I thought I would talk about one of the most common mistakes made in the world of headaches, & it’s especially frequent at this time of year

There are literally thousands of people in the country suffering from bouts of headaches the main features of which are a feeling of pressure and pain in her forehead, under her eyes, and possibly over the cheeks. Often they “feel stuffy,” though without fever, cough, sneezing, or nasal discharge/mucus. Many of them frequently takes pain killers or ‘sinus/congestion ‘ medication which rarely help a great deal.

Most of them, not surprisingly, think they are experiencing sinus headaches (an opinion often shared by their GP). The typical story is, “I get congested, I take antibiotics, and 2 days later I’m better.”
In fact most of these patients are typically experiencing a variant of migraine.

Here’s some data (albeit from the US );

The largest study involved almost 3000 adult patients recruited from a primary care setting with a history of self-reported or physician-diagnosed “sinus” headache who reported at least six headaches during the previous 6 months. On evaluation, 88% of these patients met International Headache Society (HIS) diagnostic criteria for migraine-type headaches. The most common reported symptoms in this group were sinus pressure (84%), sinus pain (82%), and nasal congestion (63%).
The Sinus, Allergy and Migraine Study (SAMS), which recruited patients who believed they had sinus headaches via newspaper advertisements, came to essentially the same conclusion. Approximately 100 patients participated. Final diagnoses, based on IHS criteria, were:
• Migraine with or without aura: 52%;
• Probable migraine: 23%;
• Chronic migraine with medication overuse headache: 11%
• Nonclassifiable headache: 9%.

So how long does it take for a patient initially misdiagnosed with sinusitis to get a correct diagnosis of migraine?

A more recent study recruited 130 adult patients with migraine who were seen in a referral practice. Just over 80% of this cohort had initially been misdiagnosed as having sinusitis, with a mean delay of migraine diagnosis of almost 8 years.
Not surprisingly chronic migraine was more common in this initially misdiagnosed group than in patients appropriately diagnosed at the onset.
More worryingly medication overuse headache was also only in the misdiagnosed group.
One should also not forget the issue of inappropriate use of antibiotics contributing to an increase in antibiotic resistance

So if you are getting frequent bouts of what you think are ‘sinus’ headaches it may well be worth a second opinion from a specialist in headpain.
A good place to start would be here at Epsom & Ewell headache and Migraine Centre to see if in fact you may have a different type of headache for which another type of treatment would be more appropriate/effective.

Wishing everyone a Happy & headache free Christmas.

I recently had a case of the below condition & thought some of you may be interested in this relatively uncommon, but distressing type of migraine (note headache is only present in 40% & presentation is extremely variable !)

As always diagnosis by a specialist in headache & migraine is essential & other causes of recurrent vomiting must be definitively ruled out.

Once again I should stress the below is a brief summary only & there can be many subtly different ways in which the child/adolescent may present.

Migraine-associated cyclic vomiting syndrome (periodic syndrome)

This syndrome is characterized by recurrent periods of intense vomiting, at least 4 times per hour, separated by symptom-free intervals, with attacks occurring at least 1 week apart. Many patients with cyclic vomiting have regular or cyclic patterns of illness. Symptoms usually have a rapid onset at night or in the early morning and last at least 1 hour and up to 10 days (usually 6-48 hours). Associated symptoms include the following:

Abdominal pain – 80%

Nausea – 72%

Retching – 76%

Anorexia – 74%

Pallor – 87%

Lethargy – 91%

Photophobia – 32%

Phonophobia – 28%

Headache – 40%

Headache often does not appear until the child is older. Migraine-associated cyclic vomiting syndrome usually begins when the patient is a toddler and resolves in adolescence or early adulthood; it rarely begins in adulthood. More females than males are affected by cyclic vomiting.

Infections, psychological stress, physical stress, and dietary triggers are often clearly identified in the patient’s history. Examples of triggers include cheese, chocolate, monosodium glutamate (MSG), emotional stress, excitement, or infections. Usually, the parents or siblings have a family history of migraine.

