Posts Tagged "cluster headache"


Last updated on April 7th, 2021 at 08:07 pm

ONE-SIDED HEADACHE WITH CONGESTED RUNNY NOSE, OR RED, TEARING AND SWOLLEN EYE. 5 REASONS WHY – 2021.

@Neuralgroover

BACKGROUND

Do you have a one-sided headache, left-sided headache, right-sided headache, or one-sided head pain with some variation of one-sided symptoms such as runny nose, nasal congestion or stuffiness, red eye, tearing eye, droopiness of the eyelid, puffiness or swelling around the eye, facial sweating or flushing, or clogged ear feeling? These symptoms are called autonomic symptoms, and they are a central part of several distinct headache syndromes. The headaches that occur with this combination of features are distinct types of headaches, all requiring different treatments. Therefore, it is important in differentiating them to ensure proper treatment and less misery!

 

TRIGEMINAL AUTONOMIC CEPHALALGIAS (TACs)

There is a class of headaches called the trigeminal autonomic cephalalgias (TACs), and all are terribly painful. There are 4 types of headaches within the TAC family, and include cluster headache, hemicrania continua, paroxysmal hemicrania, and SUNCT / SUNA (Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing / Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms). All of the TAC syndromes warrant preferably a brain MRI and MRA to exclude other causes such as pituitary lesions, aneurysms, or other abnormalities.

 

The TACs all share 2 common and core features. 1st, they are characterized by a severe headache that is strictly one-sided and focused around the eye, behind the eye, below the eye, in the temple or forehead areas. 2nd, they must include at least 1 autonomic symptom on the same side of the headache [lacrimation (runniness/tearing of the eye), conjunctival injection (redness of the eye), facial sweating or flushing (skin turning blushed), nasal congestion, rhinorrhea (runniness of nose), sense of ear fullness, eyelid edema (swelling), or partial Horner’s syndrome (miosis (pupil becomes small)) and/or ptosis (droopiness of the eye)].

 

So how do you differentiate these headache types when they all have similar features? Differentiation between them is based purely on their headache attack duration and pattern. So, it is actually quite easy to differentiate them as contrasted below.

 

CLUSTER HEADACHE

Cluster headache is the most common TAC syndrome and is discussed and detailed further here. It is characterized by attacks of severe unilateral (one-sided) orbital (around the eye), supraorbital (above the eye), and/or temporal pain lasting 15 to 180 minutes if untreated. There is either agitation/restlessness with the headache attack and/or at least 1 autonomic sign or symptom on the side of the headache as described above. Headache attacks typically occur from 1 every other day to 8 per day for more than half the time during a cluster cycle.  Chronic cluster headache is defined by attacks that occur for more than 1 year without remission, or with remission periods lasting less than 1 month.

 

Cluster headache attacks occur in “clusters”, or cycles, of frequent headache attacks. These cycles of cluster attacks may last for weeks or months before they go away completely. Within a cluster cycle, patients may get multiple attacks during the day or overnight. They often classically wake the patient up in the middle of sleep, usually around the same time every night or morning. The patient often gets up and paces around the house in agitated misery. They certainly can occur during the day as well. Remission periods can last months to years. Cluster cycles often occur at a predictable time of year, such as season changes (Fall and Spring are most common). Men tend to be affected 3 times more than women, but it is seen in both men and women. It is a severely painful headache, and has been termed “suicide headache” because of the pain severity.

 

Treatment of cluster headache is detailed further here.

 

HEMICRANIA CONTINUA

Hemicrania continua a continuous daily one-sided headache (side-locked, does not alternate sides) of at least 3 months duration with moderate to severe exacerbations. There should be either agitation or restlessness and/or at least 1 autonomic sign or symptom on the side of the headache as described above. Although not included in the criteria, sometimes patients describe a sensation such as something irritating in the eye on the side of the headache, such as sand, grit, or a hair, but nothing is found. Hemicrania continua is discussed and detailed further here.

 

To make the full diagnosis of hemicrania continua, the patient must respond completely to a therapeutic trial of indomethacin (a specific anti-inflammatory (NSAID) medication), used in a very specific way (“Indomethacin trial”). For this reason, this headache is 1 of 2 types of “Indomethacin-sensitive” headaches because Indomethacin is typically the only thing that works (paroxysmal hemicrania is the other Indomethacin-sensitive headache). The diagnosis of hemicrania continua is confirmed by the headache completely stopping after reaching a specific dose of Indomethacin.

 

Besides indomethacin, other treatments of hemicrania continua are detailed further here.

 

PAROXYSMAL HEMICRANIA

Paroxysmal hemicrania is characterized by attacks of severe unilateral (one-sided) orbital (around the eye), supraorbital (above the eye), and/or temporal pain lasting 2 to 30 minutes. There must be at least 1 autonomic sign or symptom on the side of the headache as described above. The attacks have a frequency of more than 5 per day for more than 50% of the time when the disorder is active.  Chronic paroxysmal hemicrania continua is defined by attacks occurring for more than 1 year without remission, or with remission periods lasting less than 1 month. Paroxysmal hemicrania is discussed and detailed further here.

 

To make the full diagnosis of paroxysmal hemicrania, the patient must respond completely to a therapeutic trial of indomethacin (a specific anti-inflammatory (NSAID) medication), used in a very specific way (“Indomethacin trial”). For this reason, this headache is 1 of 2 types of “Indomethacin-sensitive” headaches because Indomethacin is typically the only thing that works (hemicrania continua is the other “Indomethacin-sensitive” headache). The diagnosis of paroxysmal hemicrania is confirmed by the headache completely stopping after reaching a specific dose of Indomethacin.

