ICDH III Definition of Cluster Headache

At least 5 attacks fulfilling B-D below.

Severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes.

Attack is associated with at least one of the following signs on the side of pain:

Conjunctival injection                  Forehead and facial sweating

Lacrimation                                  Miosis

Nasal congestion                           Ptosis

Rhinorrhea                                   Eyelid edema

Frequency: from one every other day to eight per day

At least one of the following:

History, physical, and neurological examinations do not suggest disorders in groups 5-11 of IHS classification.

History and/or physical and/or neurological examinations do suggest other disorder, but it is ruled out by appropriate investigations.

Such disorder is present, but tension-type headache does not occur for the first time in close temporal relation to the disorder.

 

John Graham notes on treating migraine headache

John R.  Graham on medical progress and treatment for migraine

The New England Journal of Medicine November 10, 1955

It is important from the onset in prophylaxis that the physician, the patient, and the patient’s family have an understanding of the disease, the method of approach to the problem, and the limitations and duration of treatment.  All parties to the therapeutic program need to understand the following facts and behave accordingly:

That at present, there is no magic medicine or formula of treatment that universally “cures” migraine.

That the patient is “not to blame” for having inherited the migraine trait.

That the pain and misery of the migraine attack are very real and not “imaginary.”

That neither the patient, doctor, nor husband (or wife) should be intolerant, but rather all should work for better understanding of each other.

That the patient and family have the greater burden in therapy, and that the doctor is going to act as a friendly guide rather than as a “miracle man.”

That the whole program will require a considerable period, with frequent reviews of progress, temporary setbacks, changes of therapeutic signals and gradual re-education.

That the most rewarding long-term therapy will be concerned with adjusting the patient’s way of living to his or her capacities rather than with an endless round of medication.

That the patient cannot be expected to make all the necessary adjustments overnight.

That the changes in psychologic attitudes become real only through actual practice rather than through verbal instruction.

That there is definite hope for improvement through conscientious effort of both patient and physician, but that complete freedom from migraine is rarely achieved by any therapeutic program.

Errors in living

Presented below is a list of common deviations from hygienic living that many persons may well practice with impunity but that are frequently a source of headache to the sufferer from migraine.  Behind these errors in living lie attitudes in the patient that serve both to bring them about and to intensify the damage that they create.  Such errors may have to be arbitrarily eliminated at first, but as treatment progresses it is important and fundamental to ultimate success for the patient to gain insight into his attitudes and personality traits that brought them about and to attempt suitable alteration.  The errors are as follows:

Poor meals-skimpy breakfasts and lunches and large dinners eaten in a state of fatigue.

Irregular hours for meals.  Postponing lunch for an hour may give anyone a mild headache but may produce a bad sick headache for the migraine patient.

Morning deadlines.  Too little time is allowed between the rising hour and the scramble for school and the office.

Sleeping late on Saturdays, Sundays and holidays.  The patient with migraine needs a good deal of sleep-but not in the morning.  Excessive cerebrovascular dilatation probably takes place, and breakfast is delayed.  Conversely, getting to bed early is important since, to date, the only real cure for fatigue is rest.

Lack of breaks in the day.  A short rest in the morning and afternoon, regularly obtained, is helpful.

 

Overcrowded schedules.  Patients usually try to work in too many events in a day.  They need to spread their activities more evenly over several days.

 

Failure to take proper vacations.

 

Failure to get away from their own children periodically.

 

Excessive participation in community and church activities.

 

Over anxiety regarding preparations for guests, shopping trips and vacations.

 

Long automobile trips.  The migraine patient usually wishes to go the 500 miles in one day and ends up with a headache.

 

Acting as Chairman, because nobody else will accept.  Migraine patients do not delegate work to others.  They do it all themselves.

 

Making up for lost time.  As soon as the patient is over one attack, she usually rushes to repair her losses.  Consequently, the next attack comes sooner.

