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Migraine Management: Should you consider CGRP Antibody Therapy?

CGRP monoclonal antibody therapies are a new preventative treatment option for migraine. There are currently no existing treatments that eliminate migraine entirely, though these drugs have been shown in clinical trials to reduce migraine event frequency and severity in a moderate number of patients who experience frequent, disabling attacks. These medications are generally well tolerated, and are self injected on a regular schedule (monthly).

You should consider CGRP monoclonal therapy if you:

  • are moderately to severely disabled by frequent migraine attacks
  • have not benefited from existing treatments
  • have difficulty tolerating existing migraine treatments

You should avoid these drugs if you:

  • experience infrequent migraines and respond well to your existing treatment
  • have cardiovascular disease, or are at high risk of heart disease or stroke
  • are pregnant or trying to become pregnant
  • suffer from severe constipation

Other issues to consider with CGRP monoclonal antibody therapy

The long term safety risks of this class of medication are still unknown.  If you are tolerating existing treatments and are satisfied with your control of migraines, this uncertainty needs to be kept in mind. In addition, patients with psychiatric or complex medical conditions were excluded from clinical trials, and it may not be appropriate to generalize the findings to patients with these co-morbidities.

Migraine is a complex disorder, and as can be seen, multiple factors need to be taken into account before any new treatment is prescribed. If you would like to be considered for this class of medication a discussion with a headache specialist is therefore advised to review your individual treatment suitability.

Dr Nicole Limberg


How and Why You Should Keep A Migraine Diary

Do you suffer from mild or chronic migraines? If you’ve considered keeping a migraine diary (and we’d recommend you do) here’s why you should. Keeping a migraine diary helps you and your healthcare team to track the characteristics of your migraines and understand patterns and possible triggers. In fact, we recommend a migraine diary to all of our patients at Migraine Specialist in Brisbane.

The 6-8 hours prior to a migraine attack are the most important to track and retrace, as this can give you and your team of medical professionals valuable information to help diagnose, prevent and treat your migraines in the future. The more information you can provide your healthcare team, the better, so take an active role in your migraine prevention and management plan today and keep a migraine diary.

But don’t worry, it doesn’t have to be a long and arduous task – we’ve compiled some tips in this article to help you and we’ve put together a migraine diary template that you can print out and use at home.

Why should you keep a migraine diary?

A migraine diary is an important tool for your treatment team to use to help identify patterns and triggers and track the impact that medications have on your migraine symptoms and side effects.  A migraine diary also helps medical to chart your progress over time, understand what is working and what isn’t and assess when, how and why you are experiencing regular migraine attacks.

Without this information, your team of medical professionals will not be able to help you as effectively as they could, so it’s a really important part of your ongoing migraine treatment plan.

What you should include in a migraine diary?

Your migraine diary should answer the following questions…  

  • Did you experience a headache or a migraine?
  • What was the severity of the pain on a scale of 0-10?
  • Where was the pain located?
  • What symptoms did you experience during the migraine attack?
  • What day of the week and at what time did you experience the attack?
  • What was the duration of the attack (hours and/or days)?
  • What did you do before the migraine attack and what could be a possible trigger?
  • What medications did you take during the migraine attack (including prescription and non-prescription)?
  • What did you do to relieve the symptoms and pain during the migraine attack? Did it work?
  • How much sleep did you have the night before the migraine attack?
  • What is the weather like?

In addition, women should record their menstrual days in their migraine diary to assess whether this has any impact or influence on migraine onset. There are some great articles already on the Migraine Specialist blog about menstrual migrainesmenopause and migraines and migraines in women that are particularly helpful to women who suffer from regular migraines.

Here is an example of a completed migraine diary entry.

If you don’t have a migraine diary or want to start one, print out this easy to use migraine diary template each month and start to track your triggers, symptoms and recovery techniques.

