We at the Comprehensive Headache Treatment Center at the Rowe Neurology Institute see many patients with the most complicated and difficult-to-treat headache problems in this region, including migraine headaches refractory to the usual headache treatment. Many of these patients have been on the pill merry-go-round for years without relief from their headaches. Our approach to headache is comprehensive, beginning with determination of the root causes and triggers of the headache cascade, with an individualized consideration of the patient as a whole. Only then do we follow up with appropriate headache treatment mentioned below. We use all the FDA approved drugs, but we also find that in many cases there are alternative treatments that give more effective and lasting results.
Since sleep and neck problems are such common triggers of the headache cascade, and since we are experts in the non-surgical treatment of both sleep and neck problems as well as headache, we always thoroughly evaluate any problems a patient has in these two areas. Fairly frequently, addressing these problems helps a patient avoid long term treatment with many of the drugs commonly used for headache treatment and migraine treatment.
New Patients seen in 3 days.
Dr. Vernon Rowe introduces the Headache Center:
Find the Cause of the Headaches
Before choosing a treatment, it’s important to figure out what’s causing or contributing to the headache cascade. Most of our patients have migraine, but we can’t just assume that’s the diagnosis, because many brain abnormalities can mimic migraine.
It’s important to get a complete neurologic as well as headache history, do a complete neurologic exam, and consider obtaining necessary blood work, appropriate imaging such as MRI of the brain without contrast, or sometimes with contrast depending on the headache pattern and history, MRA depending on history, neck studies, and a sleep study if sleep problems are suspect. Occasionally we find brain tumors, aneurysms, Chiari malformations, intracranial hypertension, infections, severe sleep disorders, metabolic problems, neck problems, and other issues which need very specific treatments. Sleep disordered breathing can be mild, and appear in slender people, and be a major cause of insomnia and itself trigger the headache cascade.
Non-pharmaceutical Headache Treatment
There are many non pharmaceutical headache treatment therapies that often can be more effective than merely chronic medication in reducing headaches, including migraine headaches.
Sleep Disorder treatment: Treatment of Sleep Disorders can help in headache control. We find in many cases, a sleep disorder that forces side sleeping is found along with neck problems, that in turn, may be the main headache trigger. We do not know all the details yet about how sleep and headache are related, but several of our patients have had a significant improvement, and even complete resolution, of their headaches once their sleep disorder was corrected.
Physical Therapy: Most neck problems can be treated with Physical Therapy – Helpful for headache treatment of both migraine and “cervicogenic”, or neck related, headaches. This type of therapy is best done by physical therapists who specialize in evaluation of head and neck problems, and in headache treatment.
Correction of movement pattern abnormalities can lead to lifelong improvement of many headache disorders and prevent neck pain and even neck surgery later on in life. Massage therapists and Chiropractors offer different treatments with less lasting effects.
Other Types of Headache Treatment
There are a variety of treatments for migraine, including injections, stimulations, and medical treatments that are not just daily pills. At our Comprehensive Headache Treatment Center, we keep current on these developments and many are either in use or are under evaluation in our clinic. Here is an overview of some of these therapies.
Botox Injections: Since 1996, our clinic has been using Botox to help treat headaches, neck problems, dystonia, spasticity and the Chronic Migraine headache. Botox was approved by the FDA in 2010 for the treatment of chronic migraine headache. About 31 tiny injections are given in the forehead, scalp, and neck over a few minutes, using a tiny needle. This is done once every 3 months, and it’s important to know just how to give it. If it works, headaches can be markedly improved, or sometimes eliminated for 2-3 months before they come back.
The mechanism of action of Botox in chronic migraine treatment is thought to be that it is taken up by the small, uninsulated sensory nerves in the face and head, and transmitted through those nerves back to the central nervous system to affect a critical step in the migraine process, the Calcitonin Gene Receptor Peptide receptor. Though other therapies are being tested that affect this cascade and the CGRP receptor, Botox is the only one approved at this time. However, Rowe Neurology will be a site for clinical trials of important drugs to be tested affecting this important pathway. So stay tuned!
Botox works for headache treatment in a different way from its effects on muscles, when used to treat dystonia and muscle spasticity, and different from its cosmetic use to decrease wrinkles in the face. Thus, it’s important that the Botox be injected correctly.
Occipital Nerve Blocks & Trigger Point Injections – These less expensive nerve blocks and trigger point injections might significantly help or even stop particular types of headache (such as cluster headache, migraine variants, and neck-related headaches) for a few days to give patients a break and interruption of a vicious headache cycle, as opposed to more expensive, sometimes longer-lasting, Botox treatments.
Sphenopalatine Block( – This procedure involves squirting a numbing medicine far in the back of the nasal cavity, and can sometimes relieve particular types of headache for a few days or weeks. Headaches which can be helped include Migraine, Cluster Headache, and Sphenopalatine Neuralgia.
