Many medical specialty groups of doctors have been coming out with “Choosing Wisely” campaign where they recommend avoiding five things in their field. Headache specialists just came out with their own list of items that offer low-value and can be even harmful. The American Headache Society surveyed its members to develop a candidate list of items of low-value care in headache medicine. Then, a committee reviewed the literature and the available scientific evidence about the candidate items on the list and by consensus came up with a final list of five items. The five recommendations are: (1) don’t perform a brain scan (MRI or CAT) in patients with stable headaches that are typical migraines; (2) don’t perform CAT scan for headache when MRI scan is available, except in emergency settings (MRI is much more informative and does not subject the patient to radiation); (3) don’t recommend surgical procedures for migraine, unless it is a part of a clinical trial (several types of surgery are being promoted with little scientific evidence that they are safe and effective); (4) don’t prescribe opioids (narcotic drugs, such as codeine, Vicodin, Percocet) or butalbital-containing medications (Fioricet, Fiorinal, Esgic) as a first-line treatment for recurrent headache disorders because these drugs are often ineffective, can worsen headaches and can cause addiction; and (5) don’t recommend prolonged or frequent use of over-the-counter pain medications for headache. I would stress that the last item is particularly important in regard to caffeine-containing drugs, such as Excedrin and Anacin, while ibuprofen, naproxen, and acetaminophen are much less likely to cause medication overuse (rebound) headaches. Aspirin sometimes can actually prevent headaches from becoming more frequent or chronic (I admit that as a developer of Migralex I am biased in favor of aspirin, but scientific data supports this).

Art credit: JulieMauskop.com

Increased intracranial pressure is an under-diagnosed cause of difficult to treat headaches. Persistent chronic headaches that do not respond to treatment may be due to increased pressure inside the head. These headaches may resemble chronic migraine headaches and many doctors will try treating these patients with preventive medications, such as Neurontin (gabapentin), Topamax (topiramate), amitriptyline (Elavil), or Botox injections. If these approaches do not provide relief, measurement of intracranial pressure should be considered. Most patients who suffer from increased intracranial pressure have swelling of the optic nerves (papilledema), which can be detected by examining the back of the eye, a standard part of a neurological and ophthalmological examination. However, some people with increased pressure do not have papilledema and they are the ones who present a diagnostic challenge. This condition is also called pseudotumor cerebri because tumors also raise intracranial pressure. To measure the pressure a spinal tap (lumbar puncture) is performed. The cerebrospinal fluid circulates around the brain, within its ventricles and around the spinal cord. Putting a needle into the spinal fluid at the lumbar spine level is much safer than anywhere else and gives the reading of the pressure everywhere within this enclosed space, including the brain.

Factors that predispose to increased intracranial pressure include delayed effects of a head trauma, certain medications, excessive amounts of vitamin A, obesity, and other. One of the more recent theories suggests that narrowing of the veins that drain blood from the brain is responsible for this condition. This diagnosis is made by performing an angiogram or a magnetic resonance venogram (MRV, a test done by an MRI machine), tests that show blood vessels.

In addition to headaches, increased pressure can cause nausea, dizziness, pulsating noise in the ears, and blurred vision. If left untreated, the increased pressure can lead to loss of vision.

If no obvious causes are found the condition is called idiopathic intracranial hypertension. Its treatment begins with the attempts to lose weight if the person is overweight. Pregnant women who are more prone to develop this condition often obtain relief after the delivery. Medications that can help include acetazolamide (Diamox) and topiramate (Topamax). If medications are ineffective a neurosurgeon can place a shunt that drains cerebrospinal fluid into the abdomen. This is a relatively simple procedure, but it does carry a risk of infections and other complications. Shunting is reserved for patients who have uncontrollable headaches or are threatened with loss of vision.

