Hartford HealthCare Podcast
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Hartford HealthCare Podcast
Splitting Headaches: Episode 2 with Dr. Joe Casaly
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Dr. Joe Casaly, a neurologist with Hartford HealthCare Ayer Neuroscience Headache Center in Mystic, Connecticut, discusses types of headache including migraine and cluster headaches. He also gives us some great news about treatment options including medications and wearable devices new to the market.
Listen to episode one featuring Dr. Nicole Gill for a deeper dive into the triggers and treatment of migraine.
I've heard that term quote normal headaches unquote many times in my career. It's not a normal headache.
SPEAKER_00Welcome to more life. I'm another one. Our guest today in episode two of our two-part headache series is Dr. Joe Castley, Board Certified Neurologist with the Hartford Healthcare Iron Neuroscience Headache Center in Midston, Connecticut. Welcome, Dr. Castley, and thank you for joining us. First, can you tell us a little bit about yourself?
SPEAKER_04Sure. I am a board certified neurologist who's been practicing headache medicine exclusively for almost 30 years. Now I I've, for the most part, been outside of Connecticut. I have had a practice in the Dallas Fort Worth area for 20 years, really through the 2000s. We called it the Headache Center of North Texas and practiced in the Dayton, Ohio area for 10 years before that. But I'm actually back to Connecticut now. I'm a Connecticut native, born and raised in Waterbury. I went to Yukon as an undergrad, Yukon Medical School. And I saw this very good opportunity to join the Hartford Healthcare Headache Center uh late last year and uh took them up on it. So I actually started in June here at the Hartford Healthcare Mystic Facility, and as I've done for the past 30 years, I'll strictly be doing headache medicine.
SPEAKER_00Well, welcome back. We nutmeggers are glad to have you back on the East Coast.
SPEAKER_04Thank you. Thank you.
SPEAKER_00Dr. Cathley, uh your one of your colleagues, Dr. Gill, discussed in part one of this episode, which we can find the link to in this podcast description, to discuss who migraine affects most, primarily the age group 20 to 30, a lot of women. Will you expand on that for us?
SPEAKER_04I've been seeing a lot of headache patients over the years. It's remarkable to me the breadth of the age groups of patients I see. And Nicole is absolutely right. I mean, migraine is three times more common in women than men. The years that migraine is most prevalent is around 30 to 40 or so, where migraine affects the largest number of patients in the population. But really, it can affect anyone from childhood to the elderly. Yesterday I had a patient come in with the chief complaint of headaches that I thought were migraine who was 76 years old. So it's something that affects a large number of individuals in the population, although, again, more commonly in women than men, and those middle age groups really tend to be affected gravely. And I I think in the patients I see that's when migraine is most impactful to the individuals is in that age group. Back in my private practice, if I had to guess a typical patient coming in a given day, it would be a 42-year-old woman. Again, I think which is I think reflective of who suffers the most from migraines.
SPEAKER_00I'm interested in an elderly patient, which is maybe less common. Would that patient typically have experienced them younger in life, or was that a different set of circumstances where they are just experiencing for the first time in their life a migraine?
SPEAKER_04Well, as a headache doctor, that's where we have to be very careful. You know, headaches that start anew in older individuals often have secondary causes. When I say secondary, I mean non-migramous causes. And you have to be uh a detective to try to determine if there's another reason the patient is getting headaches. But some things we look for it in making a diagnosis of migraine is a long-standing history of headaches. And even though, for example, this person I mentioned yesterday, uh, who I saw who was 76 years old, even though headaches were a big complaint for her at this time, taking a careful history, she had been having headaches frequently since her middle-age years. And to me, that's somewhat reassuring because I know this person has a chronic problem that is worse recently. And so there's often a lot of detective work in determining what is migraine and what type of headache you have to be more careful about to rule out a dangerous cause.
SPEAKER_00And let's take a quick peek at the other side of the spectrum in children, which my understanding is it's less common in very young children. Do you see migraine in young children?
