Five Questions: Cowan on how to prevent, manage headaches

As someone who has managed his own migraines for years, Stanford headache expert Robert Cowan offers advice to those who experience chronic headaches.

- By Sara Wykes

Robert Cowan is the founding director of the Headache and Facial Pain Clinic at Stanford Health Care.    
Norbert von der Groeben

Robert Cowan, MD, is the founding director of the Headache and Facial Pain Clinic at Stanford Health Care. Its doctors help patients prevent and manage their headaches, working in collaboration with colleagues at the newly opened Stanford Neuroscience Health Center. Cowan, who founded the headache clinic in 2011, is board-certified in pain medicine, neurology and the neurological subspecialty of headache medicine. He holds several nationally elected positions, including chair of the section on chronic daily headache for the American Headache Society. Cowan brings a special motivation to his work: He has managed his own migraines for decades. Recently, Cowan spoke with writer Sara Wykes.

Q: Are there different sorts of headaches?

Cowan: Headache is very common: Every year, more than 90 percent of people in the United States experience some type of headache. Tension-type headache is the most common, and 70 percent of people have them at one time or another. The American Migraine Foundation estimates about 12 percent of people in the United States — about 37 million — suffer from migraines. Sinus problems only occasionally cause headache, no matter what TV ads for decongestants and allergy and cold remedies may say. Studies show that most sinus headaches are actually migraines. Headaches that do not respond to treatment of allergies are probably migraine or tension-type headaches, or they are related to overuse of pain medicines (medication overuse headache).

Q: What’s the difference between migraines and other types of headaches?

Cowan: A migraine is much more than a headache. It occurs on average one to four times a month. Unlike a tension headache, it is often accompanied by nausea or vomiting. Its pain is intensified by physical activity and is so severe it interferes with daily activities. About 30 percent of migraineurs — people with migraine — have a warning that consists of neurologic signs, or auras, they experience before the migraine episode begins. The most commonly experienced aura is visual, during which patients see small, colored dots, flashing bright lights or multicolored zigzag lines that may form a shimmering crescentlike shape. Sometimes there are blind spots in the visual field.

Aura symptoms last for 20 to 30 minutes. They are followed within five to 60 minutes by the headache. An aura shorter than five minutes may be something else, so we do not diagnose a patient with short auras as having migraine with aura. Aura symptoms that last more than one hour may be a sign of other neurological problems and should be brought to a physician’s attention. The headache that follows the aura is similar to a migraine headache without aura but often milder in intensity.

Q: Why do some people get headaches and others do not?

Cowan: Migraine seems to run in families, very often on the mother’s side. Migraine headache is three times more common in women than in men. That increased risk emerges in women when puberty begins and decreases after menopause. Genetics can also hardwire us to get headaches. That we can’t control, but environment also plays a big role. A headache may come after intense exercise at high altitude or with severe dehydration and high temperature. Some of us are just more sensitive to environmental changes, either in the external environment — too much sun, for example — or in our internal environment, from a drop in estrogen levels or a change in sleep pattern. People who are not headache-prone do not usually get headaches under stressful conditions. However, those who are prone to headache often experience headache when under stress or during the letdown period, the time after a stressful period has passed.

Q: How often can I take pain medicine for headache?

Cowan: I chose to enter this field more than 25 years ago because people with migraines and other severe headaches know how disabling they are and because I wanted to offer treatment that was multidisciplinary, that was more than stronger and stronger medication. The vast majority of headaches should not be treated with opioids or any other pain medications. It depends upon what kind of medicine you are taking, of course, but a good rule of thumb is not to take any pain medication more than two days in any week, and no more frequently than recommended on the label or as prescribed. If you need more medication to control pain, you should consult a physician. Overuse of acute medications can actually increase the frequency of your headaches. Headaches can be worsened by overusing off-the-shelf and prescription medications: analgesics, barbiturates, caffeine and ergotamine tartrate. The simple solution would be to stop overusing pain relievers. But it isn’t that easy. Most patients with analgesic rebound who have tried to stop overusing pain relievers have found that their headaches got worse before they got better. Their headaches typically became more intense within four to six hours after stopping the medication and were at their worst within one to two days. This worst period may last for two to three weeks. If this describes you and you have not already consulted a physician, now is the time.

Q: What can I do to avoid getting headaches?

Cowan: A good headache-management plan, especially if you experience migraines, starts with observation. We encourage our patients to take note and observe their own patterns of behavior and identify the things that contribute to headaches. Patients may notice they have certain symptoms that appear before a headache begins. Irritability, lethargy, yawning, neck stiffness and a food craving or aversion may be pre-headache signals to note.

A great way for those patients who suffer from chronic headaches to get started is with a diary to record headache frequency and severity, time of onset and similar information for a month or three. You may begin to see patterns that were not readily obvious when you relied on your memory to analyze your headaches. Share your information with your doctor. There are several apps, computer programs and paper diaries available to document your headache history.

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2023 ISSUE 3

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