Narrator:
0:01
Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, powered by ENCORE Research Group and hosted by cardiologist and top medical researcher, Dr. Michael Koren.
Dr. Michael Koren:
0:17
Hello, I'm Dr. Michael Koren and I'm delighted to be here with a great colleague, Steven Toenjes, and we're going to talk about headaches. A s a physician, as a clinical researcher and as somebody that runs a business, I have a lot of headaches, so I'm hoping that in this MedEvidence Hour, you're going to help us understand headaches and maybe help me and a lot of other people with your knowledge.
Dr. Steven Toenjes:
0:41
Well, that would certainly be the goal and I'm delighted at the opportunity. I'm Steven Toenjes. I'm a neurologist in Jacksonville. We do general neurology and certainly have a subspecialty niche of headache medicine for sure, and this is basically what we do.
Dr. Michael Koren:
1:03
So, first of all, Steve is an amazing neurologist. He's fabulous and he's a go-to guy in this area in northeast Florida. So thank you for what you do for our patients and thank you for what you do for research, and you also have taught me a lot over the years and you've been involved in clinical research here. So let's help everybody else understand what it is that you do, what it is that you know, and let's start with the basic concept about what is a headache. What are the different types of headaches? Obviously, I alluded to some headaches of what I have to do day to day, and we all have those in our lives, but those are fundamentally different type of headaches compared to cluster headaches or migraine headaches. So there's a lot of terminology out there that people really don't understand quite that well in my experience. So why don't you start by telling us what is a headache and what are the types?
Dr. Michael Koren:
1:51
and why they're important to have different types.
Dr. Steven Toenjes:
1:53
So there are a lot of misconceptions about what types of headaches people experience specifically with migraine. I'll sort of focus in on or pay attention specifically to migraine, because there are a lot of misconceptions.
Dr. Michael Koren:
2:14
Are migraines the worst kind of headaches or different categories are equally bad?
Dr. Steven Toenjes:
2:20
So therein lies some of the uncertainty. There are diagnostic criteria for all of the headache disorders that humans experience. It's called the International Classification of Headache Disorders. It's on its third revision and it's very easy to access online, and so those are a very well thought out and validated through the years and then thus revised set of diagnostic criteria. And so, with our migraine criteria, we really think of headaches that have a couple of particular types of characteristics. There's four main characteristics to consider them being unilateral, them being pulsating or throbbing,
Dr. Michael Koren:
3:05
On one side of the head being pulsating or throbbing on one side of the head being pulsating or throbbing in character. Does that mean they're vascular because they're pulsating? Sometimes people have that. Not necessarily. Okay, not necessarily. Sorry to interrupt you.
Dr. Steven Toenjes:
3:17
No, you're good. So unilateral, pulsating, moderate or severe in intensity. And so, yes, migraines are often moderate or severe in intensity. And so, yes, migraines are often moderate or severe in intensity. And then the fourth one is aggravated by or requires avoidance of routine physical activity. You really just need two of those characteristics, and so if you had a unilateral or one-sided headache that was throbbing, it wouldn't need to be severe. As a matter of fact, it could be mild.
Dr. Steven Toenjes:
3:46
Now, most migraines are going to be moderate or severe, but it can be misleading, because the headache does not need to be moderate or severe. As a matter of fact, it's even possible to have a migraine and have no pain. And so, along with the other four characteristics of migrainous headaches, you know the criteria would require light and sound sensitivity or nausea. The person does not need to have nausea. You don't need to have light and sound sensitivity. If you have nausea and you can still satisfy the diagnostic criteria.
Dr. Steven Toenjes:
4:22
It's important to understand that the light sensitivity and sound sensitivity that can come with migraines does not need to be severe. A lot of times, patients are confused by the fact that light will bother them. It's just not that bad. They will turn the lights off and if they've got a migraine. The radio or the TV are not on, and that counts. That behavior is there because they are light and sound sensitive, and so the photo and photosensitivity can be relatively mild. It does not need to be severe. That's a very common reason why someone is confused about a diagnosis of migraine.
Narrator:
5:03
Okay, so before we get more into migraines, we're going to spend a lot of time on that, since we do the research in that Sure.
Dr. Michael Koren:
5:10
But just for the audience. People talk about tension headaches, they talk about sinus headaches, they talk about cluster headaches. Yes, do they really have the same type of specific diagnostic criteria, or are they just general terms?
Dr. Steven Toenjes:
5:22
Absolutely. They're definitely defined very specifically. I think a lot of the confusion comes with tension and migraine, tension being the most common primary headache disorder that humans experience, migraine being the most common severe primary headache disorder that humans experience. I think it's interesting to look actually at the diagnostic criteria and if you do and you read migraine's criteria and tension headaches criteria, you'll notice that the generators of the criteria just took migraine diagnostic criteria and put the word not in front of each of the criteria, and that is tension headaches criteria.
Dr. Steven Toenjes:
6:09
So they're not unilateral, they're not throbbing, they're not moderate or severe and they're not exacerbated by routine physical activity. That's literally the tension criteria.
Dr. Michael Koren:
6:20
How about cluster? Does that mean anything?