SPEAKER_04Well, yeah, here at the Hartford Healthcare Headache Center, you know, we see adult patients with migraine, but many of these young adults who come to us have had headaches since they were young children. The prevalence of migraine does increase really from the first age where a patient can express themselves saying they have a headache, which is probably around age three or so, um, right up through the teenage years, right through young adulthood. So it's not rare in their young children, but it's less common than in an adolescent, for example. But yeah, it can affect any age group. And back in my previous practice, I saw kids age 14 and up. And um I had a pretty busy practice in the 14 to 18-year-old age group because the impact of migraine can be great on kids in school. Um, you know, school absenteeism can be a big problem with migraine. And so, yeah, again, it affects any age group.
SPEAKER_00Yeah, it's so true. I I have four children and two of them started to experience migraine around that 14-year point. Um one girl and one boy. The boy did thankfully grow out of them, and uh the girl who's now uh mother in her thirties, they got worse for her.
SPEAKER_04There's that actually that's been looked at. When I speak to adolescents and their parents with migraine, uh I mentioned that it's kind of a a rule of thirds. A third of kids and adolescents with migraine will have the headaches peter out as they get older, often late teenage years, early young adulthood. A third of kids will have an ongoing problem with headaches as they get older, and about a third will have the headaches go away in late adolescence or young adulthood only to come back later in life. Um, so that it's interesting and unfortunately unpredictable.
SPEAKER_00Dr. Castley, can you talk about the broad way migraine presents itself in these individuals who are experiencing it?
SPEAKER_04Definitely. A lot of my patients when they come in know they have migraine, but they only classify a certain subset of their headaches as migraine attacks. And those are usually the most severe headaches that they're experiencing, the ones that cause them to be disabled, you know, maybe associated with things like nausea, vomiting, severe light and sound sensitivity. And also sometimes they consider their migraine attacks as only attacks that they have of headache with associated aura. And aura symptoms are neurological symptoms that accompany migraine in some individuals, things like a patient seeing flashing lights before their eyes or wavy lines or a hole in the vision they can't see through. And they've maybe heard from friends, family members who are read of about the fact that many people with migraine have an aura. So they think those are their migraine attacks. But uh then you you ask the question carefully and say, okay, all right, so you told me what you feel are your migraine attacks, but do you have other headaches that you're experiencing besides these occasional severe attacks? And often they'll say, Well, yeah, I I do have other headaches. You know, I have anywhere from occasional to frequent milder headaches. And often patients will call them, quote, normal headaches, unquote. And I asked questions about those. The headaches are not as disabling, perhaps. They don't have major associated symptoms, they don't have the aura I just talked about. But in the headache field, we feel those are migraines also. You know, we feel that migraines are a spectrum of headaches, both within an individual and across individuals in the population. So many people with big, clear-cut migraine impacts will have even more frequent milder headaches that they just try to ride through. And I've heard that term, quote, normal headaches, unquote, many times in my career. And I I kind of like to joke with patients, there's not a normal headache. You know, it's not normal to have headaches. And so what you're actually experiencing is a mild migraine. And I say that migraine is not an intensity of headache, it's a type of headache. So you can have a whole range of severity of migraines. And often if you pull that from the history with patients, you find that it's not just the big attacks that are causing their problems, but this day in, day out, still significant headache, it really affects their quality of life, and that should be gone after also with treatments.
SPEAKER_00Sure. It sounds like maybe those milder headaches might help you, the physician, better diagnose them. Would that be correct?
SPEAKER_04Yeah, I think so. I I think it's actually unusual in my practice to have a patient who comes in and just has severe headaches. I I think there are more people out there suffering with migraines who have this spectrum of severity of headache rather than just a severe attack. So I'm not at all surprised to hear, you know, either they have this range of severity of headaches or they simply have severe attacks.
SPEAKER_00It sounds like there may be more people out there suffering from migraine than we may know.
SPEAKER_04In fact, I know that's the case.
SPEAKER_00Okay. Do you think people who have frequent headaches who might not experience any of the severe attacks could in fact be suffering from migraine?