Cyclic vomiting syndrome is a diagnosis of exclusion. It is important to differentiate cyclic vomiting related to migraine from nonmigraine cyclic vomiting conditions. Other causes of cyclic vomiting include the following:

GI disorders (malrotation)


Urinary tract disorders

Metabolic and endocrine disorders

Mitochondrial deoxyribonucleic acid (DNA) deletions

Children with cyclic vomiting associated with migraine tend to experience fewer severe vomiting episodes per hour and fewer attacks per month than those with cyclic vomiting associated with other GI disorders. These children exhibit a higher incidence of pallor, abdominal pain, headache, social withdrawal, motion sickness, photophobia, and physical exhaustion.

Cyclic vomiting associated with developmental delay, poor growth, seizures, and maternal migraine may be associated with mutations of mitochondrial DNA. When such mutations are suggested, serum lactate/pyruvate and urine organic acid levels should be obtained, preferably during an attack.


Assuming other causes of cyclical vomiting have been ruled out treatment of this migraine ‘syndrome’ needs to be tailored to the individual child ; managed by specialists such as those here at Epsom and Ewell headache & migraine clinic

The following article was reported in Medscape & may be of interest to headache & migraine sufferers in Surrey & beyond !

PHILADELPHIA — Riboflavin supplementation may decrease headacheseverity in patients with migraine who are deficient in vitamin B2 and other micronutrients, new research suggests.
In a small study, all participants experienced a 50% or greater reduction in both headache severity and frequency following nutritional supplementation.
In addition, a majority of the patients were migraine-free 2 years post treatment.
“Nutritional deficiencies could play an integral role in migraine,” investigator Madhureeta Achari, MD, a neurologist in the Department of Physical Medicine and Rehabilitation, the University of Texas Medical School, Houston, told Medscape Medical News.
She added that in her experience in clinical practice, “I’m surprised how many micronutrient deficiencies I see.”
The findings were presented at the American Headache Society (AHS) Annual Meeting 2019.
Nutritional Neurology
“Previous research showed a link between riboflavin and migraine,” said study coauthor César Escamilla-Ocanas, MD, Section of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, Houston.
In a prior trial, 59% of people with migraine who were randomly assigned to receive high-dose riboflavin for 3 months experienced at least 50% fewer headache days compared with 15% of those who received placebo.
In this and other clinical trials, 200-mg to 400-mg supplementation with riboflavin appeared effective in reducing both migraine frequency and severity. However, researchers did not assess vitamin B2 levels at study entry.
“It’s important to look at baseline levels. This is a very data driven, not survey driven, study,” Escamilla-Ocanas said.
In the current case series, the researchers assessed 42 patients with migraine whose serum riboflavin levels were in the deficient range. The cohort included patients who experienced migraine with aura and those who had migraine without aura, as well as other patients with chronic migraine.
The investigators provided supplements to increase serum riboflavin to a high level. They monitored complete vitamin and micronutrient levels through serial laboratory measurements over 2 years.
“I practice ‘nutritional neurology’ by doing blood levels of micronutrients,” Achari said.
The researchers also assessed CoQ10, zinc, and vitamin C levels, but in the study presented at the AHS conference, their focus was on riboflavin levels.

“Inexpensive, & easy to Implement”

