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  • in reply to: Treatment successes for hypnic headache? #3940

    Hello, typical caffeine doses used in most of the literature suggest and show evidence for benefit between 40 mg and 100 mg of caffeine on average. Starting out with just a cup of coffee (regular coffee which isn’t high potency is typically 40-60 mg or so) is the easiest thing to do. The dose can be titrated up as needed, and as the patient is tolerating it. Pill forms of caffeine can also be used just as easily, but I wouldn’t start too high. They may have had too high of a dose if there was ringing in the ears. If they develop insomnia, than that excludes that option. The caffeine is most commonly taken before bed, but it can also be used as an abortive strategy when the patient wakes with it to try to shorten the duration.

    Cervicogenic tends to be a different clinical entity than hypnic headache. Cervicogenic headache typically will not wake the patient up in sleep and by criteria tends to be unilateral. Hypnic headache tends to have the opposite of these characteristics. However, if they have a lot of neck pain, a lot of tenderness over the occipital nerves (which sometimes can wake the patient with pain predominantly in the suboccipital/occipital region), then it could certainly be a consideration.

    in reply to: Does a cough headache usually mean something bad? #3745

    Not necessarily, but it does require a brain MRI with contrast (preferably) and a non-contrast brain MRA to also look at the arteries of the brain. Most often it is a benign headache disorder. Chiari malformation is a common anatomical variation often associated with cough headache, or headache brought on by exertion, bearing down (such as having a bowel movement), laughing hard, etc.

    in reply to: Testing question #3733

    Much of this diagnosis comes from the clinical history as well. Specifically, a positional component. Meaning, the headache goes away or improves significantly when lying down, and worsens after standing up. It occurs most often from a spontaneous CSF leak in the spine. However, if there is a lot of clear drainage from the nose, CSF leaks can also occur into the sinuses and nasal passages. ENT (ear nose and throat doctors) have a test that they can do to test the fluid from the nose to see if it is CSF or normal sinus/nasal drainage.

    in reply to: Atypical Facial Pain #3593

    Hello Sam, our apologies for the delay. There had been a glitch where we had not been alerted to new messages on the discussion board with one of the last site updates. Atypical facial pain can be a tricky diagnosis and is often hard to manage. Management begins with the proper evaluations, which include a brain MRI with and without contrast and brain MRA without contrast. The MRI should include a trigeminal neuralgia protocol to include focused in views of the trigeminal nerves. This includes IAC/CPA views, CISS sequences, and it is typically all included if it is written to be done with a trigeminal neuralgia protocol.

    If there are sharp electrical zaps on top of a background continuous pain (or if not a continuous background pain), trigeminal neuralgia is possible. If there are features of one sided eye tearing, redness, droopiness, one sided nose running or congestion, then a type of trigeminal autonomic cephalalgia should also be considered.

    The bottom line is that it is hard to say much further without a discussion of the specific location of pain, character of pain, pattern of pain, associated features, and neurologic exam.

    Many times a cause may not be found. So it is a matter of finding the right medication to suppress the irritability of the trigeminal nerves which innervate the sensation of the face.

    in reply to: Oxygen dosing? #1664

    Typical oxygen dosing at the onset of a cluster headache attack is around 12-15 liters per minute by a face mask (not a nasal cannula) for about 15 minutes.

    in reply to: SInus headache recommendations #1663

    These headaches most likely represent migraine, although a more detailed discussion with your headache specialist or neurologist would help to confirm. If there is any throbbing, throbbiness, pounding, that is usually migraine, especially if it is a recurrent frequent pattern. Migraine also causes sinus symptoms (pressure, congestion, other sinus symptoms, etc.) in most patients. A bad sinus infection can certainly cause headache (typically along with fevers, nasty colored mucus drainage, etc.), but otherwise, most headache specialists don’t believe in “sinus headache”. In fact the International Classification of Headache Disorders doesn’t even recognize the term.

    in reply to: Test question #1595

    These type of headaches require a brain CTA (preferable since best way to image blood vessels) or an MRI and MRA of the brain to look at the brain as well as (and more importantly) the arteries of the brain to rule out aneurysm or other vascular causes. Sometimes an MRV may also be ordered, but it depends on the clinical story.

    in reply to: Testing question #1594

    Testing often begins with a contrast brain MRI (with IV dye). This can show signs of a spinal fluid leak and low CSF pressure. There are other tests that can be considered after that, depending on the clinical scenario and MRI results. Some other tests done can include MRI spine with CSF leak protocol (heavily weighted T2), CT or MRI myelogram. Radionuclide cisternogram is another test, but is not done as much anymore because it is often not very helpful. Sometimes checking the pressure of the CSF (opening pressure) is considered, although the concern is that it could potentially cause a leak at the same time since you are puncturing the dural membrane in the process.

    in reply to: Help! #1593

    If your PCP isn’t comfortable treating the headache, or you are not making progress, ultimately your best move would be to see a headache specialist. Headache and facial are all that these specialists do. If you don’t have a headache specialist nearby, a neurologist would be the next recommendation. Most headache specialists are neurologists by training, but have done additional fellowship in headache and facial pain.

    in reply to: What testing should be done for this type of headache? #1547

    This type of headache requires neuroimaging with a brain MRI and MRA or a CTA of the brain. Basically, a picture of the brain, as well as the arteries of the brain is required to rule out aneurysms, etc. This is often a benign recurrent headache syndrome with normal testing. However, these tests must be done before assuming it is benign. Your doctor may order some additional testing depending on the specific symptoms described.

    in reply to: Best way to wean off medications causing rebound headache? #1537

    This may vary depending on the medication used, but should always be done under direction of your doctor. In general, cutting down a little bit each week (such as taking away 1 day per week), until down to a day or two a week of use is a general goal. This can be more tricky sometimes with opioids or meds such as fioricet/fiorinal because they can have some nasty (and sometimes potentially dangerous) withdrawal syndromes. Many headache specialists will give a “bridge” medication out of rebound as the patient weans off with something such as a steroid to limit the severity of the rebound. Generally, headaches will often worsen temporarily before they improve as these medications are weaned off, and it can take several weeks to a couple months for things to really start to improve after the overused medications are weaned off.

    in reply to: How much of which medications can cause rebound headache? #1536

    According to published research on this, rebound (medication overuse headache) can be caused (especially if there is a history of migraine) with NSAIDs, OTCs, or triptan more than 10 days per month, opiates/opioids more than 8 days per month, or butalbital medications (such as fioricet, fiorinal) more than 5 days per month.

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