Headaches | Headache NewsBlog

Two different types of exercise prevent migraines

By: Dr. Mauskop

11-10-2017

A new study by Swiss researchers compared the effect of high intensity interval training (HIT) with moderate intensity continuous training (MCT) and with no exercise at all on the number of migraine headache days.

The results were presented at the International Headache Congress held in Vancouver last month. Not surprisingly, both types of exercise reduced the number of migraine headache days, but HIT was more effective. In the study, patients in HIT group did 4 periods of intensive exercise (90% of maximum intensity) each lasting 4 minutes, separated by periods of 3 minutes at 70% of maximum. The moderate intensity exercise was done at 70% for 45 minutes. Both groups performed these exercise twice a week.

A previous study has established that exercising for 40 minutes 3 times a week is as effective as relaxation training or taking a preventive migraine drug topiramate. Topiramate however has many potential side effects, including some serious ones. A Swedish study of 46,648 people established a strong inverse correlation between physical activity and the frequency of headaches.

HIT has been gaining in popularity since the 1980’s because it provides all of the benefits of exercise in a shorter period of time.

Telemedicine is effective to treat headache patients

By: Dr. Mauskop

19-07-2017

Headaches

We often get requests for a telephone consultation from patients who live too far to come in for a visit. Unfortunately, insurance companies do not cover telephone or video-link consultations. An additional obstacle in the US is that doctors cannot treat patients outside the state where they are licensed because each state licenses their own doctors. If patients can afford to pay, we do offer follow-up telephone consultations to patients who live out of state or abroad and who were first seen in our office.

A group of Norwegian researchers examined how safe and effective it is to treat patients without seeing them in person by using a video link. The results of their study was published in a recent issue of the journal Neurology. They compared 3 and 12 month outcomes after a single consultation in 200 patients using telemedicine with 202 patients seen in the office. All patients were referred by their primary care doctor. They included only patients with non-acute headaches, that is those whose headaches started gradually more than 4 weeks prior to the visit and showed no clinical or MRI abnormalities. Doctors ordered about the same number of MRI scans in both group (58 and 62). Over the subsequent year a serious underlying cause was found in one patient in each group. Treatment outcomes after 1 year were the same in both group, although in both groups the improvement in headache severity and its impact on the daily life was modest. There was a high level of satisfaction with the consultation in both groups.

The main shortcoming of the study is that every patient completed a variety of questionnaires and had a much more detailed evaluation than you’d expect in a non-study setting. The study suggests that a single consultation may not be sufficient to provide an optimal outcome. Also, while over 40% of patients had chronic migraines, obviously none could be treated with Botox, which is the only FDA-approved treatment for chronic migraines.

In conclusion, consultation via telemedicine is a viable option for patients in areas without headache specialists.

A new book for migraine sufferers and their families

By: Dr. Mauskop

14-06-2017

Alternative Therapies, Botox, Headache medications, Headaches

Searching on Amazon for books on migraines yields over 2,291 items. Do we need another book? Having just read the latest book on migraines, Understanding Your Migraines, the answer is a definite yes.

The book is written by two colleagues who for many years co-directed the Dartmouth Headache Clinic. Dr. Morris Levin is now the Director of the Headache Center and a Professor of Neurology at UCSF, while Dr. Thomas Ward is Professor of Neurology Emeritus at the Geiser School of Medicine at Dartmouth and the editor of the journal Headache. They are clearly highly qualified to write such a book, but qualifications are not enough – you need to be a good writer as well. And in fact, excellent writing style and case-based discussion are two of the major strengths of the book.

The book consists of 17 chapters, which cover diagnosis and our understanding of the underlying causes of this condition. What the readers will find most useful is the treatment approaches. Drs. Levin and Ward go into great detail about various non-drug options, including nutrition, exercise, meditation, acupressure, herbal products, vitamins and minerals. They also present pros and cons of various medications, nerve blocks and describe in detail the most effective and the safest preventive treatment for chronic migraines, Botox injections.

One chapter is devoted to specifics of migraines in pregnancy and another one to children and adolescents. The book also includes individual chapters on tension-type headaches, cluster and other less common headache types, and postconcussion headaches.