SPEAKER_04Absolutely. Okay. Yeah, one of the diagnostics for migraine is that a patient should suffer from moderate or severe headaches. And there's actually four criteria we look at. You know, one is you know, having moderate or severe headaches, having at least a times of pulsatile quality or throbbing quality to their headaches, also worsening of headache by light physical activity, you know, just things like walking, you know, qu briskly, climbing stairs, bending over to pick up something off the floor. And also sometimes the one-sided location of headache can be helpful. And also association with either nausea or both light and sound sensitivity. But out of those first four things I mentioned, a patient only has to have two of those four things to make a diagnosis of migraine. So, for example, a patient can have a one-sided headache that is worsened by light physical activity, and it could be typically a mild discomfort. If they have a little queasiness with it or some light and sound sensitivity, that meets a diagnosis of migraine. So, as I said before, it's not necessarily an intensity of headache, it's a type of headache. So there are people out there who you know may have occasional too frequent headaches that they just kind of work through that actually have migraine that that's not being treated or not being diagnosed.
SPEAKER_00And you touched on location. Are migraines typically one-sided?
SPEAKER_04Yeah, it doesn't have to be one-sided. Out of those four things I mentioned a minute or two ago, um, the patient should have two of those four things to make a diagnosis of migraine. So a person with migraine can have bilateral headaches, but about two out of three people with migraine at least at times have one-sided headaches. And then in most of those individuals who have one-sided headaches, in one attack it could be on the left side of the head, the next attack it could be on the right side of the head. So sometimes they switch sides. And even with an attack, the headache can switch sides in some individuals. So it's one clue. Again, a lot of detective work in making a diagnosis of migraine. But if you hear that one-sided headache and it's recurrent over time, yeah, that helps make a diagnosis of migraine.
SPEAKER_00Talk a little bit about that frequency. How many headaches are too many headaches?
SPEAKER_04Oh well, uh, I I think any headache is too many headaches. Right, well, but that's being a headache doctor. Um But uh you know, I I often hear people before they have problems with migraine, I ask them, well, what were your headaches like before they became problematic for you? And they they say, Oh, well, I would have one or two days a month of a mild headache, and I would take a a couple of ibuprofen or acetaminophen tablets for it, and it would go away, and it really never bothered me. That to me is not a headache disorder. You know, when a person has a headache disorder, often their headaches are are above that one or two days per month of frequency, and then there's a whole range of frequencies above that, from you know, people who have pretty significant headaches a couple of days a month and even less frequently if they're if they're severe, to a person having a headache every day. Um and what we call chronic migraine is is a person who has a migraine quality of headache at least eight days a month, but has some degree of headache 15 days per month or more. And uh a lot of people with chronic migraine have a headache every day. In fact, you know, one to two percent of the American population has a headache every day, or or m the majority of all days, and I think the majority of those people have chronic migraine.
SPEAKER_00Now, I'm assuming you think anyone suffering that much, especially with daily headaches, should be seeking treatment. What can be done for them?
SPEAKER_04Well, uh, we have two broad approaches to the treatment of migraine. Uh one is preventive therapy, which is therapy designed to decrease the frequency, severity of headaches, often makes the headaches easier to stop when they occur and makes the headaches less impactful on a person's life. And then there's acute therapy, you know, which is therapy that we use at the time of uh in an individual headache to try to stop that attack. And in the vast majority of the patients I see with headache disorders, we're using both. You know, they're they're complementary approaches, they're preventive and acute approaches. And in terms of preventive therapy, there's many things we can do. There's a lot of non-medicinal techniques that can be effective. I I kind of call them with patients migraine hygiene. You know, things like keeping a set sleeping and mealtime schedule every day, um, staying well hydrated, exercising, decreasing daily caffeine use, which is if you're a big caffeine user, that can sometimes drive headaches along. You know, getting rid of overuse of over-the-counter painkillers, which can sometimes worsen headaches. Um, and then there's more structured non-medicinal therapies, things like relaxation training, biofeedback training can be helpful. You know, certain what we call nutraceuticals, which are vitamins and minerals, can be helpful if taken on a daily basis to prevent headaches. So there are those things we can do, but also there are medications that can be used to prevent headaches. And and you know, even though a lot of patients don't like to take prescription medicines on a daily basis, I think a lot of people do a lot better if if we can focus prescription medicinal therapy to try to prevent their headaches.
