(gentle music) - [Announcer] The region's premier medical information program, "Call the Doctor."

- Headaches are common.

Most everyone gets them from time to time, and typically they can be alleviated.

But headaches can have a number of different causes and can vary greatly in severity.

And in some cases, headaches can be debilitating, causing people to miss out on work or time with their family and friends.

We'll look into the most common sources of headaches, when you might want a medical opinion and what you might try to help them go away.

Now, on "Call the Doctor."

Hello, and welcome to "Call the Doctor."

I'm Julie Sidoni, I'm the news director here at WVIA, and I'll be the moderator for the show this season.

Now, this episode is all about headaches which most people get once in a while, some more than others.

And for certain people, headaches aren't much more than an inconvenience, but most of us know people who really struggle living with chronic headaches.

We wanna talk about all different types and find out what steps there might be to take to help us get rid of headaches whenever possible.

We've invited a couple of experts onto the panel to help us through all of this.

And I would love to introduce them to you, specifically, actually I'd like them to introduce themselves.

So we'll start with you, Dr. Chua.

- Alright, thank you so much.

So my name is Abigail Chua.

I'm a neurologist and fellowship trained headache specialist.

I work at Geisinger.

I'm primarily out of Wilkes Barre and Scranton, and my practice focuses on treating a wide variety of headache and facial pain disorders in adults.

- That's great to have you here.

Thank you so much.

- Thank you.

- And what about you, Dr. Horchos?

- Well, my name is Paul Horchos.

I was born and raised here in the area.

I've been a partner at Northeast Rehab Associates for the last 25 years.

And my interest in headaches stems from my interest in concussions and post-traumatic headaches.

And I've experienced this myself on one or two occasions, and it was really a learning experience so I devoted myself to really becoming an expert in it and helping people.

- Well, thank you.

It's good to have you here.

I wanna start with the most basic question of all, which is, we use the term headache so much, I think people don't really understand, myself included, what is a headache?

What's happening when you get a headache?

Dr. Chua, we'll start with you.

- So I think the most important thing to realize is when we say headache, a headache is not a diagnosis.

A headache is a symptom.

So having a headache does not tell us really anything of what's going on in your brain or why you have this pain in the first place.

So basic definition, headache is just any pain, discomfort, strange feeling in your head or face area that is bothering you.

So I think people think that a headache has to be severe for them to classify it as a headache, but that it's not true.

So mild pain can be classified as a headache, mild facial pain, like anything in this area that's painful or disturbing can be a headache.

But in terms of what kind of headache is the real question.

Because for that, then I can answer what is going on in your brain.

- We'll stick with that for a few minutes if you don't mind, 'cause I would love to know how you go about figuring out what kind of headache someone might have.

- So my primary job when I see a person for the first time is to determine whether or not they have a primary headache disorder or a secondary headache disorder.

So primary headache disorders are problems that are coming inherently from your brain or structures within your brain.

Examples of a primary headache disorder would be a migraine or a tension type headache.

Secondary headaches are being caused by something else.

So for example, an illness, like a viral illness or a head injury, like a concussion, like Dr. Horchos was saying, or maybe even medications.

So if something else is causing your headache, it's considered a secondary headache.

And if there's features of your headaches that kind of peak my interest and make me concerned that something else is going on, then that usually leads to more testing, imaging studies, that kind of thing, to help me determine what is really causing your headache.

- Are there certain types of headaches, people will come to you for help with, Dr. Horchos?

- Sure.

I've become sort of the doctor of last resort when patients have had headaches that they've just decided to live with, they come to see me, and that's usually because they don't have a primary headache disorder.

They they've been tested to look and see whether they have an aneurysm, whether they have a tumor.

They don't.

But they still have these persistent headaches.

And so we've really focused in on some of these other ancillary or these other issues that could be driving headaches, whether they be cervicogenic pain, which means basically headache pains that are coming from the neck, visual based headaches that can occur after people have disruption of their visual focus capabilities, problems with regards to their jaw.

If they have issues with their temporomandibular joint that can cause headaches.

And so these are things that people just tend to learn how to live with, and they don't need to do that.

We can help them.

- Can you explain a little more about why pain in someone's jaw or neck or appear in their shoulders might like be a headache or feel like a headache?

- Right.

It all has to do with the referred pain system in our body.