 

Besides indomethacin, other treatments of paroxysmal hemicrania are detailed further here.

 

SUNCT / SUNA

SUNCT/SUNA are two variations of a rare type of headache called short-lasting unilateral neuralgiform headache attacks, and they are discussed and detailed further here. Short-lasting unilateral neuralgiform headache attacks (which include SUNCT and SUNA) are characterized by moderate to severe unilateral (one-sided) orbital (around the eye), supraorbital (above the eye), and/or temporal pain. The duration of the pain lasts for 1–600 seconds (1 second to 10 minutes, although most often about 5 seconds to 4 minutes), and may occur as single stabs, series of stabs, or in a sawtooth pattern. There must be at least 1 autonomic sign or symptom on the side of the headache as described above. Attacks must have a frequency of at least one per day for more than half of the time when the disorder is active. However, the attacks generally occur in a very high daily frequency when active, sometimes even up to 200 attacks per day or 5-6 attacks per hour.

 

SUNCT and SUNA both share the above criteria. The difference between the two is that SUNCT requires both conjunctival injection (redness of the eye) and lacrimation (runniness/tearing of the eye), whereas SUNA requires only 1 or neither of these 2 features.

 

Treatment of SUNCT / SUNA is detailed further here.

 

MIGRAINE

Migraine is not a TAC syndrome, but it can sometimes have overlapping characteristics with the TACs in terms of its one-sided nature and associated autonomic features in some patients. For this reason, I have included it in this discussion. Migraine is discussed and detailed further here. The autonomic symptoms seen in migraine are not required by criteria for diagnosis, in contrast to the TAC syndromes which do require these symptoms for diagnosis. In some patients with migraine, their headache attacks can have some of the autonomic features described above. For many patients, migraine also activates the sinus pathways, so sinus symptoms of sinus/facial pressure, congestion and drainage are common. This is often misdiagnosed as “sinus headache”. However, if there is any throbbiness, pulsating, or pounding, it is almost guaranteed to actually be of a migraine origin rather than of a sinus origin.

 

Migraine headache attacks last 4 to 72 hours if untreated or unsuccessfully treated. There must be 2 of the following 4 features present: a unilateral (one-sided) headache, pounding/throbbing/pulsating quality, moderate-to-severe pain intensity, and worsening by routine physical activity. There must also be 1 of the following 2 features present: nausea and/or vomiting, or both photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

 

Treatment of migraine headache is detailed further here.

 

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING TO ASK QUESTIONS TO A HEADACHE SPECIALIST OR OTHER HEADACHE, MIGRAINE, AND FACIAL PAIN WEBSITE MEMBERS, VISIT OUR FREE DISCUSSION FORUMS HERE.

 

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TYPES OF HEADACHES.


Posted By on Mar 16, 2021

Last updated on April 10th, 2021 at 05:29 am

TYPES OF HEADACHES – 2021

@Neuralgroover

According to the World Health Organization, headaches are a global problem, affecting people of all races, income levels, and regional areas. Headache disorders impact about 50% of people worldwide. Moreover, it is estimated that 50% to 75% of adults aged 18 to 65 have suffered from a headache or a migraine within the last year. A smaller percentage of people worldwide, 1.7% to 4%, have headaches that last for two weeks or longer. Let’s take a look at the four different types of headaches, what causes them, and some common treatments that may relieve them.

The Four Different Types of Headaches

There are, in fact, 150+ different types of headaches. However, the four most common types of headaches are: tension headaches, migraine headaches, sinus headaches, and cluster headaches.

 

What Are Tension Headaches?

Tension headaches typically are moderate to mild in nature and can be best described as feeling like a tight band around one’s head. By and far, these are the most common types of headaches and their origins are not well understood. Common symptoms include a dull, aching, pressure pain in both sides of your head; tightness in your forehead, sides, and back of your head; and muscle soreness in your shoulder, neck, and scalp. They can not be a throbbing pain. If there is any throbbiness to the headache, it takes it out of tension type headache criteria and moves it into migraine criteria. Tension type headaches are not worsened by physical activity, in contrast to migraine which are. Tension type headaches should not be associated with nausea or vomiting, in contrast to migraine which can be. There may be some mild sensitivity to light (photophobia) or sound (phonophobia), but tension type headache should not have both. In contrast, migraine requires both features.

 

What Are Sinus Headaches?

Sinus headaches are usually indicated by pressure around your eyes, cheeks, and forehead. You may also experience a throbbing forehead. However, these features can also be consistent with migraine because in general, any type of throbbing pain places the headache into the migraine category. In fact, there was a large study done in the past in which almost all of the patients with either self-diagnosed or physician-diagnosed sinus headache turned out to actually be migraine headache.  Migraine also activates the sinus pathways and cavities and can cause referred pain into the teeth and TMJ areas. So for many patients, their migraines include a lot of sinus type symptoms. Therefore, it is easy to see how migraine often gets mistaken for sinus headache. For some people with true sinus headache, they feel like a sinus infection. Historically, the existence of true “sinus headaches” has been a debatable topic, and it’s presence generally revolves around whether there is an ongoing sinus infection or not. If there is, this can certainly be a source of headache, and it is typically associated with fevers and drainage (often colored, purulent discharge).  Some common symptoms include:

  • Fatigue
  • A stuffy sensation in your nose
  • Pain and pressure in your cheeks, brows, and forehead.

