TOPIC: "HEADACHES—A PAIN IN THE NECK!"

The East Bay Headache Support Group met on August 10, 1999 to hear Dr. Mannie Joel, an anesthesiologist and pain management physician, speak on the topic of headaches. The meeting was held in the Ball Auditorium at John Muir Medical Center with 34 people in attendance.

As Medical Director of a Pain Treatment Clinic with offices in Pleasanton and San Leandro, Dr. Joel helps individuals learn to effectively manage their pain and improve their quality of life. He treats patients suffering from pain from many sources: headache, back pain, cancer pain, post-surgical and post-traumatic pain, fibromyalgia, etc.

Dr. Joel came to the meeting with no prepared text or speech. Rather he wanted to talk about his own experiences in working with people in pain. During his residency, Dr. Joel was impressed by patients seen at the Montreal Neurological Institute. He noticed that the brain was relatively insensitive to being stimulated. Headache occurs in 1 of every 6 women, and 1 of every 12-15 men. This has far-reaching social, economic effects. Is every severe headache a migraine? He thinks that the answer is "usually not," and that headaches originate in the neck. The neck in contrast to the scalp has many pain sensitive structures. The nucleus of the trigeminal nerve lies in the cervical spine and influences from this area could stimulate the nucleus and produce pain. Likewise, treating the neck with a local anesthetic can abort a headache. Dr. Joel said that ultimately all headaches follow the same pathway. One’s perspective on headache changes, and classifications change over the years. Doctors have been learning a lot about migraine in the last few years.

Dr. Joel told us that pain used to be considered a "punishment" for having done some wrong and that patients were told to "live with it." Chronic pain is different than acute pain—we reflexively avoid the latter. In chronic pain, fatigue and sleeplessness develop. He said that doctors tend to avoid patients with chronic pain, but he enjoys the challenge of treating patients with chronic pain.

"I don’t treat pain alone, I can’t," stated Dr. Joel, when referring to his team of nurses, physical and biofeedback therapists, and psychologists who work with him in treating patients with chronic pain. He said pain is very very complex and that people are complex. He made the statement that you’re not going to have only pain when you have it for a long time, rather there are things developing that are negative in your lifestyle. Dr. Joel said you’re going to have to treat the whole person and make him/her realize that there is going to be pain relief, yes, but we also have to make some lifestyle changes. He said that maybe most of the time you’ll be successful when you use that approach.

Dr. Joel described an Australian study done on patients who were brought to a hospital emergency room as a result of auto accidents, and who subsequently died. During autopsy, it was discovered that the necks of these patients suffered microfractures, torn ligaments, or damage to the disks. Had these patients survived and developed headaches, they would have been labeled "post-concussional," but the actual cause might have been caused by abnormalities in the neck.

As a child we experienced a lot of bumps. By the time we reach 40 we have a lot of disease in the neck. The neck shows degenerative changes as a consequence of aging. He believes that 95% of headaches have an origin in or involve the cervical spine. Many are treatable, or at least improvable, if you treat specifically for the cause. Pharmaceutical firms realize that there is a $60 billion a year business in treating headache, in the USA alone. He said, "If you rely on medications only, you will probably become dependent on them, one way or the other, for the rest of your life." In those cases where you can actually treat the cause of the pain, Dr. Joel said you would be so much better off if you could use other modalities and then use medications only when the pain is really bad. He added that eventually medications don’t work any more. Therefore, you would be better off if you treated the source of the pain.

Some other modalities (treatments) mentioned by Dr. Joel are: Physical therapy, hydrotherapy, home physical exercises, and biofeedback to help relax your muscles. He said you should also be willing to work with a psychologist on stress reduction techniques.

Dr. Joel said that after trying these different modalities, you’ll either get to a point where you like where you’re at, or you’ll want to try something different. Then there are high-tech things you can try, such as electrical stimulation of posterior occipital nerves with an implantable device. Dr. Joel says he’s seen wonderful results with this…and many were patients diagnosed with migraine headaches.