We have structures that refer pain to various locations.

And the classic case of that is, of course, if you have a heart attack, you have pain and you can get pain into your left arm.

So certain structures in the neck can radiate pain right up behind the eyes.

And the patients can swear that the pain is really coming from right behind their eyes, but actually it can be coming from their neck.

And similarly, you can have structures inside of your sinuses that can radiate pain up into your forehead.

Or if you happen to have an injury to your eyebrow, a lot of times when people get hit with a baseball or something like that in their eyebrow, there are nerves that are running up into the forehead that then can radiate and cause pain.

- So I get a mild headache.

I take a pain reliever, drink some water, lie down for a few minutes, that sort of thing.

If that happens once in a while, is that something that you think you should see someone for?

In other words, the question I get a lot is, what's normal?

Is there normal?

What would lead someone to find help from one of you for a headache?

- I think the most important thing is if the pain is bothering the patient, then definitely ask your primary.

It doesn't have to be a neurologist.

It doesn't have to be a headache specialist.

But speaking to your primary care doctor is always a great first step because that takes a lot of that stress of what is this?

What could be causing this headache?

I would say in general, if your headaches are very infrequent, you take one pain reliever every now and then, and it goes away, and it's not interfering with your quality of life, it's not interfering with your day, you can function, you can get things done, and you're not taking something every single week, multiple times a week, then generally it's okay.

But if you see this pattern of, oh, I was taking one pain reliever every other week, and now I'm taking two every week, and now it's three every week, now four every week.

There's clearly a pattern where your brain or whatever is going on, your neck, your jaw, is getting much more irritated, you're becoming more reliant on medications, it's definitely time to speak to your doctor.

- I think also if you start to see alterations in your general lifestyle pattern, which is starting to impair your health.

For instance, we see this a lot that people will develop post-exercise headaches.

So if they try to exercise, let's say, they've always been a jogger, or they go bicycle riding, or something like that, and now when they try to do those activities, they suffer from headaches that last for either hours or even days afterwards, it's going to stop them from exercising.

And of course, that's not a good health decision.

So those are the kinds of things that if that starts to happen, you have to intervene, otherwise your health is gonna decline.

- If it's getting in the way of something that you normally do.

- [Dr. Horchos] That's good for your health.

- That's good for your health, right?

- Exactly.

- We talked a little bit about triggers earlier.

I was curious what kind of headache triggers there were.

And I was surprised by your answer, Dr. Chua.

- So there really is no 100% tried and true trigger for every single person.

Even within the same person with headache, their triggers may change.

So sometimes you'll have, let's say, classic example people usually bring up is chocolate or wine.

That may cause some of your headaches, caused some of your headaches, or, let's say, five out of 10 times, but the rest of the time, it may not do anything at all.

And there's actually new research coming out that these triggers or what we're calling triggers are actually cravings.

So because your body already knows it's about to have a migraine attack, your body needs something or is craving something.

So whether that's something sweet or salty, so chips, chocolate, whatever the case is, some wine, you would've had that headache anyway.

But now your body is just needing something.

You have it, and it looks like that thing caused your headache, but in reality, you would've gotten it anyway.

- Oh, that's very interesting.

- So it's really important to not, in my opinion, not really focus on triggers so much because the whole goal, like as Dr Horchos was saying, is to improve your quality of life.

Well, everything we're doing is to improve someone's quality of life because for most of the headache types, there really is no cure.

So everything we're doing is managing.

So this person gets back to whatever made them happy, right?

That's the whole goal.

So if you like chocolate, and if you like wine once in a while in moderation, of course, then I don't want patients to limit their life because they're afraid something's gonna cause their headache.

So this conversation always happens when I see my patients, you know, we figure out what kind of headache you have, what may actually be causing it, and then kind of use medications and treatments to help address it.

I never really ask my patients to avoid triggers because it's quality of life limiting, it's stressful.

Not everyone's like writing down everything that can possibly trigger it.

That's not improving their quality of life.

- I'm curious, you mentioned primary versus secondary so that there are some categorizations of headaches.

Are there any other categories other than that?

I mean, people might say they have a sinus headache, a tension headache, a cluster headache, the typical things they might find, say, in an internet search.

Can you talk a little bit and, and I'll give this to both of you, can you talk a little bit about the differences in headaches, if you believe there are differences there?