What Are Cluster Headaches?

Cluster headaches are called as such because they happen over cyclic time frames or “clusters.” These types of headaches can wake you up in the middle of the night and they frequently happen on one side of your head or near an eye. The pain of cluster headaches is severe, and they have been termed “suicide headaches” because of the severity of the pain. Cluster headaches are more rare than other types of headaches. Some symptoms include:

  • Pain that is situated around or behind one eye
  • One-sided pain, versus other headaches where the sensation of pain is often more global
  • Stuffy or runny nose on the side of your head that hurts
  • Red and tearing eye on the side of the head that is impacted
  • Restlessness

What Are Migraine Headaches?

Migraine headaches, according to some patients, are the worst type of headache. These types of headaches are characterized by a throbbing sensation, most commonly one one side of the head, but can also be both sides. Additionally, they often come with nausea, sometimes vomiting, and a sensitivity to light and sound. Migraines come in stages, but not everyone goes through all the stages.

The stages of migraines include:

  • Prodrome: Some mild symptoms that indicate an oncoming migraine attack, including neck stiffness, moodiness, food cravings, and other subtle symptoms. This may occur even a day or more before the attack starts.
  • Aura: Seeing bright lights or various shapes, numbness and tingling, speech disturbances, overall weakness, and other symptoms that happen right before or during the onset of a migraine. About 25% of patients get aura (classic migraine), while 75% get no aura (common migraine).
  • Attack: During a migraine attack, migraine sufferers typically experience the worst symptoms, including pain on one side of the head, nausea, and other symptoms. A migraine attack itself can last for up to 72 hours.
  • Post-Drome: After the migraine, people tend to experience tiredness and sudden head movement can bring on some pain. At this stage, people report excess fatigue, generalized soreness, and commonly report feeling like they were “hit by a bus”.

Migraines can be read about in much more detail here.

Common Questions About the Various Types of Headaches

What causes the various different types of headaches?

There is not a singular known medical cause for headaches. Primary headaches are when the headache itself is the primary health issue that the sufferer is dealing with. Secondary headaches are those that are caused by a medical condition (such as a brain tumor). Let’s take a look at what the most common causes are for the various types of headaches:

  • Tension headaches: These can be caused by stress, depression, injury, or other issues.
  • Sinus headaches: These headaches are most commonly caused by sinusitis and allergies.
  • Cluster headaches: The exact cause of cluster headaches are unknown, but it may have something to do with biological processes since cluster headaches are cyclical.
  • Migraines: As with other types of headaches, there migraines don’t have a clear cause. Common suspected causes include hormones, diet, dehydration, and other physical or lifestyle factors.

When should you seek medical attention/advice for any type of headache?

You should seek medical attention/advice when you have any type of headache. Sometimes, a headache may be indicative of a larger medical problem. At least one visit with your doctor is recommended for any type of headache because even secondary headaches (caused by a medical condition) can sometimes present as a standard primary type of headache. A visit with your doctor may uncover additional information from a more detailed history during questioning and neurological physical exam. Repeat headaches can impact the quality of your life and should be treated. Sometimes, your regular doctor may not know how to adequately deal with a headache. Some doctors are especially trained to deal with headaches, specifically headache specialists.

What type of headaches should a headache sufferer worry about?

Generally speaking, any type of headache should be a cause for concern. However, there are certain situations where headaches may be indicative of a larger, more serious medical issue. Headaches associated with the following symptoms should be a cause for concern:

  • A high fever, chills, night sweats, neck stiffness
  • The sudden onset of very intense headache pain (thunderclap headache) with peak headache intensity in less than a minute
  • Fainting, disorientation, or loss of balance or equilibrium
  • Weakness on any side of the body or any other neurological symptoms including visual loss or vision changes, double vision, trouble swallowing, numbness, tingling, speech disturbances (slurred speech, trouble getting words out, trouble understanding speech), vertigo, behavioral or personality changes
  • Nosebleeds
  • Pulsatile tinnitus or papilledema (swelling of optic nerve on eye exam)
  • Other issues, such as weight loss, vision issues, jaw cramping, and other factors
  • History of cancer, immunosuppression, HIV
  • New onset headaches under age 5 or over age 50
  • Headaches triggered by Valsalva maneuvers (coughing, straining, laughing, bending forward, exertion, exercise, sexual activity, bearing down such as during a bowel movement)
  • Progressive worsening and changing of headaches into a higher frequency or daily frequency
  • Postural worsening of headache (worsens when standing and improves when lying down, or worsens when lying down, improves when standing up)

What are some common tests for the more serious types of headaches?

Some headaches, such as cluster headaches, are not commonly understood. Other types of headaches may have an underlying cause. If you see a neurologist or other medical specialist, you might experience some of the following tests for them to better diagnose and understand the underlying cause of your headache:

  • Eye & ear exam
  • CT scan
  • MRI scan
  • EEG scan
  • Blood and spinal fluid tests

A headache specialist will often try and get access to your medical records and history so that they can better treat your condition.

Which type of doctor commonly deals with the various types of headaches?

