Importance of Keeping a Headache Diary or Headache Calendar

If you have recurrent headaches that are bad enough to take you to see a physician, then you need to keep a headache diary or a headache calendar.  As a physician, I can take good care of a patient without a headache diary or calendar, but I can take great care of patients if they keep a complete headache diary.  This blog post will try to explain the information I need at each visit to provide optimum care of my patients.

Physicians want to improve the quality of life of their headache patients.  On the initial visit, determining the headache type (secondary headache or primary headache) and subtype (migraine headachecluster headache, rebound headache, etc) is critical.  Please see my web site to learn more about these different headache diagnoses.

Between visits, it is critical for the patient to gather the information needed to optimize their care.  The first goal of therapy is to minimize and/or eliminate headache disability. In order to measure the disability resulting from headaches physicians have typically used questionairres such as the MIDAS (Migraine Disability Assesment Scale) to determine the disability burden.   However, keeping track of the number of hours they are disabled as well as all the other information needed can be cumbersome for some patients.   I developed iHeadache, an electronic headache diary that makes keeping track of actual disability time very easy.  In addition, the MIDAS score is calculated by the app.  This leads to a much more accurate representation of the patient’s headache disability.   This type of data is really not practical to collect using a paper diary.  The frequency of the headaches is also important.  This is fairly easy to track with either paper or electronic diaries.

Occasionally there is a diagnostic dilemma for the physician.  An accurate diagnosis will result in better treatment options.  To help improve headache diagnosis, the iHeadache app collects headaches symptoms from the user and then analyzes the data to determine if an individual headache meets criteria for migraine or tension type headache.  This does not make a “diagnosis” of migraine, as the app cannot determine the difference between primary and secondary type headaches.

iHeadache can also provide information that may help to correct some headache types that are commonly misdiagnosed.  Recurrent “sinus headaches” are usually found to be migraines.  In addition, patients who have severe tension headaches commonly have migraine headaches as well.  The treatment for these patients will be vastly different once the correct diagnosis is made.

Headache therapy is commonly complicated by “medication overuse” or “rebound headache”.  iHeadache keeps track of the medication taken for each headache and then scores the data for the physician to see if “rebound headache” is a possibility.

Once headache triggers are identified, they can be avoided to reduce the severity and/or overall number of headaches.  iHeadache tracks about 20 of the most common headache triggers and allows the patient to add 5 user defined triggers.

Finally, the most critical feature of iHeadache is its headache reporting function.  The app can break the electronic diary by units of time (weekly, monthly, etc), which allows the patient and physician to determine the effect of treatment changes.

So remember, keeping a headache diary helps your doctor to take better care of your headaches.  Electronic diaries are better than paper diaries and iHeadache is the best (but I am biased).

Headache experts are beginning to use iHeadache in their practices.  To date, almost 200 headache experts have requested information about iHeadache for their offices.  Information specifically for physicians is located here.  Physicians can request iHeadache  brochures for their office here.

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Qutenza for Neuropathic Pain

Qutenza® is a high dose (8%) capsaicin patch which is applied in the physician office and can provide months of pain relief.  I was one of the investigators in one of the initial Qutenza studies that led to the approval of the patch for post-herpetic neuralgia, otherwise known as post-shingles pain or pain after the shingles.  The patch works well for patients 50% of the time.  Virtually all patients with post-herpetic neuralgia are candidates for Qutenza.  Only those patients with skin breakdown, recent stroke, uncontrolled hypertension, or recent myocardial infarction are poor candidates for this treatment.  What is really nice about Qutenza is that one treatment provides months of benefit.

Qutenza is currently FDA approved for only post-herpetic neuralgia.  Is is approved in Europe for all painful peripheral neuropathies except those that are diabetic related.  This therapy is commonly less expensive than other treatments offered by  pain specialists.  Unfortunately, Bellaire Neurology is unable to offer this treatment to medicare patients because the reimbursement is insufficient to cover the costs of treatment.  I do offer Qutenza “off-label” for all patients who meet the European criteria.  I do this because the treatment is extremely safe, cost-effective, and because there are no FDA approved treatments for the indications that are approved in Europe that are not approved in the US.