- So within the categories of primary and secondary are other headache types.

So those are just the big umbrellas, but under a primary headache disorder would be things like cluster that you mentioned, tension headache, migraine.

For secondary headaches, there's literally hundreds and hundreds of possibilities.

So headache from cold.

So like ice pick headache, or having like an ice cream, or cold slushy, that's a type of headache, headaches from certain types of medications, headache from trauma, headache from certain brain diseases.

All of those are secondary headaches.

So each one is kind of very like minutely, like categorized.

But until we know what's actually going on, those two big categories are really important because then it tells us, does this person need to work up, because migraine is actually a clinical diagnosis.

I don't have to order anything.

If your story fits classic migraine, and there's nothing else concerning in your headache history, I probably won't order anything.

But if I hear something, oh, you're having this symptom that you've never had before, your headache is now changed.

It's much more severe.

You're like fainting, like whatever the case is, that's a different story.

Then we're gonna go onto a big workup to figure out what other headache types you might have in the secondary headache category.

- And does it matter?

Does it matter then?

So what I'm hearing is it matters because it kind of has a way for you to figure out then how they're treated.

- Absolutely.

So another example of a secondary headache would say, if a person was having sleep apnea.

So having issues with your breathing while you're sleeping can lead to headache.

So if I don't ask about sleep, I'll miss this huge component of why are you getting headaches when you wake up first thing in the morning?

Why are you wake up in the middle of the night with this headache?

And then I never know that you have the secondary headache from sleep, and then I'll never be able to address it.

I'll never refer you to the right doctor, and then this pattern of headache will keep going.

I'm trying all these meds, you're not getting better, and I don't know why.

So all of these questions are really important in the first visit.

We actually have a pre-made questionnaire at Geisinger that I ask patients to fill before they even come in, because it's really hard for patients to come in and, especially if they're already having a headache, and I'm asking all of these questions.

So how old were you when your headache started?

How often does it happen?

So many things.

So coming in prepared is really helpful and then helps me kind of already kind of figure out what's going on with your headache before I even talk to you.

- And narrow it down a little bit.

- Narrow it down a little bit.

Yeah.

- Can you, Dr. Horchos, talk a little bit about how you might treat a headache that comes to you.

You mentioned injections earlier, but I imagine there's a number of different options that you can give to a patient.

- Sure.

Well, you know, there's one of the more important things I think to mention about headaches in general is the concept of cephalgia.

And cephalgia basically just means pain in the scalp and the structures of the scalp.

And patients don't really necessarily think that way, but oftentimes we find that by putting our hands on the patient and being able to actually palpate their neck, palpate their posterior cervical structures, their temporals areas, we can actually see that there are areas that are tender and there maybe nerves that are in the scalp that could actually be driving that.

And then we can address those issues.

Oftentimes after patients have head injuries, they can develop hematomas.

Hematomas are collections of blood underneath the scalp.

Those heal.

And when they heal, patients develop some scarring, where their scalp can actually become scarred down to their skull.

And then when they try to smile, or when they try to laugh, and they try to move the skin, it can pull on these nerves, and those nerves can then cause patients to have pain.

So really it's very important, I think, to try to identify where the patient's pain is coming from, and if you can reproduce their pain while they're in the office, it's really very helpful.

So we oftentimes will use injections not only as a treatment option, but also as a diagnostic option.

There are these nerves that are called the greater occipital nerves that run from the rear portion of the head up towards the temple, and you can block those nerves with a very easy process, utilizing a very small amount of numbing medication.

And if that helps the patient's pain, it really indicates that those nerves are involved.

And it's a pretty simple fix.

- Might be a silly question, but what exactly are you injecting?

Are there different types of injections?

- Well, yeah, you can inject numbing medication, like lidocaine, if you want to just make a diagnosis.

Or you can inject cortisone, if you think there's an inflammatory component.

Or if you believe that there's sufficient reason for it, you can even use Botox.

And Botox is something that we use quite frequently to try to treat headache symptoms as well.

- I heard about that.

How does Botox help?

- Well, Botox is thought to be helpful in the sense that it blocks the calcitonin gene.

And this is the things that you see on these new TV commercials for the new migraine type headache medicines.

