Episode 10: Am I having a headache or a migraine? What the Neurologist says

An insightful and informative conversation with a renowned Neurologist, who has since retired from his private practice in New York City about when is it a headache or is it a migraine? Or, is it something else?
Please note that this interview is based own the experiences and knowledge of the many cases seen by Dr. G throughout the years. Please see your own physician for any medical issues or concerns.
For any questions or comments for this episode, please do so at the email address below. Thanks!

This is a podcast for those who love to talk common sense about everyday issues. You will listen to a variety of guests that share common sense ideas through their life experiences by sharing what they learned. For any comments, questions or suggestions for future topics, please contact the show at: stand4commonsense@outlook.com
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Transcript

MizzyM: 0:24

Hi. Welcome to another episode of Podcast From the Edge Talking Common Sense. This is Manju, your host, otherwise known as MizzyM. And in today's episode, I will be speaking to someone special, a man who was a neurologist(now retired) for many, many years practicing in the city of New York. And he was gracious enough to spend some of his time with us to share his knowledge and expertise on the basic question, am I having a headache or is it a migraine, or is it really something else? So I hope you enjoy the show, and I thank you so much once again for tuning in. So let's get started. Okay. So why don't you first describe what is a headache and then what is a migraine?

Dr. G: 1:23

Headache is one of the most common symptoms people have. Uh, you can get a headache from just a fever. Or you can get a headache from not sleeping and so many reasons one could get a headache. So how do you distinguish a headache, common garden variety headache and migraine headache. The most important feature of migraine headache is it is unilateral, meaning one-sided. Very, very rarely is migraine headache on both sides. That's one. And number two, most of the time when you get the migraine headache, there are some premonitory signs or precaution signs. Uh, you may have blurry vision. You may see flashing colored zigzag lines in front of one eye or both eyes both. You may get a bad smell, bad taste, or sometimes funny sensations in the skin, like crawling insects, crawling or burning, um, feeling bad and very strange, unusual skin sensation. And, uh, migraine is a kind of headache, which is triggered by something usually. This could be from anyone of the five senses, it could be a bad smell. Like you walk around New York City, you go through certain states, there is this very strong a smell of Indian food, for example, and lot of people who have migraine prone. They will, that will trigger the headache and, uh, not only smell bright light, uh, any, any kind of loud noise, sometimes

MizzyM: 3:07

caffeine or chocolate.

Dr. G: 3:08

Caffeine. Chocolate and all five senses, uh, can trigger a migraine headache.

MizzyM: 3:14

And what about, um, like a woman's menstrual cycle?

Dr. G: 3:20

Women with migraine do get bad migraine during their periods. Not every month, but most of the time they get the headache during their periods. So the point I'm making is there is always some kind of trigger that, uh, uh, triggers this migraine. Let me just, I know I don't have any blackboard or anything to draw, but I'm trying to explain it to you. The sensory input, which comes from all five sensory modes, vision, hearing, touch, taste, and smell. When it hits a part of the brain, we call the brain stem. Brainstem is, if you can imagine the brain sitting on top of a stem and the brain, the stem part is the brainstem. What we are calling now, and the most important part of the brainstem in regards to migraine is pons, PONS. So brainstem is mid brain. Pons and medulla oblongata. So pons is the key part of the migraine syndrome. The nucleus of the trigeminal nerve, trigeminal nerve is in the pons. That is where all these sensory input from the five sensations come in and connects with the nucleus. In the pons trigeminal nucleus. From the nucleus,the secondary neuron starts the second connection, which goes all the way up the brain, one side, and both sides eventually. So if I get a bad smell, that smell sensation hits the trigeminal nucleus there. It connects with the secondary neuron that carries it all the way up to the brain, and now the brain starts secreting chemical substances, which cause dilatation of the blood vessels in the covering of the brain, which is the basis of the headache. The headache is due to the dilatation of the blood vessels in the covering of the brain called the meninges, which is typically one-sided, but rarely it could get also bilateral. So the migraine headache is one-sided. It throbbing in nature. It could start in the front of the brain or in the back of the brain occipital area, you call it, and then it can spread to various parts into the ear or into the neck and, uh, very early you can even have painful sensation going into your upper arm. It is all part of the migraine. Very rarely it can become bilateral. It's extremely rare, uh, to become bilateral, and as I told you, the headache is pulsating, throbbing nature. It could be felt behind the eye as if the eyeball is exploding and many times disassociated with lacrimation, runny nose and uh, funny sensation inside the ear and inside the throat. And the headache can last anywhere from, uh, half an hour, one hour. Sometimes it can linger around for days, and once the migraine is full blown, it's very difficult to get it under control. Most of the pain medications like Ibuprofen or Naproxen will help, but for a short period, then it comes back. So it runs the course of its own, which is luckily few hours and then it goes away. But rarely, migraine can go on and on for days, needing sometimes hospitalization and injecting intravenous, intravenous pain medications, it can be so bad, certain cases.

