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Ep. 127 - LiveWell Talk On.. Migraine Headaches (Whitney Hanken, ARNP)

episode 127

Ep. 127 - LiveWell Talk On...Migraine Headaches

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Whitney Hanken, ARNP, migraine relief specialist, St. Luke's Physical Medicine and Rehabilitation

Dr. Arnold:
This is LiveWell Talk On...Migraine Headaches. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Joining me today is Whitney Hanken, nurse practitioner at St. Luke's Physical Medicine and Rehabilitation, who specializes in relief and treatment of migraine headaches. Today we'll discuss signs, symptoms, and phases of migraine headaches, treatment options, and more. Whitney, welcome.

Whitney Hanken:
Thank you for having me. Pleasure to be here.

Dr. Arnold:
I think migraine headaches are difficult to treat if you don't have some expertise and some interest in it.

Whitney Hanken:
Absolutely.

Dr. Arnold:
Headaches in general are a headache to treat. And it's because you can't see it, you can't x-ray it. You know, the measurability of it is minimal. But having a wife and a daughter that have them, they're quite disabling.

Whitney Hanken:
Very much, very much so.

Dr. Arnold:
So could you just start with, what is a migraine? And how common is it?

Whitney Hanken:
Sure. So migraines are a type of headache. A little bit different etiology than just, you know, your classic headache. Usually they start on one side. They're pretty predictable pathways. It can be both sides though. They have an intense nature, throbbing quality, usually have some sort of photophobia, sensitivity to light, phonophobia, sensitivity to sound, nausea, vomiting and they usually kind of take you out of commission. A headache, you know, if you've ever experienced one, I just found out that there are people out there that have never had a headache, which just boggles me. But they usually are bilateral, less intense, don't have any aura or any associated symptoms, and usually it can be alleviated with over the counter medications.

Dr. Arnold:
Yeah. You know, I'm one of the—I won't say I've never had a headache, but it's very rare. You know, I'm just fortunate enough that I don't get them.

Whitney Hanken:
You're a lucky man. Very much so.

Dr. Arnold:
Well, I'm a lucky man on very many levels. So what would be the threshold that someone should receive treatment for a migraine? I mean, how frequent do they have to be and whether or not they can obtain relief?

Whitney Hanken:
I always say if it's interrupting your activities of daily life at any point, you could have one every other month and, you know, if it takes you out of commission, if you have to miss work, I would say treatment is definitely an option for you. There is a difference between acute treatment and chronic treatment. Acute would be 14 migraine days a month or less, and chronic would be 15 or more head pain days per month. When you get into that range where you're having almost daily head pain, even if it's not a migraine, prophylactic treatment is definitely indicated.

Dr. Arnold:
Okay. So is it, I mean, it's my impression and I don't know this for sure. This is more common in females.

Whitney Hanken:
Yes. You hear about it more in females, but I do have a lot of patients that are men that come in and they complain of a lot of neck pain. Or, you know, like I just get a lot of headaches, I'm never head pain-free. And once I start asking them questions, you know, I'm like, I think you're having migraines. And if we use certain treatments that are very, very focused on migraines, they actually get relief. So I think more men suffer from it than they think. I have a lot of patients that confuse neck pain and migraines, because a lot of times it will start in the neck and work its way up. You know, kind of that tension headache, that people say, you know, oh, I just have tension headaches. A lot of times they're having a migraine and you just don't realize it.

Dr. Arnold:
Or in my experience, sometimes people blame sinus headache. And it's not a sinus headache, it's not sinus related at all.

Whitney Hanken:
Yes.

Dr. Arnold:
So, I mean, I was always under the impression that there's an association with the menstrual cycle and pubescence. Tell me about that relationship.

Whitney Hanken:
Sometimes, especially with hormonal changes, menopause, menstrual cycles, onset of puberty, that's when people usually notice that, you know, that they start having migraines. You know, it causes inflammatory changes in your body. Any hormonal shift, if you think of your body as a giant machine, you have chemical levels in your blood, certain things respond to certain stimuli, and your hormone maybe triggers some of that CGRP, the calcitonin gene related peptide, which causes a lot of the inflammation in the meninges that causes migraines. For some reason that seems to be a big trigger, especially for women. You know, for me, myself, I started having migraines when I was 14-ish. I had them very severely, and then I didn't have another one until I had my daughter. And then I had about five good years and now it's back. So I think, you know, different stages of life definitely can create different levels of migraines for you.

Dr. Arnold:
Sure. Now the—so I'm asking this more as a clinician than a podcast host, but at what age would I say, yeah, that's really unusual to have a migraine at that age presentation, where I would immediately see that as a red flag?

Whitney Hanken:
Sure. So, you know, I don't deal a lot in children, but I have heard up-to-date, you know, age five people having migraines. But I think if you're under 12/13 and you're having new onset head pain, that's severe and debilitating, I think neurology is definitely something that needs to be explored to make sure there's no intercranial processes going on before, you know, it's dubbed a migraine and it requires treatment.

