Headaches

For many patients, headaches are a debilitating daily burden which negatively impacts their ability to care for their family, take care of their daily needs, and to continue working. However, it does not have to be that way. With the right diagnosis and the right treatment, headaches can be managed and the number, frequency and severity of headaches significantly improved. The first step is an accurate diagnosis. All headaches are not created equal. Some headaches may be a marker of a serious underlying condition. Red flags include: headaches that start suddenly later in life, are associated with loss of consciousness, blurred vision, high blood pressure, or occur in patients who have a history of arteriovenous malformation or aneurysm. These patients should seek medical care immediately.

Most chronic headaches, however, are not indicative of a serious underlying medical condition and may be managed as an outpatient. Identifying the type of headache leads to a greater chance of effectively treating it. Some of the more common chronic headache syndromes include: Migraine, Cluster, Tension, Cervicogenic, and Exertional. Other types of headaches include: Positional or Post-dural puncture headaches, Occipital Neuralgia, Trigeminal Neuralgia, TMJ / Temporomandibular Joint disorder, Spontaneous Intracranial Hypertension (Pseudotumor Cerebri), Post-Herpetic Neuralgia of the Trigeminal nerve, Medication Overuse Headache, Traumatic Brain Injury / Post-concussive headache, and Giant Cell Arteritis / Temporal Arteritis. Below, we will go into a bit more detail reviewing these types of headaches, the accompanying symptoms, and potential treatments.

Cluster headaches can present around one eye or at the temples. Sometimes these type of headaches are accompanied with nausea, sensitivity to light and sound, watering from the affected eye, and/or a runny nose (1). Treatment may include nasal spray, oral medication such as triptans (sumatriptan, zolmitriptan or octreotide), subcutaneous injections, and/or 100% oxygen for 15 minutes. 100% oxygen has shown promise for many of those suffering from cluster headaches (1). Preventative medications such as verapamil, valproic acid, topiramate, steroids or melatonin are indicated if attacks are frequent and persistent. Sphenopalatine ganglion (SPG) blocks (lidocaine intranasal) and Greater Occipital Nerve (GON) blocks with lidocaine and steroid have shown promise in the treatment of Cluster Headache and are performed at our practice.

Migraine sufferers usually have attacks that start intermittently from ages 20 - 30. By age 25 - 40, migraines typically increase in frequency (2). Migraines can present as pain on both sides of the head, neck, or face. A sensitivity to light, sounds, and/or smells can occur in those with migraines. Migraines can have triggers, as well. This means that some sufferers can come into contact with everyday items that can initiate a migraine. For example, eating certain foods, drinking caffeine, smelling certain smells, dealing with stressful situations, changing weather, or menstruation/ovulation can start an episode. Unfortunately, migraines are oftentimes misdiagnosed as tension headaches (3). Treatment may include nasal spray (triptans such as sumatriptan), oral medication (zolmitriptan or sumatriptan, or aspirin/ acetaminophen/ caffeine combination tablets), subcutaneous or IV injections (metoclopramide, steroids, dexamethasone), Botox (Botulinum Toxin) injections, or neck injections with steroid and/or a lidocaine-like medication. We perform sphenopalatine ganglion (SPG) lidocaine intranasal blocks and Greater Occipital Nerve Blocks for migraines at Cahaba Pain & Spine Care. Migraine headaches may have a trigeminal relay through the brain. These headaches are often facial, frontal or above the eyes. We may recommend supraorbital nerve blocks, supratrochlear nerve blocks, or trigeminal blocks if the headache has a frontal/ trigeminal relay. Other migraines have an occipital type relay, and begin in the posterior skull / occipital area. These Migraines may respond to Greater Occipital, Lesser Occipital, or Third Occipital Nerve blocks, all of which we perform at Cahaba Pain & Spine. Radiofrequency ablation, either pulsed or thermal, may be beneficial for these conditions. Many of our patients have failed multiple other medications and therapies by the time we evaluate them at our practice. When we evaluate the patient, we go over all of the tried and failed medications in the past, what has worked and what has not. We make sure the diagnosis is migraine. Sometimes the patient may have cervical issues in addition to their migraines, and the cervical or neck issues may worsen the patient’s headaches. In this case, we may order advanced imaging such as an MRI to evaluate for cervical disc disease or cervical spondylosis which may be contributing to occipital based headaches. Some of these patients may respond to cervical medial branch blocks or cervical epidural steroid injections. You may discuss this with your doctor at your visit.

