CME | This is giving me a headache: Managing the headache patient without losing your mind

Jason Marker: Welcome to CME on the go. The podcast crafted specifically for family physicians by family physicians. Whether you're seeking clinical insights, professional development, or simply a sense of comradery, you'll find those all here. Plus, you can earn CME credit every time you listen. So stoke up the fire, grab your hot cocoa, hit play, and let's embark on this journey together.

My name's Dr. Jason Marker, and I'm an associate director. And clinic medical director at the Memorial Hospital Family Medicine Residency Program in South Bend, Indiana.

Tamaan Osbourne-Roberts: Hi, I'm Taman Osborne Roberts, a federally qualified health center physician from Denver, Colorado, who works primarily with underserved Spanish speaking patients.

I'm also an occasional medical exec and policy maker and early career scholar of papist studies and an occasional standup comedian.

Lauren Brown-Berchtold: And I'm Lauren Brown Bechtold, and I am the program director for the Family Medicine Residency at VCME in Modesto, California.

And beyond that, Jason, I couldn't help but notice you threw in a winter weather reference in the intro here.

Are you predicting the weather now? This recording is not gonna air for several weeks?

Jason Marker: Well, actually, the weather has definitely changed here in northern Indiana, and so I'm just guessing. In a few more weeks when we air this, we'll be into winter. But do you know what isn't a guess? Friends,

Tamaan Osbourne-Roberts: I am afraid to ask, but let me be that guy.

What, Jason, what isn't a guess?

Jason Marker: It is not a guess that when you see some of your patients appear on your schedule with headache in the chief complaint line, you are going to groan and wish you were driving a snowplow instead of being a doctor.

Tamaan Osbourne-Roberts: You are not wrong.

You're not wrong. I

Lauren Brown-Berchtold: kind of now just wanna drive a snowplow for the sake of it. So thanks for that.

Jason Marker: So what we wanna talk about today is what makes so many of us get a headache when we have to manage headaches. It shouldn't be like that.

Lauren Brown-Berchtold: It shouldn't be. And yet I think, like you said, that every person listening would say, well that's cute, but alas it is.

And and I think that part of the problem is that it's so freaking common that it affects so many people that millions of visits to the clinic and to the emergency rooms across the nation are full of people whose primary presentation complaint is headache. But more than that, it's not just how common this presentation it is that makes us so frustrated.

It's that this presentation can mean so many freaking different things that can stand in for like, go home and take a nap, or, oh my God, get to the ER right now because you're gonna die. And, and that makes it really hard.

Tamaan Osbourne-Roberts: No, I, I definitely agree with you, Lauren, and, and that's only the start of it really, like you are developing that differential is the first thing about headaches that is likely to give one a headache.

But then you get into diagnosis and diagnostic tests. Tests are typically inconclusive that are at least oftentimes are, they oftentimes require PA because you're looking at advanced radiology. An interesting one that I don't think we always think about, but that comes up is how subjective. Intensity.

Subjective is always intensity for patients, but say with abdominal pain, we at least have kind of this mild to moderate to severe piece that seems to play out with some consistency between patients. Headaches are just so much more individualized, can be really, really, really, really difficult.

Lauren Brown-Berchtold: My favorite thing that you just said right there to man was that subjective is always intensity.

And I think you meant the opposite. Intensity is always subjective, but, but I'm gonna use that phrase now because subjective is always intensity. It works for me.

Tamaan Osbourne-Roberts: I, I, I'm, I'm, I'm going with that. I'm going that. And now, now from the shame you've given me, I'm gonna lie down with my headache.

Lauren Brown-Berchtold: No, no shame. No shame.

We love you always. I, I, I would like to echo. It's really difficult to try to get a sense of severity across all sorts of different patients. It's really difficult to get a sense of the variable timelines and looking for triggers and, and asking people to us a usually imperfect memory of what the time course of this often prolonged.

Symptom has been, and, and then beyond that, if you have people who are dealing with prolonged headache issues, as in they've dealt with this as a presenting complaint for a really long period of time, you as the PCP might be like, dude, I don't know who has treated you with what I don't know for how long you were treated.

I am gonna have to recreate the wheel or just start over. And we start at the beginning and it just can be very, very frustrating.

Tamaan Osbourne-Roberts: No, absolutely. Or you could go into the opposite, which is they show up with everything that they've taken previously

Lauren Brown-Berchtold: and then you have nothing to treat them with.

