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Programme 4. - Headaches
RADIO 4
THURSDAY 02/03/06 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
PROFESSOR PETER GOADSBY
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
Hello. Nine out of ten headaches are tension headaches. Bad enough, especially if the pain is severe and you get them regularly. But nothing like as bad as migraine, when a blinding headache may be accompanied by nausea and vomiting and the desperate need to lie down in a darkened room. Even a bad migraine though pales by comparison with cluster headache. People who suffer from cluster headache describe them as the most excruciating pain possible.
Well my guest today is an expert in all type of headache, he's Professor Peter Goadsby from the Institute of Neurology at Queen Square, where he's been instrumental in new research which shows structural abnormalities in the brains of people with cluster headache. So if you have any questions about that or indeed about anything else to do with headaches and their treatment please call us now - 08700 100 444 is the number or you can send an e-mail to checkup@bbc.co.uk.
And we'll start today with an e-mail, it's from Colin Allen who says that he's suffered from cluster headaches for 15 years and he finds it very difficult to convince people just how severe the pain is. He's asking the question: Does the professor know how to improve people's awareness of a condition which is so bad that death is often a more appealing prospect than yet another attack?
That's a very poignant e-mail, is it really that bad?
GOADSBY
Thanks Barbara. I think it is that bad for some people. One of the problems with headache is it's so common that the person in the street who's had the experience sometimes thinks that that's all the experience is. If you want a good read you can pick up the headache classification that's been published by the National Headache Society, it runs to a 160 pages and will help many people sleep. And what it'll tell you is that there are simple types of headaches and there are very severe, very disabling forms of headache and certainly of all of those the worse in terms of pain is cluster headache. I don't know how to create an understanding of the severity of that, short of explaining how awful the pain is that the patients who see me describe and short of describing how much disability they have - the things that they can't do.
MYERS
And what sort of things do they say to you?
GOADSBY
Patients with cluster headache will tell you that they haven't had a worse pain and I've had patients who've obviously given birth - ladies - for men that is rather a high watermark in the experience. Knife wounds, gunshot wounds, burns, being awake during an operation - I mean the range of things are just horrendous that these patients have had but cluster headache is worse. Now imagine for a moment giving birth two or three times a day for months at a time, it is just - it takes your breath away.
MYERS
So they occur that regularly in some cases?
GOADSBY
There are patients with - patients with the most disabling forms of headache - migraine or cluster generally speaking - happen very frequently and certainly the cluster patients have often more than one attack a day.
MYERS
Let's go to our first caller because Valerie Hobbs, I think, is a sufferer of cluster headache and wants to talk about possible treatment options. Valerie, are you familiar with then the sort of pain that the professor's described and that Colin Allen tells us about?
HOBBS
All too familiar unfortunately, I'm a chronic sufferer with cluster headaches and I suffer attacks on a daily basis and that's 365 days a year. What I wanted to ask today was I've tried all the preventive medications that are listed for cluster headache, I use just the abortive medications to deal with the attacks but can the professor tell us what the future is regarding treatment for cluster headache and for chronic sufferers in particular?
GOADSBY
Thanks for that question Val. I think the future for cluster headache in particular, I think for headache in general, is bright in the context of research. As we understand the disorder better we can understand how to design new therapies and I think that the most obvious example of that that the brain and nerve stimulation therapies that have arisen out of work that we've done here in London, at Queen Square. We've demonstrated changes in a deep part of the brain, called the hypothalamus, and this has evolved into an entirely new therapy that's now beginning to be used of deep brain stimulation. And we've evolved a new therapy by the stimulation of a nerve at the base of the skull, called the occipital nerve, so called occipital nerve stimulation and that's currently under study. So there are at least two ways to move forward now in people who otherwise were completely, as yourself, intractable and whose lives are just ruined by this problem. There is hope, there's a lot of hope.