Cervicogenic headaches or headaches caused by underlying neck / cervical spine issues of the bone, joints or muscle in the neck such as degenerative joint disease, cervical disc disease, whiplash syndrome, or cervical facet syndrome/ cervical spondylosis. The headaches may occur due to recent trauma or accidents, falls. The pain is usually worse with neck movement, coughing, sneezing, and stays in one spot such as the neck, eye, or ear. The pain is typically steady and may last hours to days. Workup may include x-rays, CT scan or MRI of the cervical spine. Treatment may include anti-inflammatories or other oral medications, TENS unit, physical therapy, cervical traction collar, muscle relaxants, spinal manipulation, blocks or procedures in the cervical spine / neck such as cervical trigger point injection, cervical epidural steroid injection, cervical medial branch block, or radiofrequency ablation. For patients who have had long-standing mechanical pain in the neck, a block with lidocaine chordee medial branch block may significantly improve the pain. If they respond to this procedure, a radiofrequency ablation may provide one year or more of relief.

The most common of the types of headaches are tension headaches (4). Tension headaches present as dull pressure on both sides of the head. The pressure can radiate down the neck to the shoulders. Those with severe tension headaches, may even feel that their head is in a vise-grip (4). These headaches can be instigated by stress, fatigue, or issues with muscles in the jaw or neck (4). Treatment may include over-the-counter NSAIDs/acetaminophen, rest, or a warm compress to the neck. Further treatment maybe be required, if conservative measures are ineffective.

Greater occipital neuralgia, or occipital neuralgia, is a head pain disorder which begins in the occipital area and the posterior neck and travels up the scalp and behind the eye, typically having a nerve like character including numbness, tingling, shooting pain, or stinging. This syndrome typically responds well to occipital nerve blocks, occipital radiofrequency ablation, or third occipital nerve block. Other medications and therapies may also improve the pain.

Trigeminal neuralgia is a severe pain typically involves a portion of the face, eye, or ear defined by sudden, severe shooting and stinging pain. The pain may be brief, but often lasts hours to days. Patients have nervelike pain in the side of the face, sensitivity to pressure or light touch, and sometimes difficulty with chewing their food. The condition is severe and debilitating. Medications may be helpful. If you have tried medications and they were not helpful, CyberKnife surgery, gamma knife radiosurgery, trigeminal nerve decompression surgery, or trigeminal nerve (gasserion ganglion) block followed by neurolysis with radiofrequency ablation or pulsed radiofrequency ablation may be beneficial. Our practice performance trigeminal blocks followed by pulsed radiofrequency ablation for patients who are trying to avoid surgery and who have not been helped by medication therapy.

Positional or post-dural puncture headaches typically occur after a medical procedure on the spine such as a lumbar puncture, lumbar surgery, or epidural injection. The headache typically occurs within 24-48 hours after the medical procedure, may be associated with nausea, hearing or visual changes, neck pain, and is improved by lying down but worsened with sitting or standing. The headache most likely occurs due to a loss of cerebrospinal fluid following the medical procedure. Traditional treatments for this headache include caffeine, increased fluid intake, abdominal binder, bed rest, and analgesics such as Tylenol, anti-nausea medications and anti-inflammatories. However, some patients may not improve quickly, and may have severe symptoms. For these patients, Epidural Blood Patch may be an option. Cahaba Pain and Spine Care takes referrals for Epidural Blood Patch from outside providers and performs this procedure as an outpatient same-day procedure. An epidural blood patch is thought to help the epidural headache / post-dural puncture headache by stopping the leak of csf / cerebrospinal fluid which causes the headache. This procedure is performed under fluoroscopy, with a small epidural needle, and involves withdrawing the patients blood to inject a small amount and stop the leak. Patients typically notice near-immediate relief from the epidural blood patch and are able to walk out of the clinic greatly improved.

In conclusion, identification of the type of headache is imperative to selecting the appropriate treatment. Thankfully, there are many treatments available. Talk to us about any concerning headache symptoms; we are glad to help.