If you are interested in obtaining Qutenza®, please make an appointment to see me at my office.  If you are coming from out of town, please let us know of your interest in Qutenza at the time you are scheduling your appointment so we can have it available, if needed, to treat you the day of or the day after your scheduled appointment.  This will minimize your travel cost.

You can learn more about the shingles and pain after the shingles here.

Qutenza® is registed by NeurogesX, Inc.

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Botox for chronic daily headache (migraine)

In exciting headache news, Botox brand of botulinum toxin A was FDA approved October 15, 2010 for chronic daily headache.  To have chronic daily headaches, you have to have a headache more than 50% of the days in each of the last 3 months.   To have chronic migraine headache, at least 8 of these headaches each month have to meet the criteria for migraine headache.  This is the first medication approved for chronic daily headache.  The study that proved its effectiveness can be found here.

Botox was tested in two studies that were identically designed.  Briefly, patients who met criteria for chronic daily headache with a history of migraine were randomized to either receive Botox (155 to 195 units) or placebo.  In the end, the treated group had 8.4 fewer headache days compared to 6.6 fewer headache days for the placebo group.  While the difference between the two groups is relatively small, this represents the first medication to approved for this indication.  Chronic daily headache is a relatively refractory form of migraine headache and the placebo response for pain studies is quite high.  Therefore, it is difficult for treatments to be proven effective in this disease.  Allergan deserves a lot of credit for pursuing this indication instead of the easier indication of frequent migraine headache.

Valproic acid, Topiramate, and long acting Propranolol are FDA approved to prevent frequent migraines with headaches that are less than 15 days per month.  These medications, as well as others, are used off-label for chronic daily headache and chronic migraine as well.  My website includes additional information on migrainechronic daily headache as well as prevention of frequent migraine.

I have used Botox for migraine headache for more than 15 years.  Prior to this approval, insurance companies rarely paid for this therapy.  I suspect all insurances will cover this treatment after a couple of trials of less expensive treatments.  I think it will be essential to keep an excellent headache diary for 4 weeks before and after the botulinum toxin treatment in order to determine how effective this treatment is for an individual patient. Besides headache days, keeping track of disability hours each day I think is the best indication for effectiveness of treatment.  The electronic headache diary app iHeadache includes all of this information and can prepare reports for you and your physician to assess how well Botox (or any other preventive treatment) works for you.

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Does light make your migraine headache pain worse? (Understanding Photophobia)

Photophobia (sensitivity to light) is a common symptom of migraine headaches.   Thanks to great work from Dr. Rami Burstein and his associates at Harvard Medical School, we now have a much better understanding on how light makes migraine headaches more painful.  Just as important, we can use this information to prevent migraines from becoming more severe.  I heard him speak on this subject at the summer American Headache Society meeting.

Dr. Burstein’s group published their research in Nature  Neurosciences.  Their research was very clever.  They used patients who were blind and also had migraines and determined which of them had photophobia and which ones did not.   Then they looked for differences between these patients.

Are you wondering how someone can be blind and  have migraines that get worse from light?  Let me give you a brief explanation.   There is a group of cells that respond to light called ‘intrinsically photosensitive retinal ganglion cells’.  These cells are not involved with the ability to see images.  Therefore, it is possible to be blind and still have these cells intact.  These cells are wired in such a way that they increase the pain during the migraine attack. Unfortunately, it only takes seconds of light exposure to make the pain worse and at times the effect of the exposure can last several minutes.

These cells respond most strongly to blue light.  On the color wheel, red is the farthest away from blue.  Therefore, I recommend migraine patients to literally see the world through rose colored sun glasses.  For those with frequent migraines, I recommend installing red lights in their homes.

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