Tamaan Osbourne-Roberts: Yes, exactly.

Or they may be on several things, or they may have fallen into, if you will, the opioid hole where somebody has not known what else to use and they're now on opioids for a headache that may or may not have that as the best possible treatment. And it just, it gets complicated so quickly.

Jason Marker: Well, I think, I think we go on a long time with this line of, of reasoning, but these are the things that, that we have strong feelings as physicians about what could cause a headache and what we're gonna need to do about it.

And it's quite a spectrum and that's pretty triggering for us because we know that we're gonna get it wrong some of the time and we don't want to do that. But. It doesn't have to be like that. And that's what we want to do. A little myth busting around today. We're family doctors, we've got this. We just have to do our usual things, which is to take a good history, do a little bit of exam, begin our well down diagnostic flow chart in our brains, and that's gonna lead us to a treatment plan and.

Thankfully we've got a lot of support from our own AAFP. I, I went into the American Family Physician Journal website and there's like a whole section just on headache articles and so there's lots of really good information out there. We'll, we'll put some of those and links in down on the show notes for y'all, but they're easy places to start and they're with the exam and they're with the history, and that's where we're gonna start this conversation as well.

Lauren Brown-Berchtold: Yeah, I, I think that the compendium from AAFP is really amazing. And if you wanna get even nerdier and start going to source materials, the place that you're gonna wanna look is the International Headache Society. Yeah. And they have this really great international classification of headache disorders.

It's in the third edition. And so if you are someone who is. A super nerdy about this, or B, potentially most of your, of your patient population could be presenting with headaches. I could imagine. You know, family docs are able to do wild and wonderful things in the world of medicine, and so I could imagine that a family doc might have a neurology type practice, and so they get.

Into the nitty gritty and I mean into the freaking nitty gritty. But if we back up a little bit, the major classification that they talk about that I think is really helpful for us as we think about history is going into the division of. Primary versus secondary headaches. And that's super helpful, especially as we get later.

Right. And Jason, you're gonna talk about some of the main diagnostic criteria and diagnoses of some of the, the large buckets within those, but the question is, is this a primary headache? Is this going to be sort of an independent pathology that doesn't forough anything that is life-threatening? And that's, that's a really common.

Qualification for headaches, something like 90, potentially up to 98% of all headaches that are presenting to the primary care clinic or a primary headache versus are we looking at a secondary headache? And that's where we start talking about these potential red flags that we've all been taught in medical school and residency where the headache is just a symptom.

It's pointing to something else that's causing that symptom. And very frequently we're really worried about those secondary headaches. We're worried about things like a subarachnoid hemorrhage. We're worried about things like tumors. We're worried about things like infection. What can get really, I, I think, complicated is that I'm getting a little bit anxious, but I know that my patient is a little bit anxious or a lot a bit anxious about is this headache pointing to something that's gonna kill me?

And so now I'm not just dealing with the medicine I'm dealing with, with all of the emotion that's just entered the room.

Jason Marker: Yeah, and I think that it's reassuring for patients when we start our diagnostic workup and start taking history that as soon as we get the sense that this is most likely to be a primary headache, we can remind them that those are overwhelmingly benign, non-life threatening things.

Yes, they may be stubborn to treat and hard to manage, but they're not likely to be a harborer of something really life altering or life ending for them. Once we get down to that classification. You know,

Tamaan Osbourne-Roberts: despite how they may feel, because honestly, headache's very, very unpleasant. Yeah. You know, which brings up a really good point, and again, a point that amongst our listeners may be one of the veins of their existence, which is, okay, this patient has a headache.

Okay, do I have to do a full, top to bottom neuro exam, which as we all know, is the longest and arguably most painful portion of the physical exam. That is, is

Lauren Brown-Berchtold: the top to bottom part. It's, it's just all of it.

Tamaan Osbourne-Roberts: It's just all of it. Just like how, how much, how much do I gotta do here? And really, once you're looking at that, it really, history is your guide.

So there are some things that really, absolutely. We require what I would call full touch neuro exam, neuro head to toe plus cranial nerves that you can consider additional specialized neural exams, neurological exams if you want to. And those are the ones that come with really kind of the red flag signs.