Transcranial direct current stimulation (tDCS)—This procedure stimulates the brain using a handheld brick-shaped magnetic stimulator with sudden, controlled bursts of magnet-induced electricity to interrupt and modify the brain circuits during a headache aura responsible for causing migraine pain. At least, that’s how we think it works when it works. This therapy is not yet available in the US.
Forehead Scalp Neurostimulation – A 20 minute per day stimulus tries to limit pain signals from deep in the brain by stimulating a branch of the trigeminal nerve, where migraine headaches sometimes start. It is hoped to change the trigger threshold of migraine headaches, making them less frequent, less painful, or even to help eliminate them altogether. The FDA approved device is called Cefaly, which is not covered by insurance, and costs $350 to purchase. We at the RNI try to assess the effectiveness of this device for any particular patient before anyone has to purchase the device from their own funds.
Biofeedback / Neurofeedback – Helps migraine and certain other headaches very well in some patients, but again is not covered by insurance.
Cognitive-Behavioral Therapy & Acceptance and Commitment Therapy (Psychological Counseling) – Usually very helpful in some patients when a cause or specific trigger cannot be found, and when psychological factors are playing a major role in triggering the headache cascade.
Acupuncture – May help as a last resort in some patients, but the procedure itself is extremely operator dependent and trials are subject to bias.
Non-pharmaceutical, Non-device Headache Treatment
Aerobic Exercise – Approx. 40 min. 3 times per week helps many patients, and certainly is a good health practice for all patients.
Isometric Neck Exercise – This must be used cautiously and should be directed by a Physical Therapist.
Avoiding Common Triggers such as: – Too little sleep, arising from sleep too late, too much caffeine, too many opioid analgesic medicines (opioid medications should not be used in the treatment of chronic headache), skipping meals, too much stress (some stress is a good thing), MSG overuse, and other specific known food additive triggers like nitrites.
Headache Treatment that is Controversial and Not Recommended
Surgery to prevent Migraine – All of the various headache surgeries are highly controversial in the US, and some are illegal in certain other countries. There are several types and they are all expensive and have limited success. They all amount to cutting off your leg if it hurts. Surgery to correct a deviated septum has very little evidence that it benefits headache. TMJ surgery helps TMJ pain, but doesn’t have strong evidence that it will help Migraines. And TMJ is frequently caused by bruxism, or teeth grinding, which itself is frequently caused by disorders of breathing in sleep.
Implantation of electrical stimulators in the scalp is said to provide at least temporary good benefit for some headache sufferers, but again this is not well studied.
Repair of patent foramen ovale in the heart has not been shown to help headaches, though there was interest in this expensive and problematic procedure years ago.
Alternative Headache Treatment Using Supplements
Some dietary supplements may help, but you should know these are really medications themselves, and are not regulated by the FDA.
Magnesium – 400-2,000 mg per day taken daily with food. Use of the slow release version may be best, and caution diarrhea as a side effect if the dose is too high. Must be tried for about a month. Also, avoid if a kidney disorder is present.
Co-Q-10 – 300-1,200 mg in the morning may help migraine (avoid taking at night)
Butterbur (Petasites hybridus) – 75mg twice-per-day may help migraine, but it can cause birth defects (if taken while pregnant), liver disease, and even cancer. So this supplement must be used, if at all, with extreme caution.
Feverfew (Tanacetum parthenium) – Often helpful for migraine if a standardized extract is used, but this is not available in the US and “feverfew” products available in the US are so variable in content that they are unpredictable and often don’t work.
Folic acid, Vit B-12 (cyanocobolamine), & Vit B-6 (pyridoxine) – May work as a combination for migraine patients who’s labs showed an elevated homocysteine level
Inhaled Oxygen – Greatly helps stop a cluster headache if used at 10+ liters per minute for 5-15 minutes, but does not help if taken other ways and does not help other kinds of headache, like migraines or tension-type headache.
Capsaisin – Spray into the nostril daily to prevent headaches or as needed to stop headaches. May help cluster or migraine headaches, but detailed studies are not available, and can be irritating to the nasal passages.
Aspirin 325 mg per day (preferably buffered) – This easy to get, inexpensive, and common medication has had major success in preventing Migraine. Remember though, aspirin is an effective antiplatelet agent and can cause bleeding.
Timolol eye drops – Possible slight benefit for stopping a Migraine, but the jury is still out on this therapy.
Most importantly, headaches that are hard to control need evaluation in a Comprehensive Headache Treatment Center like the one at the Rowe Neurology Institute. Don’t just get on the pill merry-go-round or buy the latest gadget “guaranteed” to cure your headache. Find out what really triggers your headache cascade, and what the priming factors for your migraine really are. Take your life back!
By Vernon Rowe, and Elizabeth Rowe