This post is part of our "Key Questions" series, which we developed to help you understand more about what questions a Headache Specialist should ask during the process of diagnosis and treatment. Click here to visit the Key Questions Series page to see all the posts in the series and learn more!
Your medical professional should address the following questions and concerns regarding any triggers or additional factors that may be contributing to the cause of your headaches:
Do you have any known triggers for your headaches?
Awareness of migraine and cluster headache triggers is a huge factor in managing headache disorders. Each person is susceptible to different trigger thresholds that are unique to their phenotype of migraine or cluster. This means weather and stress may be contributing factors that induce Mary's migraines, but they may never cause John to have migraines. His trigger may be second-hand cigarette smoke.
You cannot control your genes and you cannot control the weather, but many triggers can be avoided and are crucial for eliminating migraine and cluster and promoting more headache-free days. Alcohol is a very specific trigger for most cluster headache patients, but not all. Click here for a list of potential triggers, and click here for a list of specific food-related triggers.
Some common triggers to be aware of are:
- Weather changes/storm fronts/ barometric pressure changes/increased pollen counts
- Stress or stress release after you feel more relaxed/weekend headaches when off work
- Hormonal changes/menstruation/ovulation/pregnancy/after childbirth
- Sleep: too much/not enough/napping/change in pattern of sleep
- Certain foods: smoked or cured meats with added nitrates, pickled products, aged cheeses, artificial sweeteners, MSG, foods containing sulfites, caffeinated beverages, caffeine withdrawal
- Alcohol: red wine/all wine/beer/liquor/all alcohol
- Skipping meals
- Bright or flashing lights
- Loud noises
- Pain medications
How often do you exercise?
Many people with pain may not feel like exercising but the evidence is overwhelming that 30 minutes per day of exercise is beneficial for migraineurs. An hour per day is recommended for the diagnosis of fibromyalgia, a common comorbidity of migraine. Two other common comorbidities of migraine, depression and obesity, see a dramatic improvement with consistent exercise. And hypertension, common in Mississippi and in our headache population, is also improved with an exercise regimen. In fact, exercise is probably the single best way to keep people off of medication.
What about your flexibility? Are your joints hypermobile? Can you extend them easily and painlessly beyond the normal range of motion?
The Beighton score is often used as a quick test to assess the range of movement in some of your joints. Migraine is more common in patients with joint hypermobility disorders (extreme flexibility / double jointedness). Female patients with a diagnosis of a joint hypermobility disorder are three times more likely to have migraine.
Joint hypermobility, an inherited condition, causes extreme flexibility of joints and musculoskeletal symptoms such as pain, joint instability and myalgia (muscle pain). Patients with joint hypermobility should be assessed for secondary headaches like low-pressure headache caused by spontaneous spinal CSF leaks.
Low-pressure headache manifests as a constant daily headache that is a treatable condition requiring blood patches, treatment with fibrin glue infusions, or possibly surgery. Many patients have a daily headache for years or decades due to undiagnosed low-pressure headache that was misdiagnosed as chronic migraine.
BRUXISM and TMD:
Do you grind your teeth? What about at night when you are sleeping?
Bruxism is when you clench or grind your teeth. People can clench and grind without being aware of it. It can happen during the day and night. Bruxism during sleep is often a bigger problem because it is harder to control.
Clenching your teeth puts pressure on the muscles, tissues, and other structures around your jaw. The symptoms can cause temporomandibular joint problems (TMJ).
Do you have temporomandibular joint disorder (TMD)?
The is the temporomandibular joint (TMJ), located just in front of the ears on either side of the head. These joints are the hinges upon which your jaw moves when chewing and talking. The TMJ can rotate up and down as well as slide, and is considered the most complicated joint in the body.
Medical problems relating to the TMJ are known as temporomandibular disorders or TMD. One of the most common symptoms of TMD is headache. These headaches are often misdiagnosed as tension-type headaches. Treatment for tension headaches will not cure TMD. TMD is treated by dentists, physical therapist trained in myofascial release, and is severe cases by oral and maxillofascial surgeons. Untreated bruxism or TMD can lead to headaches and trigger migraines in a patient with the gene for migraine.
Jaw clenching when you are asleep produces a massive amount of noxious input and the typical jaw-clencher wakes most every day with some degree of headache. In fact, many chronic migraine sufferers don’t mention the “daily background headache” to their medical providers... usually because the providers never ask.
Do you eat or drink products containing caffeine daily? How many?
Along with the usual culprits such as coffee, tea, and soda these products can also include BC powders, Goody's, Excedrine, Fioicet, Fiorinol, Esgic, Midrin, and Prodrin.
Caffeine is a drug that increases alertness, decreases fatigue and improves muscle coordination. Caffeine is found naturally found in coffee, tea, and chocolate, and it is often added to soft drinks and non-prescription drugs like pain-relievers and cold remedies.