And one of those red flag signs that I think most of us know is headache with the presence of vomiting and particularly vomiting without nausea. That's one of those ones where no, that's, that's gonna be a full workup kind of at the start. But as you go from there, there are again additional things that probably require a full neurological exam.

One is a lot of primary headaches, so if somebody's coming in that have a headache, it's described as severe. That's hard to know exactly what that is, but severe could. Be anything from thunderclap, which certainly represents very, very acute, potentially acutely grave sorts of things, or it could be a migraine.

The long and the short is that usually is a full neurological exam. As you move away from there, there are things that I would call light touch exams. I, I wouldn't say no touch. I'm not certain that there is ever the headache where you don't want to do at least a basic of some sort of exam, but a very, very common form of headache.

For instance, tension headache. And if a patient has tension headache, you may not need to do a full neuro. What you may need to do is to determine whether or not they have trapezial spasm, whether a headache is secondary to such. You may need to determine whether or not there are TDJ issues, whether or not there's temporal spasm.

Really kind of these sorts of things that are I relatable on a musculoskeletal exam? Those are actually a lot of the exams that I see in my patients, given the preponderance of. Physical work that they, they happen to do and the amazing quantity of Trapezial Spa. So I see at any given week. But you know, that's one of those ones where, where that goes.

But it really is very, very, very important to let the history be your guide. In most practices, you're gonna see a brief neuro exam usually being indicated because so much of it is primary headache. That is the thing. In addition to that, you have to think about whether or not a vision exam makes sense.

And it can be easy, it can be reassuring against a range of things you, you could consider a fundoscopic exam, although for some people those are a little harder to do in the office depending on the equipment they happen to have available. And there's skill in doing so, but that really is something to consider.

Lauren Brown-Berchtold: Yeah, I'm not sure if I can pick up pap edema, honestly. Even if I'm looking, oh, come on Lord. And that's a me problem, but Hold on.

Tamaan Osbourne-Roberts: Railroad track it. Railroad re. I

Lauren Brown-Berchtold: know, I'm sorry. I'm sorry.

Tamaan Osbourne-Roberts: No, no, no. It's, and honestly, that's gonna vary. It really will vary based on equipment. You know, there are. Times. For instance, in my personal kit, I have a panoptic and that's a little easier to, to kind of pick that up on the clinic I work in.

And I don't always bring my equip in and by, I don't always, I mean never happens to have only traditional endoscopes. So those are a lot harder to use for a lot of people. You know, a lot of people are like, great red reflex and the pediatric exam, that's as far as they got in using them. So the reality is if you do have both the equipment and the skill set.

It may be something to do with not, you'll have to consider referral or whether or not it makes sense. Another thing is, I have already intimated, is that it makes sense to do a musculoskeletal exam in some cases. Not all, it's going to depend, but really that's, that's where we find ourselves. And then one shouldn't forget the possibility of a headache secondary to carotid dissection.

It's not the most common finding, but is a particularly grave one. If you have a history that is suggestive of that, don't be shy about examining the carotids and going there.

Lauren Brown-Berchtold: And it's so interesting because even as I think through what are history taking pearls versus what are the examination pearls, it's really difficult in my mind for me to map those out and separate them because so much of.

Of that history guides my exam and guides my, my diagnostic process. But, but going back to the basics of like, do you have a history of tumors? Do you have a history or, or, or some sort of cancer, right? Do you have a history of a significant reason to be concerned about infection? Like HIV? Do you have recent trauma as opposed to the basics of what we do, which is.

Talking about like, when did this show up? How often does it show up? How long does it last for? And then potential triggers that might lead to such things. And so really, as we're parsing out those historical factors, what we're trying to to do is say like, worried or not worried, right? Sick or not sick.

And those can feel like really basic differentials. But once you have the sense from a history that this person is not. Sick from a life-threatening perspective that that basic neuro exam that you do that rules out any neurologic deficits is going to be really reassuring.

Tamaan Osbourne-Roberts: Very, very, very much so. I, I very much agree and I, I would say it also goes in the other direction.

If you find something that is focal and strange, you're kind of like, okay, we know where to zero in. Let's start to zero in there. It'll help really to narrow your diagnostic tree in that way. Another thing actually to consider is the other sort of brain illness as opposed to neurological, psychiatric.

That really is one of those sorts of things that you also want to consider because headache is one of the primary forms of somatization that we happen to see in a lot of our patients who may be somaticizing, depression, or another disorder. So P HQ one, two, or nine GAD sevens may be helpful. It's an important thing to consider.