SPEAKER_00And doctor, can you enlighten us a bit about the acute treatment of migraine?
SPEAKER_04Yes, we need to stop attacks when they occur. Um, prevention is important, but even with the best preventive approaches for migraine, patients will have breakthrough headaches. We can't completely eliminate migraine for an individual. So we like to have the patient have tools to try to stop the attack when the attack occurs. Um probably the most in fact, definitely the most popular class of medicines as acute therapy for migraine are a class of drugs called the tryptans, you know, which have been around since 2001 when when Imitrex came out, which the scientific name for Imatrex is Sumatriptan. And that really was a breakthrough therapy for patients with migraine. You know, patients who are not able to stop their headaches would often be able to stop them quickly with the use of these drugs. And there's actually eight different tryptans available now. There's been relatives of Sumatriptan that have come out over the years, and we can often find one of these agents that is effective for an individual. We we like most of them are oral, but there are nasal spray forms of them too. And sumatryptan is available as an injection in a device, kind of an automatic injection device like an EpiPen that many patients with very severe attacks will use to abort their headache. Um we like to ask patients to use these agents quickly when the attack starts. Um there's very good scientific evidence that these medicines work best when they're used early in the attack. If they do so, um often within an hour or so the attack can be stopped. There's now not everybody responds to trypt dance. Um many people with migraine do, but there's other options if patients don't respond to trypt dance. Um anti-inflammatory drugs can be effective. The class called the non-steroidal anti-inflammatory agents. And you know, a very simple, straightforward one is ibuprofen. Um I personally think ibuprofen is the best non-prescription acute therapy for migraine out there. Helps a lot of individuals, but if ibuprofen is not effective for a given person, there are prescription anti-inflammatory drugs that can be effective too. There's new migraine-specific acute therapies out there, and when I say migraine specific, I mean directed right at the migraine process. There's two agents that are called CGRP receptor antagonists. Kind of a complicated name, but a way to explain this is we know have known for years that CGRP is important in the occurrence of migraines. It's a small, what we call neuropeptide that interacts with nerves and blood vessels in the coverings of the brain and the brain itself. These agents block the receptors of CGRP in the nervous system and can be effective in avoiding a migraine attack. There's two of them. One is called Ubralvi and the other is called NERTEC. They've only been available since 2019, early 2020, but they give us a new tool in coming after uh the migraine attack. There's one other called Ravow that is it acts at the same general type of receptor, but a different subset of that receptor. So it's another useful tool out there.
SPEAKER_00And new to the market, breaking news for those suffering from migraines. Dr. Casley, can you talk about some of the other non-medicinal options that those suffering from migraine might have, such as devices or neuromodulation, correct?
SPEAKER_04Yeah, I I think neuromodulation devices are agents that are applied typically by the patient to themselves that stimulate either the brain or certain nerves in the head and neck as a way to change the way the brain processes pain signals. And using these neuromodulation devices can can actually in patients both stop an acute migraine attack and also prevent migraine attacks. And I think they're good things for a patient to try, um, especially if a patient is somewhat concerned about using medicinal preventive therapy. I think it's a good approach. Um there's actually several of them out there. Um the first one to come out was was called cephali. And I don't know exactly the year it came out, but I'm going to guess in the late 2000s this device came out. And it's kind of a neat-looking device. It's kind of a diamond-shaped device that goes on the patient's forehead above their eyebrows, kind of in the center of the head, and it stimulates what's called the the superorbital nerves. And superorbital nerves are nerves that carry sensory uh signals from the forehead and kind of front half of the head back to the brain. And the cephaly device can be used acutely for a migraine attack, you know, where a person turns on this device for an hour and it can sometimes shut down a migraine that's occurring. But also, if it's used for 20 minutes every day, it can serve as a a preventive therapy for migraine. It's typically fairly comfortable to use. The stimulation for the acute therapy of migraine to try to stop an attack is is kind of intense. It's an electrical simulation, you know, that is that is applied to these nerves.
