The Headache Clinic

The Headache Clinic is a specialty program of The Minneapolis Clinic of Neurology, Ltd. Dr. Jessica Heiring and her associates have developed special interest in treating headache disorders in adults.

Evaluation and Diagnosis

Your evaluation will consist of meeting with a neurologist and often a RN who will obtain a complete medical history and perform a comprehensive neurological exam. Time will be spent going over past treatment trials and determining what lifestyle factors me be contributing to the frequency of headaches. You will be given a diagnosis as to what type, or combinations of types of headaches, you are experiencing.

Diagnostic testing may be done in certain circumstances but is not a routine part of the headache evaluation.

Treatment and Follow-up Care

Treatment is based on traditional medication approaches as well as alternative treatments such as physical therapy, acupuncture, trigger point and Botox injections when appropriate. Education and identifying lifestyle factors the patient can correct to control and treat their headaches is a primary focus of the clinic.

We frequently participate in FDA approved clinical research trials into new treatments for headache and we will offer opportunities to participate in these trials to interested patients. Follow-up is individualized but typically 3-4 times a year.

Rehabilitation

The Rehabilitation Department at The Headache Clinic consists of physical therapists and exercise physiologists. We are known for our extensive expertise and experience in the evaluation and management of headache conditions. Our goal is to help you become more independent in decreasing the frequency, duration and/or intensity of your headaches, and perhaps decrease or eliminate your need for medication.

The physical therapists at The Headache Clinic consider the following to be crucial in the management of each unique headache patient: headache education and self-management skills, alteration of daily posturing and activities, ergonomics (job specific tasks) considerations, muscle relaxation and stress management, musculoskeletal dysfunction treatment (myofascial release, joint mobilization, craniosacral therapy, therapeutic exercise), and treatment of the jaw and/or dizziness conditions, if problematic.

Our exercise physiologists have the experience to develop the ideal individualized exercise program for aerobic conditioning and strengthening to help you manage your headache condition more effectively, while taking into account any other health or musculoskeletal conditions you may have.

• Cluster Headache
• Migraine Headache
• Tension Headache

Cluster Headaches

Cluster headaches are episodic headaches that occur repetitively one to several times per day for a few days to several weeks (in "clusters"), followed by an asymptomatic period. Headaches are frequently characterized by severe pain around one eye with tearing of the eye, drooping of the eyelid, nasal congestion on one side and flushing on one side of the face.

These types of headaches, which are found three times more frequently in men than in women, are not generally associated with a family history of vascular headache (involving the dilation of the blood vessels in the brain and brain stem). Alcohol, even in small amounts, tobacco and vasodilators such as histamine and nitroglycerin, can provoke attacks. Hormonal influences in women do not appear to precipitate cluster headaches.

There are two types of cluster headaches:

• Episodic (classic) cluster headaches: These types of headaches occur in clusters, called "cluster periods", which can last six to eight weeks. Patients are headache free between cluster periods.
• Chronic cluster headaches: Approximately 20% of cluster headache patients experience chronic cluster headaches, which are present throughout the year and do not occur with the characteristic pattern of episodic cluster headaches.

Causes

While the precise causes of cluster headaches are complex and often unclear, the vascular system seems to be involved in some way. Blood vessels become sensitive to the trigger substances (alcohol, tobacco, etc.) during cluster periods, even though they are not overly reactive to these substances during headache-free periods. Statistically, most cluster headache patients are heavy smokers and alcohol drinkers.

Symptoms

• Severe pain, with a burning or piercing quality.
• One-sided pain that remains on the same side throughout a cluster period.
• Pain is localized behind the eye, but may radiate to the forehead, temple, nose, cheek, or upper gum on the affected side.
• Tearing, swelling and drooping of the affected eye; the pupil may contract.
• Nasal congestion on the affected side.
• Excessive perspiration; face may become flushed on one side.
• Pain lasts from 20 minutes to several hours, with an average duration of 45 to 90 minutes.
• Pain may recur several times in the same day during a cluster period, generally at the same time of day.

Treatment

It is difficult to treat acute attacks since cluster headache pain is relatively brief. Often, the acute attack has subsided or even disappeared by the time patients arrive at the emergency department or doctor's office for treatment.

Acute Treatments

• Sumatriptan (Imitrex®) in self-injection or nasal spray forms is used successfully by many patients. These forms of medication are the most effective.
• Fast acting oral tablets, such as Sumatriptan (Imitrex®), Zolmitriptan (Zomig®) and Rizatriptan (Maxalt®), may be helpful for some patients.
• Oxygen inhalation is the safest and most effective treatment if used at the first sign of an acute cluster attack. An oxygen tank may be purchased for home use.
• Intramuscular D.H.E. 45 or Migranol® nasal spray works quickly, but may produce nausea.
• Ergotamine is effective if used immediately upon onset of symptoms.
• Intranasal applications of a local anaesthetic agent, such as lidocaine, may also be prescribed.

Preventative Treatments

• Corticosteroids: Used to stop a headache cycle until the daily preventative medications described below start working.
• Verapamil (Calan®): Verapamil, a blood pressure lowering medication, is the most commonly used preventative treatment for cluster headaches. Verapamil should be used as early in the cluster period as possible to decrease the length of the cluster period and the severity of the attacks.
• Lithium (Sansert®) or Depakote may also be prescribed.
• Surgical intervention may be considered for patients who do not respond to standard forms of therapy.

Where can I get further information on cluster headaches?

To schedule an appointment with our headache specialist, please contact our office at 763-588-0661.

Migraine Headache

A migraine headache is a recurrent, frequently unilateral (one-sided) headache often associated with nausea, vomiting and sensitivity to light and noise. Many physicians believe that migraine headaches are caused by abnormal regulation of pain control in the brain. Environmental irritants can initiate neurological activity in the brain, which causes inflammation of blood vessels and migraine symptoms.