Neurologists are the most common type of specialized doctor that headache sufferers see. However, they will often refer to a headache specialist for more complex headache and facial pain disorders, or if treatments are not helping the patient. General medical practitioners may be able to make a referral and provide some basic treatment, as they are often the first line of headache evaluations. On occasion, an ENT doctor may provide treatment for secondary headaches that are related to sinus and ear issues.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING TO ASK QUESTIONS TO A HEADACHE SPECIALIST OR OTHER HEADACHE, MIGRAINE, AND FACIAL PAIN WEBSITE MEMBERS, VISIT OUR FREE DISCUSSION FORUMS HERE.

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Last updated on April 10th, 2021 at 05:26 am

WAKING UP WITH HEADACHES: 6 TYPES OF WAKE UP HEADACHES.

@Neuralgroover

 

WAKE UP HEADACHE

Do you frequently wake up with a headache? This is a common feature with several types of headache disorders, but they are all distinct headache types with completely different treatments. Let’s discuss the 6 most common types of wake up headaches and the reasons why you may be waking up with headaches.

 

1) MIGRAINE

Migraine commonly causes wake up headaches for many patients, and is by far THE most common cause of wake up headaches. Sleep stage transitions can be a trigger for migraine attacks in many patients. Migraine is also susceptible to changes in sleep patterns. So for many, sleeping in (such as on the weekends or on vacation) can be a common (and cruel) migraine trigger leading to waking up with headaches. Thus, trying to maintain a similar sleep schedule on the weekends and weekdays can help with this type of trigger.

 

Other causes of wakeup headache commonly occur in patients that are stuck in chronic migraine (15-30 days per month with at least 8 headache days with migraine features), particularly if they are in rebound headache (medication overuse headache) from excess pain or “as-needed” medications. This occurs when a person with migraine is using triptans, OTCs (over-the-counter pain meds), or NSAIDs (non-steroidal anti-inflammatory drugs) more than 10 days per month, opiates or opioids more than 8 days per month, or butalbital medications such as fioricet or fiorinal more than 5 days per month, on average. Rebound headache occurs because as the patient is sleeping, the overused medication is being metabolized and eliminated from the body and the headache (typically migraine) is triggered as a result of withdrawal from the medication and the need to take more. Patients in this cycle will often notice that after they take their overused medication, the headache calms back down again. It starts to worsen again as they are due for another dose and it is wearing off. This pattern is characteristic for rebound headache. Caffeine withdrawal headache can also be a cause of wake up headaches, for similar reasons as described for rebound headache.

 

Treatments for migraine are discussed here. The key for abortive (as-needed) migraine treatment for waking migraines is that is must be something fast acting to have a chance to catch the migraine. The difficulty with waking migraines is that you are already “behind the ball” by the time you wake with the migraine because you’ve missed the early treatment window where most medications such as the triptans would normally be most effective. So for waking migraines, injectable Sumatriptan (Imitrex), nasal Zolmitriptan (Zomig) or Sumatriptan (Imitrex), are typically going to be the most effective triptans. With that said, sometimes patients can get away with a fast-acting oral triptan such as Rizatriptan (Maxalt) as well. Other options for waking migraines would be DHE (Migranal nasal spray or injection), or one of the new gepants (Nurtec ODT, Ubrelvy) since they can still be effective if taken up to 4 hours past the migraine onset, which is really great and expands the migraine onset treatment window. A neuromodulatory device could also be considered.

 

If you are averaging more than 4 migraines per month, a daily preventive treatment is generally recommended. There are many options for this including a daily pill, natural supplements, a once monthly or quarterly CGRP monoclonal antibody (Aimovig, Ajovy, Emgality, Vyepti), Botox, or a neuromodulatory device.

 

 

2) CLUSTER HEADACHE

Cluster headache is another classic cause of wake up headaches. It is a very distinct form of headache that is easy to pick out with its characteristics. Cluster headache is classified as a trigeminal autonomic cephalalgia (TAC). There are 4 types of TAC syndromes, and cluster headache is the most common of them. The other 3 TAC syndromes are hemicrania continua, paroxysmal hemicrania, and SUNCT/SUNA, none of which are waking headache types. There are some overlapping characteristics between all 4 of these TAC headache types, but cluster headache is the only one that often wakes the patient from sleep.

 

Cluster headaches can occur anytime during the day, but classically occur at the same time every night, often waking the patient up from sleep, many times shortly after falling asleep within an hour or two. Men tend to be affected 3 times more than women, but it is seen in both men and women. It is a severely painful headache, and has been termed “suicide headache” at times because of the pain severity.

 

Cluster headache is characterized by attacks of severe unilateral (one-sided) orbital (around the eye), supraorbital (above the eye), and/or temporal pain lasting 15 to 180 minutes if untreated. There is either agitation/restlessness with the headache attack and/or at least 1 autonomic sign or symptom on the side of the headache [lacrimation (runniness/tearing of the eye), conjunctival injection (redness of the eye), facial sweating or flushing (skin turning blushed), nasal congestion, rhinorrhea (runniness of nose), sense of ear fullness, eyelid edema (swelling), or partial Horner’s syndrome (miosis (pupil becomes small)) and/or ptosis (droopiness of the eye)]. Headache attacks typically occur from 1 every other day to 8 per day for more than half the time during a cluster cycle. Chronic cluster headache is defined by attacks that occur for more than 1 year without remission, or with remission periods lasting less than 1 month.