SPEAKER_00So it feels kind of weird, I would expect.
SPEAKER_04I think is the best way to describe it. But you know, patients will say it's a a lot better than having the headache. Yeah. So um, you know, a lot of patients will will take that kind of intense tingling sensation to get rid of the attack itself. So cephali was the first one to come out. Then in the past decade or so, there's been a few more. Um there's a device called the GammaCore device, which is a vagus nerve neurostimulator. It's placed on the neck, um, kind of right below the jawline, and it stimulates a nerve called the vagus nerve. And it is applied in pulses. The the sensation is brief, um, but you use multiple brief pulses to the vagus nerve. That also can be used as both an acute therapy to stop a migraine attack and also as a preventive therapy for migraine. There's another device called the Spring TMS. Device that is a transcranial magnetic stimulator. It's placed on the back of the head, and using electrical impulses that are created by magnets in the device, it actually can alter the brain's physiology directly, the brain's electrical activity directly. And that additionally can be used as acute and preventive therapy. And then probably the newest device, in fact, the newest device out there is something called nerivio. It's a band that goes over a patient's upper arm and it delivers electrical stimulation to the nerve endings in the upper arm for one hour during an attack of headache. And by the the brain pain modulating systems picking up those electrical signals from that device, the brain can actually shut off the migraine attack via the use of that device. So these are options for patients that can be helpful for individuals and should be loaned into that non-medicinal preventive therapy group.
SPEAKER_00Are there any side effects?
SPEAKER_04For the neuromodulating devices, yes. Again, the the discomfort with something like cephali, you know, can be moderately intense, again, often well tolerated. Some people can get some uh you know mild skin reactions from the devices, just from the interaction of their skin with the product. With the Spring TMS device, the transcranial magnetic stimulation, an occasional person will get a little dizzy with it or a little kind of floaty feeling. But in terms of tolerability, I I think when you compare the tolerability of neuromodulation devices to the side effect profile of some of the oral preventive therapies we use, um I I think the neuromodulation devices uh are generally better tolerated.
SPEAKER_00And preferable to a paralyzing migraine. It's so good to hear that there are these options out there. And the million-dollar question are these devices expensive and or covered by insurance?
SPEAKER_04Right. That that's an important thing to talk about. I unfortunately insurance plans have not been as enthusiastic in in picking up on these devices as uh the headache specialists have been. And frankly, the patients have been. And insurance companies typically do not cover these devices. You know, they they can be somewhat expensive, although in Rivio, um, the newest device costs a patient ninety-nine dollars for twelve treatments.
SPEAKER_03Oh, okay.
SPEAKER_04And so is that expensive? Well, I'm gonna call it inexpensive, but if you can get relief of twelve migraine attacks, you know, for ninety-nine dollars and avoid, you know, work absenteeism from that, avoid being disabled in your day-to-day activities from that, uh it probably would be cost effective.
SPEAKER_00Yeah, for quality of life.
SPEAKER_04But I I think I I think you know the the downside of of the insurance companies not covering these devices readily is you know the the frequency of utilization of the devices by practitioners prescribing them and and by the patients themselves. It's kind of a deterrent to using these things. And some of the devices can be pretty costly. And I I I wish we had better insurance coverage of them. And I I I because I think they are they're important modalities for migraine treatment, and you know, maybe things will change as as time goes on.
SPEAKER_00I'm with you. I hope we see a change there. Also, if someone were interested in pursuing one of these options uh device, would they go to their doctor? Where do you start?
SPEAKER_04Well, any doctor can prescribe these devices.
SPEAKER_00They all do they require a prescription?
SPEAKER_04Yes. Um any doctor um who is treating a patient for migraine or cluster headache is another type of headache that's less common than migraine, but also can be treated by the uh the gamma core device, the vagus nerve neurostimulator. Um any doctor can prescribe them. Um now I think in all practicality, these devices are more commonly marketed to neurologists and particularly headache specialists, just because the device makers know that you know we're seeing many patients with these headache disorders. But yes, it does require a prescription.
SPEAKER_00Dr. Kessley, could you please describe to us the less common cluster headaches?