How to keep a migraine diary

It’s really easy to keep a migraine diary and ensure it is updated regularly. Here are our top tips:

  1. Share as many details as you can recall in your migraine diary, even if you think it is not important or irrelevant. This includes your symptoms such as vomiting, nausea, dizziness and drowsiness.
  2. Think about what the possible triggers might have been for the onset of the migraine. Some common migraine triggers are: change in usual routine, exercise, food, skipped meals, oversleeping, lack of sleep, change in diet or events and social outings that are outside of your normal schedule.
  3. Have your migraine diary in an easy to find place so you can update it quickly and easily throughout the day. Stick it to the fridge, keep it on your desk at work or pop it in the back of your diary. You might like to keep a migraine diary at home and at work so you always have access to it.
  4. If you prefer to have your migraine diary on a digital device so it is always with you, try an app or digital migraine diary like the Migraine Buddy app.

When you keep a migraine diary you and your treatment team can start to draw conclusions about when you are most likely to experience a migraine attack, what you can do to prevent migraine attacks and how you can manage them when they are coming on.

What about a headache diary?

Even if you suffer from irregular headaches that are not as debilitating as a migraine, it’s still a good idea to track them in a migraine or headache diary to understand what might be triggering your headaches so you can avoid them in future.

The more you know, the more you can help prevent and manage your headaches, no matter how severe they are.

If you have any further questions about how to keep a migraine diary and why you should, feel free to call our Brisbane migraine clinic on 07 3831 1611 and our staff can pass on some more helpful information.

Note: information on this site is not a substitute for professional medical advice


What impact does nutrition have on my migraines?

An active lifestyle and nutritious diet are important for your overall health, but did you know research suggests there is a link between nutrition and migraines specifically? From dietary changes that help prevent migraines to tips on what to eat and drink when you are experiencing a migraine, in this article, we explore the link between nutrition and migraines.

While certain foods or chemicals may trigger a migraine in one person but not another, there are some common dietary triggers for headaches and migraines. These include:

  • Chocolate
  • Processed meat
  • Citrus fruits
  • Cultured dairy products
  • Aged cheese
  • Caffeine – in coffee, energy drinks and tea
  • Foods that contain additives like monosodium glutamate (MSG), nitrates and aspartame
  • Some wines, beers and spirits

In addition to these food triggers, dehydration and your dietary eating habits and patterns, such as missed, delayed or inadequate meals, can trigger migraines too.

So, what changes can you make to your diet to prevent headaches and migraines or help relieve them during an attack?

Understand what your dietary triggers are

The first step is to work out what your dietary headache or migraine triggers are. You can do this by keeping a headache food diary, recording what you ate and any headache/migraine symptoms that occur as a result. Look for patterns and foods that trigger your headaches and then avoid these foods and find alternatives to them. This may involve spending some time reading food labels and eating more home cooked meals so you are aware of exactly what you are eating.

Once you know what your dietary triggers are, it is much easier to avoid and prevent them by planning your meals in advance and making better options when eating out.

At Migraine Specialist, we ask all of our patients to carefully complete headache diaries as part of their treatment plan, and detailing the food they eat and the symptoms they experience is an important part of that.

Small changes that will have an impact

In addition to learning more about what your personal dietary triggers are, you can also make some general changes and substitutes to help with prevention and management of your migraines. These small changes include:

  1. Eat more fresh foods such as vegetables, fruit, whole grains and lean proteins and avoid foods with added preservatives like MSG.
  2. Stay hydrated – Avoid dehydration by drinking a minimum of 2-3 litres of water throughout the day. Of course, this will depend on your climate and activity level, but make sure you are getting at least 2-3 litres each day. A good way to keep track of your water intake is to carry a water bottle around with you and make sure you drink a lot of water especially if you feel a headache or migraine coming on.
  3. Keep your blood sugars stable and eat regular meals and snacks that are balanced. Choose fibre rich, wholegrain or low GI carbohydrate foods and avoid missing or delaying meals.
  4. Include probiotic and prebiotic foods in your diet for your gut. Probiotic foods include sauerkraut, miso, kombucha, tempeh and kimchi and prebiotic foods include oats, asparagus, garlic and legumes.

The relationship between your gut and brain

We spoke to nutritionist Dietitian & Nutritionist Rebecca Gawthorne about the connection between your gut and brain, and how this can impact headaches and migraines.