Lauren Brown-Berchtold: Totally.

Jason Marker: I think that these are all great things. I, I have almost given away my interest in doing the review of systems. Like, it's just, it's not part of billing and coding anymore, but an undifferentiated headache problem. I, I get back to my review of systems, like we're just, we're just gonna go for it.

We're gonna do all the things I learned in medical school to do a review of systems and sometimes that is where I gather the clue that I need to decide what sort of exam I'm gonna need to do. So I think not skimping on your history of present illness. Maybe leaning into that review of systems, doing a, a focused or if necessary, comprehensive neurologic examination.

I think the clinician of who's, who's been trained as a family doctor, like should be able to whip through those. Listen, be compassionate and empathetic listening space. And do that exam and be able to get that done. It is not gonna take you an hour to do this. It may take you a little longer than otitis media and a three-year-old, but it's not gonna take you forever.

Like take your time, take the history, let it guide your exam, and then you've gotta decide, do I need to do some diagnostic testing here or not? And that can be a tricky situation, but, but one that you've gotta decide on.

Tamaan Osbourne-Roberts: So what if the otitis media and the 3-year-old is causing them headache? Ooh.

Jason Marker: Yeah, that's, that's a, that's a, let's not go that We can't do that in this kind of episode.

That's, that's,

Lauren Brown-Berchtold: and then they're screaming at you, which is causing you a headache on top of the mom who's crying, and all of you have headaches. Jason, your face right now is amazing.

Tamaan Osbourne-Roberts: Then you go home and you complain to your significant other, and that gives them a headache, like. Headaches. They are conta are, are apparently an infectious disease.

Lauren Brown-Berchtold: They are contagious. That's what I just learned. We are not aware, oh my gosh.

Jason Marker: I think that's what you call a tertiary headache. Tertiary.

Lauren, Lauren Brownberg told, will you please talk to us about diagnostic testing.

Lauren Brown-Berchtold: Okay.

Diagnostic testing. So. This is not gonna be a surprise to either of you or to any of our listeners, but some of that idea of diagnostic testing is actually taking a step back and saying, do I have reasonable cause to need a test?

And so I would be remiss if we went any further and did not talk about the most ridiculous pneumonic in the world, which is S 10, but it spelled with two Ns. And some of you might be familiar with Snoop four with one end, which is slightly less insane. Snoop 10 with two ends is this pneumonic that was developed as a uh, uh, ability to help us remember what might be some criteria for secondary headaches.

And the real question is if you are sorting into any of these red flags or. Alternatively, if you don't like that sort of generic phrase, what are concerning signs for, for a secondary headache, then what you're talking about is, is this an urgent evaluation at another location potentially with imaging, or is this an emergent imaging?

And, and that's the real question that you're asking. And so, and to be really clear with our listeners, if this is not. A secondary headache. You don't really need imaging like that is the answer. Right? That would be considered if it's a primary headache in general, that's going to be considered an uncomplicated headache.

And there's this really interesting data from a journal called Cephalalgia. Which I didn't know existed until recently, but it is the Journal of the International Headache Society. It's been around for decades and, and there's this great article from 2021 that says that the probability of finding an abnormality on imaging is the same in patients with headache as compared to an age matched population of patients without headache.

Wow. Right, so, so the other way of saying that is like, just pick someone off the street, whether they do or don't have a headache. They're going to have the same probability of an abnormal finding on their imaging exam. And so from a guidance perspective, from a diagnostic perspective, and also from a resource use perspective, that that is a really poor use of, of imaging.

Now, in the patients that we are concerned about something that is systemic or that is a focal neurologic issue, the the answer there is that in general, what we need is an MRI That is the best test usually with contrast, unless. You actually have an emergent situation and you just have to get it done, and in that case, going to the ER for a CT without contrast is going to be the thing to do to be ruling out intracranial bleeding or mass effect.

Right now my caveats are that you might have a normal ct, but if you actually think that this person has a subarachnoid hemorrhage, you need to be following that up with with an lp. And so you in the clinic saying, I am this concerned, is really buying some meaningful resources, but impact to this patient.

And so wanting to be really aware of how you're using those thought processes. The one thing that I sometimes get questioned on is EEG and in the Choosing Wisely campaign, the American Academy of Neurology said, just do not do an EEG for headaches. Now that is not an N of one perspective. I could certainly imagine.