Dr. Steven Toenjes:
6:22
Absolutely so. Cluster is very different and mentioning cluster does bring up a very useful aspect of diagnostic criteria. Duration of a headache is a very, very important piece of the puzzle. Migraines untreated or unsuccessfully treated last between four and 72 hours. They don't last 30 minutes. Cluster headaches are generally fairly easily differentiated from migraines based on simply the duration of the headache. A cluster headache really does not last more than 180 minutes.
Dr. Steven Toenjes:
7:01
So it's not up to three hours and usually it's down around 30 minutes, maybe an hour, and cluster headache is severe or very severe. And so cluster headaches are quite different and have a lot of automatic.
Dr. Michael Koren:
7:16
They hit you hard and they hit you quickly.
Dr. Steven Toenjes:
7:17
They do. They do and they're not nearly as common as migraine. You mentioned one sinus headache and that is something that is often confused with migraine, because migraine can hurt in the region of our sinuses and the vast majority of what is even diagnosed by physicians as a sinus headache is migraine. The statistics are 85% of what a physician diagnoses as a sinus headache is migraine, and so almost all sinus headache is migraine.
Dr. Michael Koren:
7:53
Interesting? Yes, and is there any way to distinguish that? If they respond to antihistamines it's more sinus or
Dr. Steven Toenjes:
8:01
The diagnostic criteria. Okay, gotcha.
Dr. Michael Koren:
8:02
And then you know, I'm sure there are other categories and others post-concussive headaches and others. Are there any other major ones that you want to bring to the fore?
Dr. Steven Toenjes:
8:10
You know, we do see a lot of post-traumatic, post-concussive headache syndromes. A significant percentage of the time I would say a majority of the time when we're seeing these patients in clinic, they are actually a migraine patient whose headaches have increased in severity after the putative trauma, and so sometimes it's difficult to really decipher the difference between a post-traumatic headache syndrome and a migraine syndrome. Post-traumatic headaches are often migrainous. They often have very typical migrainous characters, and when we look at studies on efficacy, it is migraine-based therapies that wind up demonstrating efficacy.
Dr. Steven Toenjes:
8:59
Limited studies.
Dr. Michael Koren:
9:01
Any other major categories to throw out there?
Dr. Steven Toenjes:
9:06
I don't think so. I think those are, you know, it's really. You know, migraine is just such a common issue. You know, one in five females, one in 10 males, have migraine.
Dr. Michael Koren:
9:18
So, yeah, that brings up an interesting issue. So headaches is a big problem in terms of workplace productivity, among other things. Obviously, we like to relieve people's symptoms, but it's interesting from what I've heard, insurers are actually very positive about paying for migraine treatments and other headache treatments because of the productivity issues at the workplace. So you may want to comment on that.
Dr. Steven Toenjes:
9:41
So in global burden of disease studies, where we're really assessing the impact of a particular syndrome on essentially disability or the ability to function in life and at work. In the Global Burden of Disease Studies, migraine is number two in the list of most disabling conditions in women of childbearing ages. It's clearly number one, and so it is by far one of our top most disabled.
Dr. Michael Koren:
10:18
Number one would be heart disease, I assume.
Dr. Steven Toenjes:
10:20
No, number one is lower back pain.
Dr. Michael Koren:
10:22
Really yes, low back pain.
Dr. Steven Toenjes:
10:25
And so there are different ways to sort of slice up the disability with migraine. There is, of course, what we refer to as absenteeism, right, so someone's missing work because they have a bad migraine or unable to function for that day. There's also what we term presenteeism, meaning the person stays at work.
Dr. Michael Koren:
10:50
It is worthless. It is basically worthless headaches and two are the triggering elements of headaches.
Dr. Steven Toenjes:
11:14
You know, in terms of genetics, I think that the genetic stuff is not really ready for prime time in terms of we're not regularly doing any kind of genetic assessments in clinics. I do believe that that is the future to come.
Dr. Michael Koren:
11:31
Do migraines run in families?
Dr. Steven Toenjes:
11:37
Oh definitely, there's no question about that. There is a genetic component. We just don't understand it well. You would term it a polygenetic disease. And yes, if a parent one parent, is a migraineur, the likelihood of any individual offspring being a migraine patient is 80%.
Dr. Michael Koren:
11:54
Wow, and if both parents are migraine patients.
Dr. Steven Toenjes:
11:57
It's 95%.
Dr. Michael Koren:
11:58
Okay, so that's not Mendelian, but there's something going on there.
Dr. Steven Toenjes:
12:02
Clearly interesting.
Dr. Michael Koren:
12:03
Yes, and then talk about triggers. I know that's a huge discussion point from parents for people that have headaches.
Dr. Steven Toenjes:
12:10
I would tie trigger discussions up with lifestyle suggestions. We often are not aware of the impact of our sleep habits on various things. Definitely, migraine is extremely sensitive, often to derangements in our circadian rhythm, certain food-related triggers. Generally those tend to be pretty obvious to a person. I mean, if somebody drinks a glass of red wine and a high percentage of the time they are vomiting in the bathroom with a severe pounding headache when they do that they figure that out very, very easily.
