The August 11, 1998 meeting of the East Bay Headache Support Group was held in the Aspen I and II Conference Rooms at John Muir Medical Center with 17 people in attendance. Our guest speaker was Michael Varon, M.D., a primary care doctor, or "family physician," with a private practice in Concord. His message to the group was about the family physician’s perspective on treating patients with headaches.

Dr. Varon stated that the family physician is usually the first medical contact for a headache patient. Family physicians see a broad spectrum of patients—from newborns to old people; and they see a variety of head pains. He said his patients often don’t bring up the problem of their headaches until the very end of an office visit with him, and it’s almost as an afterthought.

Since Dr. Varon often sees all the members of a family, he does have the advantage of sometimes hearing the story of a patient’s headaches from a family member, perhaps from a spouse or parent, before the patient actually comes in for a visit.

There are many differences between a family doctor’s practice and that of a specialist:

• The family doctor often treats a large number of patients.

• His/her patients must be seen in a shorter period of time.

• He/she must make a quick diagnosis.

• Sometimes the family doctor needs to decide who’s real and who’s not real, i.e. people are adept and cunning at getting legal narcotics, either for their own use, or for selling on the street.

• The family doctor may have an advantage in that he may know the patient’s family background.

• He may need to decide when it’s appropriate to send someone to the hospital emergency room.

Dr. Varon put his headache patients into three catagories:

1.) Some patients come in with a headache with no prior diagnosis.

2.) Some see him with the diagnosis of headache or migraine, but they haven’t been told about prophylaxis (medication to prevent the onset of headaches, rather than medication to abort a headache already started).

3.) Some come to see him with a history of headaches.

He said that when people first appear concerned about their headaches they ask him if they have brain cancer or perhaps an aneurysm. He then tries to allay their fears. In his practice Dr. Varon has seen patients with headaches apparently caused by stress, caffeine withdrawal, chronic sinusitis, etc. He also sees people taking medications that were prescribed for others, and medications with an expired potency.

There is an international classification of headaches which helps Dr. Varon to diagnose migraine in his patients.

Which of his patients complaining of headaches are serious enough for him to refer them to a neurologist? His answer to this question is:

• People who are hard to diagnose.

• People who fail treatment.

Dr. Varon said he leaves complex neurological things to the specialists.

Children’s headaches are special, as they may more often be caused by tumors or intercranial pressure. Headaches in adolescents may be triggered by tension from peer pressure, or from taking illegal drugs. Working adults may have headaches brought on by work stress and from non-ergonomic work environments. Finally, in the elderly there may be blood flow problems or tumors to consider.

Dr. Varon again said that as a family physician he has a perspective from the rest of the family (the wife tells on the husband, parents tell on their kids). He hears about the family dynamics, the stress levels, whether there is alcohol abuse or physical or emotional abuse. Dr. Varon also concerns himself with the genetics of a family. For instance, if a mother has migraines and then her thirteen-year-old daughter starts complaining of headaches that occur around the time of her periods, he is suspicious of migraine in the daughter.

Rebound headaches are a topic that Dr. Varon is still learning about. Rebound headaches are brought on by the excessive use of over-the-counter analgesics, or some prescription drugs, and they may cause the patient to complain of a daily headache.

There are many factors which bring on migraine in the headache-susceptible patient, such as:

• Psychological (stress)

• Physiological (foods eaten, not enough sleep, etc.)

• External Factors (temperature, odors, etc.)

Dr. Varon said that as a family doctor he tends to be more conservative in headache treatment than specialists. He will prescribe the nonsteroidal anti-inflammatories first, and only then go on to the new migraine medications: Imitrex, Amerge, Zomig, Maxalt.

Drug companies are now advertising their products to the general public, rather than just to medical personnel, so people frequently ask him for a specific drug that they’ve heard about.

He concluded his talk with the statement that he is able to treat most of the patients who come in to see him complaining of headache, and the others are then sent on to specialists.

Q: Dr. Michael Stein asked about the use of older medications, such as Fiorinal and Midrin.

A: Dr. Varon stated that he still uses Midrin, especially since it is considered safe for women to use during pregnancy. He is getting away from the medications that were used for many years in the past, though.

Q: Dr. Stein asked if formularies cause problems for Dr. Varon. Formularies are lists of acceptable medications and their uses that the health maintenance organizations (HMO’s) insist physicians use when prescribing treatments for their patients.