In total, 35 of the 42 participants did well on nutritional therapy alone, Achari noted. The remaining seven required additional prophylactic medications to treat their migraines.
Rescue medications were allowed, including over-the-counter treatments and triptans.
Results showed that the number of migraine days per month was reduced from an average of 14.4 at baseline to 3.4 after riboflavin treatment. In addition, 81% of the participants were migraine free at 2 years.
The findings suggest that a subset of patients with migraine could benefit from supplementation, Achari said.
“This could work for many people with migraine,” she added. “Riboflavin is important for cellular function and influences the mitochondria of the cell.”
Nutritional supplementation is inexpensive, easy to implement, and is well tolerated by people with migraine, she said.
Asked if the level of riboflavin is the only factor involved, Achari answered, “We don’t know that. There could be other confounders.”
“We are hoping this study leads to more research,” Escamilla-Ocanas added.
Gives Reason for Benefits?
Commenting for Medscape Medical News, Huma Sheikh, MD, a neurologist who specializes in headache medicine and who is assistant clinical professor of neurology at Mount Sinai Beth Israel, New York City, noted that the study findings were particularly striking.
“This is interesting because it may be able to provide a reason that B2 supplementation is sometimes helpful in migraine and works as a migraine preventive,” said Sheik, who was not involved with the research.
She pointed out that an advantage of vitamin B2 is that it is water soluble, so “extra is usually excreted out.
“It is also rare to have a vitamin B2 deficiency, since it is found in many common foods, but still, this is an interesting finding,” added Sheikh, who is also co-chair of the special interest section on migraine and vascular disease at the AHS and is a member of the AHS committee to develop guidelines for vascular issues and headache.

Richard Katesmark comments; Vit B2 ( Riboflavin ) has be part of the supplement protocol for migraine for many years here at the Epsom & Ewell migraine clinic. It’s nice to see further trials supporting this approach.

The following article recently appeared on Medscape, although it is not about headache or migraine it is relevant to chronic headpain sufferers as it concerns insomnia. As I have mentioned in various posts poor sleep ( quantity or quality) frequently coexists with chronic headpain & if present needs addressing at the same time as managing the headpain to ensure a positive outcome.

Reuters Health – Children who suffer adverse experiences like abuse and neglect may be more likely to have sleep problems in adulthood, a U.S. study suggests.
Adverse childhood experiences (ACEs) can include witnessing parents fight or go through a divorce, having a parent with a mental illness or substance abuse problem, or suffering from sexual, physical or emotional abuse.
For the current study, published May 21 in the journal Sleep, researchers surveyed 22,403 adults who were 47 years old on average about any adversity they experienced during childhood. Overall, 42% of the participants didn’t report any ACEs, while another 23% experienced one type of ACE and the rest were exposed to at least two ACEs.
About 61% of the adults got an optimal amount of sleep – 7 to 9 hours a night – and roughly one-third of them got too little sleep – less than 6 hours nightly.

Each ACE people experienced was associated with 22% higher odds of getting too little sleep. People with three ACEs were more than twice as likely to get too little sleep, and the risk was more than tripled for adults with five or more ACEs.
“Previous studies have shown that adults who experienced adverse childhood experiences have an increased likelihood of sleep disturbance, and poor sleep quality,” said lead study author Kelly Sullivan of Georgia Southern University in Statesboro.
What makes the current study unique is that it shows the that adverse childhood experiences can also impact sleep duration, Sullivan said by email. This is likely due to the lasting effects of toxic stress.
“Excessive or prolonged stress has been shown to biologically alter the brain and affect health, learning and behavior,” Sullivan said. “These effects can last throughout the lifespan.”
People in the study were typically overweight, which can impact the risk of sleep problems. Almost half of them were former smokers, and about 21% were current smokers, which can also negatively impact sleep quality and quantity.
Only 10% of the adults reported experiencing frequent mental distress.
Mental health challenges or poor physical health didn’t appear to influence the association between ACEs and insufficient sleep in adulthood, however.
Out of all the different types of ACEs, domestic abuse, child abuse and rape had the biggest impact on sleep duration in adulthood.

When people did experience ACEs, they most often reported emotional abuse, living with an alcoholic, or parental divorce.
The study wasn’t a controlled experiment designed to prove whether or how ACEs might directly cause sleep deficiencies.
One limitation of the study is that researchers lacked data on the duration of the ACE or age at exposure, which could impact how these exposures contribute to sleep issues down the line.
Even so, the results offer fresh evidence of the long-term impact of childhood exposure to toxic stress, said Dr. Nicole Racine of the University of Calgary and Alberta Children’s Hospital Research Institute in Canada, who wasn’t involved in the study.
Children who are exposed to abuse and adversity experience heightened levels of toxic stress, Racine said by email. She added, “Toxic stress has a wear and tear on the body and also impacts a child’s developing brain, including areas of the brain that regulate sleep.”
SOURCE: http://bit.ly/2ENJlea
Sleep 2019.
Reuters Health Information © 2019 

Mr Katesmark comments; Here at Epsom & Ewell headache & migraine clinic identifying if sleep issues are present & relevant to the headpain is a key part of the examination. If a sleep is a problem/aggravating factor then management of this can be key to solving the headpain. Treatment approach will depend on the cause, in the cases where past emotional trauma is involved this would usually mean referral to one of the practitioners here that are expert in dealing with such matters.

