On Sunday, September 18, 2022, neurologist Dariush Saghafi, MD, presented an informative and engaging presentation on how to evaluate headaches in primary care to HealthTap’s Doctor Network. Dr. Saghafi is the Director of the Headache Clinic at Louis Stokes Cleveland Department of Veterans Affairs Medical Center in Cleveland, Ohio. 

For the full presentation, titled: “Challenges in Telemedicine: The HA Patient,” you may watch a video recording of Dr. Saghafi's informative webinar. 

Summary

In his talk, Dr. Saghafi went over these key points:

• He outlined and described the distinguishing characteristics of the four categories of headaches: 
  • tension, 
  • migraine, 
  • trigeminal autonomic cephalalgias, and 
  • other (e.g., related to cough or sexual activity).

• He noted that substance withdrawal headaches (medication overuse headaches) are very common from overuse of NSAIDs.
• He reviewed danger signs of headaches caused by serious/critical illnesses.
• He completed a brief review of the treatments for cluster and migraine headaches.

Questions and answers

HealthTap doctors had quite a few questions for Dr. Saghafi. Here is a summary of the answers from Dr. Saghafi and the HealthTap team: 

• Food triggers
  ⁠When asked about food triggers and migraines, Dr. Saghafi commented that food triggers are highly variable from person to person. Per the American Migraine Foundation: "Commonly reported migraine triggers do include alcohol (especially red wine and beer), chocolate, aged cheese, cured meats, smoked fish, yeast extract, food preservatives that contain nitrates and nitrites, artificial sweeteners, and monosodium glutamate (MSG)." (See “food triggers” supplemental information below.)
  
• Red eyes and cluster headaches
  ⁠How long does the eye stay red and angry looking after a cluster headache? Answer: This is an acute symptom of hemifacial dysautonomia that resolves when the headache improves. (See “cluster headaches” supplemental information below.)
  
• Post-traumatic headaches
  ⁠In post-traumatic headaches, what are the indications for obtaining visual field studies, magnetic resonance venogram, or lumbar puncture with dynamic opening manometry and/or treatment with acetazolamide for presumed pseudotumor cerebri? 
  Answer: Emergency doctors usually order a plain CT scan to rule out intracranial bleeding. An MRI reveals a wider array of underlying brain pathology, but is less sensitive at detecting small bleeds. The most sensitive way to detect any bleeding is to examine the CSF (via lumbar puncture). Post-traumatic pseudotumor cerebri is rare after mild traumatic injury, but may be heralded 2–3 days after injury by significantly worsened headache, papilledema, and/or cranial nerve findings. (See “post-traumatic headaches” supplemental information below.) (See Secondary intracranial hypertension (pseudotumor cerebri) presenting as post-traumatic headache in mild traumatic brain injury: a case series)
  
• Hemiplegic migraines
  ⁠When asked to review diagnostic considerations for hemiplegic migraines, Dr. Saghafi commented that these migraines are associated with focal neurological symptoms (e.g. one sided extremity weakness, numbness or tingling in one side of the face, mild slurring of speech) that are otherwise suggestive of a stroke. He advised that if focal neurologic symptoms are present, treatment with triptans is contraindicated. (See “hemiplegic migraines” supplemental information below.)
  
• High-flow oxygen and cluster headaches
  ⁠Why does high-flow oxygen work for cluster headaches? Also, using 10–15 liters/minute could empty the tank quickly, so do patients have large tanks when using this treatment Answer: We don't know why it works, but it can be very effective for cluster headaches (but not for other forms of migraine). Usually patients have a delivery service which will leave them extra tanks at home, and don’t usually run out of oxygen even at a high rate of delivery. He suggests advising patients to request a delivery right away when they may be running low. (See “high-flow oxygen and cluster headaches” supplemental information below.)
  
• Other treatments
  ⁠When asked about other modalities of treatment, Dr. Saghafi commented that a device delivering alternate cold and heat to the head can be effective, that botulinum toxin works for migraine but not cluster headaches, and transcranial magnetic stimulation (TMS) appears to have benefits too, though it is less widely available and quite expensive. He had no experience with the Cryotron, which is a non-invasive cold-therapy delivered into the mouth for migraine relief. 

Supplemental information from Dr. Saghafi

Food triggers

Discovering precise food triggers can be a daunting task in some patients though many have a good idea of the foods and beverages they need to avoid in order not to get migraine headaches. However, my general rule of thumb when explaining how to document potential triggers in a headache diary is to ask patients to be cognizant and aware of the foods or beverages they have ingested in any two-hour time period preceding migraine attacks or migraine aura.  