Rebecca said, “Your gut and brain are closely connected and research is finding that maintaining a healthy gut may benefit headache and migraine sufferers. Research suggests that those who regularly experience gastrointestinal symptoms have a higher prevalence of headaches than those who don’t have gastrointestinal symptoms, meaning that those who get frequent headaches may be predisposed to gastrointestinal problems. Digestive conditions, such as irritable bowel syndrome and celiac disease, also may be linked to migraines. Treating these digestive conditions may help reduce the frequency and severity of migraines.”

Rebecca also said when you include probiotic and prebiotic foods in your diet, you can help your gut maintain a healthy balance of gut bacteria and which in turn, may reduce headaches and migraines.

What should I eat during a migraine

We know that migraines are uncomfortable, painful and debilitating, and there are lots of side effects. While it is important to follow advice from your doctor or medical professional and take prescribed medications during a migraine attack, both Rebecca Dr Limberg have also offered nutritional and diet suggestions that may be helpful when you are experiencing a headache or migraine.

Firstly, if you feel a headache or migraine coming on or are experiencing an attack, drink lots of water and stay hydrated to relieve the pain. If you are experiencing nausea, you may need to sip slowly on water and if you have been vomiting, an electrolyte replacement drink can help rehydrate you more effectively.

If you feel like eating, bland folds like plain crackers or bread can also help if you have been vomiting. Some people may also find ginger or peppermint helpful in relieving symptoms.

In addition, avoid any of your headache and migraine trigger foods and opt for foods that you know don’t cause any migraine symptoms for you, such as fresh vegetables and fruit. If you think that your headaches and migraines may be related to skipping a meal, eating something containing carbohydrates, like some fresh fruit, may help.

Dr Limberg also said that caffeine can have pain relieving effects, and a cup of coffee, with a combination of analgesic medications, can be beneficial at the onset of a migraine event.

Most importantly, know that you don’t have to suffer alone and in silence – there are so many options for prevention and management no matter how minor or severe your headaches and migraines are. Check out our blog for more resources on headache and migraine prevention and management, or give us a call on (1300 696 447) if you want to chat to our team about a solution that is right for you.

If you know someone who suffers from frequent headaches and migraines, pass on this article so they can make some small diet and nutritional changes that have a big impact.

Thanks to Dietitian & Nutritionist Rebecca Gawthorne and our Neurologist Dr Nicole Limberg for their advice and expertise on the link between nutrition and migraines for this article.


Cannabis for Pain and Headaches

The use of cannabis or marijuana, for medicinal purposes is deeply rooted through history, dating back to ancient times. It once held a prominent position in the history of medicine. The father of modern medicine, Sir William Osler, published the textbook, ‘The Principles and Practice of Medicine’

In this he advocated for cannabis (cannabis indica) use in migraine;

Cannabis fluid extract medicine bottle from 1906

The use of marijuana based products to treat neurologic disorders dates back to the 1800s. Through the decades, this plant has taken a fascinating journey from a legal and frequently prescribed status, to illegal, driven by political and social factors rather than by science.

The plant genus Cannabis is a member of the plant family Cannabaceae, and there are 3 primary cannabis species which vary in their biochemical constituents: Cannabis sativa, Cannabis indica, and Cannabis ruderalis. Marijuana is derived from the plant Cannabis sativa, which contains over 60 different pharmacologically active compounds referred to as cannabinoids. Delta-9-tetrahydrocannabinol (THC) is the major psychoactive compound which causes the euphoric effect. Other cannabinoid compounds such as cannabinol and cannabidiol (CBD) are not known to have psychoactive properties. The psychoactive effects can acutely alter a patient’s cognition and inhibit normal functioning. Long term effects on learning and memory may occur. Thus, from a safety perspective, the use of products with a high THC component is controversial.

Cannabis works in the brain through the endocannabinoid system. This system is widely distributed throughout the brain and spinal cord. An endocannabinoid deficiency is theorized to underlie the pathophysiology of migraine or headaches. Cannabinoids are active through CB1 (cannabinoid 1) receptors in the areas of the brain and brainstem involved with migraine pathophysiology.

