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Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole and today we are discussing headaches. Joining me is Dr. Susan Broner. She's the Medical Director of the Weill Cornell Medicine Headache Program. Dr. Broner, it's a pleasure to have you with us. This is a really good topic as people by the millions suffer crippling headaches. Some people suffer ones that are just kind of light and dull and hang around all day. Can you even tell us what a headache is? Do we know why we even get them and tell us some of the challenges of treating them.

Susan Broner, MD (Guest): Melanie, it's great to be here today. Thank you so much for inviting me. And yes, headaches are really common. And very debilitating. In fact, headache disorders are amongst the world's most debilitating conditions globally. In fact, migraine itself is the second most disabling condition in the world in terms of years lost to disability. And if you look at populations of people under 50, it's the first most disabling condition yet many people go undiagnosed and untreated.

And headache disorders have a very great effect on people's lives, where they're missing activities, either at home or in social events. People are less productive at work. And in fact, half the cost of migraine is related to presenteeism where people are actually coming to work or trying to work, but aren't as productive because of the pain they're experiencing. And in fact, headache itself is a term that's used to describe a symptom rather than a diagnosis in the same way that stomach ache doesn't give you a diagnosis of a disorder, but just gives you what the person suffering from. And we actually group headaches into a number of different types. We call them either primary, meaning there is either a genetic predisposition or no specific underlying cause. And those include migraine and tension headache, and cluster headache amongst others. And then secondary disorders, which people worry about like brain tumors or even sinus infections that can cause headaches.

Now, although tension-type headache is the most common disorder of headaches and about 70 to 80% of people will experience that it's generally less debilitating. So, migraine is really the most common headache disorder that I see in my practice.

Host: Well, thank you for that excellent explanation. So, you've mentioned a few things here, as far as what it can do to productivity and absenteeism and quality of life really is what this is about. So tell us some of the common triggers for headaches and migraines, and I've even heard Dr. Broner that overmedication can actually contribute to headaches.

Dr. Broner: That's absolutely correct. Triggers or terms that we use to describe factors that can give or contribute to you're getting a headache. And those triggers can be something external, like weather changes or foods or alcohol. Some people say that aged cheeses can bring a headache or things with MSG or darker liquors or red wine, but there's also internal factors that can also be a trigger. For women, hormonal changes are a very common trigger. Also just things like too much or too little sleep, skipping meals, not getting enough protein in your meal, too sugary foods and so forth and stress of course can also be a trigger. But it's not that they cause headaches, is that they trigger an underlying inherited predisposition to have the pain which we call migraine. And migraine itself, as I said is inherited. Although people don't always identify the person from whom they inherited it, and it's actually a complex neurological disease in which pathways around the brain and in the brain are activated in the setting of these triggers and it contributes to the symptoms of moderate, to severe pain with either light and sound sensitivity or nausea or loss of appetite, or even vomiting, of attacks, recurrent attacks that last four to 72 hours untreated.

Host: So, before we get into what's going on in your field and some treatments that people can try, can we prevent them from happening? Can various lifestyle modifications actually help or possibly prevent headaches?

Dr. Broner: Absolutely. So, I think of lifestyle modification as one of the core basis for improving your migraine health. Now that doesn't mean that people can really modify their lifestyle and still not see improvement because migraine is complex. And it's not sort of a lot of patients I think, feel that it's their fault. And if they just sleep well and eat well and exercise right, then they won't have migraines. Well, migraines are something that we don't cure, but we can manage. So, for some people, these lifestyle factors make a big difference and those lifestyle factors include things in diet like hydration, keeping well-hydrated, drinking, sort of 50 to 60 ounces of water a day if you're an average sized person. Limiting caffeine, caffeine is always a mystery to people because many people find that it helps a headache, but some data suggests that drinking more than eight ounces a day of caffeine, whether it's coffee or tea or sodas can increase your risk of having more frequent migraines. Also fluctuations in blood sugar can trigger a migraine. So, I usually recommend to my patients to eat balanced meals with protein, veggies, whole grains, not skipping meals and keeping healthy snacks on hand so that they're not getting dips of blood sugar that might contribute to migraines. Also, stress is a big factor.

Stress is in all of our lives and it really depends how we manage stress whether or not it affects us. For some people, stress is a great thing and they thrive on it. For others, it can become overwhelming and lead to headaches and other health issues. So, some of the strategies that I recommend to my patients is to plan your week ahead. For example, if you have a big stressful week, trying not to tackle it all one day before everything's due, will lead to less of what we call a post-stress let down headache and trying to take time to decompress every day with activities that rejuvenate you, including things like meditation and self care.