Some further research showing a link between thyriod dysfunction and headache disorders , this time from a study in Greece & published in Amsterdam
— Patients with migraine who have subclinical hypothyroidism and receive thyroid treatment have significantly fewer and less severe headaches, new research shows.
“To the best of our knowledge, this is the first study showing that treatment of subclinical hypothyroidism was effective in reducing both the frequency and severity of migraine attacks and improved the quality of life in patients,” said study investigator Antonasia Bougea, PhD, Department of Neurology, National and Kapodistrian University of Athens Medical School and Eginition Hospital, Athens, Greece.
The results suggest that patients with migraine should undergo thyroid function tests, said Dr Bougea.
The findings were presented here at the Congress of the European Academy of Neurology (EAN) 2017.

“A Matter of Debate”
The association between migraine and thyroid disease is still “a matter of debate,” Dr Bougea told conference delegates. Treatment for hypothyroidism is effective in the relief of headaches, but data are “largely lacking” on treating the subclinical form of hypothyroidism, she said.
Between 0.04% and 1.3% of migraineurs have subclinical hypothyroidism.
The cross-sectional study included 45 consecutive patients with migraine without aura and with subclinical hypothyroidism, attending a single outpatient headache clinic from January 2015 to February 2016.

These results “are important,” said Dr Bougea. “Improvement after levothyroxine has not yet been recorded.”
A comparison of domains of the SF-36 showed that the treatment also had a positive effect on quality of life, including such areas as limitations due to physical health or emotional problems.

Dr Bougea reported that at 10-month follow-up, the frequency and severity of migraine were “stable” and the “good results were maintained.”

Mr Katesmark comments “In my opinion sub-optimal thyroid function can certainly have an impact on the brain, which may be reflected in a predisposition to (or aggravation of) headache & Migraine. The problem is detecting this sub-optimal function as not only can the symptoms be subtle, but standard/routine blood tests for thyroid function, such as TSH, are often not sensitive enough for these borderline/subclinical cases. Careful screening questions specific to thyroid function during the history are vital with additional tests being utilized if there is any suspicion of hypo/hyperthyroidism. This is standard practice here at our headache & migraine clinic in Ewell, Surrey.

It’s also worth remembering that a study in 2016 suggested Patients with a headache disorder have a 21% increased risk of developing hypothyroidism, and the risk is even higher — 41% — in those with possible migraine.

The following article appeared in Medscape & was written by Megan Brookes. The original study was funded by the Netherlands Organization for Scientific Research and the European Community.

Alcohol, especially red wine, is perceived as a common migraine trigger, new research suggests.
In a cross-sectional survey of more than 2000 patients with migraine, alcoholic beverages were blamed for triggering migraine attacks by more than one third (35.6%) of the respondents.
Among the various alcoholic drinks, wine — especially red wine — was identified as the most likely to provoke a migraine (77.8%), while vodka was the least likely (8.5%). However, only 8.8% of the participants reported that red wine consistently led to an attack.
“Migraine patients should be careful drinking red wine during the happy holidays in order to stay happy instead of suffering from migraine after dinner,” Gisela Terwindt, MD, neurologist at the Leiden University Medical Center, the Netherlands, and one of the study authors, told Medscape Medical News.
The findings were published online December 18 in the European Journal of Neurology.