The American Academy of Neurology released a position statement in 2014, which was updated in 2018, recognising that cannabinoid compounds may have the potential for therapeutic benefit in some neurologic disorders. In terms of research however, most studies are small and poorly designed. They expressed concern with regards to the psychiatric and neurocognitive adverse effects that have been described. The interaction of these compounds with prescription medications, which are often required in patients with chronic, complex neurologic diseases, is also uncertain.

The AAN therefore does not advocate for the legalization of marijuana based products for use in neurologic disorders at this time, as it is felt that further research is needed to determine the safety and benefits of such products.

Conclusion

As we have seen therefore, there is anecdotal evidence and historical accounting of cannabis use for headache. Research however, in particular, controlled clinical trials evaluating formulations of medicinal cannabis or prescription cannabinoids for either acute or prophylactic therapy in migraine or other headache disorders is required before their use can be supported.

References:

Position Statement: Use of Medical Marijuana for Neurologic Disorders, American Academy of Neurology, 2014

Comprehensive Review of Medicinal Marijuana, Cannabinoids, and Therapeutic Implications in Medicine and Headache, Baron, Headache Currents, 2015

Cannabis for Pain and Headaches: Primer, Kim, Fishman, Current Pain Headache Reports 2017 Apr; 21(4):19

Note: Information on this site is not a substitute for professional medical advice


Photosensitivity and Migraines

School holidays are upon us and many of you may have taken the kids along to see Incredibles 2.  The movie has a warning for “photosensitive conditions’, migraine is one of these, today we discuss photosensitivity in this condition, as well as other sensory triggers in our blog.

Migraine is associated with altered processing of sensory stimuli.

Migraine attacks typically consist of intense, unilateral, throbbing headaches that are associated with sensitivities to light, sound, odours, and stimulation of the skin, as well as nausea and vomiting with or without accompanying auras.

Several studies have demonstrated that migraines differ in their processing and perception of sensory inputs. During the migraine attack, migraines develop an enhanced perception of painful and non-painful sensory, visual, auditory, and olfactory sensations.  Between migraine attacks, atypical sensory perception persists, with migraines often demonstrating low discomfort thresholds to various experimentally applied stimuli.

Migraineurs have hypersensitivity to auditory still, altered perception of sound, an abnormal acuteness of hearing, activation of migraine attacks with auditory triggers and aversion of noise during migraine attacks. Approximately two=thirds of migraines report sensitivity to sound between migraine attacks.  Migraineurs report that noise, such as traffic noise, can trigger migraine attacks.  Sensitivity to sound increases during a migraine attack.  Approximately 70-90% of migraine patients report sensitivity to or aversion to noise during a migraine attack.

Various odours, including pungent odours, perfumes, food smells, cigarette smoke and cleaning detergents, can be irritating to migraines. Migraineurs report sensitivity to odours during and between migraine attacks.  Between attacks, migraines can detect the odour of vanillin, a pure olfactory nerve stimulant, at weaker concentrations compared with non-migraine healthy controls.  About 50% of migraines report that odours can trigger their migraine attacks.

Migraineurs process and perceive visual information atypically. Most migraines report increased sensitivity to light between migraine attacks (75%) and light-induced aggravation of headache during a migraine attack (60-90%).  As with auditory stimuli, migraine’s have reduced visual discomfort thresholds as compared to non-migraineur.  Various visual stimuli can trigger a migraine attack, including exposure to sunlight, flashing or flickering lights, television, computer screens, and patterned lights.

Enhanced perceptions of sensory stimuli that are normally painful as well as those that are normally non harmful are displayed by Migraineurs. Approximately 60-70% of migraines develop cutaneous allodynia during the migraine attack. That is, they describe normally non harmful stimulation of the skin as painful.  For allodynic migraineurs, shaving, showering, wearing earrings and classes and brushing hair can cause pain.