Dr. Arnold:
And what age would you consider that, you know, somebody presents at 62, would that draw you to say, this is an age I should probably look for something other than a migraine because it's late in life.

Whitney Hanken:
Right. Usually the patients I see that are later in life, usually don't have new onset. Usually they have had it for years, they've just been dealing with it. There haven't been good treatment options, but if someone has what we call a Thunderclap headache, the worst headache of their life and they haven't had any of these symptoms before, I would say in their fifties, sixties definitely need to be worked up for neurological issues as well. Most of the patients I see, they've been dealing with this all their life or for a lot of their life. So often by the time they get to me, it all that's been done. If someone comes to me for back pain and they have new onset migraine, definitely warrants treatment, especially in those younger and older populations.

Dr. Arnold:
Now we, in the opening, I made reference to the phases. I know migraines have kind of four distinct phases. You want to walk us through those phases just so people can understand that concept?

Whitney Hanken:
Sure. So there's the prodrome, the aura, the actual migraine, and then the postdrome. So the prodrome is usually, you know, it can be 72 hours before you have a migraine. You know, people just, something's not right. I'm feeling anxious. My mood is low. I'm extremely fatigued. Constipation can be, you know, part of the prodrome, unusual food cravings. It almost sounds a little PMS-like, but really it can be related to migraines. So that's your prodrome phase. A lot of people don't recognize that phase because there's no pain associated with it. And the aura, if they have auras, because you can have migraines with or without auras, but the aura is the next phase. And that's when people are like, oh gosh, yes, a migraine is coming on. And that can be sensitivity to light, noise, sound. It can be the presence of spots, floaters, visual field cuts. Sometimes people smell things that aren't there. It's a very specific smell that they smell, so olfactory. Or they have, you know, some tinnitus or ringing in the ears, and then they know, okay, this is happening. I need to maybe start looking at treatment options. Some people also will have some numbness/tingling in their arm, face, neck and that can signify migraine as well. Then the pain hits and that can last anywhere from a few hours to a few days. It depends on the patient, and the pain's usually the unilateral, most people know their pathway. It starts back here, it comes here, or it comes up and around my head and then they are out of commission. They have to sit in a dark room. They can't go to work. They have trouble caring for their children. It's very, very debilitating. And then there's the postdrome, which is kind of like the prodrome. It wraps up the whole cycle. People—it's almost like a postictal, after a seizure, where you're feeling just kind of foggy, tired, anxious, any of those things that happen in the prodrome can happen in the postdrome as well.

Dr. Arnold:
So, I guess we probably should've premised this by saying people should still seek symptoms if they think they're having a stroke, but when you talk about how migraines can mimic a stroke.

Whitney Hanken:
Yes. So there is something called a hemiplegic migraine where people will actually have one side of their body that is weakened. It's associated with the migraine pathway that they have, and usually is accompanied by the severe pain. Usually those patients, if that's a new onset thing and it's not normal for them, I definitely recommend people going and getting evaluated in the emergency department. Because a stroke, you know, it's not something you want to put off. It can be something that's life-threatening or really life-changing. After, you know, you've been worked up and you know there's nothing going on in there, but you notice every time you get this pain, you know, you get numbness and tingling down your right side, you know that that is part of your migraine process. So in any time that changes, definitely seeking out care is very important.

Dr. Arnold:
Absolutely. Could you kind of walk the listeners through a first visit for someone that may have migraines? I mean, how, what happens?

Whitney Hanken:
Sure. So usually people will come to me. They have been kind of complacent with just, this is something I'm going to deal with and I guess this is just how it's going to be. So I'll meet the patient, I'll talk to them about their symptoms, how long it's been going on. I always ask very specific questions. How many migraine days in the past 30 days? How many severe debilitating where you were, you know, out of commission? And then, this question is always kind of eye-opening for patients. How many days are you completely head pain-free in a month? And they'll sit there and think about it. And they'll say, Hmm, I'm never had pain-free. And that indicates to me that they really, really have been, you know, suffering and they're not living their best life, obviously. They're not living well. So prophylaxis in that instance is warranted. I will also, usually before you arrive, if I have the records, I'll go through and see all the medications that they have tried, failed. I'll ask about any side effects with medications, if sensitivities, and also what they do for work and, you know, what their responsibilities in life are. Because we definitely don't want to prescribe something that's going to cause them to have difficulty completing tasks, enjoying life, anything of that nature. So, you know, just kind of getting to know a patient and knowing what their needs are, is very, very important in our first visit.

Dr. Arnold:
Okay. We talked about the treatment. What are some of the medications that are used to treat?