MizzyM: 7:18

Well, um, what about, uh, you know, when I used to have headaches, it, I used to get something, um, the day before a migraine and you used to tell me it was an aura.

Dr. G: 7:30

Yeah. That is what you call the word is aura. A u r a. The aura could be, as it said, visual or seeing flashing lights. It could be bad smell. It could be also hearing ringing noise or funny, painful noises in the ear or in the skin sensations of various kinds that can happen on one side of the body. Uh, typically it is on one side of the body and this, this kinda symptoms are warning pre monitory symptom symptoms could be sensory. Or sometimes motor, which, which I mean, uh, giving you an example, uh, a British woman came to JFK airport, collected her bag and was ready to get out and get a cab to come to my office. While she was walking to the cab, she felt this funny sensation on her face. Then by the time she's in the cab, her right hand was numb and in the cab she felt weakness of both right arm and right leg. So she had difficulty getting out of the cab when she reached the Hilton(Hotel). And from there, the hotel sent her to the emergency room. That is where I saw her in the emergency room. By the time she was not only having sensations- she had difficulty moving the right arm and right leg, the whole thing cleared. By the time I came to the ER to see her from my office, barely 45 minutes or maybe 50 minutes, she was okay. She was sitting up and taking her breakfast and, and coffee. The whole thing disappeared by the time. This, is what we call hemiplegic migraine-hemiplegic means one-sided paralysis. It can last from minutes to hours, sometimes up to a day or even a day and a half. It can take that long. So migraine by no means is just a headache. It is a symptom complex. Many things can happen during the migraine phenomenon. And, uh, to put it in a, what, what can I say? In a electro physiological context, a group of cells. In one part of the brain, maybe in the front or in the back of the brain, gets irritated, gets stimulated, gets stimulated by the migraine process. It generates electrical impulses. If it starts in the back of the brain called the occipital area, this electrical activity can spread forward coming to the front of the brain, which can affect your speech. Which can affect your motor function, which can affect your sensory function and make you sometimes act like a, what do you call, a someone who lo lost his mind like a schizophrenic patient. If it hits the front part of the brain, it is nothing but an electrical wave starting at one point in the brain and spreading forward, and it can also cross over. and come on the other side, then it becomes bilateral. You can also lose consciousness in some cases. There are many instances, especially in children in including me when I was seven or eight years old. You certainly pass out for no reason and. Wake up very quickly, and when you wake up, you feel sick, nauseous, and then this throbbing headache comes. It, it, it's very common in children, very common. And many times this fainting spell is the only warning sign for several months or years before the child develops, a full blown, migraine. A lot of times, uh, parents become so upset when children pass out for no reason and they go to the doctor. MRI is normal. EKG is normal. Everything is normal and nobody knows why the child fainted. It is migraine, so always be aware of that. Unexplained fainting in children when, and they wake up within a few minutes or maybe within the half an hour will could very well be the beginning of migraine. It may not be anything else. Okay.

MizzyM: 11:42

What about if you vomit or you have nausea? Yes. Is that part of a migraine?

Dr. G: 11:47

Common warning, one of the flashing lights, nausea, vomiting, tearing from the eye, noise in the ear. All these things involving all the five sensory modes can happen as a warning or a prem monitory, signs of migraine.