“Different From a Hangover”

In the survey, one third of the 2197 total participants said migraine typically hit within 3 hours of drinking alcohol and almost 90% said migraine onset was within 10 hours, regardless of type of alcohol consumed.
“Because of the rapid onset of the attacks after the intake, it is not a hangover headache and thus the underlying mechanism is different from a hangover,” Terwindt noted.
“It is likely that it is a combination of triggers, eg, including additional factors as sleep deprivation and the menstruation period, that provoke migraine attacks,” she added.
Terwindt said it’s also important to note that drinking alcohol will not provoke an attack each time. Still, one quarter of patients said they stopped drinking alcohol or never started because of presumed trigger effects.
Asked to comment on the study by Medscape Medical News, Noah Rosen, MD, director of Northwell Health’s Headache Center in Great Neck, New York, said, “It’s interesting that most people do not find alcohol to be a trigger and even fewer find it a regular event, but a significant minority still does.
“More people avoid it due to fear of a trigger rather than the actual risk, probably because a migraine is a strong negative reinforcer,” said Rosen, who was not involved with the study.
The study suggests “that migraineurs should be aware of each drink they have and the fact [that] it may be another risk, particularly if in association with other common triggers such as stress, dehydration, poor sleep and skipping meals,” he added.
“If you do choose to drink, it should be in moderation, interspersed with nonalcoholic beverages and spread over longer periods of time,” Rosen said.

Richard Katesmark comments ; “I have found at the Epsom & Ewell headpain clinic that whilst alcohol is frequently blamed for triggering headaches, people often forget the number of times they have consumed alcohol and NOT ended up with a migraine. However there is no doubt that in many patients it is a contributing factor, so for instance if drinking alcohol is combined with a late night & possibly dehydration, a headache will inevitably follow. Interestingly many patients find that if other factors contributing to their headaches are dealt with (such as diet or neck issues) then they can often go back to drinking alcohol in moderation without a problem.”


As mentioned in the previous posts, insomnia frequently coexists with chronic migraine, and small trials have suggested that cognitive-behavioral treatment for insomnia (CBTi) may reduce migraine frequency.

Insomnia is by far the most common sleep disorder among headache sufferers, affecting the majority of those who seek treatment for migraine. Prevalence and severity of sleep problems increase proportionally with headache frequency, such that individuals with chronic migraine experience more frequent and severe sleep disturbance than those with episodic migraine. Insomnia is characterized by regular difficulty obtaining sufficient restful sleep—manifesting as difficulty with sleep initiation, maintenance, duration, or quality—with resulting daytime symptoms (eg, fatigue, irritability, concentration problems).

Cognitive-behavioral therapy for insomnia (CBTi) is a well established treatment for insomnia, such that the American College of Physicians recently issued a clinical practice guideline recommending CBTi as the front-line treatment for adults with chronic insomnia.

Completer analyses of 2 randomized trials comparing CBTi to a sham control intervention (Calhoun and Ford, 2007; Smitherman et al, 2016) were used to quantify the effects of a brief course of treatment on headache frequency in chronic migraineurs.

Results showed there is high probability that individuals who receive CBTi experience greater headache reduction than those who receive a control intervention equated for therapist time and out-of-session skills practice.

COMMENTS; We have a fully qualified clinical psychologist here at Epsom & Ewell Headache and Migraine clinic who is very experienced in the use of CBT for insomnia ( & chronic pain). There is also information and advice for people having sleep difficulties available on the useful downloads page.


I came across the following brief article in medscape;

AMSTERDAM — Patients with migraine, especially chronic migraine, are at increased risk for sleep disturbances, including sleep apnea (SA), a new study suggests.
About 37% of patients with migraine responding to a survey were deemed to be at high risk for SA, which is much higher than estimates in the general population.
And because over 75% of migraine respondents with SA were diagnosed by a physician, “it may be worthwhile to start asking our patients about this,” said Dawn C. Buse, PhD, a licensed clinical psychologist and associate professor, Department of Neurology, Albert Einstein College of Medicine of Yeshiva University, New York City.
“We haven’t tested this yet, but the hope is that if sleep apnea is associated with more frequent headaches, treating sleep apnea might benefit headache.”
Dr Buse, who is also director of behavioral medicine for the Montefiore Headache Center in New York City, presented the new results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) study at the Congress of the European Academy of Neurology (EAN) 2017.
Both depression and anxiety have a bidirectional relationship with migraine, Dr Buse told delegates. Such a relationship also exists in sleep disorders; sleep disorders can aggravate migraine and migraines can worsen sleep disorders.
Researchers recruited participants from an online panel by using quota sampling. Survey invitations were sent to 16,763 CaMEO study respondents, of whom 12,810 provided valid data.