The authors also mention an exciting new treatment option, which we expect to be approved by the end of 2018. Four companies are racing to bring to the market CGRP monoclonal antibodies, which act like vaccines against migraines. A single injection will provide 1 to 3 months of relief with very few side effects. It is likely that this treatment will help about 60% of patients with both episodic and chronic migraines. Cluster headache patients might also benefit from these biologic drugs.

Reading so much information can make it difficult to understand how to actually use it and how to talk to your doctor about all these options. The authors successfully tackle this problem by providing many real-life cases and by including a chapter, How to Communicate with Your Medical Team.

I am sure that this book will help many migraine sufferers find relief. You can buy it on Amazon.

A new drug is approved for temporal arteritis, cause of headaches in those over 50

By: Dr. Mauskop

31-05-2017

Headache medications, Headaches, New treatments

Temporal arteritis occurs in one out of 5,000 people over 50. Women are 3-4 times more likely to be affected. It is not common below the age of 60 and becomes more prevalent with the advancing age. Temporal arteritis is also known as giant cell arteritis because it causes inflammation of arteries with giant cells seen under the microscope.

Headache is often the first symptom and it is typically localized to one temple, but it can involve other parts of the head and occur on both sides. If left undiagnosed and untreated temporal arteritis can cause a stroke and blindness, which can affect both eyes.

Besides headaches, temporal arteritis can cause neck and jaw pain, weakness, muscle aches, and a mild fever. The preliminary diagnosis is made by blood tests (ESR and CRP) and it is confirmed by a biopsy of the temporal artery. Polymyalgia rheumatica is a related rheumatological condition, which can occur alone or with temporal arteritis and it causes severe muscle pains.

Temporal arteritis (and polymyalgia rheumatica) are treated with steroid medications, such as prednisone. Although the initial dose is high, relatively small doses are usually effective for maintenance. Since the condition can last for years and long-term intake of prednisone can cause many potentially serious side effects it is very important to perform a temporal artery biopsy in most cases, rather than rely just on blood tests and clinical diagnosis.

Subcutaneous injection of Actemra (tocilizumab) was just approved by the FDA for the treatment of temporal arteritis. This drug has been available since 2010 for the treatment of rheumatoid and other forms of arthritis. Actemra was injected every two weeks for a year along with prednisone, but more patients were able to get off prednisone if they received Actemra rather than a placebo injection. Unfortunately Actemra also has potentially dangerous side effects, such as serious infections and it requires regular blood tests.

Because headache is one of the main symptoms of giant cell arteritis, the condition is often diagnosed by a neurologist or a primary care doctor. The treatment though is typically handled by a rheumatologist and they are already familiar with tocilizumab.

Preeclampsia can have lasting effects on the brain

By: Dr. Mauskop

27-05-2017

Alternative Therapies, Brain disorders, Headaches

Preeclampsia and eclampsia are complications of pregnancy which manifest by a severe headache and high blood pressure. If left untreated, they can cause strokes and kidney failure.

Fortunately, these conditions are very responsive to intravenous infusions of high doses of magnesium (5-6 grams at a time, while we give 1 gram to our migraine patients). A study recently published in Neurology suggests that even if preeclampsia is treated effectively, it can lead to persistent brain lesions. The researchers found these small white matter lesions (WMLs) in the healthy controls as well, but not as many as in women who suffered from preeclampsia 5 to 15 years prior to the study. We also see these lesions, which appear as small spots, on MRI scans of patients with migraines. The exact nature of these spots remains unclear, but the leading theory is that they are due to impaired blood flow.

The authors looked at a wide variety of factors that might have predisposed women to preeclampsia and subsequent WMLs, but did not find any. They did confirm previous findings indicating that age and high blood pressure increases the number of WMLs, but those with preeclampsia had more WMLs in the temporal lobes of the brain. They also found a decrease of the cortical volume, which means loss of brain cells on the surface of the brain.

Surprisingly, one of the factors they did not measure was magnesium levels. If preeclampsia responds so well to magnesium, it is possible that these women have chronic magnesium deficiency. Magnesium deficiency predisposes people not only to migraines, but also to heart attacks and strokes. The test that should have been done is red blood cell (RBC) magnesium since 98% of magnesium is inside the cells or in the bones. The most commonly used serum magnesium level measures the remaining 2% and is highly unreliable.