MYERS
So would this be an operation you would have and you'd implant an electrode that would stimulate this hypothalamus, the area that you've discovered is connected with cluster headache and is it available - I mean I don't know about whether you'd be interested - is it experimental or are we talking about this available in the clinic already?
GOADSBY
There are - there are two operations, there's one involving putting an electrode in the brain and there's another one involving putting an electrode at the base of the skull with a stimulator, as you say, just in the chest where the pacemaker would normally sit. And the second operation is starting to be done in our institution, there's some limited availability and some difficulties around that shall we say.
MYERS
So watch this space. But Val you mentioned that you're already having certain treatments, have any of them been helpful or are you really just without anything that works for you?
HOBBS
Well the abortives work for me, i.e. they're the painkillers, that's an injectible form of a drug called sumatriptan. And I also use high flow oxygen, which is very effective.
MYERS
What is that?
HOBBS
Basically it's inhaling a 100% oxygen at a flow rate of about 8-15 litres a minute and you would do that for about 20 minutes and usually that is sufficient to abort an attack. And it will work about - I'd say about 85% of the time to abort my attacks. The injections work within about 15 minutes or so but of course you're limited - you can only have two injections per day - they're only licensed to use two a day otherwise it can be a bit dangerous.
MYERS
So hence you need to do something rather more drastic.
HOBBS
Looking in the future, many years of having to do this on a daily basis, having to give myself injections on a daily basis and it's not something that people relish but certainly hearing about the two procedures that the professor has mentioned is certainly going to give me some hope for the future.
MYERS
Okay Valerie for that, thanks for the call. Just to pick up on those two treatments, perhaps not everyone who has cluster headache would even know about the oxygen treatment or the injectible triptans, so they can very helpful in fact for people to a certain extent?
GOADSBY
Yes, Val's making the distinction between treating the attack and preventing the attack and the procedures we were talking about would prevent the attacks. To treat the attacks by both, what she described, oxygen and sumitriptan injections, are extremely effective and oxygen should be relatively easily available to any cluster headache sufferer on the National Health Service, as should the sumitriptan injections, which have a specific indication in cluster headache in the national formulary.
MYERS
Thank you. Let's go to another caller - Ghislaine is waiting patiently in Watford, your question please Ghislaine for Professor Peter Goadsby.
GHISLAINE
Hello. Hi it's Ghislaine here. I'm lying in my bedroom at the moment in the dark, recovering from a nauseous migraine state. And really my question is when I'm in the really chronic state of nausea and being sick there's nothing I can take but today I felt I was not - didn't feel sick anymore and I wondered if there's something that I can take that might make me bounce back a bit more quickly because although I feel better I still I'm not able to get up and do anything, every time I get up I feel dizzy and I have to lie down again.
MYERS
Sorry to hear you're not so well, thanks for coming on the phone.
GOADSBY
You illustrate a very good point that the World Health Organisation recognised when it put migraine right at the top of the disability scale. Considering all conditions that humans suffer and at first glance people think that's silly but there are you, an adult, lying in bed, restricted to your house, you may as well be quadriplegic as be - as be migrainous and that's the way the World Health Organisation thinks about it because this disease is so disabling. It's not that it kills you but makes your life an absolute misery - as you're describing it. How long have you had the attacks?
GHISLAINE
Well for the last two years probably about every six weeks and it lasts sort of three to four days.
GOADSBY
Well in general terms for migraine there are three things you can do. The first thing is you can try and address trigger factors and I guess we'll come back to that. And the second thing, because you asked me specifically, is what to do about acute attacks. And then the third thing is preventing them. So talking about the attacks that come, there are big picture things you can do. You can take painkillers, and no doubt you have, you can take things that will improve the nausea - drugs like metroclopramide, and domperidone, both of which are widely available on the NHS. And then you can use combinations of painkillers with the antinauseants - to stop you throwing up and make things settle down. And if they don't work then we have a class of drugs - the triptans - which are specific migraine and cluster drugs - which act against both the pain and the nausea and in fact also improve that sensitivity to light that you mentioned, so that you can get on with your day in a more reasonable way.