Caffeine is also addictive. The body quickly absorbs caffeine and it moves rapidly to the brain. It doesn’t stay in the bloodstream, but is removed via urine. People vary in their sensitivity to caffeine. If used excessively, caffeine can be too stimulating and cause anxiety, sleep problems, muscle twitching, or abdominal pain.
Caffeine is a common ingredient in many prescription and over-the-counter headache medications. Some sources suggest that caffeine additives can assist pain relievers by up to 40% in treating headaches. Caffeine can help the body absorb headache treatments faster. In some instances it may allow you to take less medication. However, caffeine can also be harmful for migraineurs. It can cause withdrawal or rebound headaches. The migraine brain prefers balance and routine. It craves consistency. As with all other aspects of migraine management, consistency is the key to handling your caffeine intake.
Do you have allergy or asthma symptoms? Have you been tested? Are you being treated? Is the treatment effective?
Chronic migraine is closely associated with allergies. 60% of the people that have chronic migraine report having allergy symptoms. People that suffer from airborne allergies and/or asthma have a higher risk of also having migraine. And people with migraine are more likely to have allergies and/or asthma than the non-migraine population.
It is important to note that there is not a causative relationship between allergy and migraine. This is simply called a common comorbidity.
Do you have sinus headaches? Have you been diagnosed with sinus headaches? Does anyone in your family have sinus headaches? Does the weather trigger your headaches? Do you get ocular or nasal symptoms with your headaches? Do you suffer from hay fever or seasonal allergies? Have you ever been tested for airborne allergies? Do you get shots for allergies? Have you had a CT of your sinuses or consulted with an ENT?
Sinus headache is the street term (or layman's) term for migraine. In the absence of a viral or bacterial infection, sinus headaches are actually migraine headaches. They may seem less severe or disabling to some, but they are almost definitely migraine. For more information on sinus headache, click here.
HORMONAL RELATIONSHIP/BIRTH CONTROL:
Do your headaches come with or a few days before your menstrual cycle? Do your headaches come when you are ovulating? Are the headaches around your cycle worse than your other headaches during the month? Does your attack medication work as well when you are on your cycle? Does your daily prevention eliminate the headache days you usually have around your cycle? Do you take birth control pills? Do they make your headaches better or worse? Have you had a hysterectomy? Do you have to take HRT?
70% of women report a menstrual association with their migraines. It is also more difficult to effectively treat and prevent migraines during a woman's cycle. Menstruation is arguably the number one trigger for women with migraine. Click here for more information about menstrual migraine.
Note: birth control should always be discussed with female patients as most drugs are not safe during pregnancy or have not been studied in pregnant women.
What is the patient's temperature?
This is important to rule out a secondary (infectious) causes of headache. Meningitis, strep throat, and influenza can all present with a severe headache and no other initial discernible symptoms.
What is the patient's pulse/heart rate?
The health care provider (headache specialist) cannot choose a beta-blocker as a preventive medication if the patient's resting heart rate is too low. Likewise, if the blood pressure is too low, antihypertensive medication (one of the major categories for migraine and cluster headache prevention) should be avoided all together.
What is the patient's blood pressure? Is it normotensive? Is it controlled with blood pressure medication? Is the patient adherent (adherence link here to define mediation compliance) to antihypertensive medication? Does the patient monitor his or her own BP at home if on antihypertensive medication? Is the BP too high or uncontrolled? Is it just due to "white coat" hypertension? Or is high blood pressure a trend in this patient?
Many of our migraine-specific and cluster headache-specific attack medications cannot be prescribed for patients with uncontrolled hypertension. In these cases, headache specialists choose to put patients on antihypertensive medications that have either FDA-approval for migraine prevention, or great evidence (clinical research) that they are efficacious in treating headache disorders, both migraine and cluster. Note: cluster headache is typically is treated with verapamil first line. This requires baseline and follow-up ECGs to rule out heart block.
Height and weight are measured which gives us a calculated Body Mass Index (BMI). BMI is used to give us a sense of weight management. Obesity is linked to migraine as well as secondary headache disorders that can cause blindness if left untreated. Weight loss and exercise is encourage in patients with a BMI near or greater than 30. Also, many daily medications that we prescribe for migraine and cluster headache prevention can cause weight gain which for most people is considered a negative side effect. Conversely—but very rarely—some patients lose too much weight on medications we prescribe, and therefore we must adjust our plan to avoid unhealthy consequences. We monitor for these consequences.
This is why great headache specialists see their patients back very frequently (like every 4 to 6 weeks) until their plan has proven to be successful and stable with minimal side effects of medication therapy. Respiratory rate is measured to rule out any respiratory distress, which is typically not associated with headache disorders and thus usually indicates some sort of pathology which may or may not be associated with the headache disorder. Not all headaches are benign. A great headache specialist is familiar with monitoring for suspicious presentations of headache.
What makes the headache better? Sitting? Standing? Lying down? Being still? A dark, quiet room? Rocking your head back and forth? Hitting your head? Pressure applied to the temples or occiput? Neck massage? Cold packs on your head? A heating pad? Exercise?