Dr. Joel then asked for questions from the audience. When he was asked to talk about the treatment of chronic headaches, he stated that patients have significant muscle spasm if they have chronic headaches. These involve muscles of the neck, thoracic, and lumbar spine. Treatment of the muscle spasms involves physical therapy and home exercises to relax the muscles. He said if joints in the neck are a cause of pain, then the muscles in the neck need to be strengthened. Dr. Joel said the use of cervical collars on a chronic basis is counter-productive.

One participant asked Dr. Joel about headaches and sleep, and he answered that most patients with chronic pain don’t sleep well—their sleep is restless, non-relaxing. If you wrestle with pain all night long, you’ll awaken with pain. He tries to restore a good sleep pattern in his patients. This often relieves the chronic awakening with headaches. When asked about the best position for sleeping, Dr. Joel answered that position isn’t as important as the quality of sleep. And various pillows don’t make a difference.

He did say, however, that having a "sleep routine" is important. Avoid stimulant chemicals around bedtime such as caffeine. He also said that it is difficult to restore normal sleep patterns in patients who have had problems with it for a long time. He recommends avoiding water beds if you have problems with sleeping.

Dr. Joel was then asked a question about structural causes of headaches, and he answered that 30% of patients with a "normal MRI" have an abnormality. Also, 30% of patients with abnormal MRI’s have no symptoms. Other tests, such as NCU (undefined), may miss dysfunction in "small nerve fibers." Tests may also not be sufficiently sensitive to detect an abnormality at this point. Dr. Joel stated that most pain has an organic basis, and emotional factors may (and usually do) color the pain. He told us to always pursue other possibilities.

An audience member asked Dr. Joel what he thinks about acupuncture, especially in the neck, and how it helps headache. Dr. Joel answered that acupuncture may provide temporary, but not permanent relief. It can even make pain worse, such as in cases of reflex sympathetic dystrophy. Dr. Joel went on to say that he is not a strong advocate of this technique, but he conceded that he doesn’t know that much about it. He said acupuncture doesn’t work for everybody. It also doesn’t have untoward effects.

When asked a question about the classification of migraine, Dr. Joel said that he thinks any severe headache can mimic symptoms of migraine. Migraine with aura is, in his opinion, unquestionably migraine. If there is no aura, then it may be caused by some other factor. He said he is not convinced that dietary factors are that central. If the sphenopalative ganglion is numbed, a headache can be transiently aborted (for 20 minutes). Dr. Joel thinks that treatable causes of headache should be sought out.

Dr. Joel was asked about Imitrex (sumatriptan) and why it helps a headache if the headache is cervical in origin. He answered that brain chemistry is only poorly understood. Just because he says it isn’t a migraine doesn’t mean that these medications (such as Imitrex) won’t work. He went on to say that most headaches are "mixed headaches," and they also change over time.

Donna Johnson, one of the planning committee members of the headache support group, is a patient of Dr. Joel’s; and he was asked what he did to treat one of her severe headaches. Dr. Joel said he didn’t recall, but that he likely injected sodium bicarbonate into her muscle, and used a numbing medication, and some steroid. He also tried nasal lidocaine.

When asked about trigger points, referred pain, and cervicogenic headaches, Dr. Joel answered that referred pain is very common, although it’s not intuitively clear. Trigger points are pains in muscles. They may be chronic even when the underlying pain- producing phenomenon is resolved. This is usually a symptom of something else—frequently some abnormality in the spine.

What criteria define what would be considered a cervicogenic headache? What should make an individual suspect this is the cause? Dr. Joel answered that headache is precipitated or aggravated by certain neck positions or movement, but this is only a generality. Also, a history of trauma to the neck should be considered, and what things (activities) tend to bring it on. If pain involves the shoulder and arm, it is suggestive of cervicogenic headache.

Dr. Joel was asked about headaches that begin later in life and then change over time, especially after some trauma to the neck. He said that a patient may have tension type headaches and if there is some injury to discs in the upper cervical spine it can worsen them. There can also be injury to the facet joints as well. When these joints are painful it sets up muscle spasms which further worsen pain arising from the upper cervical disks.

The intention of the East Bay Headache Support Group is to provide information and resources. It does not provide medical advice, which should be obtained directly from a physician.