GHISLAINE
And are these prescribed from the doctor?
GOADSBY
Yes. The triptans are prescribable from your GP and I'd encourage you very strongly to go along and talk to your GP about - not just about the fact that you've got pain but talk to him about the amount of disability that you have, it's important that doctors understand that this is not just a headache, so to speak, but this is a disorder that ruins part of your life and when they understand that they're very sympathetic to wanting to do the best they can for a patient with your sort of problem.
MYERS
And would you say Peter that in recent years the advent of the triptans - this class of drugs - really has revolutionised the treatment of migraine?
GOADSBY
Yeah the triptans have certainly revolutionised the treatment of migraine. They've done it in two ways. The first way is they've excited people to want to do research and that's helped enormously in understanding the disease. And the second way at a very practical level - they've taken people who are otherwise stuck in their bed, lying at home, not able to function, and put them back into society and I think that 15 years later sometimes we forget how really excellent these medicines are for the people who have access to them. They're not the last word and they're not perfect for everyone and they're not right for everyone and there will be other developments that will come but they were an important milestone.
MYERS
Thanks for the call Ghislaine, hope you feel a lot better soon.
We talked about or mentioned trigger factors, Winifred Booth is on the line interested to know about possible trigger factors, because I guess if you can avoid a known trigger factor you can perhaps avoid an attack. What do you find triggers migraine Winifred?
BOOTH
Red wine, dark chocolate and I'm now discovering my white grapes are starting ...
MYERS
So do you try to avoid these or do you still want to have them?
BOOTH
I want to still continue with the white grapes. I can't take the red grapes because they're a trigger but now I'm discovering the white grapes are the trigger - starting to be a trigger. Only at certain times, whether there's a change in the grape and that is a trigger in it but for weeks I can be eating them, because they're lovely at this time of the year, and they're just starting - I had an attack on Sunday that triggered the migraine and all the symptoms you've just been talking about is what I was suffering on Sunday.
MYERS
Let's see what Peter makes of this because there seem to be as many trigger factors as there are things out there - I've heard about people being triggered off by the weather, changes in the weather and things in what they eat, particularly gluten I've heard about. What's your view on this - what's the rationale anyway for, as it were, these external things triggering the migraine Peter?
GOADSBY
Migraine is a fundamentally inherited disorder where your biology, yourself, meets the external environment and attacks get triggered off. And the caller has just described some triggers. They've described the variability and let me - let me challenge the caller to think about whether what's varying is the grape or what's varying is you. Migrainers very often describe that on some days they can sleep in or some days they can skip their meals or on some days they will have stress that won't affect them but on another day if they just have one of those things it will trigger an attack. And we think it's because the brain's susceptibility to the attack varies as well as the interaction with the triggers. So what I think is happening to you is that your brain's ability to be turned on, so to speak, is varying rather than what's in your grapes. I mean the theme of migraine triggering is about change in what's called physiology, so that if you change the way you sleep, change the way you exercise and change the way that you - times that you eat then that can trigger attacks. So it's difficult for a migrainer because they've not only got to watch the outside world but they've got to be a little bit sensitive to when they're going to be triggered themselves.
MYERS
Is keeping a diary a good idea?
GOADSBY
I find it invaluable when advising patients about migraine to keep a diary because I think it's terribly important to work with the patient to try and understand what are the triggers but what are the things that aren't really triggers, they're just their own - their own biological variability, I think that is the first stage of management. It's important and I think physicians are interested in that sort of holistic approach to the problem.
MYERS
Moving on from Winifred, I've got an e-mail from Helen, which perhaps ties in. She says that she's never been a headachy person until recently and then she started to have debilitating headaches at the beginning of her menstrual period. She does also mention that her sister has frequent migraines and her mother has a lot of severe headaches. She's 29. She's wondering whether it would be something to do with the menstrual cycle I guess or perhaps linking in with the family.
