patients is the first step to true wellness. The individualized headache management program incorporates education, counseling, medication, and referrals to other medical specialists when appropriate.

Dr. Christina Peterson is the author of “The Women’s Migraine Survival Guide”, published by HarperPerennial. She has also contributed  the “Differential Diagnosis of Headache”, published in two editions of Chiropractic Management of Spine-Related Disorders. She speaks on the subject of migraine and other headaches to hospitals, employers, physicians and nurses, as well as lay audiences. Dr. Peterson is often asked to consult on the subject of headaches and migraines in a variety of business and clinical settings. She has published on the subject professionally, and is a reviewer for the journal, Headache.

Dr. Peterson is a member of the National Headache Foundation, the American Headache Society, the International Headache Society, the American Academy of Neurology, and the Headache Cooperative of the Pacific.

While migraines have been associated with women, who account for 75% of migraine sufferers, men do experience migraine headaches. Men’s symptoms are no different from women’s symptoms. What is different, though, is that men are somewhat less likely to seek medical care for their migraines—and when they do, they are less likely to receive a migraine diagnosis. Middle-aged men with migraine are 42% more likely to suffer a heart attack than are non-migraineurs.

OTHER HEADACHES IN MEN

Tension-Type Headache

Tension-type headache, the most commonly occurring headache, occurs almost equally in men and women.

Chronic Daily Headache

This headache type occurs in both men and women, and is somewhat more prevalent in women. However, a study of chronic daily headache found that men were more likely to report disability than were women.

Cluster Headache

Cluster headaches occur far more prevalently in men than in women. In the past, an 8:1 male to female ratio had been reported. More recently, a 5.4:1 male to female ratio had been reported, and now, the ratio has dropped to 2.1:1, suggesting lifestyle changes for women have increased their risk and reduced the difference in the ratio.

Cluster headache is defined as severe or very severe unilateral pain occurring around, behind, or above the eye/orbit or in the temporal area, and occurring anywhere from once every other day to 8 times a day, lasting 15 minutes to 3 hours. The headache pain must be accompanied by at least one of the following:

• Tears
• Red eye
• Nasal congestion
• Runny nose
• Forehead or facial sweating
• Pupil constriction or droopy eyelid (ptosis is the technical term)
• A sense of restlessness or agitation

Sex Headaches

Contrary to popular belief, sexually-induced orgasmic headaches occur more commonly in men. There are two types. Pre-orgasmic headaches are a dull ache in the head and neck, associated with awareness of tight neck and jaw muscles during sexual activity, that increases during increasing sexual excitement. Orgasmic headache is a sudden, severe, explosive headache occurring at orgasm. Understandably, this can be quite alarming the first time it occurs. It would be best to see your doctor for evaluation to make certain it is not a sign of something more serious.

Posttraumatic Headaches and Traumatic Brain Injury

Men and women both experience head trauma, and are thus both affected by posttraumatic headaches. However, recent emphasis on post-traumatic headache due to traumatic brain injury in football and other sports, as well as in returning Iraq and Afghanistan War soldiers, suggests that there may be a male predominance.

Migraine sufferers surely can develop a sinus infection, especially if you also have seasonal allergies. However, it’s been found that many supposed sinus headaches are, in fact, migraines. Why would this be? This is because the sinus cavities are lined by sensitive tissues whose nerves are fed mostly by a branch of the trigeminal nerve. This is the same nerve responsible for migraine headaches. When you have sinus congestion, it can cause what is called referred pain, sending pain to distant areas in the face and head away from the sinuses themselves. So, sinus headaches may cause pain that is not in the sinus region, and migraines can cause pain that is in the sinus region. This makes it very confusing if you happen to have both allergies and migraine. Just to make things even more confusing, some migraine sufferers experience nasal congestion or watery eyes with their migraine attacks. This happens because the trigeminal nerves can release neurotransmitter chemicals that cause blood vessels to dilate, which is why your eyes get red and watery and your nose gets congested. We don’t yet know why this happens to some people and not to others when they get a migraine attack.

In the Sinus, Allergy and Migraine Study, 100 subjects self-diagnosed with sinus headaches were investigated. They were then evaluated by headache specialists, and 63% were diagnosed with either migraine with aura or migraine without aura, and 23% with probable migraine. In the final analysis, only 3% actually had sinusitis. Interestingly, 62% reported that exposure to allergens was a significant headache trigger.

So, How Do You Tell Sinus Headache and Migraine Headache Apart?

Although the symptoms can overlap, these general guidelines can help somewhat in telling migraine and acute sinus infection apart. Chronic sinus headache is more difficult.

SINUS INFECTION

Usually bilateral
Fever*
Discharge thick, yellowish-green*
Diminished or absent sense of smell*
Minor factors: halitosis (bad breath), cough, headache,
dental pain, ear pressure, fatigue
Facial pain or pressure—more likely to be non- throbbing
Sinus CT or direct examination positive

MIGRAINE

Often (not always!) one-sided*
No fever
Discharge thin, clear if present
Heightened or altered sense of smell or avoidance of odors
Occasional symptom: watery, red eyes

Facial pain or pressure—more likely to be throbbing or pulsating*

Diagnosis based on symptoms.