 

Suffering petty wrongs in silence until they mount to unbearable heights.  It would be better to settle differences while they are small.

 

Aiming for impossible goals and worrying when they cannot be obtained.

 

Lack of exercise.

 

Lack of recreation.

 

Allodynia and medication overuse headache

Allodynia comes from the words “allo” which means “other” and “dynia” which means “pain.”  Clinically it refers to pain produced by a non-painful stimulus, such as touch.  Allodynia is an uncomfortable heightened sensitivity to touch.   Normally it doesn’t hurt to touch the head or the brow or the temple, but during the late stages of a migraine or during medication overuse headache, a simple touch to the head or temple may be perceived as painful.  This is like a sunburn.  Normally if I touch my arm it doesn’t hurt but after a sunburn at the beach, my arm is painful to touch.  This is what allodynia is like.

Allodynia can be divided into: tactile allodynia-pain from touch or light pressure like a belt or bra strap, mechanical allodynia-pain from motion across the skin such as light massage or the touch of fabric, and thermal allodynia-pain from heat or cold that makes the limbs feel needle like, sharp pain.

The pain of allodynia can be provoked by combing or brushing the hair, shaving, showering, wearing glasses, or earrings.  The pressure of a strand of hair may feel like the jab of a hot knife.  Allodynia is the migraine patient who notes on the third day of headache suffering that it hurts her to brush her hair or lay her head on the pillow.

Allodynia occurs mostly in long duration episodic migraine attacks or in patients transformed to medication overuse headache by overtreatment of headache with analgesics.  The duration of migraine is 4-72 hours, as defined by the International Classification of Headache 2004.  Migraine is generally an episodic, paroxysmal disorder occurring at most 2 times a week.  One can easily see by doing simple math that multiplying 72 hours or 3 days by 2 equals 6 days.  This is why periodic migraine rarely occurs more than twice a week.  Daily headache or headache 3 or 4 days a week is usually Chronic Daily Headache (CDH), a syndrome defined as >15 headache days a week.  About 70% of persons with CDH have a common headache syndrome from overtreating with analgesics, caffeine, or triptans called Medication Overuse Headache.

An attack of migraine has 4 stages: 1) trigeminal activation, 2) neurochemical release, 3) arterial vasodilatation, 4) central sensitization of the thalamus in the brain.  In general patients with an attack of migraine are at stage 3 in two hours and after two hours they are in stage 4.  Thus, patients with long-duration (headaches lasting more than several hours) episodic migraine attacks spend most of the time in stage 4 central sensitization.  The general thinking is at all patients with medication overuse headache are continuously in stage 4 central sensitization.  Both of these circumstances can produce allodynia.

With episodic migraine the allodynia clears when the headache ends and the offending neurochemicals are metabolized and excreted.  The same thing occurs during treatment of medication overuse headache when the patient is detoxed off of analgesics, caffeine, or triptans and in time the offending neurochemicals are metabolized and consequently the headache clears.

BTD 10/22/09.

Betablockers for migraine prevention

Betablockers are “Vasonormalizers” which prevent dilation and constriction of arteries. Adrenaline is made in two varieties: Alpha—which works on the lungs, and Beta—which work on arteries.  Thus, the name Betablocker.  The archetype Betablocker drug is Inderal, known generically as propanolol.  This drug works to block some of the effects of adrenaline on arteries.

It has been approved by the Federal Drug Administration for the treatment of a large variety of medical problems which includes:  Migraine, Benign Essential Tremor, Hypertension, Angina (the chest pain heart patients get), and Cardiac Arrhythmias.

It comes in a short term (4 hour lasting) dose or in LA (long acting-24 hour) form.  Common doses are 80-320 mg/day.  For younger patients with migraine or tremor the dose may be discontinued safely at a low dose such as 80 mg/day, while older patients with heart disease and higher doses should have the dose tapered slowly.