Migraineurs differ from non-migraineur in their processing of sensory stimuli. Increased sensitivity to sensory stimuli, lower discomfort thresholds to such stimuli, and migraine attack triggering via visual, auditory, and olfactory stimuli serve as evidence for atypical basal functioning of multiple regions in the migraine brain.

Future studies are needed to further define the mechanisms underlying atypical processing of sensory stimuli in migraineurs between and during migraine attacks.

Reference:

Curr pain Headache Rep. Harriott, Schwedt, 2014 Nov:18(11):458

Note: Information on this site is not a substitute for professional medical advice.


What You Need To Know About Migraines in Women

Migraine is one of the most common neurological disorders and it impacts women more than men at a rate of 3:1. It is well established that sex hormones play an important role in the epidemiology of migraine. As children, boys and girls are equally affected, but the female predominance emerges after puberty which is why migraines in women are much more common than in men.

Many women who suffer from migraines note an increase in attacks in the perimenstrual period. Compared with non-menstrual migraines, menstrual migraines cause more impairment, are longer and are more likely to relapse within 24 hours, which significantly increases their burden.

Gender also plays a role in the chronification of headache, likely due to hormonal differences, and women have a higher prevalence of chronic daily headache than men. In addition, several studies have suggested that women have more frequent, more severe and more long-lasting headaches when compared with men. Women also experience more of the associated symptoms of light and noise sensitivity and nausea.

Women, pregnancy and migraines

For some women, a worsening of their migraines may be the first indicator of pregnancy. Migraines worsen during pregnancy because of factors such as the hormonal changes of pregnancy, nausea, dehydration, lack of sleep and stress. However, 60 to 87% of women with menstrually related migraine (MRM) improve in the second and third trimesters.

To minimize risks to the developing fetus and reduce pain and disability in women during pregnancy, approaches to treatment that do not include medication are recommended. Instead, lifestyle factors such as a healthy diet and regular sleep, maintaining good hydration, minimizing caffeine intake, avoiding triggers, moderate exercise and acupuncture, icepacks or heat are some ways to prevent and manage migraines during pregnancy.

Migraine symptoms often become apparent in the postpartum period as oestrogen levels rapidly fall. Breastfeeding may delay the return of migraines because it keeps oestrogen levels elevated.

Women, menopause and migraines

For many women, the period prior to menopause brings worsening migraines because the combination of fluctuating ovarian function with fluctuating hormone levels results in irregular periods, hot flushes, sleeplessness and difficulty concentrating. This chaotic hormonal combination can lead to higher migraine frequency and worsening severity, even for women who have suffered from relatively mild or infrequent migraine attacks in the past.

There is more information about women, menopause and migraines in this article.

Migraine is one of the most common neurological conditions and is the third most common disabling disorder globally. Women are disproportionately affected by a ratio of 3:1, compared to men, in part due to hormonal differences, with changes in oestrogen appearing to be the principal factor.

If you’re suffering from regualr migraines and you’re unsure of the cause or need a personalised treatment plan, reach out to our team at Migraine Specialist.

Note: Information on this site is not a substitute for professional medical advice

References:

Migraine in Women, Broner MD et al, Semin Neurol 2017; 37:601-610


Chronic Migraine: Neurological Diagnosis and Management

Patients with chronic migraine represent the most severe, and disabled segment of the migraine spectrum. Specialist help, with a Neurologist who has a particular interest in Headache and Migraines, would be of benefit for most of these patients.

Essentially, a patient with chronic migraine is a patient with migraine who has progressed to a very frequent headache pattern. When these patients are asked, ‘On how many days a month are you completely headache free?’, the answer will often indicate that the patient has more headache days a month than initially thought, as patients may not have been considering their milder headache days.

These frequent headaches need not all have migrainous features (ie pulsating, one sided pain, light and noise sensitivity, and or nausea), and as noted can be somewhat milder in nature. Diagnosis by a Neurologist is an important step in management, for if the patient is incorrectly diagnosed with chronic tension type headache, then management will not be suitable.

Central sensitization of the pain systems likely plays an important role in the development of chronic migraine, and these patients have been shown to have diminished pain thresholds on sensory testing, as compared to subjects without this condition.