MizzyM: 12:04

So do you recommend anything to prevent migraines?

Dr. G: 12:10

There is truly nothing much to prevent migraine. Uh, very difficult to prevent it, but what I used to do, or what made me very famous in New York and all over the country is, you could prevent this migraine, uh, in the long term by addressing the basic physiological events that happen in the brain. As I told you, the brain cells have to generate abnormal electrical activity, and that electrical activity is what? From back to the front or from front to the back of the brain and causing all these problems with migraine. So the initial starting point is destabilization of the cell membrane, which causes an electrical impulse to be generated. So preventing migraine basically means you have to stabilize the brain cell membranes, which will not depolarize or which will not generate an electrical activity. So one thing I very successfully used in many, many of my patients are, which made me very popular in, in, in, in this area, is what, how do you control the destabilization of the, of the cell membrane in the brain? One is magnesium. Magnesium has a very stabilizing effect on the cell membrane without proper, uh, uh, what do you call it, concentration of magnesium in the cell membrane. Uh, you cannot prevent the cell becoming destabilized and creating an electrical impulse. So I recommend taking two 50 milligrams of magnesium oxide or magnesium citrate. Once or twice a day. Lot of people cannot tolerate it twice a day, but at least once a day they could tolerate. That's number one. And number two is, uh, coq 10, coenzyme Q 10, which is a intracellular. Uh, chemical, uh, in the mitochondrial, uh, influencing the mitochondrial function in the brain and stabilizes the brain. So between the CoQ10 and the magnesium, you truly stabilize the cell membrane without getting electrical activity generated. It helps been very useful and in young people, especially young women who develop migraine. Each episode of migraine depletes the serotonin level in the brain. And how do we know that? There used to be a, a scientist at Merck. Uh, he was the main scientist who ran the migraine lab at Merck. He had done lots of studies, of women in part after a bad migraine episode, if you collect the urine- 24 hour collection of urine in patients who have migraine, you will notice that there is a huge increase in the level of serotonin metabolites or breakdown products of serotonin in the urine, which tells you that during a migraine the brain depletes serotonin. The brain does not produce a hell of a lot of serotonin. It's very difficult to produce serotonin in the brain. So if you are getting migraine frequently every week, every two, two times a week and things like that, you are depleting the serotonin levels in the brain, which predisposes you to more. And the low levels of serotonin makes you irritable, uh, cantankerous in your behavior and eventually you'll get depression cause you need enough serotonin in the brain to keep your normal functioning of your psyche and your uh, and your, uh, emotional attitudes. So that is one reason why lot of people with frequent migraine become very irritable and difficult to deal with. You know, people, it is not their fault because, They don't know that they're lacking serotonin in the brain. So part of the treatment of, uh, migraine, especially chronic migraine sufferers is depleting or replacing the serotonin by giving small doses, you don't have to give them big doses, small doses of, uh, serotonin enhancing drugs that are a whole variety of them. Most of the women tolerate it very well without any side effects. But very rarely if small doses of uh, uh, Lexapro and things like that, the drugs like that can cause sexual dysfunction in women. So patients usually don't like to take it. It's becomes a big problem. Uh uh, they is no food or anything that actually can increase the serotonin level in the brain. It's difficult to do that. You have to hold the hands of the patients, and I usually convince them to take it for a short time. When the levels goes up, I maintain it and then take it off. That's what I do.

MizzyM: 17:27

Okay, so then now since we discussed headaches and migraines, How does, how are they both different from, let's say, having a cerebral vascular attack or an aneurysm or like a subdural hematoma, something where there's bleeding in the brain? How can you tell if any of those things are going on?