A really strange patient with a headache and a host of other issues that that did need an E, EG. But I, in general, from the Choosing Wisely campaign, the recommendation is to not go down that route.

Jason Marker: If you're looking for a great table that summarizes the Snoop 10. Pneumonic criteria really well I'd, I'd send you down to the show notes through the link to the 2022 article in the A FP titled, acute Headache in Adults, A Diagnostic Approach.

Dr. Vera and Dr. Enteno are from Duke. Have a really great Table five. It goes through all of the Snoop 10 mnemonics possible workup, differential diagnosis. It's a great table for you. Alright, so. Probably not gonna be reaching for diagnostic testing too often. And when we do, it's because we're very concerned that there's a secondary headache.

It's gonna be that smallest percentage of things we're probably gonna run towards an MRI, but not likely an EEG, maybe a CT if it's really an emergency. Then we've gotta decide what are we gonna do here? And so this is where we really come back to our primary and secondary buckets and say, how are we gonna manage this?

So primary is gonna be something that sort of feels migraine like, or something that feels like a tension headache. Secondary are gonna be all of those other conditions that cause a headache. And the treatment for those is generally going to be. Solving the other underlying problem.

So from a treatment standpoint, I'd like us to sort of lean into the two different types of, of primary headache, migraine like, and attention headache like, and see if we can summarize maybe where our starting point is in, in our medication options for those who wants to.

Take a crack at that.

Lauren Brown-Berchtold: I can tackle that. Jason, from the perspective of a, of a couple of different types of headaches, when we're thinking about this sort of catchall phrase that is not necessarily a migraine and not necessarily stress or tension headaches, chronic daily headaches are, are sort of a higher level term and what that technically means is that you have headaches for 15 or more days per month.

Might be tension headache, might be overuse, headache or medication overuse, headache, and. Is really interesting because so many of our patients with tension or stress headaches end up having this chronic daily headache. And so what we're really going after is a a good night diagnosis. B reassurance because I cannot tell you how many patients are coming back to, to talk to me.

And they're saying like, yeah, my doctor said it was nothing to worry about, but I'm pretty sure I have a brain tumor. Right? And so being able to move past those conversations with a place of trust with our patients is something that's going to make our lives easier and is really important. And so then at that point saying like, what are our options?

We have, we have pharmacology, and then we have non-pharmacologic options, right? There is some pretty good. Data around cognitive behavioral therapy, some osteopathic manipulation, cervical exercises as to man was talking about trapezius and, and tightness earlier. I was thinking about when I go to the masseuse and they go, oh God, your neck feels real tight.

Right? We, we can be doing some things like stretching and like massage to, to really be working on. Some of the symptomatology that we're dealing with, and that is probably not going to be satisfactory to a lot of our patients. And so there are a wide number of, of medications that we can be using from, again, thinking more of a stress re tension type headache into chronic daily headaches like.

Amitriptyline, Gabapentin, which even though Gabapentin has its issues, man, I really enjoy using it because it is so effective for so very many things. NSAIDs are really effective. What's interesting is that the number needed to treat for attention headaches is 14, which is an incredible number that headaches resolve within about two hours.

For one in every 14 people that were giving some sort of NSAID to. And then another medication is an adjunct to NSAIDs that has been, in my opinion, making a comeback over the last five plus years, which is T Zine. The brand name is called Zanaflex, and that that can be really effective from both a muscle relaxant perspective.

That's not necessarily going to be centrally acting and sedating while also providing some some actual pain relief. And then we can go into like our Topamax and our Valproate if we're needing some other medication. Options for these types of headaches. What's interesting is that a medication overuse headache, if I can just divert there really quickly, is technically a secondary type of headache, but it can lead to a chronic daily headache, which is commonly thought to be a primary type of bucket.

And if you actually untangle the medication overuse headaches and are able to unmask the primary headache disorder, that then becomes. In the vast majority of cases, like 80% of people actually have an underlying migraine disorder. And so that I think is, is the specifics are probably not that important, but what's interesting is that it really speaks to how complicated diagnosis and workup can become.

Even if that workup is just the really good history and untangling of everything this patient has gone through. And so really briefly when we're thinking about medication overuse headaches, the counseling again, is that like there's not necessarily something that is concerning from a life-threatening perspective.

