Ate chocolate, getting a migraine: “weather”, “vessel” and “from the neck up” – why headache

How to distinguish the different types of headaches why neurologists Botox, what to do with the weather dependent and osteochondrosis, and where did the dystonia says the neurologist, head of the University clinic headache Cyril Skorobogatyh.

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To get the symptoms of the patient

— There is a widespread belief that the headache should not be tolerated. The other turns out to be, namely headache stands out?

Cyril Skorobogatyh

— To come to an answer, it is better to start with, what are headaches. In General, a lot of them — more than 200 species, they are all counted and sorted in the International classification of headaches. In this classification for patients it is important that all headaches are divided into two types – primary and secondary.

Secondary – this means that the headache from another disease, it is only a symptom. For example, maxillary sinusitis: a person snot, fever, but also headaches in the forehead area. Or, for example, arose intracranial hemorrhage — will be a terrible headache. Such options secondary pain very much, but, fortunately, they are statistically no more than 10%.

And 90% is a group of primary headaches, that is independent of disease. And we first need to understand what kind of pain to decide you can tolerate or not.

Thundering pain when its peak intensity grows to 10 points out of a possible 10 in just a few seconds — this is a very serious symptom, to endure is not worth it, should run to the emergency room, if the person is still conscious.

And a tension headache, for example, is quite easy, score of 3, without concomitant symptoms of nausea and vomiting, pressing can occur at the end of the working day and place by itself, when people took to the street. In this case it is not necessary to drink the pill.

And with migraines the situation is the following: the earlier a person begins to stop the attack, the faster it will completely end.

— How to understand the secondary or primary is a headache?

The first task of the neurologist, just to eliminate secondary pain. This is important because then you need to treat the underlying disease. There are “red flags” that allow us to suspect that the headache is a symptom of another disease.

Features include: the emergence of a thundering headache; headaches that occurred after 50 years; dramatically changed the nature of the headache — for example, it was oppressive as if the head was clutching a helmet, and now began to ache somewhere behind the eye; pain is accompanied by watering eyes or stuffy nose; if the headache was triggered by sneezing, coughing, straining, occur when a sharp physical activity; pain provoked by change of body position — the man lies, my head hurts, got up — feel better or Vice versa; headache and fever.

Plus doctors alarming neurological symptoms, when the neurologist examines the patient with a special hammer and he doesn’t like reflexes. In such cases, the patient undergoes an MRI or CT scan of the brain, sometimes in a special mode that allows you to see vessels. No other studies are not necessary, but people come with folders and a bunch of tests, there is repeated electroencephalography, rheoencephalography, skull x-ray, duplex scanning of neck vessels, which are the changes announced by the cause of headache, but in fact is a variant of the norm — for example, different blood flow velocity in the right and left carotid arteries, or tortuosity of the artery. This is not the cause for the occurrence of headache, though, because for some reason a lot. Ultrasound of neck vessels generally necessary in very rare cases.

So, if we have not found these “red flags”, we have a primary headache. How do we make the diagnosis then? Our diagnosis is based on the characteristics of the pain, there is no analysis that would allow us to say that here something has changed so that such and such diagnosis.

Look, a migraine. Criteria for the diagnosis of what? Headaches often unilateral, pulsating, moderate or high intensity, limiting physical activity when you tilt the pain is worse, for example. The pain must be accompanied by nausea and/or discomfort from light and sound. It is a misconception that it is always unilateral, migraine can be from both sides, if the throbbing pain, strong enough and a bit nauseous.

The diagnosis is based on the ability of the doctor to get the symptoms of the patient. Without any treatment the migraine attacks last from four hours to three days, the migraine often leads patients to the doctor, other primary pain or very rare, or softer.

A tension headache is actually more common, but it’s not as intense, no nausea and photophobia, and if the neurologist paid, this additional barrier.

Ate chocolate – getting a migraine

— What is a migraine?

— Migraine is a disturbance of brain function, it’s not something with the blood vessels or whiplash, as often presumed. Any headache is implemented through the system of the trigeminal nerve. If you have a toothache, irritated endings of the trigeminal nerve, then, as through the wires, it all goes to certain area of the brain — the nucleus of the trigeminal nerve, then from the other wire — gets the grey matter in that area, which is responsible for a tooth, and we are aware of the pain in the tooth.

Also realized the pain from the punch in the nose, for example. The trigeminal nucleus is like a box of electric machines in the apartment, all wires, all pain impulses are coming in there. Migraines such incoming impulses, there is no formal, nucleus and trigeminal nerve to become active themselves, suddenly, and sent up signals of pain, which is not.

Why the kernel gets in such a state of activation — an issue that is still being studied. We understand that there is a genetic predisposition, a set of genes that determines that the trigeminal nucleus is so responsive to some provocateurs.

Approximately 80% of the people say that migraines something provoked. This files most often have emotional stress: nervous — had a heart attack.

Or at the beginning of the menstrual cycle in women, if you’re sleep-deprived, hungry, or drank red wine. These factors are removed from the balance system of the trigeminal nerve.