 

Cluster headache attacks occur in “clusters”, or cycles, of frequent headache attacks. These cycles of cluster attacks may last for weeks or months before they go away completely. Remission periods can last months to years. Cluster cycles often occur at a predictable time of year, such as season changes (Fall and Spring are most common).

 

Treatments for cluster headache are discussed here. In general, at the onset of a cluster cycle, a course of high dosed Prednisone is often started over 1-2 weeks to try to break up or shorten the cycle. An abortive option is also mandatory, and the most effective options are oxygen by a face mask, injectable Sumatriptan (Imitrex), nasal Zolmitriptan (Zomig) or Sumatriptan (Imitrex), or DHE (Migranal nasal spray or injection). A preventive daily treatment is also typically started at the onset of a cluster cycle and there are a variety of options for this.

3) HYPNIC HEADACHE

Hypnic headache has also been called “alarm clock” headache because it often wakes the person up at almost exactly the same time every night. These recurrent attacks occur only during sleep, causing wakening. They typically occur on 10 or more days per month for more than 3 months. The headache lasts 15 minutes and up to 4 hours after waking. This headache usually begins after age 50, but can occur in younger ages too.

 

The pain is typically mild to moderate, but can be severe occasionally. The pain usually occurs on both sides of the head (as opposed to cluster headache which is 1 sided). There is no restlessness during the headache (as opposed to cluster headache). Hypnic headache is NOT associated with autonomic symptoms [lacrimation (runniness/tearing of the eye), conjunctival injection (redness of the eye), facial sweating or flushing (skin turning blushed), nasal congestion, rhinorrhea (runniness of nose), sense of ear fullness, eyelid edema (swelling), or partial Horner’s syndrome (miosis (pupil becomes small)) and/or ptosis (droopiness of the eye)] (as opposed to cluster headache which requires these autonomic symptoms for diagnostic criteria).

 

Treatments for cluster headache are discussed here. The most common treatments are some caffeine before bed (in those who can tolerate it and not cause insomnia), or upon waking. Indomethacin taken before bed is also a common treatment.

 

4) OCCIPITAL NEURALGIA

Occipital neuralgia is a miserable nagging soreness, pain, and headache in the back of the head. I tell patients to think of occipital neuralgia as “sciatica of the head”. It is sometimes associated with cervicogenic headache (headache originating from the cervical spine with associated prominent neck pain), but more commonly occurs by itself. It is typically felt in the suboccipital region (where the base of the skull meets the top of the neck) and radiates variably into the back and top of the head and behind the ears. It can less commonly even radiate to the frontal areas (by the trigeminocervical circuitry in the upper cervical spinal cord and brainstem). It can be one sided or both sides. The pain is often described as an intense stabbing, sharp, shooting, shocking, or burning pain. It often occurs in attacks of pain which may last seconds to minutes, but can also be a continuous unrelenting pain. Sometimes it may not be as intense and may be a lower-level pain such as pressure, aching, soreness or throbbiness. Some patients may have a sensation of numbness or tingling in the back of the head. Associated neck pain is typically in the mix too. The back of the head in the area where the skull meets the neck often feels very sore or tender along the ridge of the skull bone. The pain and tenderness often increase by pushing on the back of the head and along the skull base, or lying on the back of the head. Thus, for some patients, when they lie on the back of the head during sleep, it puts pressure on the occipital nerves and they continue to get more irritated and painful until they may wake the person up from sleep due to the pain.

 

Treatment for occipital neuralgia is discussed in much greater deal here and here. In general, first line options are neck physical therapy to this area, as well as an anti-neuritic pain medication such a tricyclic antidepressant (TCA) of Amitriptyline (Elavil) or Nortriptyline (Pamelor), an anticonvulsant such as Gabapentin (Neurontin), or an SSRI such as Duloxetine (Cymbalta) or Venlafaxine XR (Effexor XR).

 

 

5) SLEEP APNEA HEADACHE:

Sleep apnea is a common cause of a headache present upon waking in the morning. However, in comparison to the headache types listed above, this headache does not “wake you up”, but rather, you “wake up with it”. It generally fades away as the morning goes on and most often has tension type headache characteristics. So if you snore, often feel unrefreshed when you wake up in the morning, and this is associated with a headache, wake with a sore throat or dry mouth, a conversation with your doctor about possible obstructive sleep apnea evaluation should be pursued. If your bed partner witnesses times where you seem to stop breathing during sleep, then this is very likely. Sleep apnea is associated with elevated high blood pressure and increased risk of stroke and heart attack, so it is important to not let it go untreated. During the deep stages of sleep, your brain is replenishing its neurotransmitters. So, if you are not getting into those deep stages because the sleep apnea is disrupting progression through normal sleep stages, fatigue, memory and cognitive complaints are common.

 

Treatment varies depending on the severity of the sleep apnea. This is determined by an overnight sleep study called a polysomnogram. These have historically been done in a controlled setting such as a hotel room, but they are now commonly done remotely in your own bed from home too.

 

 

6) HEADACHE ATTRIBUTED TO INTRACRANIAL NEOPLASM (BRAIN TUMOR)

Lastly, brain tumor is always in the differential (and at the very top of everyone’s mind when they come in the office), depending on age, prior headache history, and other clinical symptoms. These headaches are typically associated with some other neurological complaints or findings on neurological exam such as vision deficit, imbalance, speech dysfunction, memory or cognitive impairment, or one-sided numbness or weakness. However, this isn’t an absolute, and headaches can certainly present by just themselves as well. With all of that said, this is an uncommon reason for wake up headache or headache in general, surprisingly. Thus, why I have listed it last. However, it is still a reason that you should always be evaluated by your doctor for not only wake up headaches, but for any headache, especially if you don’t have a prior history of headaches, it is a different type of headache from your prior headaches, or you have any associated neurological symptoms.

