While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment
Headache
The incidence of migraine headaches rose dramatically during the 1980s, particularly in women, according to a new study by researchers at the Mayo Clinic. The study, which was published October 2022 in the Journal of Neurology, compared first-time migraine diagnoses documented in patient medical records from 1979 to 1981 with those from 1989 to 1990. Records from 1342 patients were included in the study. Overall, the incidence of migraine increased by 56% in women and 34% in men. The most striking rate of increase was in women aged 20 to 29—from 600 to 1000 new cases per 100,000 women per year. In men the same age, the rate increased from 200 to 250 per 100,000 men per year. This brings up obvious questions. Maybe, healthcare providers are identifying headaches more easily? Are these headaches related to diet changes? I suspect many times diet strongly contributes to headache intensity and frequency.
Some specific headache types:
Migraine, tension, medication overuse, daily persistent headache, menstrual migraine, traumatic brain injury, cluster headache.
Acute treatment:
NSAIDs, acetaminophen, triptans, calcitonin gene related peptide (CGRP) receptor antagonists, muscle relaxants, antiemetics, dihydroergotamine, oxygen.
Prophylactic treatment:
First-line: Beta-blocker, amitriptyline, topiramate (possible CGRP receptor antagonist), valproic acid (not for use when childbearing potential)
Second line: CGRP receptor antagonist monoclonal antibodies (aimovig, ajovy, emgality, vyepti), calcium channel blocker, magnesium, muscle relaxants
Third line: Pregabalin, cyproheptadine, botulinum toxin injection, monoclonal antibodies targeting calcitonin gene related peptide receptor
Diet: Restriction of specific triggers. Headache triggers: Alcohol, artificial sweeteners, beans, caffeine, cheeses, yogurt, foods containing monosodium glutamate, processed meats, some herbal supplements extremely cold or extremely hot foods (think Carolina Reaper pepper).
Consider carbohydrate restriction.
-Ketones are more efficient energy than glucose. Ketones increase mitochondrial efficiency and production. Ketones also have an antioxidant effect on mitochondria, and decreasing damage to cells. -Ketones increase GABAergic tone and decrease Glutamateric tone. Increasing GABAergic tone results in inhibition of neurotransmission, improves sleep, improves anxiety, “calming effect”. Glutamate can damage or kill nerve cells if overactive. Excessive glutamate has also been associated with the following conditions: ALS, MS, Alzheimer's disease, Parkinson's disease, Huntington's disease, stroke, fibromyalgia, and chronic fatigue syndrome. Mental health conditions associated with a glutamate disorder include: Anxiety, autism, depression, obsessive-compulsive disorder, and schizophrenia. -Ketones increase the release of BDNF (brain-derived neurotrophic factor), promotes survival and maintenance of nerve cells.
Treatments based on etiology of headache:
Traumatic brain injury:
Pathophysiology: Metabolic, physiologic, and micro structural injury to the brain. Autonomic nervous system dysregulation occurs. The autonomic nervous system regulates cerebral blood flow, blood pressure, and heart rate. Heart rate variability post injury due to damage in the vagal nerve tracts can result in early fatigue, and inappropriate increases in blood pressure and heart rate during activity. (See my other post regarding concussion).
Treatments:
Limited rest, then low level activity as tolerated
Preventing blood sugar and insulin excursions with low carb, high fat diet, intermittent fasting
Stimulate the endocannabinoid system with exercise, meditation, and foods such as: Truffles, dark chocolate, coffee, oregano, curcumin, cinnamon, Chia seeds, hemp, walnuts, sardines, eggs, anchovies.
Some evidence that CBD oil is helpful also
Meditation and non-sleep deep rest
Cold Thermogenesis therapy. Stimulates dopamine and adrenaline.
Stress reduction techniques including: Singing, cold exposure, and abdominal belly breathing increase parasympathetic tone.