But the nice thing about Botox is that Botox is given and it can last anywhere from three to four months in duration.

So it's really a very effective intervention.

And patients, they're a little fearful at first before it's done.

But once it's done, they really realize it's no big deal at all.

- And one more question for you.

Do you have any, I guess, physical therapy type, is there ever an option for different types of movement?

I'm not exactly sure what I'm asking here, but aside from medication and injection is- - Well, Julie, really one of the biggest problems these days with regards to the development of headaches is really tech neck.

You know, this position of having your head in a forward position like this.

And so a patient sometimes when they come in to see you, you know, you mentioned posture to them, and they feel like, you know, like this is old school.

But it's old school, but it's really, it's still very, very important.

And for every inch you bring your head forward from a neutral position, it's adding 10 pounds to that weight of your head.

So your head normally weighs about 15 pounds, but every inch you bring it forward from the neutral position adds another 10 pounds.

So if you're walking around like this or looking at your cell phone all day long, your head feels like it's 40 pounds.

So then all of a sudden you start to develop all of these muscular spasms in the back of your neck, that then drives the cephalgia condition.

So yes, posture and therapy can be very helpful to correct those symptoms.

- I'm thinking of all the teenagers and children I happen to know who do this all day long, including two of my own.

- That's right.

- We talked a little earlier, Dr. Chua, about how often you see migraine in particular.

Do you think people have headaches and don't know that they're migraine?

- Absolutely.

So one of the most common things I hear is that people think they have sinus headaches, or their family member has sinus headaches.

So sinus headache is actually most of the time, studies have shown about 90% of the people who think they have sinus headache actually have migraine.

- [Julie] 90%.

- Yes.

So when someone has migraine, one of the biggest areas involved in the head is something called the trigeminal nerve.

So this nerve kind of plays a role in giving us sensation here, pain here, in our face.

And those are the same areas that people have pain when they're having allergies, a sinus infection, right?

So you feel tension in your forehead, behind your eyes.

You might have some congestion here, a lot of pressure.

And people interpret that as a sinus headache.

But it's really uncommon to have a sinus headache and especially having a sinus headache, let's say, every day, every week that goes on for hours and then stops and then comes back.

Most likely those patients have migraine.

So unless they're truly having a sinus infection, so fever, a lot of like copious things coming out of their nose, things like that, then more than likely they have migraine.

- Is there a genetic component to that?

- There is, actually.

So for people who have a parent or both parents who have migraine, or, let's say, sinus headache, and they didn't really know it, there's a 50 to 75% chance that offspring will have headache as well, migraine as well.

So it's when we ask about family history, we'll ask, you know, do you have anybody in your family who has headache?

And usually they say no, and then I'll follow it with, do you know anybody who has sinus headache in your family?

Oh yeah.

A lot of us have sinus headache.

So that's really important because then, number one, that gives those people an opportunity to maybe seek help for their headache as well.

- Why sometimes do people get nauseous with headaches?

How does, I mean, obviously everything is all connected, but what's happening in your system when your whole body is now involved in a headache?

And that's kind of what you were talking about earlier, right?

- Right.

Well, I mean, this is one of the things that can make a migraine sort of feel like a whole body experience, okay?

So there's this type of nervous system that we have in our bodies that it's called the autonomic nervous system.

And the autonomic nervous system kind of takes care of our bodies for the things that we don't normally have to worry about.

Like if you become hot and you start to sweat.

That's taken care of by the autonomic nervous system.

If you're chilly and you start to shiver, it's taken care of by that.

And so sometimes there can be involvement of this automatic or autonomic nervous system when you have a migraine headache, and it can cause these other sorts of symptoms, such as the nausea and the vomiting, and that's a type of headache.

And it's very important to be able to tell your doctor that you're experiencing those symptoms because that does direct care.

- That tells them a little something.

What were you gonna say about that?

- Well, there's actually a really strong connection between the gut and the brain.

So there's something called serotonin that is in the brain, but it's also found in your gut in high levels.

So there's a lot of connection between migraine and the gut.

And there's actually a migraine type called abdominal migraine, that usually happens in children.

So these are kids who get like attacks of abdominal pain that go on for a couple hours, but there's nothing wrong.

That goes away.

They see a doctor, they get an exam, their stomach is fine.

And then it happens again and again.

