Sleep and headaches
Medication over use headache
self-test for migraine
What is a caffeine withdrawal headache? How to
Do you have a sinus headache? Probably not...
About Trigger Point Injection
Many foods trigger or set off vascular or
migraine-type headaches in susceptible individuals due to certain chemicals
contained in the foods. This is not a true allergy but is food sensitivity.
The initiation of the migraine is felt to be related to an effect of these
neurochemicals such as Tyramine, Nitrite, MSG on blood vessels. Avoidance of
the foods listed below is important in preventing or reducing the incidence
of these headaches. MSG and Nitrite (Sodium Nitrite) can be identified on
labels of suspected foods. Although some authorities espouse that almost all
headaches are triggered by foods, we believe that foods are only one of many
types of trigger, and these triggers are only significant in susceptible
individuals, not everyone.
a. Dairy Products including Pizza,
Macaroni and Cheese, Sour Cream, Yogurt, aged cheese: Cheddar, Gruyere,
Stilton, Emmentaler, Brie, Camembert, Gouda, Mozzarella, Parmesan,
Provolone, Romano, Roquefort (Blue). Exceptions: Cream, Cottage, and
b. Alcoholic Beverages including
Beer and Ale, Wine: Chianti, Sherry, Riesling, Sauterine, Red Wine,
Champagne, dark or heavy drinks
c. Meats including Liver, Dried Fish
(Pickled Herring, Cod).
d. Others including Vanilla, Chocolate,
Yeast Extract, Soy Sauce, Canned Figs, Raisins, Fava Beans.
Nitrites including Hot Dogs, Bologna,
Liverwurst, other packaged or processed meats, Bacon, foods containing
Monosodium Glutamates (MSG) including
Chinese Food, Meat Tenderizer like Accent, Tangy Soups, Corn Ships, etc.
Caffeine including Coffee, Tea, Iced
Tea, Cola. Decaffeinated versions are ok.
Nuts including Peanut Butter.
Citrus Fruits and Juices including
Oranges, Grapefruits, Lemons, Limes, Pineapples.
Certain other fruits including
Bananas, Raisins, Red Plums, Canned Figs, Avocados.
Certain Vegetables including Broad,
Navy, Lima, and Fava Beans, Pea Pods, Sauerkraut, Onions, Mushrooms.
Certain Bread Products including
Homemade Yeast Breads, Sour Dough Breads, other yeast risen baked goods.
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Sleep and your headache
The relationship between headaches and sleep is
complex and poorly understood, but it is commonly observed that it is hard
to get control of your headaches if you do not have high quality sleep. Too
much sleep, too little sleep and not the right kind of sleep all are
contributing factors into making your headaches more difficult to control.
Some sleep disorders actually have headache as a common symptom such as
sleep apnea and upper airway resistance syndrome (UARS).
Long time headache sufferers generally figure
out that they can not sleep too little or too much. Whereas many people can
get by with cutting back on sleep time during the week and getting catch-up
sleep over the weekend, headache sufferers do better with regular sleep
which is typically for adults 7-8 hours.
Normal sleep consists of 4-6 sleep cycles that
are about 90 minutes long. Each sleep cycle is composed of stages including
deep slow wave sleep and some REM (rapid eye movement) sleep. Workers who do
shift work or people who have erratic sleep habits may develop headache
Sleep can actually be a way to relieve
headaches, particularly in kids. The instinct to go lie down in a quiet dark
room is generally a good one when one has a headache, as sleep can be
restorative and often alleviates headache. This is why it may be the case
that your doctor may give you some sleep inducing agent that helps with
sleep for the difficult times that you have troubling headaches.
Even though sleep can be restorative it is not
at all uncommon for headache sufferers to wake from their sleep with a
headache. In fact it is said that 50% of migraine starts during sleep. This
can make aborting a migraine a challenge, if one wakes up with the headache.
Not only migraines are experienced upon arising, and in fact if one begins
to have daily morning headaches, this can be medically significant, and may
require prompt attention.
Seek medical attention if you have: Have a
change in headache pattern and have developed daily morning headaches Have
loud snoring, breathe holding episodes, choking spells associated with your
headaches Frequent insomnia associated with your headaches Fall asleep
inadvertently during the day such as when driving a car, talking.
