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Headache Diagnosis
and Treatment:
An Overview
An Interview with John Claude Krusz, MD, PhD
BY TERI ROBERT
DR. KRUSZ
is actively involved extensive research in the area of headache and
pain disorders. He is in private practice in Dallas, operating from his multidisci-
plinary clinic, the Anodyne Headache and PainCare Center. He is Vice President
of the American Board of Electroencephalography and Neurophysiology. Dr. Krusz
serves as a Medical Advisor on the Board of Directors of MAGNUM and is on the
editorial board of the American Journal of Pain Management, the quarterly pub-
lication of the American Academy of Pain Management. Dr. Krusz was elected
to the Board of Directors of the Texas Pain Society and is in the special interest
group for Refractory Headaches in the American Headache Society.
Q. When a new patient comes into your office with a headache, what
is the first thing you do? Are there particular questions you ask or
aspects of a patients medical history that are especially important
for diagnosis and treatment?
DR. KRUSZ.
Everything is important. It is essential to spend time with the
patient and obtain a thorough medical. In addition, patients should be asked
about: the site of their headache, onset, intensity, duration, frequency, severity,
associated symptoms, and precipitating factors. Looking at psychological and
emotional factors and family history is also important.
I am particularly interested in the endocrine aspects of a persons history
because they are often overlooked even though they can impact the patients
headaches. Although a womans estrogen levels are often considered, the
endocrine hormones and their potential impact on headache are not. Taking a
sleep history is important as well. Poor quality sleep and sleep patterns can be
a significant headache and migraine trigger. Sometimes a traumatic brain
(concussive) injury history needs to be factored into the equation.
If there is a sudden onset of headache, or if the patient has frequent or
daily headaches, its important to rule out organic disorders, which may have
morbid consequences. want to make sure that the patient does not have a con-
dition such as brain tumor, ruptured intracranial aneurysm, giant cell arteritis,
which are quite rare, or TMJD (Temperomandibular Joint Disorder).
Q. Are imaging studies recommended for all patients presenting with
headache? What about lab work?
DR. KRUSZ.
Imaging studies are not that useful unless youre aware of the
fancier types of MRIs that are available. For example, a 3Tesla brain MRI can
be quite useful in specific circumstances, such as documenting shearing
injuries in a concussive-type injury.
( o p p o s i t e )
Title:
What the Headache Does to Me
Media:
digital photograph
Artist:
Stephanie Samanski I order lab work to look for blood glucose dyscontrol, thy-
roid dysfunction, pituitary dysfunction, cortisol dysfunction,
and sex hormone aberrations. Dyscontrol or dysfunction in
these areas can cause headache or trigger migraine. These vari-
ous imbalances make the body more vulnerable to headache .
Because lab normal values are not always the patients true
baseline, treating by symptoms rather than lab values must be
considered.
Q. What types of headache are physicians likely to
encounter in their practice?
DR. KRUSZ.
Millions and millions of people suffer with
headaches in this country, so its quite likely that every clinician
will see patients with headaches at one time or another. The
most common types of headache a practitioner will see are ten-
sion-type (TTH), migraine, and cluster. In any given practice,
tension-type headaches are the most common, yet migraine is
probably seen more often because fewer patients seek medical
care for tension-type headache. Its also quite common to see
patients who present with what they believe to be sinus or ten-
sion headache when the headache is actually migraine.
Q. Could you describe each type of headache?
Lets start with migraine.
DR. KRUSZ.
The most common form of migraine is migraine
without aura (formerly termed common migraine). Migraine
with aura, formerly termed classic migraine, is experienced by
15 to 25% of migraineurs. Most patients who experience
migraine with aura do not have the aura phase with each
migraine attack, and so they are diagnosed with both migraine
with aura and migraine without aura. Either of these may be
experienced without the headache phase, but skipping that
phase does not change the diagnosis. Descriptive terms some-
times applied to such migraine attacks are acephalgic and
silent migraine. Menstrual migraines are those triggered by
the hormonal fluctuations of the menstrual cycle, and men-
strual migraine is a description rather than a diagnosis.
Also, its not unusual to see patients who have been diag-
nosed with ocular (or ophthalmic) migraine. Patients with this
diagnosis experience the visual symptoms of migraine with
aura, but do not progress to the headache phase. Often these
patients are diagnosed later with migraine with aura.
Q. Tell us more about migraine without aura. How long
does this type last? How is it most often treated?
DR. KRUSZ.
Migraine without aura generally lasts from 2 to
72 hours without treatment or when treatment fails. The
headache is more often unilateral, but may be bilateral, pul-
satile, of mild to moderate intensity, and aggravated by routine
physical activity such as walking, bending over, or climbing
stairs. Accompanying symptoms may include nausea, vomiting,
sensitivity to light, and sensitivity to sound.
Acute treatments include: triptans, ergotamines, NSAIDs
(nonsteroidal anti-inflammatory drugs), and antinauseants. Pre-
ventive treatment includes: neuronal stabilizing agents (often
called anti-convulsants), SSRIs, SNRIs, calcium channel block-
ers, beta blockers, and many others. Natural preventives
include: Coenzyme Q10, feverfew, Vitamin B2, and magne-
sium.
Q. What about migraine with aura?
DR. KRUSZ.
The headache of migraine with aura is like that of
migraine without aura except that it has at least one of the fol-
lowing symptoms of aura (but no motor weakness): fully
reversible visual symptoms including positive features (e.g. flick-
ering lights, spots, or lines) and/or negative features (e.g., loss of
vision); fully reversible sensory symptoms including positive
features (e.g. pins and needles) and/or negative features (e.g.,
numbness); and fully reversible dysphasic speech disturbance.
Or, it may have at least two of the following symptoms:
homonymous (on the same side as the other symptoms) visual
symptoms and/or unilateral sensory symptoms; at least one aura
symptom that develops gradually over 5 or more minutes
and/or different aura symptoms that occur in succession over 5
or more minutes, with each symptom lasting no more than 60
minutes.
Acute treatment includes: triptans, ergotamines, NSAIDs,
and antinauseants. Preventive treatment includes: neuronal sta-
bilizing agents, SSRIs, SNRIs, calcium channel blockers, beta
blockers, and many others. Natural preventives include: Coen-
zyme Q10, feverfew, Vitamin B2, and magnesium.
Other forms of migraine include: basilar-type, familial
hemiplegic, sporadic hemiplegic, and retinal migraine. Compli-
cations of migraine include: chronic migraine, status migrain-
ous persistent aura without infarction, migrainous infarction,
and migraine-triggered seizure.
Q. Tell us about tension-type headache.
DR. KRUSZ.
Tension-type headache has also in the past been
called psychomyogenic headache, stress headache, muscle con-
traction headache, ordinary headache, and essential headache.
Tension-type headache usually lasts 30 minutes to 7 days with
at least two of the following: bilateral location; a pressing/tight-
ening (nonpulsing) quality; and mild to moderate intensity (not
aggravated by routine physical activity). People describe this
headache as the feeling of a band or vise around their heads.
There is no nausea or vomiting with tension headache; there
may be sensitivity to sound or light, but usually not both.
Tension-type headache is most often treated with tramadol,
or muscle relaxants such as tizanidine (Zanaflex). Preventive
treatment includes: neuronal stabilizing agents, SSRIs, SSNRIs,
calcium channel blockers, beta blockers, and many others. Nat-
ural preventives include: Coenzyme Q10, feverfew, Vitamin B2,
and magnesium. For people with tension headache, comple-
mentary therapies such as massage and biofeedback that relieve
stress can be very helpful. These modalities may also bring
acute relief for some patients.
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