headache

Dealing With Pain After A Car Accident

/ Thomas Cohn, MD

car accident injuriesTrauma from motor vehicle accidents can cause significant ongoing injuries. Typically, lingering injuries that require medical care resulting from a car accident include:

  • Lower back injuries
  • Spine injuries
  • Headaches and neck injuries
  • Broken bones and and large lacerations
  • Whiplash injuries to the head and neck

Treatments For Car Accident Injuries

Treating acute pain is done symptomatically. Ice and heat for muscle strains in both the neck and the low back region is recommended. Immobilizing the neck with a brace for several days to rest the muscles may also be helpful. That said, wearing a neck or back brace for more than a week or two is not a good idea as the muscles need to move in order to heal correctly. Restoring normal movements is one of the main objectives in early treatment. In most cases, the muscles are only strained and not torn and will heal within a short period of time. Restoring movement and strength may require assistance and physical therapy. Chiropractic or massage treatments may also be helpful in the short term, but continued passive treatments are usually not helpful for larger issues.

If pain is a significant issue, over-the-counter medications are often very helpful. Initially, acetaminophen and nonsteroidal anti-inflammatory medications like Advil or Aleve may provide significant pain relief. If the nonprescription medications aren’t providing sufficient relief, it is time to see a physician. The physician may opt for a short course of narcotics along with regular physical therapy. With aggressive early treatment, most people will resolve their injuries within a month or two.

Continued Pain

If your pain has not resolved in two months, at that time, asking your doctor to be referred to a pain specialist would be beneficial. A pain specialist can perform a comprehensive evaluation and determine further tests and treatment that would help resolve your ongoing medical problems. Sometimes injuries such as whiplash cause microscopic damage to the spine and joints, and the use of injections along with other medications and physical therapy will allow for almost complete resolution of symptoms. There are many options in managing pain related to a motor vehicle accident, and depending on the unique characteristics of each person, a program can be found that meets any individual’s needs. A pain specialist is an expert in the complex problems that cause ongoing symptoms and is extremely knowledgeable about all the possible treatment options that will allow you to return to a full life.

5 Rare Types of Headaches & How to Treat Each

/ Thomas Cohn, MD

cluster headachesHeadaches are a common and painful occurrence. Almost everyone has had a headache at some point in his or her life. We’ve already talked in depth about common headaches like tension and migraine headaches. But there are less common headaches including:

  • Cluster headaches
  • Cervicogenic headaches
  • Giant cell arteritis
  • Subarachnoid hemorrhage
  • Idiopathic intracranial hypertension

These headaches are much more rare and usually diagnosed only by specialists. In this article we will explore the causes of each headache and discuss possible treatment options.

Cervicogenic Headaches

Cervicogenic headaches are a type of tension headache generated from muscle spasms in the neck.  These occur most often after neck injury, commonly a whiplash in a motor vehicle accident or similar type of trauma.  Cervicogenic headaches often improve greatly as trauma heals within one to two months.  Massage, heat, and ice, over the counter medications, chiropractic adjustments, and physical therapy may all be useful.  About 5% of these require more aggressive treatment by a pain specialist including cervical injections.  If the headaches are not resolving, a physical medicine pain specialist can be extremely helpful in coordinating more aggressive management to stabilize or cure symptoms.

Subarachnoid Hemorrhages (SAH)

Subarachnoid hemorrhages (SAH) are very distinct, severe headaches.  Known as thunderclap headaches, they are described as the worst pain you’ve ever experienced in the head.  They occur suddenly, lasting minutes to hours, and almost always send the person to the hospital for treatment due to the severe pain and symptoms.  A CT scan of the head usually shows the bleed, but sometimes lumbar punctures and MRI scans are also needed.  Depending on the severity and cause of the bleed, treatment may require neurosurgical intervention versus supportive care.

Cluster Headaches

Cluster headaches are a rare type of chronic headache.  They are most common in men.  Typically, they consist of one-sided pain, with tearing of the eyes and runny/stuffy nose.  They occur daily for a period of time and then stop, before starting again some time later.  At this time they are thought to be associated with serotonin release and the hypothalamus.  Treatments include avoiding triggers, breathing oxygen, pain and migraine medications.  A neurologist specializing in headaches usually coordinates management.

Giant Cell Arteritis

Giant cell arteritis is an inflammatory condition of the blood vessels in the head.  It affects mainly the elderly, those over 60 years of age.  It is characterized by pain over a blood vessel, often in the temporal region.  Blood tests show signs of inflammation, especially the ESR being very elevated.  Biopsy of the vessel is often done to help make the diagnosis.  Treatment is with steroids, and often it may be necessary to take them a long time.  Not treating the condition can lead to complications like strokes.

Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension, previous known as pseudotumor cerebri, is where there is increased intracranial pressure.  The headache is a dull deep pressure with nausea, vomiting, and visual changes.  It is most commonly seen in young, obese woman.  MRI brain scans looking for other causes of symptoms and lumbar punctures are necessary in the evaluation.  By its name – idiopathic, the cause is unknown.  Treatment may include medications and sometimes requires neurosurgical management.

The above headaches are rare.  Most of them have unusual presentations and send one to see a physician immediately.  A neurologist is most commonly involved in both the diagnosis and management depending on the problem.  When symptoms do not improve despite optimum management, occasionally secondary specialty headache clinics become involved.  Generally, once one of these rare headaches is diagnosed, the treatment is effective.

Have you ever experienced any of these rare headaches? We’d love to hear your story in the comments!

How to Identify & Treat Tension Headaches

/ Thomas Cohn, MD

tension headacheMuscle tension headaches are the most common type of headaches in adults.  They have a tight “band-like” quality on both sides of the head. The headaches are not affected by routine physical activity and they can last from 30 minutes to several days. Pain intensity is mild to moderate.

The frequency is variable, from occasional to chronic daily.  Up to 80% of adults have tension headaches occasionally, and approximately 3% are chronic daily sufferers.  Women tend to have headaches twice as frequently as men.  Most people have only one or two of these headaches a month.

Causes of Tension Headaches

Muscle tension headaches have no single cause. They involve the muscles in the back of the neck or elsewhere in the head tightening up.  The most common cause is mental or emotional stress, or depression with anxiety.   Other common causes include:

  • Poor posture
  • Lack of sleep
  • Overexertion

Understanding the cause of the muscle tension helps determine the possible solutions. Muscle tension headaches are not caused by significant problems in the brain.  Tumors, bleeding in the brain, and brain injuries have different symptoms.  Tension headaches do not require brain scans or sophisticated imaging of the head.  Sometimes fairly routine blood analysis may be helpful to determine if there are any chemical imbalances in the body contributing to the problem.  Most important to the diagnosis is a good history and physical exam.

Treatment for Tension Headaches

Treatment of muscle tension headaches is multifaceted.  Tension and stress most often have physical, mental, and emotional components.  Recognizing and having insight into the factors causing the headaches may be difficult.  Professional help may be necessary to deal with emotional and mental factors contributing to symptoms.  Here are some common treatment options for tension headaches:

  • Medications to deal with stress and anxiety
  • Physical therapy to help with physical components of muscle tension
  • Massage, acupuncture, and manipulations
  • Injections to muscles, joints, and nerves as well as Botox injections

Most people can be treated by their primary physician with good control of symptoms.  When headaches become frequent and are not controlled, Neurologists and Pain physicians can determine a logical more complex and comprehensive treatment and management strategy.

A medical specialist should treat chronic daily muscle tension headaches.  The medications used for occasional headaches may make daily headaches worse.  Pain medications, some anxiety drugs and muscle relaxers can cause rebound headaches and worsening of symptoms.  A specialist can determine different treatment strategies that may be more effective for the individual.

Read more about other types of headaches in our previous blogs:

Post-Concussion Headaches: Cause & Treatments

/ Thomas Cohn, MD

concussion headacheConcussions have been a recent hot topic in the news and in medicine. But for Neurologists and Physical Medicine physicians, this is actually a very old topic.   Recently, due to high profile athletes having problems with concussions, the general public is better understanding the significance of this disorder.

What is a Concussion?

Concussions are traumatic brain injuries.  The severity of symptoms is highly varied.  Neurologists have long been in the forefront with diagnosis of brain injuries and Physical Medicine doctors as part of their training have extensive experience treating and coordinating care for these patients.

Concussions result from blows to the head.   They are a “mild” form of traumatic brain injury.  Loss of consciousness is not necessary for problems.  The severity of the blow to the head also does not correlate to severe symptoms.   Any blow to the head, or sudden shaking of the head can cause problems.  The trauma to the brain is felt to cause microscopic damage to the brain and connections between neurotransmitters.  The first symptoms may occur almost immediately with the person being slightly dazed or confused.  Recognizing a possible concussion is important such that a person is removed from further injury and healing can be facilitated.