- Use the bed for sleep and not as a place to
do activities such as work or watching television
- Make sure the bed is comfortable. Most
people sleep best in a dark, quiet and slightly cool environment
- Try to sleep regular and consistent number
of hours each night
- Eliminate stimulants such as nicotine and
- Exercise regularly, but not before bedtime
- Night time sleep might be improved by
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Are Headaches Hereditary?
Absolutely, headaches run in families and the presence of headache in the
family is one of the things that helps to establish the diagnosis.
If one looks at children and adolescence almost
all have a known family member with migraine. Specifically if one has a
single parent with migraine then one’s risk is about 30% and if both parents
have migraine then one’s risk is about 70%.
It is important to realize that migraines
manifest themselves differently at different ages. For example children
might get cyclic vomiting without the headache and older people might get
visual auras without the pain, but it is the family history as well as the
personal history that often helps with making the diagnosis.
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Medication over use headache
It’s easy to overuse headache pain medication
as there are abundant treatments available over the counter. Overuse or
rebound headache can be a result primarily of over the counter products, but
also of caffeine and some prescription pain medication. While one do not
always know if one’s headaches will completely clear up with withdrawal of
the offending agent (i.e. true rebound headache) or simply be easier to
manage, all headache specialists feel that medication over usage is to be
avoided and headache control is easier off of the offending agents. Rebound
or medication overuse headache can be a vicious problem to treat. Rebound or
overuse headaches often require professional help for detoxification. If you
take off-the-shelf or prescription pain medication on more than 2 days a
week, or drink 4 or more cups of caffeinated products a day, then you are at
risk of developing overuse headache or analgesic rebound headache.
Medication overuse headaches typically last
many hours per day and are a steady, pressure type pain all over the head.
They may resolve temporarily with another dose of pain killers, but a
hallmark is that they are headaches that become unresponsive to the usual
dose of pain killers.
If you think you may have medication overuse
headache, a headache consultation may be helpful.
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Here is a quick self- test for migraine
Do your headaches sometimes limit your day’s
activity, and cause disability?
Do you experience nausea when you have a
Does light bother you when you have a
A “yes” answer to two out of three of these
questions could mean that you have migraine and should seek consultation for
this condition. A YES answer to all 3 questions makes it very likely that
you have migraine. It is possible that you could still have migraine even if
you answer “no” to all 3 questions as there are many with atypical
migraines, but this test captures a large amount of people who did not
realize that they had migraines.
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What is caffeine withdrawal headache? How
to minimize the risk
Many people discover that they have caffeine withdrawal headache when they
stop drinking coffee. Others are not aware they have this problem but get
headaches on the weekend when they wake up late and miss their early morning
caffeine fix. Caffeine is ubiquitous and is in many products other than
coffee and tea, for example, Extra Strength Excedrin, Mountain Dew,
chocolate and no-doz pills.
When does one get caffeine withdrawal headache? If a person is used to
ingesting approximately 200 mg/day of caffeine over several months to years,
then on a day when the caffeine level drops either through abstinence or a
decrease in usage, then one can experience caffeine withdrawal. The headache
feels like a throbbing headache, just like a migraine, which may improve if
one takes some caffeine.
Rather than experiencing caffeine withdrawal, most headache sufferers would
be better off avoiding this by limiting the amount of caffeine they ingest
on a daily basis. If they are less dependent on caffeine, then caffeine can
actually be used like a medication to abort acute headache.
Typical doses of caffeine found in various
|Coffee- based on 5 oz serving
|Soft Drinks, based on 12 oz
Cola including diet
Ginger Ale, Root Beer
Excedrin extra strength
|Chocolate/Cocoa 1 oz
Cocoa 6 oz
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Do you have sinus headache?
Sinus headache was a term coined by the folks
who made Bayer aspirin which gained popularity, but it is a misnomer, few
actually have headaches due to their sinuses even though the pain is
commonly located over the sinuses. The reason for the pain over the sinuses
and the presence of clear nasal drainage has to do with the innervation of
the nasal passages with branches of the trigeminal nerve which is irritated
In a large study of approximately 3500 patients
who carried the diagnosis of “sinus headache” were examined by a group of
seasoned neurologists, only 5 % were found to have significant sinus disease
and the rest were predominantly found to have migraine or other vascular
Sinus headache should be seriously entertained
when the individual has thick discolored nasal discharge, pain to palpation
over the affected sinus, possibly fever. Although this is not always seen
depending upon the location of the sinuses infected this is the more usually
scenario. Endoscopic sinus examination or sinus x-rays or CT may be
necessary if there is any doubt about the situation.