GOADSBY
Yes you make two very good points. Migraine is an inherited problem and most patients who we speak to will have a family member - mother, father, brother or sister who've got typical migraine or very often are headachy because that's the essence of the disorder. And just like you can't get new parents you can't trade in your headachiness, you learn to manage it. And menstruation is a big trigger and so it sounds like at the age of 29 Helen's mum and sister are catching up with her, so to speak, and she's going to need to take some advice about how to manage what sounds like attacks that are triggered by the menses.
MYERS
And there's nothing much you can do about your menstrual cycle I suppose, maybe go on the contraceptive pill, would that make any sort of difference to the way your hormones work?
GOADSBY
Yeah one of the things that are popular to do at the moment and providing there's no contraindication to it is something called tripacking, where you take the oral contraceptive pill back upon back to try and reduce the frequency of menstrual migraines, particularly useful - particularly appropriate for women who do not have so-called aura or neurologic systems where there are no particular risks for the pill.
MYERS
You're listening to Check Up, it's 18 minutes past three, I'm Barbara Myers, my guest today is the neurologist and headache specialist Professor Peter Goadsby. We go to another call. Barbara - another Barbara - in Lancaster this one, got some strange visual sort of pain, what's all this about Barbara?
YOUREN
I can be doing anything - sitting, relaxing, walking - and suddenly it's as though someone sticks a knife into my head, can best be described as a severe zig zag, akin to sort of lightning, without the lightning in my head, and severe enough to sort of make me cringe with a great intake of breath, then my head - in fact I had one yesterday and a friend was here and said for goodness sake you ought to have that seen to. But I have had them on and off for a few years, sometimes just it's a case of one sort of sharp knife attack or other times a series of them throughout an afternoon or the day.
MYERS
How very disconcerting because what happens if you're driving for example?
YOUREN
Well exactly, that's what's worrying me now. In actual fact I was singing in a concert and in the midst of - mid-song which was Art Thou Troubled - which I was - I had one of these attacks ...
MYERS
And went off key.
YOUREN
... they don't happen very often but when it does it really is grim.
MYERS
Lucky you're not a soloist I suspect. Okay, let's put the question. Actually Peter's nodding his head as though you've heard of this before have you?
GOADSBY
No I've heard this story. How many seconds does it last for did you say?
YOUREN
It could last from, it can sort of go zzzzzzum, goes through or sometimes a longer like a knife attack and then that could stop and then I could have - followed by another one. You were talking about clusters and I wondered if maybe ...
GOADSBY
You've given me the impression your zzzzums last about five seconds or not particularly more and you've had them for a few years.
YOUREN
I have.
GOADSBY
Do you get any other things that happen with it, like eye watering or redness or your nose blocking?
YOUREN
No but I do - I do suffer from glaucoma.
GOADSBY
Yeah. Does anything trigger them - can you touch ...
YOUREN
That's the funny part - nothing, my food doesn't seem to do it, they just sort of come out of the blue. I did mention it to the doctor some years ago and he said don't worry about it, you're alright aren't you - so that was it really.
GOADSBY
Assuming you have a normal examination and that's one of the limits of radio there's a form of headache called primary stabbing headache - you'll think I've made it up, but it's in the book. And it's sudden stabs or jabs of pain that come out of the blue, they're not triggered, they're not associated with eye watering or redness or foods - as you describe. They go as quickly as they come, the pain is awful when it's there and it happens in about .5% of the population. If you're related to migrainers it's more like 40-50% of the population. Sudden horrible pains. For the migrainers it typically happens in the area where they have their migraine and for the non-migrainers it can happen anywhere. It never shortens life and it is no more than the stab and that's it and there is no particular way to stop them I'm sorry.
YOUREN
That describes it perfectly and also you said association - I couldn't think of anybody with headaches, apart from my son did suffer from migraine in his teenage years.