This is a central sensitization. From a pathophys perspective and that really the prevention of developing a medication overuse headache is the treatment meaning both, Hey, if you have a headache disorder, we need to be advising you. Don't be overusing your headache, your your headache medication 'cause you'll develop another type of headache disorder.

But also let's use medications to prevent the headaches from from occurring. In the first place, and again, NSAIDs T Zanine can be really good adjuncts as we're trying to potentially wean people off of the medication that they have become dependent on. But, but it depends on what their actual medication that they're on is that has led to the medication overuse.

Jason Marker: It would always be nice if we could just say like, here's the medicine you use for headaches. But obviously you've listed off, you know, a dozen choices for us here in, in the last few minutes, and this is one of those areas where knowing your patient well, having taken that history and exam and looking at that list of maybe a dozen medicines, and thinking to yourself, where am I gonna start?

Right. Actually, I don't find that it's too hard to narrow it down to probably two or three that are probably gonna be best in this particular situation. And then partnering with my patient in some shared decision making to say like, I've got two or three things we could try here. Let me tell you about them and see where we think we want to go with this.

I think there is a place where you're gonna have several reasonably good options and being a little transparent with the patient that you've got some choices that need to be made and you probably don't have a strong reason why one's better than another. And letting them weigh in. Maybe somebody in their family has used a particular one and thinks that sounds great, or thinks they wanna avoid that.

Like there's gonna be some family medicine magic that happens to help you decide which the final choice is gonna be.

Tamaan Osbourne-Roberts: No, I definitely agree with that, and I would certainly say that part of the Family Medicine magic is what we have available is resources. So American Family Physician Journal actually has several different really, really good articles on various types of headaches, including two of the, the ones that are actually maybe a little more easily and better, well defined in some cases, not all, in some cases.

Then some of the general, uh, primary headaches, we, we, we, we've been discussing one of those is cluster headaches, and the upside to cluster headaches is there's a fairly. Robust diagnostic tree. The downside is that, uh, the vast majority of treatments are not exactly ones you would do in home. So if somebody has a really kind of true cluster headache, if it's unilateral associated with the eps, eye and tearing and, and really all of the, the classic clinical teachers that we think about, the upside is if you live in the state of Colorado where oxygen bars are readily available, sure you can do this.

Outpatient high flow oxygen is still arguably the best treatment for this. And by high flow, I don't mean the little oxygen canisters that you can buy everywhere around here in Walmart. For people who get altitude sickness after flying into Denver, that's not gonna work. Wow. Something that's substantial and it, trust me, it's, it's amazing how, how popular those are.

But no, you really do need something that's true. High flow oxygen in a physician's office. Arguably in an oxygen bar, although I wouldn't go that route. That's certainly one thing ever. Injectable sumatriptan as opposed to oral fromer Tryptan indicated in, in this case. So there's some other alternatives.

We leave those off. They're a little less common, and you can certainly read the article about those. The other is true classic migraine, which as we've discussed for this entire episode, is not necessarily. Distinguishable in all cases from chronic daily headache. It, it really, there's a lot of overlap in the pathophysiology of the two, which has been understood a bit more over recent years.

But if you have traditional classic, you know, with aura migraine or post migraine neurological symptoms that, that have been rule warped up and ruled out as TIA or stroke or things like that, and somebody is, is looking for chronic therapy, there's, there's really good options for both abortive therapy.

And prophylactic therapy. And as far as abortive therapy, first line are the oral triptans. And again, a lot of this in the articles, but interestingly enough, also acetaminophen and also NSAIDs. These work, as Lauren said, remarkably well in many cases, they don't work for everyone. But they are oftentimes cheaper, more available, and have fewer formulary restrictions than the triptans.

Triptans work very well in terms of abortive therapy, have a few more restrictions in terms of contraindications in the NSAIDs, but oftentimes can be used in a wide variety of patients are really good. However, patients having incredibly frequent migraines or migraines that are not responding as well to acute therapies oftentimes need to consider prophylaxis.

And once you start getting into prophylaxis. You're really looking at three first line sorts of treatments. One, which a lot of us are familiar with are beta blockers. Oftentimes metoprolol. You can certainly use propranolol and there are protocols available for both of those if folks are having side effects on those bradycardia, dizziness, decreased exercise tolerance, potentially impotence, things like that you can certainly consider either prior to those or after those.