A: Dr. Varon answered that formularies do cause problems for him—often he is restricted from prescribing a certain medication just because the patient’s insurance company won’t allow it.

Q: What does Dr. Varon recommend for menstrual migraine?

A: Some of the medications Dr. Varon has prescribed for menstrual migraine are:

Imitrex, birth control pills (to regulate hormones), Naprosyn (a nonsteroidal antiinflammatory), Lasix (a diuretic), and Prozac (an antidepressant).

Dr. Stein then said that some physicians have tried treating their menstrual migraine patients with 25 mg of Imitrex three times per day, starting three days before the onset of their periods. The result of a study where Imitrex was used prophylactically in this manner was:

• 50% had no headaches with their period.

• 45% saw an improvement in their headaches.

• Only 5% saw no improvement.

Q: Dr. Varon was then asked about sleep disorders and resultant headaches.

A: He said that sleep apnea can cause daily morning headaches. A person who is a heavy snorer will experience short periods of not getting enough oxygen into his lungs. If you know a person who snores heavily while asleep and then experiences daytime somnolence (sleepiness) or wakes up with a daily morning headache, have him seek treatment for sleep apnea, such as sleeping with a nasal mask or having surgery to open up the airway.

Dr. Varon made the statement that he has to take it on faith that a patient who comes to see him is actually suffering from head pain. Some drug users will go to an urgent care facility to see specific physicians they have identified as being pushovers, who have the reputation of easily dispensing drugs, such as Demerol. The user may come in at the end of the day, get his Demerol, and then go to sleep.

Q: Why was it required that a physician administer the first dose of Imitrex for a new patient?

A: The side effects of Imitrex, at least in the injectable form, are dangerous for patients with heart problems. Therefore, doctors were required to administer the first dose and watch their patients for the first hour in the event of hidden heart problems.

Q: How often do you see rebound headaches?

A: Dr. Varon answered that he probably sees a higher percentage of rebound headaches than he actually realizes.

Q: Dr. Stein asked him how he treats rebound headache patients.

A: Dr. Varon answered that he tells the patient he must reduce his medications by one per day (Excedrin or other product containing caffeine). This is a weaning protocol. He stated that among family physicians, anyway, there is a reluctance to tell patients that they have to quit the medications, because they’ll just go to another doctor. According to the Mayo Clinic Newsletter, Reggie Fong then said that if you are taking three or more pain relievers per week you may be suffering from rebound headaches. The problem is that many people think that over-the-counter medications are not real drugs, but they are and they have side effects.

Q: What are the causes of vascular or migraine headaches, and tension headaches?

A: Genetics play a strong part in whether a person will develop migraines. Also a person’s lifestyle can play a role. In vascular headaches there are blood flow changes in the brain-- which can be chemically induced or emotionally induced. Tension headaches are caused by muscle contraction, a tightening of the muscles of the scalp.

Dr. Varon stated that families can get very frustrated with a member who suffers from headaches. He lets other family members know what’s going on with the patient and tries to get them to be  more supportive.

Q: What about dietary modifications?

A: Dr. Varon tells his patients about food triggers and elimination diets. He said the patient most needs to eliminate known triggers from his diet, such as caffeine, chocolate, heavy spices, alcohol, etc.). He then went to suggest hypnosis and acupuncture as possible methods of treatment. He has a healthy respect for acupuncture—he has seen where it has worked for patients. Chiropractic treatment is another matter, however.

Q: What can be done for arthritis in your neck?

A: Dr. Varon said it’s tough to treat the cause. He can use anti-spasmodic medications for the muscles, but the patient could require a spinal fusion or something drastic to eliminate the pain.

Q: Ellen Place, a biofeedback therapist, mentioned dietary deficiencies as possibly triggering headaches. She said a number of adolescents have come to see her recently and told her their headaches started after they became vegetarians.

A: Dr. Varon said he sees adolescents who will skip a meal and then get a headache. Perhaps they are hypoglycemic. He went on to say that in young kids, the hot dogs they eat can trigger headaches (it’s the nitrates). Vegetarianism can be a cover-up for anorexia. It seems to be trendy now. Dr. Stein mentioned that two teenage friends of his daughters are vegetarians.

Q: How can you identify whether a food has MSG?

A: MSG goes by a bunch of names. A person may be getting headaches from eating prepared foods which may be loaded with MSG, such as Mexican foods, canned foods, TV dinners, etc.