 

These are certainly not the only causes of nocturnal headaches, but they are typically the top 6 that are evaluated for first. Disorders such as nocturnal bruxism (teeth grinding and jaw clenching) and TMJ dysfunction, or headache attributed to temporomandibular disorder can also be a contributor to headaches. However, these types of disorders don’t typically cause the patient to wake up with the pain. In addition, the pain is primarily in the temples, in the areas in front of the ear, into the face, and in the master muscles in the jaw. The headaches related to this are more often a tension type headache in description and not severe, and an ache and soreness in the jaw muscles and around the TMJ regions. A dentist should be able to easily diagnose if there is significant nocturnal bruxism happening by evaluating the teeth. Bed partners are also good historians on observations of teeth grinding during sleep.

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING TO ASK QUESTIONS TO A HEADACHE SPECIALIST OR OTHER HEADACHE, MIGRAINE, AND FACIAL PAIN WEBSITE MEMBERS, VISIT OUR FREE DISCUSSION FORUMS HERE.

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Last updated on April 9th, 2021 at 12:44 am

CEFALY vs. NERIVIO vs. GAMMACORE vs. SPRING TMS. NEUROMODULATORY DEVICES FOR MIGRAINE AND CLUSTER HEADACHE: WHAT ARE THE DIFFERENCES AND WHICH IS BEST?

@Neuralgroover

BACKGROUND

Cefaly vs. Nerivio, Nerivio vs. GammaCore, Cefaly vs. GammaCore, Nerivio vs. SpringTMS, Cefaly vs. SpringTMS, GammaCore vs. SpringTMS. These are common questions that patients have about migraine neuromodulation devices. Many patients do not respond to conventional migraine abortive medications, they do not tolerate them, do not like taking medications, or they cannot take them due to medical contraindications. These standard migraine abortive options are discussed here. Luckily, there have been several neuromodulatory devices for the treatment of migraine which have entered the market over the last few years. These non-invasive neuromodulation devices open up new migraine treatment options for those in these sensitive and difficult patient populations, including pregnancy as well. These also avoid the complications of medication overuse headache (rebound headache) that is often an issue with using too much abortive migraine medication, as discussed in greater detail here.

But do they really work? Is one better than the other? Do they hurt? Are they used for abortive or preventive treatment? Are they expensive? Does insurance cover them? How do they compare, and is one best for you? This blog will address all of these questions.

These devices include Single-Pulse Transcranial Magnetic Stimulation (sTMS) (SAVI, SpringTMS, sTMS mini), external trigeminal nerve stimulation (eTNS) (Cefaly), noninvasive Vagus Nerve Stimulation (nVNS) (GammaCore), and the most recent, wireless remote electrical neuromodulation (REN) (Nerivio). We’ll discuss these devices in the order in which they became available and FDA cleared. The table further down is a summary of comparison data between devices gathered from published studies and directly from the companies as well. It’s important to keep in mind that the data in this table are not from head to head studies between devices. Each of these devices had separate study designs (which were quite varied), and the results of those studies is what is reflected here, certainly not a direct comparison between devices. All devices require a prescription from your doctor. Pricing and intermittent promotional specials can be found on each device’s website and some of these are discussed below. Sometimes the long-term costs equal out or can even be less than the cumulative cost of many medications and treatments used abortively and preventively.

 

SINGLE-PULSE TRANSCRANIAL MAGNETIC STIMULATION (sTMS)

The first device which was FDA cleared was the Single-Pulse Transcranial Magnetic Stimulation (sTMS), made by the company eNeura. It was initially FDA cleared for the acute treatment of episodic migraine with aura in adults in December 2013. It then received FDA clearance for both acute and preventive treatment of migraine in adults in 2017. This clearance was then expanded to the acute and preventive treatment of migraine in children 12 years of age and older in February 2019. Prior models included the Spring TMS and sTMS mini. The newest model, SAVI, is currently the only FDA cleared device for both the acute and preventive treatment of migraine in adults and children 12 years of age or older. Since the device is used acutely and preventively, the FDA approved it for a maximum of 17 pulses per day.

The user holds the device against the back of the head, and presses a button to release a very short magnetic pulse at the onset of aura or a migraine attack with or without aura. The magnetic pulse delivers a fluctuating magnetic field which induces a mild electric current through the skull and onto the surface of the occipital cortex (visual cortex) of the back part of the brain. This modifies the electrical excitability and hyperactivity of the cortical neurons to block or prevent the onset of a migraine from evolving to a full-blown migraine. The device stops cortical spreading depression, which is suspected to be the basis of migraine aura in the occipital cortex. It is also suspected to interfere with thalamocortical pain pathways that are normally activated during a migraine. The company offers a 90-day money back guarantee, and it is typically rented in 3-month increments.