Though this may seem to be a rather short block of time beyond which ingested foods and beverages are not considered part of the potential culprit list — in reality, studies have found that most ingested substances tend to cause reactions in migraineurs within two hours if they have relatively normal G.I. transit times and no other significant comorbid conditions that could block food absorption or the digestive process. 

The two-hour timeframe also makes documentation efforts much more manageable for most patients who have busy schedules and cannot necessarily recall everything they have eaten throughout the day any longer than two hours (especially if migraine attacks follow).

Cluster headaches

The international classification of headache disorders specifically speaks to a duration of time for cluster headaches as being no shorter than 15 minutes and no longer than 180 minutes.  The rapidity with which these headaches come on, reach their zenith and subside, is impressive and can be witnessed by clinicians and family members as they occur.

Typically, dysautonomia features that characterize cluster headaches such as conjunctival injection, tearing, and facial asymmetry can last the entire duration of the headache or any part thereof.

However, as a general rule of thumb, the longer the duration of the headache from start to finish the shorter the time of some of the more impressive or visibly notable symptoms such as the “red and angry eye.“ I have found that in patients with cluster headaches lasting one hour or less symptoms related to the orbit in the eye tend to run the entire course whereas patients with time frames longer than this tend to resolve their eye and/or orbital symptoms within one to two hours, though the severity of the headache itself and other sensory/autonomic changes can persist right until termination of the event.

Post-traumatic headaches

Good management in patients suffering from mild traumatic brain injury (mTBI) should always include at the very least confrontational visual field testing in the office or bedside which can be rather sensitive in the detection of small visual field defects not otherwise noticed by patients. If such “dropouts” in visual integrity were to be discovered by the examining clinician then, more sophisticated and detailed testing using visual perimetry devices and computers can be ordered.

Although any number of imaging studies could be obtained in post-traumatic brain injury patients it is generally agreed that the best single test in such cases is the non-contrasted MRI of the brain. In post-traumatic brain injury cases, my threshold for performing an MRV is guided by other clinical parameters, such as: 

• slowly developing changes, 
• decreases in mental status, or 
• alertness in a patient who was previously considered awake and communicative at least 12 hours following the acute incident. 

Other clinical parameters I watch for are: 

• convulsive activity, 
• nausea or vomiting, 
• not responsive to conventional medications, 
• sudden or unexpected elevations in body temperature, 
• unrelenting vertigo, or 
• even something as nonspecific as unusual bouts of forgetfulness not characteristic for the patient.

Hemiplegic migraines

Even though motor weakness of a focal nature is considered to be one of the key features of aura in hemiplegic migraine, it must be noted that in some cases this weakness can be subtle and even overshadowed by other symptoms, such as:

• impaired speech and language function, 
• paresthesias and sensory changes which may be unilaterally based, and 
• in even some rarer cases, the switching of sides during or between attacks of motor weakness or other sensory symptoms.  

Even though the diagnosis of hemiplegic migraine is stated to be rare, I believe it is highly underreported due to lack of relevant questioning by the clinician of the patient in terms of motor and sensory symptoms that are generally not considered part of the migraine aura phenomenon in patients who do not have hemiplegic migraine. Full and complete history-taking in a migraine patient involves asking whether or not anyone else in the bloodline suffers from not only similar headaches, but similar associated symptoms of either motor or sensory changes during their headaches, as this could be a clue to the familial hemiplegic migraine subtype.  

Another key piece of history in these patients is the characteristic finding in hemiplegic migraine of onset of symptoms, typically in the teenage years and more uncommonly after their 20s or 30s, which may actually be peak years of incidence for migraine headaches with or without aura not including any hemiplegic subtype.

The most important reason to either include or exclude the diagnosis of hemiplegic migraine in any new headache patient being seen for the first time is so that the triptan family of drugs can either be considered with confidence as a possible treatment option, or avoided altogether since triptans can increase the risk of both stroke and heart attack during such episodes.

High-flow oxygen and cluster headaches

To date, the exact mechanism of action for high-flow, 100% O2 in cluster headache remains unclear, but proposed mechanisms of action seem to focus on oxygen‘s ability to modulate areas of the brain specifically targeted by cluster headache such as the trigeminovascular system, the cranial autonomic system, and perhaps most importantly, the hypothalamus.  

There seems to be no question that the trigeminovascular system is a key player and highly activated during cluster headaches. As a result, neuro-inflammation can occur, which results in the release of significant amounts of neuropeptides and CGRP concentration elevations, which are all effectively countered by the oxygen treatment. High-flow O2 is believed to reduce and even terminate the effect of this inflammatory rush upon trigeminal afferents which may also explain the rapidity by which this therapy can act in cluster headaches.

Thank you to Dr. Saghafi for his fascinating presentation.