SPEAKER_04Cluster headaches are clearly less common than migraine. The statistics regarding them are they affect perhaps I I believe it's like three out of one hundred thousand people. But at a headache specialty center, we see a lot of patients with cluster headaches because they naturally gravitate to, you know, doctors who specialize in this disorder. Cluster headaches are a type of headache that's much more common in men than women, actually six times more common in males than females. Um, can affect a patient at any age of life, although uh I I the demographics of it are typically patients that are in their twenties or thirties when they first start getting cholesterol headaches. And they're called cluster headaches because they tend to occur in cycles, you know, where a person will have these headaches on a daily or near daily basis for weeks to months at a time. And probably the most common duration is maybe six weeks to a couple of months. They will have them on a daily basis, sometimes multiple times during the day, and then they'll go away. You know, so that's the cluster. You have a a cycle of headaches over this period of time, they go away, but then often they come back. When they will come back is is difficult to predict. Some people get a couple of cycles per year of cholesterol headaches, some people will get a cycle every several years of cholesterol headaches. But the attacks are very intense when they occur. It's it's been described as one of the most painful things to occur to a human being. The attacks are severe, they're usually in and around an uh a single eye and temple. They're often associated with swelling of the face in the region of the headache, tearing of the eye, um, the eye gets red, the nose on the same side of the headache gets stuffy and runs, and it's often difficult for a patient to stay still because of the high intensity of the pain. I mean, a lot of people with cholesterol pace around a room during the attack just to try to make themselves a little more comfortable. It sounds terrifying. It is of excruciating discomfort. Now, the there's no good news about cholesterol headache, but you know, one point about cholesterol headache is the attacks tend to be shorter than the attacks of migraine. The attacks of cholesterol tend to last anywhere from 15 minutes to four hours, and I would say probably the most common number I hear in that range is about an hour or so. So it does go away, but it can be very intense when it occurs, and some people can have up to three to five attacks a day of cluster headaches. It it is very treatable though, so I I I think a lot of us in the headache field like to see patients with cluster headaches because you know it's nice to relieve that terrible discomfort with some of the techniques we have to help them.
SPEAKER_00And what are some of those techniques? Are do are they similar to migraine?
SPEAKER_04No. No, I uh you know, I don't recommend the non-medicinal treatments for patients with cholesterol headaches. I think you have to get into prescription medicines to help these individuals. You know, a short course of uh steroid medicine like prednisone uh at a high dose can sometimes quickly dampen down the frequency and severity of cholesterol headaches. There's a a medicine that's been used for years for high blood pressure and heart disease called virapinil that is effective. And uh one of the monoclonal antibodies, uh, you know, my associate may have talked to you about these, and they are used as preventive therapy for migraine headaches. But one of them, M-galaxy, is effective as a preventive therapy for cluster headaches, also. And it involves just giving having a patient give themselves three injections once every 30 days, and uh it it can be successful in decreasing the frequency of these headaches significantly. Um also sumatriptin, which many people uh know as Imatrex, which is the old brand name for Sumatriptan. Sumatriptan's been around since uh 2001. Um but sumatriptin given via injection is often quickly and remarkably effective to stop an individual attack of cholesterol headache. So cholesterols are very responsive to treatment. So a patient certainly should not suffer with this type of headache before seeking medical attention.
SPEAKER_00And there is hope out there for them. That is great news.
SPEAKER_04Absolutely.
SPEAKER_00Dr. Casley, thanks so much for joining us. We've learned a lot, and we really appreciate your time helping us navigate our way through headaches.
SPEAKER_04And you're welcome. It's been a great pleasure.
SPEAKER_00The team of specialists with the Hartford Healthcare Iron Neuroscience Headache Center are seeing patients in West Hartford, Cheshire, Mystic, Norwich, and Stamford. For more information, go to HartfordHealthcare.org slash headache or call 860-696-2923. If you haven't already, be sure to listen to Episode 1 in this two-part headache series featuring Dr. Nicole Gill. And don't forget to hit the subscribe button. Thanks for listening. Two more likes.