Dr. Michael Koren:
12:51
Or they're on a GLP-1 angonist.
Dr. Steven Toenjes:
12:53
Correct, and so the dietary and behavioral triggers are often pretty well known to a patient. Most of the time that's something I ask the patient and they tell me. I don't tell them. But there are triggers like dehydration, ie you should drink water and stay hydrated.
Dr. Steven Toenjes:
13:17
Prolonged fasting, skipping meals, is actually often a prominent migraine trigger. So we should eat regular, healthy meals. Altering circadian rhythms, bed and wake time sleeping enough. And then the last behavioral approach we would say is exercise. Exercise is actually very useful. E xercise causes headaches or relieves them? No it's very beneficial to have regular exercise.
Dr. Steven Toenjes:
13:46
One special trigger that I would point out is something that is just extremely potent would actually be musculoskeletal neck pain. Pain in our mid and upper cervical spine is very commonly really the trigger or culprit that ends up with a patient, you know, needing to come to our clinic. Yeah, it is, and it's very useful to identify that, because there really are some special physical therapists in the community who are capable of impacting the neck pain-related trigger and thereby the headache syndrome with essentially exercise, stretching and careful strengthening, and that's not a medicine.
Dr. Michael Koren:
14:33
Very interesting. So a little bit more clarity on the amount of time from trigger to symptoms, that would be typical. I know some people aren't 100% sure if something caused it and what that time course should be.
Dr. Steven Toenjes:
14:47
I would say it's variable because a migraine event remember the pain part of it I alluded to being a four to 72 hour window event. There are different phases of migraine. There is the painfully obvious pain phase.
Dr. Michael Koren:
15:06
Right.
Dr. Steven Toenjes:
15:07
But there's a prodromal phase that can last hours to a full day or so before a migraine, and then there can be a post-drome or a quote-unquote migraine hangover after the pain is over, and so it could be difficult for someone to identify that a trigger tipped them off into a prodromal phase that may last as much as a day, but usually, I mean, our brains are very good at figuring out what kind of stuff is making us hurt, and so a person usually will figure that out Pretty quickl.
Dr. Michael Koren:
15:42
PSo it's not usually necessary to do sort of trial and error with regard to different substances and see what causes problems and what isn't. Challenges very specific types of challenges per se.
Dr. Steven Toenjes:
15:55
I think that a person can't, you know, if somebody is having a difficult time with their migraines. There is some utility to focusing on potential dietary and behavioral triggers, with filling out diaries and keeping track of things in that manner and most of the time they're going to be, you know, capable of identifying them. Some triggers are amazingly impressive, particularly smell-related triggers. I mean, there are a high percentage of patients who, if they smell a particular perfume or a particular smell, will instantaneously have a migraine.
Dr. Michael Koren:
16:37
Instantaneously, isn't that ?
Dr. Steven Toenjes:
16:38
craz High percentage. Very, very interesting, often very disabling, especially if you're a teacher and you're a migraine with aura and your aura includes expressive aphasia and your teenage kids figure out that they can trigger a migraine in you and you can't talk.
Dr. Michael Koren:
16:56
Isn't that crazy.
Dr. Steven Toenjes:
16:59
TShe had to quit her job.
Dr. Michael Koren:
17:00
Oh, my goodness, yeah, huh. And that brings up another point. So do you need to have headaches and get the diagnosis of migraines? You hear about these other type of symptoms associated with migrainous problems type of symptoms associated with migrainous problems.
Dr. Steven Toenjes:
17:16
So do you need pain as part of tha Oh, that's a great question. The answer is no, and so one of the phases that about a quarter of migraine patients are capable of having is the aura phase. A lot of people have generally heard of visual aura. You can get funny visual phenomena that can occur. Generally, a person will see something like a scintillation, a light or a kaleidoscope that sort of grows and spreads across visual space. Generally, a visual or any other aura symptom is going to be something that will evolve over minutes, last less than an hour, typically 20 to 30 minutes and then go away, most commonly then being followed by the pain phase or the headache. But you can have aura and not have a headache. True, acophagic migraine or no, head pain, migraine or the official term.
Dr. Steven Toenjes:
18:17
In the international classification of migraine disorders, I would point out, the most common migraine aura symptom is a visual one. The second most common is an evolution of hemibody numbness and the third is an expressive aphasia body numbness. Oftentimes these will come one, two, three the visual aura, then the sensory aura, then aphasia, and that lands patients in the emergency room.
Dr. Michael Koren:
18:41
Right. So aphasia just for people's knowledge means you can't speak.
Dr. Steven Toenjes:
18:45
Yes, you know what you want to say, but you can't get your words out Exactly, and so one of our more common clinical scenarios is where we see people with one of their first aura events that includes aphasia or numbness in the emergency room for suspected stroke.
Dr. Michael Koren:
19:01
So in our next segment, I want to talk about the treatments, and I'm going to give a little tease for that. It's anywhere from caffeine to Botox, to a bunch of other things.
Narrator:
19:18
Thanks for joining the MedEvidence podcast. To learn more, head over to MedEvidence. com or subscribe to our podcast on your favorite podcast platform.