Exercise itself is really helpful. It increases your natural endorphins, which are substances that help to reduce pain and create a feeling of enhanced wellbeing. And also sleep is so important to our health. And particular with migraines, it's not just how much sleep you get, it's also the regularity. So, keeping a regular time that you wake up every day can be very helpful in reducing your vulnerability to getting migraine attacks.

Host: Wow. This is such a great episode. So, much information. You're a great educator, Dr. Broner. So, when do people worry about their headaches? Of course, we all, you know, me included get a headache and, oh my God, right away, I think stroke or brain tumor or any of these things. And when do we worry about a headache?

Dr. Broner: That's a great question and something that's so important. So, to put things in perspective, when I was speaking about primary headaches versus secondary headaches, the vast majority of people experience these primary headaches disorders, which means that they're not going to be life-threatening, although they can be life altering based on how much you're getting them. But it is important to know that about 5% of headaches can be caused by something that's more worrisome or even a secondary cause like a sinus infection, or other infection that's going on systemically.

So, there's something that we call red flags, which are symptoms that people should be concerned about if they get them associated with a headache. For example, someone having an explosive sudden onset worst headache of their life. That's a headache that should not be ignored, but someone should seek immediate attention for, as should occur the headache that comes on with any neurological symptoms like numbness or weakness to make sure you're not having a stroke or an aneurysm. Headaches that come in the face of a fever, a high fever with a stiff neck that would be concerning for something like a meningitis. Other things that are more subtle are if you're getting a change in your headache symptoms. So, if they start to feel different or they're progressingly worsening, those are something that requires attention to examine for secondary causes.

The other aspect, actually, that's very important is if your headaches start to escalate and you have a primary headache disorder, you should seek help. So, if your headaches are interfering with your activities, if they're becoming more frequent or harder to control, and especially if there's a question about your diagnosis, you want to see either a neurologist or a headache specialist to really understand what the disorder is going on to make sure there's no secondary process and to, get anything that is going on under control.

Host: Well, Dr. Broner, you've given us some great kind of non medicational and procedural kinds of treatments, talking about calming and meditation and exercise and caffeine and all of these other things. What about the over-the-counter medications or any prescribed medications that you might use?

Are these things good to use? Do prefer Motrin or Tylenol? If they're are occasional headaches and not migraines and not something that's really severe, can we be taking those NSAIDs? And do you have a preference between those two?

Dr. Broner: So, when patients ask me what's the best medication for their headache, I tell them it's the medication that works best at eliminating the pain and the associated features within two hours and get you back on track. For people who have mild to moderate pain, those may be the over-the-counter medications like ibuprofen or Tylenol, or some of the combined analgesics like aspirin and Tylenol with caffeine.

If people are using those episodically and they're very effective, I think that's an appropriate treatment. You had asked earlier about what about medication overuse and is that a thing and yes, using too many over the counter or even prescription medications can, in some people lead to more frequent attacks. So, if you find that these are working well for you, but the more you take them, the more headaches you get, that's a sign that you probably need prevention. Something to reduce the frequency with how often you're having headaches. Now for people who aren't responding to the over the counter medications, there are a number of wonderful migraine specific medications.

Our first migraine specific medications came to market in the 1990s, and there are seven of these on the market and they're called triptans like sumatriptan or risatriptan and so forth and they can eliminate a headache rather quickly. Now, not everybody responds to those. Some people shouldn't be taking them. For example, people with vascular disease, they may not be appropriate for. And then there are also our newer medications that have come out a year ago, including something that blocks a molecule called CGRP or calcitonin gene related peptide. This is our newest migraine specific medication that can abort an attack within two hours and seems to be very well tolerated.

There's also another class of medications, that work on blocking other serotonin receptors that don't have the vascular risk that the triptans have. There's also devices people can use electric devices or tens units that can be used on the arm or on the forehead to abort a migraine attack or even a cluster headache when people are having them.

So, I just want to get across to your listeners that there are so many treatments, and if you find yourself struggling and you take your medicine and it works, but it just comes back or you're getting more frequent headaches; speak to either your doctor or a headache specialist or neurologist about what other treatments and approaches you can take to really get your headaches under control and stop them from interfering with your life.

Host: What great information and a perfect place to wrap up. Dr. Broner, thank you so much for such great information. What an informative episode this was and Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience, to download, subscribe, rate, and review Back to Health on Apple Podcast, Spotify and Google Podcast. For more health tips, go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole. Thanks so much for listening