Low-dose naltrexone decreases inflammation, increases endorphins, and improves immune function
Other medications can be used to stimulate serotonin, dopamine, etc. such as amitriptyline and SSRIs
Use a red light and low light conditions at home. When red light is used within 3 hours of wakening, you have decreased free-radicals in the mitochondria, improved cellular ATP production, and improved cell function.
Use blue blocker glasses or other sunglasses to cut down on eye strain
Medications such as propranolol and indomethacin
Optimize vitamin D levels
Optimize sleep. Address mouth breathing, allergies, sleep apnea, sleep hygiene, use white noise
Elevate heels by 12 degrees. Improves glymphatic system washout (clearance of cellular debris from brain).
Creatine monophosphate supplementation up to 5 g daily. Helps regulate calcium, ATP production, and neuronal function.
Tension headache
Seems to have central and peripheral sensitization pathology. Due to muscle contraction, tight muscles, and possible inflammation.
Upper back/postural exercises-for tension component of headache
- Dead hangs (both arms, advanced to single arm at a time)
- Face pulls (adjust to about level of throat)
- Ring reverse push-ups with feet on a bench
- Close grip rows for latissimus, wider grip for upper back and trapezius
- Y, I, T-raises (semi-prone and bring both arms up and lateral with free weights)
Osteopathic manipulative technique, gentle indirect and stretching techniques to the neck and upper back.
Seventy-percent of all headaches are either migraine, tension, or menstrual-related.
Migraine headache
Etiology is felt to be secondary to the triggering of nociceptors in the trigeminovascular pathway. C nociceptors in the dura are also activated in migraine. When activated, these nerve endings release CGRP. Resultant cortical spreading depression occurs in the cortex of the brain activating nociceptors and triggering neurogenic inflammation with vasodilatation and even mast cell degranulation. Serotonin and CGRP also appear to be connected. Low serotonin levels can dilate blood vessels and initiate migraine. Triggers include: Menstruation, emotion, light, lack of sleep, alcohol, certain odors (perfumes most frequent), heat, exercise, stress, decreasing barometric pressure changes (altitude or storms), and foods. Caffeine may worsen or improve. Some meds that can be helpful for prophylaxis including: Cyproheptadine (serotonin and histamine antagonist?), benzodiazepines, and dopamine antagonist.
Tension and migraine headache treatments:
Omega-3 fatty acids, 1 g/day, Botox treatment (possibly blocks neurotransmitters regarding pain signals), acupuncture, peppermint, and eucalyptus oil, curcumin 80 mg to 2 g anti-inflammatory effect (caution with anticoagulants, also will potentially interfere with dihydrotestosterone). Ginger possibly decreases CGRP levels.
Premenstrual syndrome-related headache treatments:
During the late secretory phase of the menstrual cycle, estrogen is low and the production of serotonin decreases. This leads to an increase in CGRP and substance P from the trigeminal nerves. These substances cause vasodilation of intracerebral vessels and sensitization of the trigeminal nerve. The blood brain barrier permeability increases and pro inflammatory mediators affect the meninges. Estrogen increases endothelial cell nitric oxide synthetase activity, resultant increased production of nitrous oxide, a vasodilator. This increases during the luteal phase of menses at the same time a drop and serotonin occurs. Omega-3 fatty acids 1 g/day. Oral contraceptives may help prevent estrogen drop (focus on continuous dosing)
Occipital nerve block.
This can be helpful for occipital neuralgia, chronic migraine, cluster headache, and hemicrania continua. Use either lidocaine 1 to 2% or bupivacaine 0.25% or 0.5% approximately 2 to 4 cc per nerve block, use 1.5 inch 27 gauge needle. Steroid mixed in with local anesthetic has not been proven to improve recovery or prevent recurrence of headache.
This post was a fairly comprehensive discussion of headaches. The best practice is to avoid complicated abortive and headache preventative medication regimens. Use proper diet and stress-reduction to increase your chances of being headache-free!
I hope this information helps you and your loved ones!
Jason Williams, D.O.