If you’ve suffered from preeclampsia or eclampsia, in addition to reducing other risk factors for vascular problems – control your blood pressure, sugar and cholesterol, stop smoking if you smoke, lose weight, and exercise, you may also want to ask your doctor to check your RBC magnesium level. If the level is low or at the bottom of normal range, take a magnesium supplement. A good starting dose is 400 mg of magnesium glycinate taken daily with food. If subsequent tests show no improvement, the dose can be increased to 400 mg twice a day and even higher.

Non-drug treatment of insomnia helps headaches

By: Dr. Mauskop

01-05-2017

Alternative Therapies, Chronic migraine, Headaches, Migraine, Psychology of headaches

Migraine sufferers are more likely to have insomnia than people without migraines. Depression and anxiety, which are more common in migraineurs can often lead to insomnia as well. Surveys indicate that 38% of migraine sufferers sleep less than 6 hours, compared to 10% of the general population. Insomnia is more common in patients with chronic migraine compared with patients who have episodic migraines. Chronic migraine is defined as having 15 or more headache days each month with a migrainous headache on at least 8 of those days.

Most people are reluctant to start taking sleep medications because of the reasonable fear of becoming dependent on medicine, having somnolence the next day and other short-term and long-term side effects. Fortunately, non-drug therapies can be quite effective. In some, natural remedies, such as magnesium, valerian root and melatonin work well without any side effects. Another approach is cognitive-behavioral. According to a study by psychologists at the University of Mississippi, behavioral treatments can be effective in relieving insomnia and in reducing headaches in people with chronic migraine.

The researchers compared cognitive-behavioral therapy specifically developed for insomnia with sham treatment. Those in the active group were asked to go to sleep at the same time, try to stay in bed for 8 hours, avoid reading, watching TV or using their cell phone in bed, and not to nap. If they could not fall asleep after 30 minutes, they were told to get up and engage in a quiet activity. Some were also subjected to sleep restriction – not being allowed to sleep for more hours than the patients reported getting prior to treatment, in the hope that this will lead to better sleep in the long term. The sham group was instructed to eat some protein in the morning, eat dinner at the same time, keep up with their fluid intake, perform range of movements exercise, and regularly press on an acupuncture point above the elbow.

After two weeks of this intervention headaches improved in the sham group slightly more than the active group, but six weeks later, headache frequency dropped by 49% in the active group and 25% in the sham group. Improvement in insomnia symptoms strongly correlated with the headache frequency. The cognitive-behavioral group had a significant increase in the total sleep time and the quality of sleep.

This was a relatively small study, but there is a large body of evidence that behavioral therapies do relieve insomnia. And it is no surprise that better sleep is associated with fewer headaches since sleep deprivation is a common migraine trigger. Sleep restriction is the only part of this treatment that has contraindications – it should be avoided in patients with bipolar disorder or epilepsy.

Another simple method, which I’ve used over the years whenever I cannot fall asleep, is visualization. You have to use not only visual images, but engage all of your senses. For example, imagine yourself in a place where you tend to feel relaxed (lying on a beach, on a cool lawn, on a float in a pool, etc). See all the details and also hear the sound of the wind or waves, smell the ocean or the grass, feel the touch of the wind or sand. It takes an effort at first, but use the same image every time and after a while, as soon as you go to that place, you fall asleep in minutes. Here I found more detailed instructions for this method.

Soccer is not good for your brain, at any age and whether you head the ball or not

By: Dr. Mauskop

08-03-2017

Head trauma, Headaches, Headaches in children

With 13 million participants, soccer is the third most popular sport in the US after basketball and baseball. Worldwide, 250 million people play soccer. Unfortunately, a number of studies have linked playing soccer with neurological symptoms. The latest study from the Albert Einstein College of Medicine published in Neurology evaluated 222 amateur soccer players aged 18 and older (mostly in their 20s and 30s) over a two-week period.

The study suggests that playing soccer even without heading the ball is associated with symptoms of a concussion. Those who did not report heading the ball often had unintentional head impacts (head to head, elbow or knee to head, head kicked, etc) and were much more likely to have concussion-related symptoms which were rated as moderate or severe. These symptoms included headache, dizziness, feeling dazed, and other. Unintentional head impacts were experienced by 37% of men and 43% of women, while heading-related symptoms were reported by 20%.

Not all symptoms necessarily represent a concussion and some pain and dizziness could be neck-related, so additional large studies are needed. Some studies have detected brain changes in soccer players who frequently head the ball, but these findings are considered to be preliminary and not conclusive.