Art Credit: JulieMauskop.com

Spinal tap, or lumbar puncture headache occurs in one out of four people undergoing this procedure. Spinal tap is usually done to examine spinal fluid for infections, bleeding, multiple sclerosis, and other conditions. A small percentage of people undergoing epidural anesthesia, which involves placement of the same kind of needle into the same space between vertebrae, also develop a spinal tap headache. This happens because the needle is accidentally placed too far and it causes a leak of spinal fluid. Spinal tap headache is very easy to diagnose – it stops as soon as the person lies down and begins within minutes of sitting up. Normally, the brain floats in cerebrospinal fluid, but if this fluid is drained away by a spinal tap, the brain sags, pulls on the brain coverings, called meninges, and causes a severe headache. The majority of people do not develop this headache after a spinal tap because as soon as the needle is withdrawn, the hole in the dural sac that covers the spinal cord and the brain closes. In some people, especially if it takes a few sticks to get the fluid flowing and with a larger needle, the hole may not close right away and the fluid keeps leaking inside the spine. In most people the headache stops on its own within a day or two. If it doesn’t, the problem can be fixed by a “blood patch” procedure. It involves taking the patient’s own blood from the vein and injecting it into the same space between vertebrae where the spinal tap was done. Patient’s blood clots and seals the persistent leak of the cerebrospinal fluid, which stops the headache, often within minutes.
A similar headache can rarely occur without a spinal tap or even a trauma to the spine. It is called spontaneous low cerebrospinal fluid headache and it is also very positional, meaning that it gets better when the person is lying down. This headache is more difficult to diagnose, but an MRI scan of the brain sometimes shows inflamed meninges around the brain, which suggests this diagnosis. Finding a leak is more difficult and requires looking at the flow of the spinal fluid and searching for a leak. When a single leak is found, a blood patch procedure can help, but with multiple leaks the treatment becomes more complicated. A single case of using Botox to helps this type of headaches was described here last year.

Many patients visiting the New York Headache Center with persistent post-traumatic headaches report having had a relatively mild head injury. The perception by neurologists has always been that milder injuries without loss of consciousness are more likely to cause headaches that severe ones. A research study just presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles confirms this old observation. Dr. Sylvia Lucas and her colleagues at the University of Washington in Seattle evaluated 220 patients with a mild traumatic brain injury (TBI) and a group of 378 individuals with moderate or severe brain injury. Both groups were evaluated within a week of the head injury and then again, by phone, 3, 6 and 12 months later. Both groups had similar demographics (age, sex, etc) and similar causes of injury (motor vehicle accidents was the most common cause). In the mild TBI group headaches were present in 63% after 3 months, 69% after 6, and 58% after 12 months. In the moderate and severe TBI group these numbers were 37%, 33%, and 34%. In both groups about 17% also had headaches prior to the injury. As far as the kind of headaches these individuals experienced, migraine was the most common type in both groups. It remains unclear why a milder injury should cause so many more headaches than a severe one. Treatment of post-traumatic headaches includes the usual approaches to the treatment of migraines – aerobic exercise, biofeedback and relaxation training, magnesium, butterbur, CoQ10, and other supplements, abortive medications, such as Migralex and triptans, prevention with Botox and other medications.

A throbbing headache in the left temple with sensitivity to light and noise, occurring daily and present for almost a year seemed to indicate a typical chronic migraine headache in a man I saw last week. His headache did not respond to pain medications, short courses of steroids and sinus surgery. The MRI scan of the brain and neurological examination was normal. The only unusual part was that this was a 66-year-old man who never had any headaches before and who had no family history of headaches. Migraines can begin as early as infancy and as late as 50’s, but it is extremely unusual to start having migraines for the first time in the 60s. Headaches that occur in later years are more likely to be due to conditions such as brain tumors (primary – glioma or meningioma, or secondary due to metastases from breast, lung and other tumors), subdural hematoma, or inflammation of blood vessels, which was the case in this 66-year-old man. He suffered from temporal arteritis, also called giant cell arteritis. The diagnosis is confirmed by blood tests (elevated ESR and CRP) and biopsy of the artery. Treatment is usually very effective and typically consists of a steroid medication such as prednisone. Unfortunately, many patients with temporal arteritis need to stay on at least a small amount of this medicine for many years if not the rest of their lives and this drug has many potential serious side effects. However, if left untreated temporal arteritis can cause strokes and blindness, so it is very important to diagnose and treat it as soon as possible.