It is certainly the case that patients may have
sinusitis or nasal allergies as a trigger for their migraines. This may be
why relief can come from using antihistamines and other sinus preparations;
but the best relief comes from specific migraine medications such as the
triptans acutely and other preventive medication.
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Botox™ (botulinum toxin A) is one of many of the
Botulinum toxins. There are several other that are commercially available,
but we will refer to Botox generically as this is the agent most widely
used. It has gained popularity in the practice of Neurology since its first
approval by the FDA in 1989, but was discovered to have medicinal properties
by the American military around the time of WWII in the process of
developing biological weapons.
Botox™ was specifically approved by the FDA for
treatment of painful dystonic conditions such as blephorospasm (eyelid
twitching), torticollis (neck tilting), spasticity (for example as seen
after stroke, spinal cord injury, cerebral palsy) and later gained approval
for other purposes as well such as wrinkle treatment and, hyperhydrosis. In
the course of treating patients for wrinkles it was discovered that
treatment also alleviated headaches. For the last 10 years or more many pain
specialists have been using Botox™ for treatment of migraine. Botox™ works
by blocking neurotransmitter release from nerve endings to muscle, allowing
the muscle to relax. As a result, abnormal movements or muscle contractions
Individual response to Botox™ is highly variable
in part because the method of delivering treatment is customized and there
is no uniform protocol that is the standard of care. Hence treatment with
Botox is subjective and dependent upon the skills and experience of the
operator. For headache numerous small injections are made typically 10-20.
Because of the variability in technical skills and treatment strategies
Botox™ has been very difficult to study and to demonstrate consistent clear
cut effectiveness. We have found that treatment success for our patients has
been fairly high and many patients return multiple times for reinjection. In
general the benefits of Botox™ start within 2 weeks after injection and last
about 3 months. Typically the best response occurs after the second or third
series of injections.
Botox™ treatment is not without side effects, but
they are rare and transient as the effects of the medication generally wear
off after 90 days. After very long term use or large doses of Botox™, there
is a slight chance of developing antibody resistance rendering treatment
ineffective with this agent, but treatment can still be continued if one
switches to another botulinum toxin.
For torticollis, spasticity, and other dystonias,
most insurances including Medicare cover the treatment. For other
indications, coverage is variable and a pre-authorization from the insurance
company is needed if reimbursement is desired. For further policies
regarding this matter please feel free to call Andrea Dorsett, our billing
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Trigger Point Injection
This is a technique
that was popularized by the late Janet Travell, MD and her associates
working in the 60’s-80’s. She discovered that tight contracted muscles had
trigger points, tight ropy bands or muscles or knots that twitch when
touched, squeezed or pricked and that caused refer pain into other areas.
EMG studies suggest that the muscle spindle is the source of the
contraction, and when it is treated successfully it relaxes and the referred
pain and tight muscle dissipate. In addition muscle strength is enhanced by
treating a trigger point as a contracted muscle is a weakened muscle and a
relaxed muscle is a stronger muscle.
The goal of
myofascial therapy and trigger point injection is to relax these contracted
muscles to alleviate pain. Sometimes despite stretching, strengthening,
massage and physical therapy muscles remain contracted and tight. This is
why trigger point injection therapy may be helpful. A thin needle is used to
pierce the muscle multiple times. The goal is to elicit a twitch response in
the muscle. Although some Lidocaine or Bupivicaine may be added to the
injection needle, this is only so that the procedure is less painful. Dry
needling is also possible without any medication with equally as beneficial
point injection is done as an adjunct to physical therapy. Sometimes it is
done diagnostically or as a tool of demonstrating to a patient that their
pain is muscular in nature. Occasionally this is done repeatedly when other
techniques fail to elicit a long term response, for example in a patient who
is already hyperflexible. Trigger point injection generally last 2-4 weeks.
Typically patients will be encouraged to do stretches and strengthening of
selected muscles to help maintain the pain relief.
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