When to See a Headache Specialist? 2024
Tension-type headache, (TTH), and migraine are the two main headache diagnoses in the world. TTH and migraine are 99% of headache in general, but most of the patients who come to the doctor have migraine as TTH patients rarely come in unless they are overtreating and get medication overuse headache.
TTH and migraine are called “primary” headaches, which means that the cause is uncertain, but the neurologic exam and all tests for work-up such as blood work, lumbar puncture, and CAT or MRI scans are normal.
Hypertension is referred to as “primary” also, because the majority of patients have no apparent medical abnormality found after workup.
Although many neurologists and primary care physicians treat persons with headache, a true headache specialist has specific qualifications that make them especially equipped to treat migraine and other headache disorders.
It is always a big decision to go see a new doctor and most sort of dread it. Would it be helpful to find legitimate, reasonable decisions as to when to see a headache specialist?
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This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.
When headache is more frequent and severe and medical treatments haven’t worked, or the diagnosis is uncertain, then it’s time to see a headache specialist. When headache is disturbing your life, your work, your general health and your sleep, it’s time to see a headache specialist.
Related questions
1.What Is a Headache Specialist?
Doctors who specialize in headache have their own personal interest in headache and they like to read about it in scientific journals and books. They go to headache meetings. Many of them have migraine themselves. During their neurologic training they may later take a headache fellowship program.
Because most headache patients a doctor sees occur in persons who are generally healthy and have a normal neurologic exam and tests, headache doctors gain a lot of experience seeing the same kind of problem over and again.
Eighty to ninety percent of new patients to a headache clinic have medication overuse headache which is a syndrome due to overuse of pain killers and headache medication.
The doctor may hear that their patient used to have episodic headaches lasting hours to 2-3 days but during the past 6 months the headaches have occurred continuously and daily.
The headache pattern may have migraine features of being one-sided, severe, throbbing or stabbing pain, nausea or vomiting, and sensitivity to light or sound.
Then on interview the doctor may find the patient is drinking 4 cups of Starbucks coffee a day and taking tramadol several times a day. Caffeine is the number one drug over the counter that causes medication overuse headache and tramadol is an opiate narcotic that should really never be used for headache because of addiction and headache provocation issues.
The doctor will do a careful neurologic exam on that patient and review or order tests such as blood work or CAT or MRI scan, but the rest of the interview will be educating that patient that he needs to stop caffeine and tramadol, either suddenly or slowly by tapering off.
Then the doctor will substitute treating the daily severe headache with 1 or 2 weeks of cortisone, which usually helps, start a preventive drug, like one of the new CGRP drugs, and offer an acute treatment drug like Timolol eye drops or DHE which don’t cause the medication overuse problem but help treat the severe headaches.
2.What are concerning symptoms, “red flags” that should provoke a patient to see a headache specialist in the clinic or go to the ER?
Complicated headaches with unusual symptoms.
Feeling weak or numb on one side of the body; change in level of consciousness, trouble walking, change in memory, vision, or ability to speak.
Having a migraine longer than 72 hours (the International Classification of Headache Disorders 3 states that a migraine may last only 4-72 hours.
Persons with complicated medical or psychiatric problems such as patients with fibromyalgia, asthma, epilepsy, insomnia, anxiety, depression, or panic disorder.
Having headaches more than 2 days a week.
Headaches that make you miss social events, school, or work.
Headaches that affect relationships with family, friends, or coworkers.
Headaches occurring while pregnant or nursing.
Thunderclap Headache: very severe sudden onset headache that reaches its maximum immediately (within a couple of minutes). Thunderclap headaches require emergent medical evaluation to rule out intracerebral aneurysm bleed. These headaches are “the worst ever, explosive, like something ruptured in my head.”
Positional Headache: headache that substantially changes in intensity in association with changes in position, such as standing from lying or vice-versa.
Exertion related headaches: headache from straining at the toilet, sneezing, or coughing.
New onset headaches--especially if the patients is over 50 years of age, or if there are other medical conditions like cancer, or a blood clotting disorder.
A documented change in headache occurrence, such as an increase in frequency or change in headache characteristics
Constant headache which is always on the same spot in the head.