*Major features of each disorder.

Sinusitis affects 15% of the population— an even higher rate than migraine, unless we take into consideration the possibility of overdiagnosis of acute sinusitis in the migraine population.

Contact Point Headache

There is another headache type called Contact Point headache. This occurs when you have a deviated septum or bone spurs in the nose, and the bone from the center of your nose comes in contact with the sensitive tissue on the other side of your nose. This can cause headaches that can feel very much like a migraine.

What Should You Do for Sinus Headache Symptoms?

It may be worthwhile to see an allergist if you think you have allergies triggering your migraines. Specific allergy treatment may reduce migraine frequency. If you think you have a sinus problem, it may be worthwhile to see an ear, nose, and throat physician (the fancy name is otorhinolaryngologist—whew!). Treatment of a mechanical problem like a deviated septum, bone spurs, or other physical sinus problems can be helpful if you truly do have chronic sinusitis or contact point headaches. Gastric reflux can also be a cause of chronic sinusitis.

Be careful about treating yourself with over-the- counter sinus medications, especially if you do so on a frequent basis. This can result in rebound rhinitis, causing more nasal congestion than you might otherwise have had. They can also cause rebound headaches if used frequently. It is always best to see your doctor for examination, particularly since this can be such a confusing diagnostic challenge. One thing is for sure, though—antibiotics are not the best treatment for migraine!

So don’t just pick up the phone and ask for a prescription. If there is any doubt, go in and be seen.

What are RLS symptoms?

Restless legs syndrome is an unpleasant sensation that is often hard to describe. Words sometimes used are tingling, itching, creeping, crawling, jittery, burning, or grabbing. RLS affects calves more often than feet or thighs, and is usually bilateral. Being still for long periods brings it on, and moving around helps.

RLS symptoms are usually worse in early evening or later at night, and may cause insomnia.

RLS is present in about 10-15% of US, Canadian, and European populations, but is less common in Asia. RLS affects African-Americans less than white persons. RLS affects women about twice as often as men. Women who have not borne children have the same risk as men.

Restless leg syndrome is often reported during pregnancy. It most often occurs in the third trimester, and resolves with delivery. RLS affects 25-40% of pregnant women.

The Sleep Heart Health Study showed more stroke or heart disease occurring in those with RLS than those without. There was a correlation between greater frequency or severity of RLS symptoms and occurrence of cardiovascular disease. RLS itself most likely does not cause heart disease. We do know, however, that interrupted sleep can be a risk factor for heart problems.

RLS is more common in smokers.

Causes of RLS

Most cases of RLS are primary, which means that it runs in families, and is most likely genetic. RLS is familial in 25-75% of cases. Several genes have been identified, both dominant and recessive.

There are also several causes of secondary RLS, one of the most common of which is peripheral neuropathy.

Secondary RLS can be caused by:

• peripheral neuropathy
• iron deficiency
• folate deficiency
• magnesium deficiency
• diabetes mellitus
• Lyme disease
• lumbosacral radiculopathy (pinched nerve root)

• rheumatoid arthritis
• Vitamin B12 deficiency
• Sjögren syndrome
• uremia (kidney failure)
• pregnancy
• medications (these can cause or make worse existing symptoms of RLS)

diphenhydramine (present in many over-the-counter medications)
SSRI antidepressants
lithium
beta blockers
antidopamine medications (many antipsychotics, some nausea medications)

• alcohol

• caffeine

Restless Legs Syndrome and Advances In Treatment

Treatments for RLS start with self-help measures, such as hot or cold baths, whirlpool baths, exercise, limb massage, and avoidance of any triggers. There are also several medication treatments. It’s important to work with your doctor to make sure you don’t have one of the conditions that cause secondary RLS.

References:

1. Manconi M, Govoni V, De Vito A, et al. Restless legs syndrome and pregnancy. Neurology. 2004;63(6):1065-1069.
2. Winkelman JW, Shahar E, Sharief I, Gottlieb DJ. Association of restless legs syndrome and cardiovascular disease in the Sleep Heart Health Study. Neurology. 2008;70(1):35-42.
3. Walters AS, Hickey K, Maltzman J, et al. A questionnaire study of 138 patients with restless legs syndrome: The `Night-Walkers’ survey. Neurology. 1996;46(1):92-95.
4. Young, WB, Piovesan, EJ, Biglan, KM. Restless Legs Syndrome and Drug-Induced Akathisia in Headache Patients. CNS Spectrums. 2003; 8(6):450-456.
5. Hornyak M, Grossmann C, Kohnen R, et al. Cognitive behavioral group therapy to improve patients scoping strategies with restless legs syndrome: a proof-of-concept trial. J Neurol Neurosurg Psychiatry 2008;79:823–825.