GOADSBY
I should say you can treat them if they're very frequent. There are some people who get 20, 30, 40 of these a day, they're the very unusual group, and there is a treatment for that but for the person who gets one every so often I would leave it alone and next time your friend asks you tell it's primary stabbing headache.
MYERS
It's good to have a name to attach it. Thanks very much for that. I mean there's obviously reassurance there. I wonder though if there are occasions where someone does suddenly get a blinding headache and are perhaps not at all familiar with it, Barbara's familiar with the stabbing that she's experienced, but are there ever any reasons that you would go immediately for emergency treatment for a headache that was quite out of the blue?
GOADSBY
Barbara illustrated a very good point about headache. The headaches that people have over many years are generally debilitating, they do things - they can ruin their lives, they can limit what they do but they won't shorten their life. If you've never had a headache before and all of a sudden bang - I won't hit your microphone - bang, you get a sudden onset, very severe, pain and particularly with neck stiffness or being bothered by the light then yes you need to hot foot it to the local hospital because part of the differential diagnosis is something called subarachnoid haemorrhage which is absolutely life threatening - about 50% of people with that will die. So there are forms of very severe, very sudden onset headache that are very, very worrying. Fortunately they're the rarer forms.
MYERS
And can you also clear up this idea that brain tumours are always - start with a headache, I mean is there any connection at all, I mean fortunately brain tumours are rare but is a headache part of the story?
GOADSBY
People with brain tumours will - can have headache, it's not necessary and it's usually not in isolation and it's almost invariably not severe. Brain tumour headache tends to be rather nondescript. And what brings the problem to the attention of physicians is usually some other thing, like a fit, for example. So the idea that very severe debilitating headache is brain tumour is almost invariably not correct.
MYERS
Thank you. Let me take you on to another e-mail, this one from Amanda who's started having quite bad headache. It clears up when she gets up and starts moving around in the morning. But she goes on to say that a few months ago she had surgery on her foot, was taking paracetamol on a regular basis, in fact she still is taking paracetamol. She's wondering if she should try and stay off the painkillers. Could there be a connection?
GOADSBY
Oh there are two - there are two points to make. The first one is early morning headache, we don't know how old Amanda is and it would be polite not to ask, but the issue I wanted to raise is the possibility that she snores and there's a condition called obstructive sleep apnoea which can present with early morning headache, it typically happens in people who snore and are overweight and their partner would tell them they stop breathing during the night, please see your doctor soon about that. Painkillers - it's an epidemic. About 2% of the UK population overuse some form of painkiller and it just makes the headache problem worse. If you're sitting at home now opening a paracetamol or codeine containing tablet or caffeine and you've had - and you're having 10 or more per month you're overusing and it's creating a problem. And I know that what people are doing is responding to the pain and treating it as best they can to function but it creates a problem - medication overuse. And if that fits the bill please see your doctor about it, you need to do something about it.
MYERS
Thank you. Quick last call from Rosie, Rosie your question please.
ELLIOT
Hi yes I'd like to ask the professor about cyclical headaches. I'm not a headachy person but about four years ago and lasting for about 15 months I used to have every Tuesday the most debilitating headache, it would start about 10 in the morning and it would go on literally right the way through to the end of the afternoon where I'd literally have to just sit in a dark room.
MYERS
Let's just pick that up and say that you're not the only one who's mentioned a particular day, someone else said they always have theirs on Sunday. Very quick answer to that?
GOADSBY
The most likely thing you're describing is a form of migraine that's coming and going. It's a good example of keeping a diary, watching what happens the day before, having a good chat with your GP and making sure that there's no sort of systematic trigger factor but it does sound like a migraine.
MYERS
Okay thanks for that Rosie, and thank you very much to our expert guest today Professor Peter Goadsby. Thanks to everyone who called, if you'd like more sources of information then call our action line, that's 0800 044 044 or try our website. And join me again next week, if you will, when we'll be talking about keeping your mouth healthy.
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