Whitney Hanken:
Sure. So it's really, really exciting because prior to the past year or two there's been very little new developments in the migraine world and they come with a lot of risks. So triptans usually were the mainstay, and most people who take those have quite a bit of side effect. If they take it, it doesn't always take all the pain away or they have cardiovascular risk factors, which could result in heart attack and death. It's a very fine line. And honestly, if you take it, oftentimes you're out for the day, it has a high sedation side effect for some people. Now, we have medications that work directly on the CGRP, which is the inflammatory mediator of most migraines, they've found. Not all of them, but most of them. And those are very well tolerated. Very little side effect, no cardiovascular risks with it, no vasoconstriction. That's the big thing with triptans, it causes the vasoconstriction. There's also the prophylactic monoclonal antibodies that you are injecting once a month or once every three months. And that has been very, very successful for my patients. I've started quite a few people on those and they haven't had a migraine since. Sometimes we do a mixture of those two, so in case they have breakthrough, they can use a rescue medication. We do trigger point injection. We do Botox injections for migraine. We also, you know, occipital nerve blocks, if it's stemming from the occipital area, is helpful.

Dr. Arnold:
Well, then that leads to my next question. Where does acupuncture come up?

Whitney Hanken:
Yeah, actually acupuncture and trigger point injection, or dry needling, kind of do a lot of the same things, but the outcome is different. What we're looking to do is different. Acupuncture a lot of times is energy work. We're looking to redirect things. Dry needling is an amazing thing for patients, especially with that really, really tight scalp and shoulder area. It's just, you know, it's kind of like acupuncture. It's like a little needle. They tap in, find that point, you'll kind of spasm up, and then it releases. It gives it that satisfaction so that it can release. And that tends to last a lot longer than many other modalities, especially if with a lot of tension. Trigger point injection is a very small needle. We use a long-acting lidocaine to help relax that muscle and also block the pain. Often, I have patients that come in every four to six weeks and they do very well with that. You know, if the barometric pressure changes, I tend to see more patients because—About two days before a storm comes in, Iowa is very volatile with that. And so it's not a great place for pain patients. But I'll see people about two days before the weather changes and we'll do a bunch of injections and then they do better.

Dr. Arnold:
So what about the patients? What are the treatment options, or maybe you could answer how often you see this, that it's just a chronic headache, but it's not a migraine. What happens to those patients?

Whitney Hanken:
Absolutely. So chronic headache usually has a migraine related, you know, indication or etiology. It's not normal to have head pain every single day. I've found that a lot of patients who do have daily headaches that aren't, you know, they don't have any associated symptoms that a migraine would have with like nausea, vomiting, the sensitivities, anything of that nature. I find that I'll ask them, have you been in a car accident in your past where you've had a whiplash incident and almost, I'd say 99% of patients, will be like, yeah, I did. It was a really bad accident, but it was 30 years ago. I said, when did your pain start? And they're like, well, probably about a year or two after that. So a lot of my patients will have something called cervical dystonia with the head pain. So a lot of times the headache pain medicines are not helping. So if we take care of the dystonia, then it allows the other medications to work better.

Dr. Arnold:
Okay. So they're, kind of like inflammatory bowel, there's kind of a spectrum or continuum that people might present on.

Whitney Hanken:
Yes.

Dr. Arnold:
So Whitney, I know that you and Dr. Matthew and your colleagues up there have a full service pain clinic and have—We just did a podcast with Dr. Matthew here recently. But tell me how'd you get interested in migraines? You had mentioned earlier that you had them, was that part of the motivation?

Whitney Hanken:
Absolutely. So I have suffered from migraines and daily head and neck pain for most of my life. And I have been to my primary cares, I've been to a neurologist. And they're like, you just need to reduce your stress. There wasn't really a good option for me to get relief. And stemming from that, I never really felt heard a lot of the times. So being able to give people, and understand the process and how that affects your life, made me really, really interested in specializing in this. It's something I understand. It's something I go through. I know, usually if I'm recommending something, I've tried it myself. So it's something I'm really passionate about because I know so many people that have migraines and they suffer in silence often. You know, obviously the first two medications didn't work and it just seems like there's nothing that can be done. Migraines are actually the second leading cause of disability right behind back pain. So it's super prevalent. So it's definitely needed here in Iowa and across the nation. So I figure, you know, I understand it, I can empathize with you, so I want to help.

Dr. Arnold:
I think then the next step is, how does someone get referred to your clinic? How can listeners get help?

Whitney Hanken:
Sure. So if your insurance requires it, you can get a referral from your primary care, or you can call our office and ask, you know, I'd like to be seen for migraines and ask for an appointment with me. They'll usually get you in within the first two weeks. So it's pretty quick. We can get you relief pretty quick.

Dr. Arnold:
What is that phone number?

Whitney Hanken:
It is (319) 369-7331. There's a couple options. So if you listen for Dr. Matthew, my name, push that button and it'll get you to the secretaries that will help schedule.

Dr. Arnold:
Well, that's great to know. That's good, not only for the patients, but also for the thousands and thousands of primary care physicians that listen to this podcast each time.

Whitney Hanken:
Yeah, bring them to me, I'm ready.

Dr. Arnold:
All right, Whitney. Hey Whitney, thanks for joining me today. Once again, that was Whitney Hanken, nurse practitioner at St. Luke's Physical Medicine and Rehabilitation. For more information visit UnityPoint.org.

Whitney Hanken:
Thank you.

Dr. Arnold:
Thank you for listening to LiveWell Talk On. If enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.