Richard Katesmark comments; Anyone who works with headache & migraine will know that sleep problems ofter coexist. Identifying as association between breathing issues at night ( which effect sleep quality ) & migraine is therefore no real surprise. Here at our surrey headache & migraine centres sleep issues are always looked into and addressed.

NEW YORK (Reuters Health) – Patients diagnosed with migraine are at increased risk of experiencing tinnitus, according to Taiwanese researchers.
In a paper online July 12 in JAMA Otolaryngology-Head & Neck Surgery, Dr. Hwang of Dalin Tzu Chi Hospital stated that in such patients “a history of migraine might lead to inner ear symptoms, especially tinnitus, later in their lifetime, even though they do not have episodes of migraine anymore.”
in Chiayi, and colleagues stress that “migraine” is not a synonym for “headache.” That’s simply one of many symptoms and they sought to determine whether cochlear disorders might be another.
The team examined a Taiwanese insurance database and identified 1,056 patients with migraines diagnosed between 1996 and 2012. They were compared with 4,224 propensity-matched controls from the same database.

Subgroup analysis showed that after adjustment, the hazard ratio for tinnitus was significantly higher among people with a history of migraine. There was no significant increase in the risk of sudden deafness or sensorineural hearing impairment.
In light of these findings, Dr. Hwang continued, “inner ear symptoms might be a variant of migraine presentation” and he and his colleagues “propose a new diagnosis of ‘cochlear migraine’ for this situation.”

Richard katesmark from the Surrey headache & migraine clinic in Ewell comments;
” Migraine has long been known to often be associated with dizziness and balance symptoms, & I have also noticed that tinnitus seems to be present more often than one would expect in Migraine patients ( as are other other neurological symptoms ), this report provides a very high level of evidence that confirms what I have suspected : that there is a relationship between migraine activity and the development of auditory (hearing) symptoms, including tinnitus .”

The following was taken from Reuters Health –
Even when a headache specialist refers migraine patients for proven behavioral treatments like biofeedback, relaxation training or cognitive behavioral therapy ( C.B.T) , barely half of them go, suggests a recent U.S. study.
Of 69 migraine sufferers treated at a large academic headache practice and referred for behavioral therapy, just 57 percent got as far as making an appointment with the behavioral practitioner, researchers found.
The patients who ignored their doctor’s recommendation cited time limitations as the main barrier to treatment. Concerns about cost and insurance coverage were also an issue. And some were skeptical about whether the treatment would work; others worried about the potential stigma of seeing a psychologist, the study team reports in the journal Pain Medicine June 5.
Opioids are still being prescribed as the first line of treatment for migraines when evidence shows that behavioral therapy is more effective and safer in treating migraines
“I don’t think that people realize that behavioral therapy alone can result in a 50 percent reduction in headache days. It’s not only effective alone, but when combined with medications it can have a synergistic effect. Behavioral therapy improves patients’ quality of life : they perceive less pain, miss less work and can enjoy their activities again,” said Dr. Nauman Tariq, director of the Johns Hopkins Headache Center in Baltimore, who was not involved in the study.

Richard katesmark comments. “ It is not a great surprise that many people do not try behavioural approaches to help with their headpain, In my opinion this is either because they are simply unaware of the benefits or because they are under the impression that ‘talking’ therapies are only for ‘mad’ people. It is important to realise that from a brain perspective they can change the perception of pain & may be very effective for many chronic migraine sufferers . Therefore C.B.T. is just one of the therapies that may be recommended at the Headpain relief clinic here in Surrey

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