Migraine with aura patients that have long or quick onset aura symptoms. Migraine aura symptoms may be the visual aura which may be a bright light or zig-zag image, numbness in the one side of the body which start in the fingers, next move to the forearm, then arm, and then commonly to the same body side of the face or cheek.
Migraine with aura patients may also have trouble speaking, called dysphasia, where they can’t find the right word to say and can’t write or read well.
The progression of these aura symptoms should have a slow onset and resolve within 60 minutes. But if they don’t improve in an hour, emergency medical attention is then required with a visit to the ER and emergency scanning to rule out a stroke or a brain tumor.
Headache that never goes away.
Headache plus systemic symptoms such as fever, chills, weight loss, or night sweats.
New headache in a patient with cancer.
Headache that keeps getting worse over 24 hours.
Headache after head injury.
Headaches that come with visual blackouts, pain while chewing, body arthritis, or weight loss (temporal arteritis).
3.Problem with the diagnosis of migraine.
There are lay medical diagnoses in our culture that a patient may think they have which are usually migraine when that patient is seen by a headache specialist.
Migraine has “false names” or “pseudonyms.” These are:
Sinus headache
There is no legitimate “Sinus headache” and the name was created by the pseudoephedrine industry in the fifties to sell pseudoephedrine, known as a mild nasal vasoconstrictor and a decongestant.
Currently there are over 200 pseudoephedrine type drugs in the United States. “Sinus headache” is not found in any other country in the world except the U.S. and is an inaccurate medical term which usually denotes migraine headache.
Menstrual headache
At the end of the 3rd week of a woman’s cycle estrogen levels drop and over two-thirds of female migraine suffers develop a menstrual or estrogen related headache.
The International Classification of Headache Disorders (ICHD3) defines menstrual migraine as migraine attacks occurring during the period extending from 2 days prior to onset of menses to 3 days following onset of flow, with such attacks occurring in at least 2 of 3 menstrual cycles.
This could be menstrually related migraine with or with out aura for women who have headache with menstruation or at other times during the month. Some women have pure menstrual migraine and only get a headache during their cycle time.
Nocturnal headache.
There is a differential diagnosis of night-time headache but over 90% relate to migraine. Other considerations would be hypnic headache, cluster headache, obstructive sleep apnea, temporal arteritis, benign post-orgasmic headache, post-intercourse subarachnoid hemorrhage, and essential hypertension.
Sick headache.
Migraine turns on the vomit center in the brain stem and makes people nauseated or vomit. Hippocrates described sick headache 300 years before Christ.
One-sided headache.
Galen, a Roman physician, in the 3rd century described “hemicrania” which means half of head. As time went on the “he” part of the word was removed and you’ve got micrania, which then became migraine. Migraine comes from a word that means half of head and being one-sided is the most common migraine symptom.
Hungry headache,
Fasting or a low blood sugar level promotes cerebral vasodilation which can start or aggravate headache in persons with migraine. The treatment of hungry headache is to feed it.
How can I find a headache specialist?
Your primary care doctor likely has a list of doctors he refers to and would be a good place to start.
Your county or state medical society may have a list of doctors for headache referral.
Word of mouth or the internet can be helpful, but avoid doctors who use opioid narcotics or butalbital, also known as Fiorinal, Fioricet, or Esgic.
The American Academy of Neurology and the American Headache Society have lists of headache doctors in various medical cities.
How to prepare for your first visit with a headache specialist.
Prepare a complete summary of drugs you take, over the counter and prescription too.
Write down how often you take drugs for headache.
Comment on any family history of migraine, because migraine is genetic and is inherited. Tell the doctor that your mother and your sister have migraine.
Caffeine in coffee or tea is important for the doctor, and is a common migraine aggravator.
Bring your imaging discs or medical testing such as blood work or any previous doctor office notes you can provide. In my experience many patients show up with no data, but have asked their referring doctor for information which didn’t come.
Unfortunately, there is a shortage of headache specialists in the U.S. Because of this wait times can be long. Get on-line and read some of the educational articles. Go to reliable sources like the Mayo Clinic, the American Headache Society.
Go to my website. Trust me. I have lots of data on headache organized into categories at www.doctormigraine.com. Click here to go there.
And remember although headache is a terrible painful, disabling medical condition, it is not usually due to any serious medical problem.
Check out my Big Book on Migraine Here.
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All the best.
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Britt Talley Daniel MD