Everyone has heard about food triggers. They are the migraine trigger most commonly talked about. But in truth, only about 25% of migraine sufferers, on average, have any food triggers. Some studies show up to 40%, and others as low as 18%, but most of these are surveys by self-report. Migraine food triggers are generally not food allergies. Migraine sufferers with various food triggers have been tested for allergies to their offending foods, and no markers of allergy (IgE) have been found.

These are common food triggers:

Aged Cheese, Sour cream, Yogurt, Buttermilk
Citrus
Nuts
Legumes:
Peas
Beans
Soy:
Soy sauce
Tofu
Edamame
Soy “Nutraceuticals” used instead of estrogen HRT
Soy may hide in ingredients as texturized vegetable protein
Onions
Garlic
Pickled foods, Vinegar: Salad dressings, Ketchup, Relish

These are moderately common triggers:

Aspartame (Nutrasweet®)
Chocolate
Wine, Beer, Other alcoholic beverages
Wheat/gluten*
Caffeine

*This trigger applies primarily to those who have a comorbid condition called gluten insensitivity or celiac disease. This condition is slightly more common in migraine sufferers than it is in the general population.

Sulfites

Wine, especially red
Dried apricots, apples
Dehydrated potatoes
Shrimp, lobster
Used as a dough conditioner
Used to bleach food starch
Glacéed fruit
Jams
Prepared gravies
Molasses
Soup mixes
Vegetable juices
Fruit juices
Hard cider

Nitrates/Nitrites

Smoked fish
Corned beef
Bologna
Pastrami
Pepperoni
Canned ham
Bacon
Sausages
Frankfurters/ Hot dogs
Beef jerky

These are less common triggers:

Bananas
Papayas
Pineapples
Figs
Avocados
Olives
Yeasty foods, like freshly baked bread
Intensely sweet foods
Intensely salty foods

MSG – this may hide as the following:
Hydrolyzed vegetable protein
Hydrolyzed plant protein
Natural flavoring
Kombu extract

MSG has been questioned as a trigger. Although many people are convinced it is their trigger, the scientific basis for this has been debated. Glutamate is widely distributed throughout the brain as a neurotransmitter. Some scientists feel that it may be the sodium in MSG to which migraine sufferers are reacting, rather than the glutamate in MSG.

Almost everyone who has ever had a troublesome headache has worried at some point in time that they might have had a brain tumor. So let’s talk about what a brain tumor headache feels like.

Here are some reassuring facts: although up to 70% of people with various brain tumors have a headache at the time of diagnosis, only about 8% of tumor patients have headache as their first and only symptom. Many older sources have described a “classic” brain tumor headache as one that is worse in the morning, and is more likely to be a dull pain, but with nausea and vomiting.

However, neurologist and cancer specialist Dr. Casilda Balmaceda, Assistant Professor of Neurology at Columbia University College of Physicians and Surgeons in New York, states that there is no typical brain tumor headache.

Symptoms for headaches associated with brain tumors

Nausea and vomiting do not usually show up until the tumor has gotten big enough to put pressure on the brain. This increased pressure phenomenon can also be the reason for morning headaches. However, morning headaches are far more likely to be due to sleep disorders like sleep apnea.

A brain tumor headache can link to the spot where the brain tumor is. So if you always get a headache in the same spot, there is a possibility that it could mean a brain tumor—but it’s not a big chance. If most of your headaches are on one side, but a few are on the other, your headaches are still most likely to be migraines.

Migraine patients who have had the misfortune to later develop a brain tumor report that the headaches due to the tumor are different from their migraine headaches. Do you always get a headache with a brain tumor? No—sometimes you get other symptoms instead, like weakness or a personality change.

Children with brain tumor are more likely to experience headaches than are adults.

References:

1. http://www3.interscience.wiley.com/journal/119263829/abstract
2. http://www.ncbi.nlm.nih.gov/pubmed/2022972

Not everyone with migraine headaches will require a preventive medication. If you experience only a few headache days a month, and you are not disabled by your headaches, you may be able to treat your migraine headaches successfully with a migraine-specific medication alone.

Research has shown, however, that although about 40% of migraine sufferers are candidates for preventative medication, only one-fifth of those who would benefit from migraine prevention are receiving such medication therapy.

There are many, many medications used for the prevention of migraine, but only a few have been approved by regulatory agencies like the U.S. Food and Drug Administration, Health Canada, or the European Agency for the Evaluation of Medicines (EMEA). Only five of these are approved by the U.S. FDA for the treatment of migraine; one of those five is no longer on the market in the U.S.

Medications that have not yet been approved for a specific condition by a regulatory agency, but are prescribed for you by your doctor anyway are used in what is called “off-label” use. It does not mean that is unsafe to do so; it just means that the drug has not been tested for that condition. This is why you might go pick up your prescription, and be told by the pharmacist that you have been given a blood pressure medication, or a seizure medication, or an antidepressant. Your doctor knows you don’t have these conditions, but we have found that some of these medications are useful for the prevention of migraine. Many of them have been tested in a formal fashion for migraine, but simply have not been subjected to the very expensive and rigorous testing necessary to obtain the approval of the appropriate regulatory agency for a secondary condition (migraine), since it is already known that they are safe and effective for their primary use.