The most common side effects were mild and brief light-headedness/dizziness, tingling over the back of the head where treatment is performed, brief tinnitus (ringing in ears), nausea, and muscle spasm. You should not use this device if you have a cardiac pacemaker, vagus stimulator (VNS) or other implanted neurostimulator, implanted cardioverter defibrillator (ICD) or any implanted medical device that stimulates the body or uses any signal from the body. It is also suggested that patients with implants affected by a magnetic field should not use this device. Examples of such implants include aneurysm clips or coils, cochlear implants, cerebral spinal fluid shunts, bullets or pellets lodged in the head or upper body, metal plates, screws, staples or sutures in skull, neck, shoulders, arms or hands, and facial tattoos with metallic ink. Dental implants, fillings or other dental appliances are okay to use the device.

Acute migraine treatment consists of 3 sequential pulses (early) at the onset of a migraine (aura or pain). Then wait 15 minutes. If needed, treat with an additional 3 pulses. Then wait another 15 minutes. If needed, treat with an additional 3 pulses. Studies reported that 39% of patients were pain free at 2 hours.

Prevention treatment consists of 4 pulses twice daily. This is performed by giving 2 consecutive pulses, waiting 15 minutes, and then repeating 2 consecutive pulses. Studies reported that 46% of patients had a greater than 50% reduction in monthly headache days and averaged approximately 3 less migraine days per month.

Unfortunately, eNeura filed for Chapter 7 bankruptcy on 8/7/20, so it is unclear what exactly the future holds for these sTMS devices.

 

CEFALY

Cefaly was the next neuromodulation migraine treatment device that became available, and is an external trigeminal nerve stimulation (eTNS) device (similar to a TENS unit mechanism). It is made by Cefaly Technology. It works by neurostimulation of the trigeminal nerve branches in the forehead. It was FDA cleared for the prophylactic (preventive) treatment of migraine in adults in March 2014, and acute treatment of episodic migraines in adults in November 2017. The Cefaly Dual device is the most recent model, and has settings for both acute and preventive migraine treatment. The company offers a 60-day money-back guarantee. As of 10/13/20, the Cefaly Dual neuromodulation device became the first FDA-approved trigeminal nerve stimulator for migraine treatment available without a prescription and can now be purchased over-the-counter. The Cefaly Dual kit includes the Cefaly device, 1 electrode (good for 20 uses), power adapter, charging cable, and storage case. It normally retails for $499. Three packs of electrodes are $25, or by a cost-saving subscription service.

Cefaly treatment is often described as a mild buzzing and pressure sensation. It should be avoided in patients with implanted metallic or electronic devices in the head, or who have a cardiac pacemaker or implanted or wearable defibrillator.

Acute migraine treatment consists of a 1-hour session. It may be repeated for a second 60-minute session if the migraine pain is not relieved within two hours, or if another migraine attack occurs. Studies reported that at 1 hour, 32% were pain free and 79% had significant pain relief. At 2 hours, 17% were pain free and 65% significant pain relief.

Migraine prevention consists of a nightly 20-minute session. Studies reported a 29.7% decrease in migraine attacks, and 38.1% of patients received at least 50% decrease in migraine attacks.

 

VAGUS NERVE STIMULATOR (GAMMACORE)

Noninvasive Vagal Nerve Stimulation (nVNS) is made possible by a hand-held device called GammaCore, from the company ElectroCore. The most recent model is called GammaCore Sapphire. It was initially FDA cleared for the acute treatment of episodic cluster headache in adults in April 2017, followed by the acute treatment of migraine in January 2018, cluster headache prevention in November 2018, and migraine prevention in March 2020. It was the first and remains the only therapy which is FDA-cleared for the prevention of cluster headache This device is placed over the vagus nerve on the side of the neck, just below the angle of the jaw where the pulse of the carotid is felt in the neck. It is suspected that the device works by suppressing cortical spreading depression (a central process in migraine and aura formation), and blocking and modulating the thalamocortical, trigeminovascular and trigeminocervical pain pathways that are normally activated during a migraine.

Acute migraine treatment consists of 2 two-minute stimulations. If the pain remains 20 minutes after the start of the initial treatment, 2 more two-minute stimulations are given. Two more two-minute stimulations may be applied if the pain remains 2 hours after the start of the initial treatment. Studies showed significant pain relief in as soon as 30 minutes, and reported that at 1 hour, 21% were pain free and 35.8% had significant pain relief. At 2 hours, 30.4% were pain free and 40.8% significant pain relief. GammaCore reduced pain intensity over 3x greater than sham (fake device) at 60 minutes and over 6x greater at 120 minutes, and reduced the need for other rescue medications.

Preventive migraine treatment is done by giving 3 treatments daily (morning, mid-day, and night) consisting of two consecutive 2-minute stimulations. Studies showed a 29% reduction in migraine days per month when used preventively, although this number was even higher in those with aura at a 35.8% decrease. Overall, 33.6% of patients received at least a 50% decrease in migraine frequency.

Acute cluster headache treatment is done by giving 3 two-minute stimulations. After completing the 3rd stimulation, the user waits 3 minutes. If pain remains, 3 more two-minute stimulations can be applied. You may treat up to 4 attacks (8 treatments) for a total of 24 stimulations per day. Significantly more episodic cluster attacks treated with GammaCore were pain-free at 15 minutes vs those treated with sham   (47.5% vs 6.2%). Combined study data showed that significantly more (over 2-4x greater response) episodic cluster headache patients responded (no pain or mild pain) to GammaCore at 15 minutes for 50% or more of all treated attacks vs those receiving sham (34.2-64.3% vs 14.9-15.4%). At 15 minutes, there were also significant reductions in pain duration and intensity with GammaCore compared to sham.