The anti-epileptic drugs. Lauren, I think you mentioned in addition to Na Topiramate, which a lot of us are using more often now as low doses for weight loss amongst other things, seeing that in a a much more broad, I know we used to be a little more afraid of using anti-epileptics as a whole, but there are options.

They are good and safe drugs in a variety of people. They do come with a slightly higher risk of side effects probably than several of the other options, but certainly something to consider. And the last. Are antidepressants, which appear to have an independent effect on migraines even outside of treating depression.

Well, the two most commonly ones considered being amitriptyline, which we're actually typically familiar with, is a centrally acting pain modulator, dealing with some of the central physiology that Lauren, I think you talked about earlier, the changes that happen in regards to that. But venlafaxine also being very effective in that regards as well.

So those are just a few of the chronic prophylactic options available to patients.

Lauren Brown-Berchtold: Can I just share though that my absolute favorite thing to have evolved out of migraine treatment recently has been that using Botox in neurology offices has become exponentially more widespread, and I have seen patients who have had their lives changed as a result of that.

Tamaan Osbourne-Roberts: No, I, I completely agree and that is another of the many options available. I'll admit I am not providing Botox treatment even for aesthetics in my office. I don't plan to do so. So Botox really is a, a referral option, you know, by the time we get to that point. Yeah, for sure. I'm sending over to a neurologist and I think that's, at least right now, a good way to go.

Jason Marker: All right, you two. I'm not sure that we did anything more than muddy the waters even further for our listeners because headaches are, are a tough problem. But if I can just summarize a couple high level points here. Take your good history, do the exam that's indicated by that. Probably not gonna lean very often into diagnostic testing, but when you do, do it smartly, start with that MRI, if you have the capacity to do that.

Think about primary and secondary causes of headache and do a little bit of reading even within the A FP, about how to break those down and then grab for some medicines. There are so many to choose from so many different things. And use a little bit of your family doctor logic and whittle your way down to a few and begin to work with those with your patients.

And I think you're gonna find some success there if you've worked through the process as well as you need to. And I know you can do that.

So. I think we're gonna wrap up now. I think we'll do our moment of gratitude and call that good for an episode. We will ask you listeners to give us some feedback on what parts you need a little bit more of out of this headache conversation, and maybe we'll, we'll do another one in a few months to sort of tie up a few of those loose ends.

But this seemed like a good starting place for us. Toman, you have something you're grateful for that you wanna share with us?

Tamaan Osbourne-Roberts: Yes. I'll say that despite this remarkably elucidating and empowering episode, I'm grateful that headaches are not the most frequent diagnosis in my practice.

Lauren Brown-Berchtold: I'm, I'm gonna flip that.

I am grateful that I have had just a very couple of migraines in my life. My sister has a migraine disorder, and I'll be really frank, like I didn't get it. I didn't get why we were all like bending over to make her life easier. When of course you just have a, a headache. That's fine. And the empathy that I learned from experiencing that for, for a couple of times has made me approach some of these patients with more understanding for.

What can be, even though it's not life threatening, pure hell, and I feel really grateful for that.

Jason Marker: Yeah. Yeah, I, I agree with that. I, I've, I've not suffered headaches very often, but I'm just surprised when I do, like, I can just do nothing else. Mm-hmm. Like, I don't even wanna lay on the couch and watch tv.

Like, I just, I don't wanna do that, and I can't imagine. How challenging it would be to try to do anything of importance, parent to child, go to work, get the groceries, anything with that kind of headache. So a lot of empathy. I have learned for the very small number of headaches that I have had, and I think that's been great for me as a physician to listen with different ears when I'm taking my history and really lean into a good quality examination and be thoughtful about appropriate follow up.

Not just saying, well, let me know how this works for you, but like we need to schedule a follow up and know how this works. A lot of learning has come to me because of that. So glad that that's not something I have had to worry about too much in my life, but also glad for what I've learned from the times I have.

Alright, friends, well, that's what we have for today.

Thank you for joining us for another episode of Seeing me on the Go. We appreciate you joining us on this journey to elevate family medicine. Stay tuned for new content brought to you twice a month, and visit the show notes for instructions on how to claim your CME credit and to find additional resources for today's episode.

Until next time, serve from your values, pursue your vision, and learn not to dread the headache visit. See you next time on CME on the go, A production of inside family medicine.