So usually this is diagnosed by a pediatric neurologist or maybe their primary care doctor.

But it's exactly like a migraine that an adult would have that's happening in their stomach.

- Hmm.

Do you see headaches a lot in children or do you treat children a lot?

- Yes, we do see, especially since a lot of children suffer from falls and other types of, you know, post-concussive conditions, I do see a lot of headaches in children.

And they can sometimes be difficult to ferret out.

And a lot of times teachers may have some concerns about what kind of symptoms the students are having because it's making them miss class and those sorts of interventions.

And I have found that physical therapy for children really helps to define exactly what are the triggers for some of their migraine headaches or their post-concussive headaches.

And then you can kind of go forth and try to adjust their lifestyle so that you can control that.

But yeah, I do think that it's pretty common.

- Anything else for parents to look out for other than head pain?

Does it often present in different ways, as you said, in children?

- So it can, I think for parents, number one, it's hard because sometimes children can't really express themselves and say exactly what they're feeling, but anytime your child is having increase in the complaints, if they're avoiding things that they usually wanted to do, hang out with their friends, go like play with their video games because they're complaining of head or neck pain, that's something definitely to bring up with their primary care doctor.

If they are not responding to common medications that the doctor has recommended, it's all these different changes.

Parents have a good sense.

Right?

So if they sense, you know, why is this not getting better?

You seem worse.

That's always important to tell your doctor.

But, honestly, any headache that's happening on a regular basis, even if it looks normal, I would bring it up to the primary.

- [Julie] It's worth getting checked out.

- Of course.

Yeah.

- Yeah.

Julie, I think one thing that should be said for the viewing public really is something called medication overuse headaches, and that's something that maybe it's even a little bit hard to understand, but basically it stems from the overuse of Tylenol.

And if patients actually start to take too much Tylenol, it can actually cause headaches.

And that seems sort of counterintuitive.

- [Julie] It does.

- But, so it's important that as a provider, you question the patient and if they are taking Tylenol, you find out exactly what the doses that they're taking.

Because sometimes the medication that they're taking can actually be causing the headaches.

- Acetaminophen in particular?

- Yes.

- Actually it can happen with many different types.

So one of the most common is Excedrin Migraine.

So, you know, that's very smart marketing where they're labeling it as migraine.

But it works.

It does work very well for a lot of people.

But because it's a combination of acetaminophen, aspirin and then also caffeine, those are all things that can make a person like physically dependent to that medication.

So I was talking to you earlier, if someone drinks coffee every single day, and then they skip a cup of coffee, they're going to get a headache, right?

So if you use, Excedrin or Tylenol, things like that on a regular basis, eventually your body becomes like physically dependent on it, and if you don't have it, your headache will come.

And usually these patients will say, well, within five to 10 minutes of taking that medication, my headache is gone, right?

So that's not usually a common story for migraine, but that is a very common story for headaches that are coming from medicine.

Because now you've put that medicine in your body and there you go, you feel better.

But really your headache is coming from that medication in the first place.

- That's something to think about.

- Yeah.

And actually, if you look at the back of an Excedrin bottle, it will say on there, if you take this too much, you will get a headache.

- Hmm.

Well, I guess my last question, we have just 30 seconds or so, but I didn't realize, I know, it goes fast, right?

I told you.

- It does go quickly.

- Yeah, it does.

- We were talking about the stigma.

I didn't realize there was a stigma around headaches.

What's what is that all about?

- Well, there's a huge stigma with headache, especially migraine, but I think, number one, it's very misunderstood.

If you don't have headaches yourself, you don't understand how debilitating it can be.

So migraine is a neurologic disease.

It is not a headache.

It's all encompassing.

It's a whole body experience like Dr. Horchos has said.

People have trouble concentrating, trouble seeing, trouble speaking.

Some people look like they're having strokes when they're having migraine.

So it is, can be very, very debilitating.

But if you don't understand that, you might think this person is being dramatic, overreacting.

Just take something and get back to work.

So it's all this misconception and lack of empathy that makes people kind of hide the fact that they have it and then they're not gonna get care.

- Well, I wish I could keep you for another 25 more minutes.

- We can stay!

- I appreciate your time.

Thank you both very much.

That's gonna do it for this episode.

I'm Julie Sidoni for all of us here at WVIA.

We'll see you next time.

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