Migraines are most prevalent in persons between the ages of 25 and 55. Women experience migraines three times as often as men. The tendency to develop migraine headaches is often hereditary. As many as 80% of migraine sufferers have a family history of some type of headache disorder.

What causes migraine headaches?

Many different factors may trigger migraines. Common triggering activities or factors include:

• Varying the sleep-wake cycle – too little or too much sleep
• Skipping meals
• Medications, such as Nitroglycerin, that cause a swelling of the blood vessels in the brain
• Frequent use of medications designed for relieving migraines or other headaches
• Bright lights, including sunlight and fluorescent lights
• Watching television or movies
• Excessive noise
• Certain foods, such as red wine, aged cheeses, MSG, meats containing nitrates, chocolate, or
• Nutrasweet
• Strong odors or perfumes
• Hormonal changes caused by menstruation, menopause, or birth control pills

The following symptoms differentiate migraines from other types of headaches:

• "Throbbing" pain, which may be felt on one side or all over the head
• Light and sound sensitivity
• An aura of visual zigzagging lines, or a shimmering light, and loss of sensation, strength, or speech, usually lasting up to an hour, may precede headaches.
• Nausea and vomiting
• Moderate to severe headache pain that inhibits or prevents activity
• Physical activity aggravates pain

Symptomatic (Acute) Treatments: The following medications can be used after the onset of acute migraine pain:

• Non-steroidal anti-inflammatory medications (NSAIDs) in tablet forms, such as Motrin® or Aleve® Midrin®
• Ergotamine: Oral, sublingual (under the tongue) or rectal types
• Intramuscular DHE 45: Self-injectable or nasal spray (Migranal®). May cause nausea.
• 5-HT Agonists, such as naratriptan (Amerge®) and Almotriptian (Axert®), are available in tablet form. Sumatriptan (Imitrex®) is available in many forms, including self-injectable, nasal spray and tablets. Rizatriptan (Maxalt®) are available as an orally disintegrating tablet that can be taken without water, as well as in tablet form.

• Beta-blockers, such as Propranolol (Inderal®) or Nadolol (Corgard®), are prescribed most frequently.
• Anti-convulsants, such as Depakote®
• Calcium channel blockers, such as Verapamil (Calan®)
• Antidepressant drugs, such as Amitriptyline (Elavil®) or Nortriptyline (Pamelor®). Prozac® may also be prescribed, though less frequently.

Are there alternatives to drug therapy?

Physicians may also recommend the following alternatives to drug therapy:

• Biofeedback: Self-hypnotic or relaxation exercises designed to control both muscle contraction and the swelling of blood vessels, which cause migraine pain.
• Dietary restrictions: Avoid foods that trigger headaches.
• Life-style changes: Eat regularly scheduled meals and establish a regular sleep cycle
• Stress management: Exercise regularly. Learn to relax.

How can I get further information on migraine headaches?

To schedule an appointment with our headache specialist, please contact our office at 763-588-0661.

Tension-Type Headaches

What is a tension-type headache?

Tension headaches are chronic recurring headaches that are caused by stress. The pain, which affects the front and back of the head and upper neck, may be short-lived, or last for days, or even weeks, at a time. The pain may inhibit, but not prohibit, activity, since it is moderate in intensity.

There are two types of tension headaches, episodic and chronic. These headaches are differentiated by the number of headaches experienced per month as follows:

• Episodic: Experiencing fewer than 15 headaches per month
• Chronic: Experiencing more than 15 headaches per month

What causes tension type headaches?

• Sleep disturbances, including difficulty falling asleep, or frequent awakening
• Depression and anxiety
• Soreness in the neck or jaw muscles from poor posture or tension, or from injuries to the neck and neck muscles.

• A tight, "band-like" sensation around the head
• A "pressure", or "squeezing sensation", not throbbing like a heart beat
• Pain in the forehead, temple, or back of the head and neck
• Pain may be felt on one-side of the head and neck, or may be felt all over (diffuse pain)

How are tension headaches diagnosed?

Our neurologists confirm the diagnosis of tension-type headaches by performing a thorough neurological examination, during which other possible causes of headache are ruled out. Tests, such as MRI or CT scans and x-rays, may also assist physicians in making the final diagnosis.

What are the treatments for tension-type headaches?

Once the diagnosis of tension headaches is confirmed, it is important that patients modify or eliminate the triggers, such as depression, anxiety, or poor posture, that may be causing pain.

Our neurologists may prescribe medications to treat tension headaches, based on headache type and frequency, as well as other symptoms.

Episodic tension-type headaches: Over-the-counter drugs, such as aspirin, acetaminophen, ibuprofen and naproxen sodium, are most effective. Combination drugs, such as Excedrin, Midrin® and Fiorinal®, may also be helpful; however, these medications must be limited to two to three days per week. Overusing these medications may result in "rebound" headaches, a cycle of repeated headaches that will only subside when drug use is decreased.

Chronic tension-type headaches: Anti-depressants, such as Amitriptyline (Elavil®) and Nortriptyline (Pamelor®), are the most effective treatments for chronic tension-type headaches. Anticonvulsants, such as Depakote®, and beta-blockers, such as Inderal®, as well as other medications, may also be helpful. These drugs work by altering the way the brain processes pain.

Medications such as those recommended for relieving episodic tension-type headaches, may be taken daily to prevent headaches from occurring. To prevent a rebound cycle, use of any one of these medications must be restricted to two to three days per week.

Non-medication therapies, such as physical therapy, biofeedback and acupuncture, are also very helpful in treating tension headaches.

How can I get further information on tension headaches?

To schedule an appointment with our headache specialist, please contact our office at 763-588-0661.