According to the US Soccer Federation children under the age of 10 should not be allowed to head the ball in practice or in games. Children aged 11 to 13 are allowed to head the ball only during practice. However, this new study suggests that soccer players of any age may be risking brain injury, mostly from heading and unintentional head injuries.

Guidelines for the use of medical marijuana

By: Dr. Mauskop

24-10-2016

Alternative Therapies, Headaches, Migraine, New treatments, Pain

Medical marijuana was legalized in New York in February of this year. Since then, I’ve prescribed it to over 30 patients and about a third of them have found it to be effective. We are planning an observational study to determine which of the three approved types (inhaled, sublingual, oral) and what ratio of active ingredients (THC/CBD) are preferred by migraine sufferers. Doctors who prescribe medical marijuana do have to take an online training course, but the course does not teach about the optimal use because no one has researched this question. There are also regulatory issues to deal with.

Several sets of guidelines have been published by various medical organizations addressing the proper use of medical marijuana, other than dosing and route of administration. Here are some of the recommendations with my comments:

“The doctor should adhere to current standards of practice and comply with state laws, rules and regulations, which may specify conditions for which a patient may quality.”
Migraine is not one of the conditions listed specifically, but it is often accompanied by neuropathic pain, which is listed.

“The doctor’s office should not be located at a marijuana dispensary or cultivation center. The doctor should not receive financial compensation from or hold a financial interest in marijuana-related businesses or be affiliated with them in any way.”
This one is easy for us.

“The physician should not use marijuana either medicinally or recreationally while actively engaged in the practice of medicine.”
I’ve never tried it.

“There should be an established doctor-patient relationship before the doctor considers the use of medical marijuana.”
I prescribe it only to our established patients.

“The doctor should do a physical exam and gather health history, including documentation of previous therapies used by the patient and information on any personal or family history of substance abuse, mental illness or psychotic disorders. The diagnosis should justify the consideration of medical marijuana.”
All of our patients undergo a thorough evaluation.

“The doctor should review other treatment options. The known benefits and risks of marijuana should be presented, along with the warning that, unlike with FDA-approved drugs, there is variability and lack of standardization in marijuana preparation.”
We use medical marijuana only after other non-drug and drug treatments fail.

“If the medical marijuana is chosen, a specific treatment plan for a limited period of time should be agreed on, with details documented in the medical record. The doctor should instruct the patient not to drive or operate heavy machinery while using marijuana.”
Yes, I do that.

“The patient should be seen for follow-up visits to monitor for efficacy and side effects of medical marijuana.”
This is a standard practice with any treatment.

“Patients with a history of mental health problems, substance abuse or addiction should be referred for further evaluation as needed.”
I typically avoid prescribing medical marijuana to such patients.

Thyroid disease and headaches

By: Dr. Mauskop

08-10-2016

Headaches, Migraine

Hypothyroidism, or under-active thyroid is known to cause headaches or worsen pre-existent migraines. Correcting this deficiency with medications such as Synthroid or Armour Thyroid often improves headaches.

Researchers at the University of Cincinnati College of Medicine tried to determine if having headaches made one more prone to developing hypothyroidism. They examined 8,412 healthy people and checked their thyroid function every 3 years over a 20 year period. They excluded from the group people with past thyroid disease or abnormal thyroid function tests at the first office visit. The diagnosis of a headache disorder was established based on person’s report of “frequent headaches,” by the use of any headache-specific medication, or a physician’s diagnosis of a headache disorder. They also recorded age, sex, body mass index, income, smoking, narcotic use, and medicines that could cause thyroid dysfunction.

Headache disorders were present in about 26% of the population and new onset hypothyroidism developed in 7%. Those who had a headache disorder had a slightly higher risk (1.2 times) of developing hypothyroidism. The researchers concluded that headache disorders may be associated with increased risk for the development of new onset hypothyroidism. These results were published in Headache.

One of my colleagues tells an embarrassing story of his wife’s headaches. She developed them after giving birth to their child, so he attributed them to stress and lack of sleep. When headaches persisted she went to her primary care doctor who discovered that she had an underactive thyroid. The headaches promptly went away with thyroid medicine.