Concussion Headaches

Headaches are one of the most common symptoms of concussions.  The headaches are diffuse throughout the head, and often are worse with noise, bright light, and movement.  Accompanying symptoms can include:

  • Memory issues
  • Mood changes
  • Irritability
  • Fatigue
  • Balance problems and dizziness

The symptoms can appear immediately or within one to two weeks.  If one has had head trauma, and has symptoms of a possible concussion, see a physician and seek treatment.  Remember, the suggestion to seek evaluation is to help the brain heal and prevent further damage.  It is not a punishment to keep a person out of sports or other activities.

The diagnosis of concussion and headaches from injury is made clinically; it is based on history and exam.  MRI scans of the brain or spine may be done to evaluate for possible problems contributing to symptoms or to see if there may be subtle tissue changes in the brain that are consistent with exam.  If dizziness is an issue, then an Ear specialist may also be involved with symptom evaluation and management.

Concussion Headache Treatment Options

Treatment of post–concussion syndrome and headaches is dependent on severity of symptoms.  Initially, it is recommended to rest and avoid too much activity and stimulation to the brain.  That may mean no computer use, no reading and no watching TV or videos.  As the headaches improve, gradual increase in activity as tolerated.  The brain needs to heal on its own time frame without being damaged or stressed.  Medications that are used are the same medications we use for muscle tension headaches or migraines, but we start simple and hopefully they will be unnecessary very quickly.  Repeated concussions often heal very slowly if ever.

Concussions and headaches from them are serious problems.  Medicine and everyone else is just starting to become aware of the seriousness of these injuries.  Treating ongoing headaches from concussions is serious; ignoring them may lead to long-term issues.  Once a diagnosis is made, follow the doctor’s orders and allow the brain to heal.  There is no such thing as brain transplants, so allow the brain time to heal.

For more information on headaches, check out our other posts:

Migraine Headaches: Phases, Triggers, & Treatments

/ Thomas Cohn, MD

migraineMigraine headaches often involve severe pain in one side of the head, and are commonly accompanied by nausea, and sensitivity to light and sound.  These headaches are thought to be vascular with constriction and then expansion of the vessels.  Migraines occur in 28 million Americans, about 12% of the population with a ratio of 3:1 for females to males.

Check out our other posts about headaches:

4 Phases of a Migraine

A migraine attack usually has four phases:

  1. Premonitory symptoms. Symptoms of this phase include fatigue, lack of concentration, yawning, visual changes, neck pain. This phase may last from hours to days.  
  2. Aura. The auras are usually a visual or sensory phenomenon, lasting minutes to an hour. These only occur in a small portion of people with migraines.
  3. Headache. The actual headaches have a gradual onset. First thing in the morning you will start to feel pain on one side of the head. The pain can start dull, then evolve into pulsating pain with jabs and jolts.  90% of sufferers also experience nausea and sensitivity to light, sound, and smells.  Mood and mental awareness changes and neck pain are common.
  4. Postdrome. After the migraine, the postdromal period, involves fatigue, impaired concentration, irritability, and general pain and weakness.

Migraine Triggers

The triggers for migraine headaches are numerous, and are partly dependent on the individual.  All of the following can be triggers:

  • Stress
  • Weather changes
  • Caffeine withdrawal
  • Menstruation
  • Sleep problems
  • Fasting
  • Certain foods including wine, MSG, nitrates, and aspartame

The correlation to a heart defect called a patent foramina ovale (PFO) is clear, but it is an association, not a cause, and fixing the heart defect sometimes does affect the migraines.  In females, there is a correlation to hormonal changes, but regulating female hormones does not necessarily improve migraines.

Migraine Treatment Options

Migraine treatment includes a variety of medications depending on the severity and frequency of the headaches.  First line medications include anti-inflammatories, combination analgesics like acetaminophen with caffeine, and sometimes nausea and seizure drugs.  If the migraines are more severe but not more than once to twice a week, triptan type medications are often highly effective. The most common has been Imitrex and there are multiple similar drugs available.

Addictive medications like narcotics or benzodiazepines should be avoided since they are likely to cause increasing difficulties in management over time.  When migraines become frequent, twice a week or more, seizure type medications and beta-blocker heart drugs may be effective.  If the headaches become uncontrollable, sometimes intense interventions by Neurologists who just specialize in headache management is necessary.

Migraines & other Headaches

Migraines can also be mixed with other types of headaches, such as pain from the neck like whiplash or TMJ jaw problems.  Treating headaches of mixed origins is often complex and needs a team of specialists and support staff including Neurologists, Pain specialists, physical therapists and psychologists to address the variety of problems these headaches cause.

If one has migraines, and simple treatment is not working, then a Neurologist and sometimes Pain specialists can be of great benefit.  A team approach can often address the variety of factors impacting and contributing to the headaches.