Recently it was found that when the pain yet, we have changes in the brain — before the headache phase is activated by the hypothalamus. Sometimes patients say they feel a few hours or even days that the pain will — this is called the prodromal phase of migraine.

It is accompanied by such symptoms: people focus, they have a bad mood, there is a yawning, bubbling in the stomach, they often run to the toilet. These symptoms are not specific to migraine and may be by themselves, but many people can notice a fit coming on. And these symptoms are in the area of responsibility of the hypothalamus and eating behavior, by the way: some want sweet, they eat a chocolate bar, getting a migraine. But not because people ate chocolate, the process is already started. And these disorders of the brain — a migraine — not visible in conventional MRI.

— That is, a patient need to question meticulously, and do not send for an MRI?

— If we suspect a secondary headache, you need to ask, Yes. Because there are indirect symptoms. For example, the migraine often undergoes during pregnancy in approximately 80% of patients. This is not a criterion of the diagnosis, but it is very common for migraines.

It is important to look at the story of the life of the patient. The seizures may become more frequent, to become chronic migraine, when the pain happens more than 15 times per month. In women, migraine occurs three times more often — it is connected with the sex hormones, but it is not clear how and why they influence. In men, the migraine, of course, also be found.

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The tablets, antidepressants and Botox…

And what do the people suffering from migraine?

— The main thing is to have realistic expectations. Migraine cannot be cured, it’s not appendicitis. It can pass itself at some period in life, and after five years to return. We have nothing to cut in the head, but can we treat it.

The first approach is to stop the seizure, that is, to remove the pain, nausea, discomfort to light or sound. Is used for this? Ordinary painkillers (non-steroidal anti-inflammatory drugs). There is a sense that if the drug helps, so it’s not a migraine is a myth, in many cases, regular painkillers enough. If the attacks of pain do not respond to this therapy, we use special drugs — triptans. They only work migraine and will not help back pain, for example. You can add anti-nausea drugs because nausea sometimes very worried.

Criteria for the evaluation of treatment — the attack is gone within two hours and has not returned within two days. Then we picked the right drugs. But if the seizures are not stopped or happen more than four times a week, we offer the patient a preventive therapy, regular intake of certain drugs to make the seizures are rare and responding better to treatment.

Is used for this? Proven effective several groups of drugs — some antidepressants, antiepileptic drugs, drugs to reduce pressure, which are used by cardiologists and even Botox.

The mechanism of action of these drugs is in no way affiliated with the name. That is, you need to understand that we don’t treat wrinkles, not depression, not high blood pressure, but some drugs have shown its effectiveness in migraines in clinical studies.

In the late ‘ 80s, scientists discovered a particular protein, a key neurotransmitter in the brain migraine, and then figured out how to influence him, and made drugs that block this protein or the receptor for it. This injections — an injection is in the stomach or shoulder once a month or every three months. The procedure reduces the number of days with headache. In the United States in may of this year was was the first such drug in July, he appeared in pharmacies, has thousands of migraine sufferers people have started to use it. In the US, he has tremendous value — about 7 thousand dollars a year, but it’s covered by insurance. We are waiting for him to appear.

— Treatment with antidepressants or Botox cheaper?

Yes. Botox is more expensive than other products, somewhere in the area of 40-50 thousand rubles every three months. There are drugs that cost 100 and used for decades.

— Why, then, someone chooses a Botox?

— Here come the individual characteristics of the choice of preventive therapy. We orientirueshsya on the positive and possible side effects, which can give these drugs.

The patient has other conditions — for example, increase or decrease in blood pressure. And if it’s a girl with pressure 90 over 60, and she will prescribe another beta blocker, her blood pressure did the rubble. Amitriptyline is gorgeous for people with sleep disorders, but it causes tachycardia and those who have it already is, will be uncomfortable.

These new injectable medications currently available data, cause a minimal number of side effects — Yes, there is yet no such long-term horizons for security, only about three years of observation. But we expect this new therapy, because there are difficulties with the selection of drugs for patients, and it solves part of the problem. All of these drugs are prescription and should be prescribed only by a doctor, there’s a whole list of side effects, you need to watch that patient.

Headache “weather” and “from a vessel”

— Can a head ache because of the weather? Is there a weather dependent?

— Indeed, many patients complain of pain when weather changes. The research was conducted, but the data that the change in pressure by 40 mm Hg in our upland leads to some physical changes in the body, no.

This is not happening — there is no connection between wind power, solar flares, changes in pressure and headache. In the plane the pressure drops much more, but nobody is beating in convulsions from a severe headache, by the way. There may be a nocebo effect.

We all know the placebo is the same thing, but on the contrary: there are absolutely harmless object or phenomenon, but the person believes that it is able to affect him, and it somehow affected.

For example, one person in the study injected the saline solution and the other drug, and even saline can occur rash all over body — this will effect nocebo. People read that tomorrow will be a flash in the sun, he negative expectations, and they are implemented in the form of headaches. It can be explained with any scientific point of view.