Besides headaches, low thyroid function can cause weight gain, fatigue, constipation, muscle cramps, intolerance of cold, dryness of the skin, memory and concentration difficulties. Many of these symptoms also occur with magnesium deficiency, so both RBC magnesium and thyroid function tests (along with vitamin B12, vitamin D, and routine tests) need to be checked when headaches worsen or new ones develop.

Common avoidable problems with Botox injections

By: Dr. Mauskop

28-09-2016

Botox, Headaches, Migraine, Pain, TMJ

One of the most common problems with Botox injections given for chronic migraines is that doctors use the standard protocol without adjusting the dose. One of my patients is an 83 year old woman with chronic migraines who has done exceptionally well with Botox injections with no side effects for the past 16 years. She recently started living in Florida during the winter and had Botox injections given by a local doctor. I provided her with a copy of the injection sites and the total dose, which was 65 units given into 20 sites in the forehead and temples. Her Florida neurologist insisted on giving her the standard 31 injections with 155 units all around the head, neck and shoulders. The result was that she developed drooping of her eyelids and pain and weakness of her neck. It defies common sense to inject a small woman who weighs 90 lbs with the same amount of Botox as a 200-lbs man.

Sticking strictly to the protocol prevents many doctors from addressing clenching and grinding of the teeth (TMJ syndrome), which often worsens migraines. Injecting Botox into the masseter muscles (chewing muscles at the corner of the lower jaw) can have a dramatic effect on TMJ pain and migraines. Other patients may need additional injections into the scalp or upper back, depending on where the pain is felt. Since Botox comes only in 100 and 200 unit vials, if the insurance company approves Botox, it sends us 200 units. Instead of discarding the remaining 45 units, we usually give additional injections into the areas of pain that may not be included in the standard protocol.

Giving injections every 3 months or even every 12 weeks works well for many patients. However, about a quarter of my migraine patients find that the effect of Botox lasts only 10 weeks and in a small number , even less than 10 weeks. Fortunately, some insurance companies allow Botox to be administered every 10 weeks, but many do not. Some even limit injections to every 3 months, and not a day earlier, even though the clinical trials that led to the FDA approval involved giving injections every 12 weeks. Having a week or two of worsening migraines can eliminate the cumulative effect we see with repeated treatments. That is, each subsequent Botox treatment provides better relief than the previous one. This may not the case if headaches worsen before the next treatment is given.

Cosmetic concerns are not trivial since Botox injections can make you look strange – as if you are always surprised or look sinister with the ends of your eyebrows always lifted. This can be easily avoided by injecting a very small amount of Botox into the appropriate muscles above the ends of the eyebrows or a little beyond them. In some patients this can be predicted before the first treatment by looking at the lines seen with lifting of the eyebrows. In others, it becomes apparent only after the first treatment. If the appearance is very unappealing, we ask the patient to return to get two small additional injections for which we do not charge.

To minimize bruising and pain we use very thin needles. A 30-gauge needle is used most often, however an even thinner, 33-gauge needle is also available, but is rarely used (higher number indicates a thinner needle). We recommend using a 33-gauge needles, at least for the forehead, where injections tend to be more painful and where bruising, if it happens, is very visible.

Many dermatologists and plastic surgeons tell their patients not to bend down or do anything strenuous to avoid movement of Botox which may lead to drooping of the eyelids. There is no theoretical or practical evidence for this restriction. Once injected, Botox does not move around freely but stays in the injected area. In my 22 years of injecting Botox, I’ve treated thousands of headache sufferers and fewer than 1% of patients developed drooping eyelids and none were related to bending or any other activities. Drooping is more common in older patients, is always reversible within days or weeks, and sometimes can be relieved by eye drops (aproclonidine).

The existence of medication overuse headache is debated

By: Dr. Mauskop

20-06-2016

Alternative Therapies, Headache medications, Headaches, Migraine

Medication overuse headache (MOH), which is sometimes called rebound headache, is included in the International Classification of Headache Disorders. However, this is one of several headache types whose existence is still debated. After years of indocrination, most neurologists and headache specialists strongly believe that every drug taken for acute treatment of headaches can cause MOH. However, we have good evidence only for caffeine and for opioid (narcotic) pain medications. It is far from proven in case of triptans (sumatriptan or Imitrex, and other) or NSAIDs (ibuprofen or Advil, naproxen or Aleve, and other).