Risk factors for progression to chronic migraine include obesity, caffeine overuse, stressful life events, and acute medication overuse. Head and neck injuries can also cause rapid transformation of episodic migraine to chronic migraine.

As patients with chronic migraine have very frequent headaches, many fall into acute migraine medication overuse. Opioid containing medications are a powerful cause of medication overuse headache, and it is argued that these medications should never be used in migraine. It has been shown that giving patients information and advice about medication overuse headache can reduce headache frequency and acute medication use.

At Migraine Specialist a Neurologist will perform a thorough history, and physical examination, and this is required to make a diagnosis of chronic migraine. In addition, neuroimaging may be required in some patients. Other forms of chronic daily headache will also be considered by the Neurologist, including chronic tension headache, new daily persistent headache and hemicrania continua.

Important to the management of chronic migraine are behavioural aspects of care, prevention and management of medication overuse, as well as acute and preventative medication management.

Behavioural Factors for Successful Management of Chronic migraine include:

  • Pacing activities to avoid triggering or exacerbating migraine
  • Self monitoring to identify factors that influence migraine
  • Managing migraine triggers effectively
  • Practicing good stress management skills including relaxation techniques
  • Having regular meals, good weight management and nutrition
  • Exercising regularly
  • Reducing caffeine use to no more than 1 cup of coffee per day
  • Maintaining healthy sleep habits including regular sleep times and adequate sleep

In general, the most effective medications for treatment of acute attacks are the triptans. Non steroidal anti-inflammatories (NSAIDs) are also important acute medications. Anti-nausea drugs are also helpful if nausea is a significant problem. As mentioned, opioid medications are best avoided where possible.

Given the high headache frequency of patients with chronic migraine, acute medications are not usually sufficient to control attacks, and medication overuse headache is a constant risk. Essentially all patients with chronic migraine warrant serious consideration for migraine medication protection (prophylaxis).

Several treatment options are available, including injection therapy. The American Academy of Neurology has concluded that injection therapy is safe and effective in reducing the number of headache days per month in chronic migraine and has recommended that it should be offered as a treatment option to patients with chronic migraine. It is important to note that the administration of injection therapy for chronic migraine prevention is best provided by a Neurologist who has undergone further specialist protocol training.

Patients with chronic migraines should be referred to a Neurologist with an interest in Headache and Migraine treatment, who can provide a comprehensive management plan. It is important that relatively new and effective chronic migraine treatments, such as injection therapy, be made available to these patients. In the near future, the same will likely be true for the emerging therapies of anti-calcitonin-gene-related-peptide-therapies, currently in development.

References:

The Diagnosis and Management of Chronic Migraine in Primary Care, Headache: The Journal of Head and Face Pain; Becker MD, Vol 57 (9), Oct 2017, 1471-1481

Note: Information on this site is not a substitute for professional medical advice


Migraine and Stroke

Migraine is one of the most common neurological disorders affecting 11-15% of the population. About one third of migraineurs have an initial aura of neurological symptoms, most often a visual scotoma (blind spot).

Research has shown an association between migraine with aura and increased stroke risk, although the aetiology of stroke in migraineurs remains unclear. Possible mechanisms of migraine induced stroke include cortical spreading depression, vascular factors, inflammation, endothelial dysfunction, patent foramen ovale, genetics, oral contraceptive pill use and smoking. Patent foramen ovale is controversial, and based on current evidence, closure of PFO is not currently recommended as treatment for migraines.

On imaging, many migraineurs are found to have white matter changes similar to those seen in patients with stroke. White matter hyperintensities (WMH) are a common finding, and are typically multiple, small, punctate hyperintensities in the deep or periventricular white matter often seen in T2 weighted MRI images. The clinical significance of these changes in migraineurs is still unclear.

The mechanism underlying the increased prevalence of WMH in migraine is also not yet well understood. It has been observed however that cerebral blood flow is significantly lower in migraine with aura subjects with high white matter hyperintensity load.