Dr. G: 17:49

Most of the time those kind of headaches due to a bleeding or due to inflammation or any other cause, uh, headache is bilateral. There is no subdural subarachnoid hemorrhage or aneurysm hemorrhage causing one-sided headaches. There is nothing like that. All those headaches are bilateral, so one headache is unilateral, especially. Associated aura, like seeing flashing lights or hearing strange noise. Bad taste. Bad smell. This is migraine. Cannot be anything else. If it, the headache is one-sided and in most cases it is one-sided. Uh, it's not difficult to distinguish migraine headache from other headaches because of that one nature. Unilateral headache, unilateral throbbing, very painful headache. Along with either visual, auditory, or gustatory, meaning taste, aura, that clenches, that diagnosis is clinched. There is nothing else that gives you that kind symptom. So before I leave that, uh, headache part of the migraine, um, lot, where I, I became very famous in New York, for example, is because of what I'm going to tell you. Not every patient with migraine has a headache. There is something called migraine without headache, sorry. We call it transformed migraine here. The patients don't get a headache at all. Now, since I mentioned it to you to make sense so that you won't get confused and you don't feel that I am telling you something very strange. I just have to tell you for one minute a little bit of anatomy. Once the pain impulses from all the five sensorium, skin, tongue, ear, taste, the. The brain, it is coming to the trigeminal nucleus. In from there, it connects and the secondary fibers go up to the brain on one side or even on both sides. And when these, uh, painful impulses hit the serotonin receptors inside the blood vessels of the brain, it causes dilatation of the blood vessels in the covering of the brain, which causes the real headache in this is what everybody knows. Every patient knows every doctor know, but not many people don't understand, including doctors who are not neurologists. The pain impulses need not always go up to the brain. Trigeminal nucleus in the pons has what we call a descending tract of the trigeminal nerve, meaning one part of that nucleus goes down like a tail all the way to the upper cervical spinal cord. So it from the pons, it goes through the medulla and from the medulla it enters the upper part of the spinal cord. There are instances where the migraine impulse hits the trigeminal nucleus but does not go up to the brain causing the headache, but it goes down through the descending tract of the trigeminal nerve, and then the symptoms are entirely different. They get vertigo with vomiting and all that, and that is when it hits the vestibular nucleus in the lower part of the pons. When it comes to the medulla it causes a whole variety of vagal or vagus nerve mediated symptoms like explosive vomiting, painful cramping of the abdomen, diarrhea, and uh, going down further. They get burning painful sensation in the upper thighs and around the umbilicus. These people will not make any connection to migraine unless you really take a very good history and they establish the fact that this patient. Typical migraine in the past and now this is what we call modification or a, uh, transformation of migraine transformed migraine.

MizzyM: 22:03

Okay. You, so you mentioned a burning sensation in the thigh and the umbilicus. So what is the umbilicus, just in case if people don't know?

Dr. G: 22:11

I had a woman from New Jersey who came, her main complaint was for the last couple of weeks. She couldn't wear her. Because the skirt, when she ties, it irritates her skin around the umbilicus so bad.

MizzyM: 22:26

Which is the belly button?

Dr. G: 22:27

Yeah, the belly button. Okay. So she had to take it out. She, she can't wear it. She had to take it out. It was so painful for her and nobody made the connection. That she was a chronic migraine sufferer and uh, I put her on what I told you earlier, the magnesium CoQ10 and the small dose of serotonin enhancing drug Lexapro within three to four months. She was completely symptom free. These kinda things can happen once you understand what I said earlier. The trigeminal nerve nucleus descends down into the middle and the upper spinal cord. You can understand all these symptoms happening without a headache; there's no headache because the impulses did not go to the upper brain and connect with the, with the brain cells. That is the reason why they don't have any brain symptoms. Uh, I hope I made it clear to you that these patients have symptoms connected to the lower brain stem symptoms, the nausea, vomiting, diarrhea, abdominal cramping, painful sensation around the umbilicus, and even up to the thigh-muscle cramping up to the thigh, and all those. You don't establish from the history that this patient mostly a woman had migraine and she's a chronic migraine sufferer. You completely miss this and you will send them to gastroenterologist, to proctologist, you name it, and nobody can find out what she has.

MizzyM: 23:49

Right. Well that was a very, very fascinating conversation and I hope we can, you know, you can come back again to talk about other things that you encountered in your practice. Thank you very much.

Dr. G: 24:05

Thank you.