Last week, I attended the annual scientific meeting of the American Headache Society (AHS) and was happy to see that despite an almost universal acceptance of the diagnosis of MOH, the organizers set up a debate on the existence of MOH. The debaters included two top experts in the field, Drs. Richard Lipton of Montefiore Headache Clinic in the Bronx and Ann Scher of the Uniformed Services University in Bethesda. Dr. Lipton and Scher have collaborated on many research projects and have published many important articles on headaches together, so the debate was friendly and based on facts.

Dr. Scher quoted the American Council on Headache Education, an affiliate of the AHS:

“It is important to know that intake of medications for acute treatment should be limited to less than twice a week. Some methods which can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications and butalbital combination medications and limit use of simple analgesics to less than 15 days a month and triptans less than 10 days a month”.

And then she posed a question: How many are being harmed vs helped by this advice?

While Dr. Lipton quoted scientific articles supporting the existence of MOH, Dr. Scher’s conclusions reflected my clinical experience that MOH is not a proven entity as it relates to triptans and NSAIDs. I see it only in those who overuse caffeine or caffeine-containing drugs (Excedrin, Fioricet, etc) or narcotic pain killers (Percocet or oxycodone, Vicodin or hydrocodone, and other).

Dr. Scher concluded that, “Since the existence of MOH has not been proven (and may be non-provable for practical purposes), one is obligated to remain agnostic about this entity. And the corollary is that there is no evidence that undertreating will prevent headache frequency progression and may harm more people than help”.

In fact, the same headache experts who limit abortive therapies to twice a week, recommend aggressive abortive therapy for migraines because undertreatment of episodic migraine can lead to its transformation into chronic migraine.

She also indicated that “Quality of evidence for medication withdrawal alone as treatment for MOH is poor” and “Medication withdrawal alone is not clearly better than doing nothing and may be worse”. Meaning that in addition to withdrawal of the acute medication, patients should be given prophylactic treatment.

Studies indicate that after one year, 60% and after two years, 70% of those with chronic migraines (15 or more headache days in a month) revert to episodic ones (less than 15 headache days a month) regardless of treatment. In 15% headaches decrease to less than one a week. This is because fortunately, migraines often improve with time on their own.

We have evidence that Botox injections and some preventive medications can make discontinuation of acute medications easier. We always try to stop Fioricet (butalbital, acetaminophen, and caffeine), Fiorinal (butalbital, aspirin, and caffeine), Excedrin (caffeine, acetaminophen, aspirin) with the help of regular aerobic exercise, biofeedback or meditation, magnesium and other supplements, Botox injections, and sometimes preventive medications.

However, we do have several dozen patients whose headaches are controlled by the daily intake of triptans. These patients have tried given prophylactic medications, Botox injections and other treatments, but find that only triptans provide good relief and eliminate migraine-related disability. The most commented on post on this blog (with 175 comments to date) is one on the daily use of triptans.

Pituitary adenoma and headache

By: Dr. Mauskop

15-02-2016

Brain disorders, Headaches

Pituitary gland which is located inside the skull and underneath the brain is responsible for secreting various hormones. Pituitary adenoma is a benign tumor of this gland and it often causes increased release of either prolactin, growth hormone, or cortisol. Very often the tumor does not release any hormones. These tumors are extremely common – a microscopic tumor is found in one out of five adults, but they cause symptoms only in a very small proportion of such people. The symptoms are related to the type of hormone that is being released or are caused by the pressure of a growing tumor on the surrounding brain structures, or both. A very small tumor can be treated with medications, while large ones often require surgery. Small tumors have traditionally not been thought to cause headaches.

A recent study showed that in a minority of patients small tumors do cause severe headaches and if these headaches do not respond to medications, surgery can provide relief. The study was done by a group of Japanese neurosurgeons who reviewed the records of 180 patients who underwent surgery for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. They found nine patients with intractable headaches as the main complaint, associated with a small, but not microscopic pituitary adenoma (average diameter of 15 mm, or 3/5 of an inch). In eight patients the tumor did not secrete any hormones and in one it secreted prolactin.

All nine patients had complete or significant relief of their headache after surgery. The surgeons measured pressure inside the enclosed space called sella, which contains the pituitary gland and discovered that the pressure was significantly higher in patients with headaches than in those without.

In conclusion, while most patients with small tumors do not need surgery, those who have severe headaches that do not respond to medications, Botox injections, and other medical treatments, could find relief from surgery.