Preventative cluster treatment is done by giving 2 treatments (morning and night) consisting of 3 two-minute stimulations. Weekly attack frequency decreased by 40% from baseline when GammaCore was added to standard of care therapy. There was a 57% decrease in the frequency of acute medication use when GammaCore was added.

GammaCore treatment is often described as a deep vibration. GammaCore should not be used with an active implantable medical device, such as a pacemaker, hearing aid implant, or any implanted electronic device. It should be avoided in patients who have a metallic device such as a stent, bone plate, or bone screw implanted at or near their neck, are using another device at the same time (e.g., TENS Unit, muscle stimulator) or any portable electronic device (e.g., mobile phone).

 

NERIVIO

The Nerivio device is made by the company Theranica. It is a wireless remote electrical neuromodulation (REN) device wearable for the acute treatment of migraine applied to the upper-arm. It was FDA-cleared for the acute treatment of episodic migraine in adults in May 2019. In October 2020, FDA clearance was extended to acute treatment of migraine in chronic migraine patients as well. In January 2021, Nerivio received FDA clearance for acute migraine treatment for episodic or chronic migraine in patients 12 years and older.

Each device provides 12 treatments. When the device is used up, it is recycled and a new refill device is sent. It is the most economical option on the market. Costs can often be similar to monthly triptan prescription costs. The device works through an app downloaded on your smartphone which controls the strength and treatments. The device itself is an arm band that easily straps around the upper arm, and was recognized in TIME Magazine’s annual list of the 100 Best Inventions in 2019.

It delivers electronic pulses into the skin to generate a proprietary “Conditioned Pain Modulation” response which helps to abort the effects of a migraine in patients with or without aura. Nerivio stimulates specific sensory nerves of the upper arm which normally sense pain. The stimulation from the device is not strong enough to actually trigger pain for the user, but the signal still travels to the brainstem, as it normally would. From here, it interferes and blocks the ongoing activated electrical circuitry of the migraine, and helps to abort it. Many think this is basically a TENS unit, but it is not. It has a proprietary stimulation signal which targets specific pain transmitting nerve fibers that disrupts the electrical activity of a migraine centrally from a remote location peripherally (on the arm).

The device is applied within 60 minutes (preferably at onset) of a migraine headache or migraine aura and stimulation is performed for 45 minutes. It is described as a vibrating sensation. Studies showed that 66.7% of patients had significant pain relief at 2 hours, and 37.4% of patients achieved complete pain relief at 2 hours. Furthermore, 89.7% of patients studied avoided having to take other abortive medications when treating with Nerivio. In the study leading to Nerivio treatment extension to adolescents 12 years and older in January 2021, 71% of patients had pain relief by 2 hours after Nerivio treatment, while 35% received complete pain relief. Pain relief and pain freedom were sustained for 24 hours in 90% of cases.

Side effects may include a temporary sensation of warmth, local tingling, numbness in the arm, pain in the arm, or redness of the skin, although 96.4% of patients studied did not report any device related adverse events. It is recommended to avoid in congestive heart failure, severe cardiac or cerebrovascular disease and uncontrolled epilepsy. It should not be used with certain medical devices such as a pacemaker or hearing aid implant. Using Nerivio with other implantable medical devices could potentially cause electric shock, electrical interference, or other injury. So it should not be used near any metallic implants.

In October 2020, Nerivio became the first neuromodulation device to receive a pharmacy/medical benefit.  is available for $10 on the initial prescription for anyone with any form of medical or pharmaceutical insurance, including government insured patients such as Medicare and Medicaid! Commercially insured patients may have their Co-pay reduced to $0 on future refills, while government insured patients will pay $99 for refills. No patient ever pays more than $99 for a refill, and most will hopefully pay $0 on refills. Theranica launched a reimbursement hub called Nerivio Express in October 2020. By working with insurance companies, Nerivio Express is able to provide Nerivio for a co-pay as little as $10, dependent on the patient’s insurance. Each Nerivio device provides 12 treatments of 45 minutes duration.  

 

  sTMS Cefaly GammaCore Nerivio
Acute Migraine Yes Yes Yes Yes
Preventive Migraine Yes Yes Yes No
Acute Cluster No No Yes No
Preventive Cluster No No Yes No
1-hour migraine pain free N/A 32% (13% sham) 21% (sham 10%) N/A
1-hour migraine pain relief N/A 79% (39% sham) 35.8% (sham 24.4%) N/A
2-hour migraine pain free 39% (sham 22%) 17% (sham 7%) 30.4% (sham 19.7%) 37.4% (18.4% sham)
2-hour migraine pain relief N/A 65% (sham 52%) 40.8% (sham 27.6%) 66.7% (38.8% sham)
Migraine preventive relief 46% had > 50% decrease in monthly HA days (20% “statistically derived” placebo) and averaged 3 less migraine days/month 29.7% decrease (sham 4.9%)

38.1% received at least 50% decrease in migraines (sham 12.12%)

29% decrease (sham 18%)

35.8% decrease in patients with aura

33.6% received at least 50% decrease in migraines (sham 23.4%)

N/A

 

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING TO ASK QUESTIONS TO A HEADACHE SPECIALIST OR OTHER HEADACHE, MIGRAINE, AND FACIAL PAIN WEBSITE MEMBERS, VISIT OUR FREE DISCUSSION FORUMS HERE.

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