— Then what do these people who have headache when changing weather is to drink ibuprofen and not to think about it?

It means that the person has some type of primary headaches. Do not blame the weather, he didn’t get enough sleep, missed a meal. You need to come to the doctor to be a diagnosis. And look closely at what factors were in those days. There is no type of headache associated with nocebo or weather dependent, you need to diagnose that pain in reality.

— Another widespread diagnosis of dystonia.

— Oh, Yes. There is a persistent myth that the vessels affect headache. It is very common, a second connection for headaches with neck. Vessels have virtually no effect on headache, disturbance of blood supply to the brain causes the pain — the brain is devoid of pain receptors, he can not physically hurt.

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I sometimes give the patients an example to dramatically emphasize this point: there is surgery when the tumor is very close to the speech area, and to preserve it, surgeons perform the operation with the awakening. A man with an open skull, the doctors slowly cut the tumor and talk with the patient to understand when it will begin to break down. Brain ischemia leads to pain. Saw the subway posters — how to identify a stroke? Ask the person to smile, raise hand to say something. There’s nothing about a headache, that is a blood disorder does not cause pain.

But there are headaches associated with vascular lesions — for example, aneurysm. It burst the man’s internal bleeding and eerie, very intense headache. Or any arteriovenous malformation, when arteries and veins are connected incorrectly in such a tangle of huge size, squashing all in the brain. And the pain will be because of this. Or injury in a car accident, when the vertebral artery from a blow stratified – there is intense occipital pain. But it’s all acute, emergency situation.

And vegetovascular dystonia is a Russian / Soviet diagnosis, such a hodgepodge, which includes a bunch of real diagnoses — anxiety disorders, dizziness different nature, headaches, depression, somatoform disorders.

Why he put? One version is that neurologists do not have the right to put a psychiatric diagnosis and treat it. Although this is very simple: the patient comes with the obvious alarming violation — why not give her therapy? What to do to call a psychiatrist?

And now for a formal bypass can be used code of the International classification of diseases “and other diseases of the autonomic nervous system”. This diagnosis refers to the “neurological group”, but allows you to assign some “psychiatric” drugs. Actually, of course, in the International classification of diseases under this code is meant not “dystonia”.

The autonomic system regulates the fact that we have no control over consciousness — the tone of the intestine, heart, sweating, and many other functions. And it can really suffer — for example, in diabetes. One of the complications of diabetes — constipation: due to the high sugar affects the parasympathetic fibers of the autonomic system and the bowel ceases to move normally. Sometimes the autonomic nervous system ceases to work normally — there is a dry mouth, constipation, fainting, if the person got up after he was lying. We understand that there is destruction of the autonomic system, but do not understand what — and there is a special code to the classification, which was used in his time, to assign treatment. And then just stuck.

Low back pain can be put almost any

— In fact with these patients simply didn’t understand properly?

— In General, Yes, it’s a hodgepodge of different diagnoses therapeutic, neurological, psychiatric. You deal with them. If a person has somatoform or depressive disorder, it is better to start with a psychiatrist, but this man needs himself a good deal in medicine, what is strange to demand of him. So the entry point can be neurologists, they are more affordable and appeal to them not associated with additional alarms. Although, in theory, and the therapist can figure out which specialist to refer the patient.

But neurologists are often confronted more with degenerative disc disease is another phenomenon of our reality. It is not a diagnosis. By itself, low back pain – what is it? Changes of the intervertebral discs and vertebrae, which are most people. It’s natural, it’s like leather in 10 years, one in 90 years — the other, and we don’t put her in any of the diagnoses. Same with the spine: the presence of a hernia is any protrusion of great information not responsible.

There is no such type of headache as cervicogenic — in Latin it means “associated with whiplash”. It is rare to put such a diagnosis, do not need an MRI or x-rays of the cervical, but need a clinical Association between exposure to structures of the cervical and headache: for example, when you turn your head or on palpation at the reception. If after this, there is a typical patient’s headache, we say: Yes, there is a connection. Then we block it with anesthetics, thus once again making sure that it is the source of pain.

— That is, a person with degenerative disc disease with nothing to do?

— It depends on what that person concerned. He did not just went to do an x-ray, which saw low back pain – probably, something hurts. We need to understand why and that hurts. But low back pain itself is nothing, it can be put almost anyone.

Neck pain is a very frequent symptom, which comes with office workers. The reason most often excessive muscle tension in the neck with a long stay in a fixed position. In some cases we see a combination of neck pain and headaches. And then the question: are two separate diagnosis or one? A migraine attack can also begin with pain in the neck. When activated, the nucleus of the trigeminal nerve reflex includes the muscles of the neck. Then people feel that they have “laid” the neck, they want to stretch, and then after 30 minutes or an hour starts a migraine attack, and they associate it with the neck. In fact, neck in this case is secondary. People run to chiropractors, but a migraine it does not help. The neck can be better, but the headaches will not go away.

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