Given the increased risk for stroke in this patient population, it is important to identify and modify any vascular risk factors such as high blood pressure, smoking, combined oral contraceptive use and lifestyle factors.

Available data suggest that the combined hormonal contraceptive may further increase the risk of stroke in those who have migraine, specifically migraine with aura. In women with migraine with aura who are seeking hormonal contraception, it is suggested against prescription of combined hormonal contraceptives, and the use of non-hormonal contraception or progesterone only contraceptives is the preferred option.

References: Zhang, Parikh, Qian, Migraine and stroke. Stroke and Vascular Neurology 2017;2:160-167

Lantz, Sieurin, Sjolander et al. Migraine and risk of stroke: a national population-based twin study. Brain 2017:140;2653-2662

Sacco, Merki-Feld et al. Hormonal contraceptives and risk of ischaemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and European Society of Contraception and Reproductive Health (ESC). The Journal of Headache and Pain 2017:18:108

Note: Information on this site is not a substitute for professional medical advice


Primary Exercise Headache

Previously known as primary exertional headache, is a rare headache type precipitated by exertion. It is commonly described as a pulsating headache, on both sides of the head. Primary exercise headache is termed ‘primary’ because it’s not caused by another condition or disorder.

The headache is typically triggered in hot weather or at high altitudes, lasting 5 mins to 48 hours, and is brought on exclusively during or after physical exertion. Interestingly up to 50% of patients with primary exercise headache report that they also have headaches meeting criteria for migraine.

The underlying cause of primary exercise headache is unclear. It is important however that patients with new or never evaluated exercise headache be considered for imaging studies to exclude possible underlying causes such as subarachnoid haemorrhage. Individuals over the age of 50 with risk factors for heart attack should be evaluated for heart disease as a cause for their headache (Cardiac Cephalgia). It has been reported however that up to 80% of exertional headache is primary, with no underlying cause identified.

The good news is that primary exercise headache is often self limiting, which means that it occurs for a period of time, and then stops occurring. This is often in the vicinity of 3-6 months. Given the self limited nature of primary exercise headache, people should be advised to avoid excessive exercise or triggering activities if possible.

In cases where the headache is mild or builds slowly, warming up before exercising, and or an exercise program that begins slowly, and increases in intensity and length over a period of months, may prevent primary exercise headache.

Naproxen or Indomethacin taken 30-60 minutes before exercise may prevent primary exercise headache in some cases. Beta blockers have also been reported to be effective and are alternative options in patients who cannot take NSAIDS. Since primary exercise headache is self limiting, it’s suggested that treatments be discontinued after 6 months for reevaluation of their need.

References: Primary Exertional Headache: Updates in the Literature, Curr Pain Headache Rep Halker, 2013, 17:337

Primary Exercise Headache, American Migraine Foundation, March 3, 2017

Note: Information on this site is not a substitute for professional medical advice 


Hypnic Headache

Hypnic Headache (HH) is a rare primary headache disorder with an age of onset typically more than 50 years old. Women are affected more than men. They are strictly sleep related headache attacks. Because the headaches often occur at the same time at night, they have been called ‘alarm clock’ headaches.

The headaches have to occur at least 10 days of the month and last between 15min and 4 h after awakening the patient from sleep. They are moderate in intensity and may be on both sides, or one side of the head. There are no associated autonomic features (eyelid drooping, eye redness, tearing, nasal stuffiness). Patients may have nausea, light and noise sensitivity. Rising from bed appears to ease the pain.

Hypnic headache like presentation can at times be reported secondary to brain pathology, night time elevated blood pressure, certain blood pressure medications, and obstructive sleep apnea. An MRI of the head, an evaluation for night time elevated blood pressure, and a review of medications, should be considered as part of the evaluation for HH.

Treatment options include a cup of strong coffee at bedtime, lithium and indomethacin have also been described as being effective.

References:Indomethacin-Responsive Headaches. Current Neurol Neurosci Rep (2015), VanderPluym, 15:516

Headaches of the Elderly. Current Neurol Neurosci Rep (2015) Bravo, 15:30

Note:Information on this site is not a substitute for professional medical advice


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