Neurologist Lisa Mannix Explains What You Need to Know About the Pain in Your Head

"People deserve to get a proper diagnosis and adequate treatment."(LISA K. MANNIX)

Lisa Mannix, MD, is a neurologist in private practice in Cincinnati.

Q: What are clues that your primary care doc is not taking your headaches seriously?

A: Primary care providers are incredibly busy and they have to know such a huge amount of disorders and treatments. It's part of the patient's responsibility to help them take it seriously. Provide headache calendars, meet and ask questions about the medications or new medications, ask "Am I someone who should see a headache specialist?" They may be very grateful and refer you. Part of it is you taking it seriously as well.

Q: Why do we understand so little about what specifically causes headaches?

A: Isn't that amazing? We're trying better to understand it. The sensitive nervous system works best when there is consistent stability in its internal environment. The whole concept is that nerves are being triggered into excitable firing because they are at a lower threshold.

Q: Do you think there is growing awareness that headaches are a serious medical condition?

A: I think there is, and I think it's because we've got science behind it now. Headaches have been thought of as being all in your head. Organizations like the National Headache Foundation are helping. We've had an increase in public figures, sports celebrities, TV and movie personalities who have been willing to come out and talk about their migraines. That all raises awareness, but I think we have a ways to go.

Q: Do headaches run in families?

A: Absolutely. If one parent has migraine there is a 50% chance their child will get migraine, if both parents do, the chance is 75%. We don't know what gene or genes it is. There is one unusual migraine type that we have figured out the genes for. It's a start. It definitely tells us that it's a real neurological disease that you inherit and what you likely inherit is that sensitive nervous system.

Q: How would you advise people with headaches to seek treatment?

A: First I would encourage them to seek treatment. Often people say it's just a headache, or it's not a life-threatening condition, or my mom or aunt went to seek treatment years ago and they couldn't do anything for her. We can do a lot more now. People deserve to get a proper diagnosis and adequate treatment. Many people are willing to give up a day of work and stay in bed but don't see it as important enough to go to the doctor. If they were bleeding from a cut, they'd go to the doctor.

They can certainly start with their primary care provider, that's where most people take these types of complaints. It's much better to start seeing your primary care doctor in their office rather than in the emergency room. Be proactive about it.

Q: If one treatment doesn't work, should you try others?

A: You should absolutely keep trying, because we don't know everything about the disorder yet. Some people may be better with one class of drug or type of treatment than another, and we haven't been able to predict who will work well with what. From a preventive side there are really only three or four medications that are FDA-approved, but headache patients will try some medications off-label or a combination of medications until they find the one that's best for them. Realize that you may have some side effects but you have to balance that with the benefit of not being affected by the headaches as much

Working with your health-care provider and providing feedback is important: "I'm having a lot of side effects with this medication." "I've been on this several months, should we change it?" Or "I'm doing really well, what's our next step?"

Q: What is the most important thing you can do as a patient to minimize your headaches?

A: A headache calendar is an incredibly powerful tool so that you can track how often the headaches are there, potential triggers, what medicines work well for you and which ones don't. The other thing I would mention is providing that consistency and stability that the nervous system needs: eating and sleeping on a regular schedule, minimizing caffeine, exercising regularly. You cannot control things like weather and hormones, but you can control what time you get up and what time you go to bed. From there you can add medication and alternative therapies. But you have to start with you, it's your nervous system that you and the provider are trying to protect and you are the first line of defense.

Q: What's the most exciting recent discovery in migraines?

A: The most important thing is that it is a real neurological disorder. Science is now supporting that. With better imaging techniques, we can actually see the brain work. If someone has a migraine, his or her MRI doesn't show anything, and there's no blood test you can do. So it's hard to see what's going on in the brain. Research is getting better at seeing the electrical and neurological changes that happen during a headache. PET scanning shows us where the brain is active, functional MRI shows you what's going on in different parts of the brain and the excitability in neurons. That all supports the presence of headache, which leads to treatment. As we better understand, we can develop treatments to target what is going on.

Q: Does everyone who gets migraines have triggers?

A: Everyone has migraine triggers. It's a matter of identifying those triggers. That can be the hard part. Triggers tend to be changes in weather, hormones, stress, sleep cycle, but they may not be the same for every person. Triggers can be additive—you have a glass of red wine and you stay up late, then you get a migraine, but if you just have a glass of wine, you may not.

It's important to realize that hormones or foods that you eat don't cause headache. They activate a nervous system that is prone to headache. There are not 50 different causes of migraine. There is a predisposition to migraine and 50 different triggers that can set it off.

Q: Why does a woman's menstrual cycle affect headache frequency?

A: The drop in estrogen before menses is a very potent and predictable trigger. For many women that is a very consistent trigger each month. When we check the hormone levels in women who have migraine, it's not that their levels are higher or lower or different in any way, it's how their nervous system responds to the change in hormone levels.

Q: Is there promise in using Botox to treat migraine?

A: Botox is not FDA-approved for migraine treatment, but it's being studied. People with migraines who were getting Botox for other reasons reported that their headaches were getting better. It's being used off label at this time. For some patients, it can be very effective. It's a matter of figuring out which patients may do well with it, in part because it's an expensive therapy.

Q: When should someone seek emergency treatment for a headache?

A: There are several red flags for a headache that indicates a serious problem: The worst headache you've ever had, if that headache is accompanied by nervous system symptoms, such as loss of vision, numbness on one side of the body, loss of consciousness; if it comes with a high fever or stiff neck, which can mean something like meningitis. We worry about headaches in young people under the age of 5 and about new headaches in people over 50. At that point you're worried that there is some other cause, potentially a brain tumor or stroke, because the risk goes up over 50. Any headache that persists after head trauma should be checked out.

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