Inderal is usually well tolerated and has few side effects, although like all drugs it has two pages of small print listing possible side effects.  The only potential side effect I warn patients about is that a small number of patients develop the so called “Inderal tired syndrome” after they start the drug, usually in the first week.  If this side effect develops, then the drug should be stopped and another betablocker selected.

How long the drug has to be given is not known at the beginning and depends on the clinical indications.  For tremor Inderal is usually given long term for years or life.  For migraine I commonly encourage the patient to consider using the drug for 3-6 months at first and then reassess this on follow up.  Many patients are able to get off the drug then although some patients with bad migraine are happy to continue.

Another betablocker that may be used for migraine prevention is Tenormin (Aetenolol) at 50-100 mg/day.

 

Topiramate for migraine prevention

Topamax (Topiramate)   100-200 mg per day.  This drug originally had an indication for treatment of epilepsy but Topamax was approved in the Fall of 2004 for preventive treatment of migraine also. It is one of the secondary drugs that may be used for treatment of benign essential or familial tremor.  It is also used for treatment of bipolar disorder. To start the drug has to be slowly added as 25 mg a night for a week and then increasing the dose to 25 mg twice a day for the second week.  The third week dose is 25 mg in the morning and two 25 mg tabs at night.  The fourth week the patient should switch to 50 mg twice a day.  The patient should then stay on this dose for several months to judge the effect on migraine reduction.

Side effects: psychomotor slowing, somnolence, word finding difficulty, numbness, pop drinks taste flat, weight loss, insomnia, anxiety, decreased sweating and hyperthermia, secondary angle closure glaucoma, kidney stones-especially in men, and metabolic acidosis.

A long acting version of the drug has been released called Trochandia XR which comes in doses of 25, 50, 100, and 200 mg.  This is one a day pill.  It has pellets which slowly dissolve to give a steady blood.  Generic topiramate taken twice a day sometimes gives more side effects which may not happen with this new drug.  It is approved for treating epilepsy and migraine by the FDA.  There is also a copay free card for insurances except Medicare and United healthcare.

For migraine-common doses are 100-200 mg a day.  For treatment of benign essential tremor-doses between 50-100 mg may be used.

Acute treatment of migraine

This refers to the medication you take for the headache you have now.

  1. Treat at onset. This means that if a person has a migraine start Monday morning at 8:00, they should take their acute therapy migraine drug then.  This is generally going to be a triptan or DHE or Cambia.  Don’t wait, thinking it’s not going to be “one of those.”  It very well may be a bad headache coming on.  Migraine headaches may start in the back of the head and move forward to the temple or behind one eye.  Treatment should begin while it is in the neck.  Migraine may start in the forehead, eye, or cheek area.  There is no “sinus headache” a term that is not in the International Classification of Headache.  Treat it as a migraine.  One of the acute onset Triptans should be used—Imitrex (sumatriptan), Zomig (zomatriptan), Maxalt (rizatriptan), Relpax (eletriptan), or Axert (almotriptan).  Frova and Amerge take several hours usually to start working and are mainly used for menstrual migraine.
  2. Take the right drug. In general, for severe migraine patients this is going to be a Triptan.  Yes, many patients with mild migraine can treat their headache with Excedrin, an NSAID, or pseudoephedrine, but the severe headache patients—the type that end up in the emergency room will usually need a Triptan.  Usually the Triptans will treat the whole migraine syndrome—headache, nausea, vomiting, photophobia, sonophobia—and they work best if taken at onset of headache.  However, a small percentage of patients will need to take something for nausea with the Triptan, such as oral 25 mg Phenergan (promethazine), or Zofran (odansetran) odt 4-8 mg.
  3. Take enough of the right drug. This is a dosing situation which varies from patient to patient.  Elephant rifle load for migraine remains injectable sc Imitrex (sumatriptan) which works the fastest, in 10 minutes, and gives the highest brain level of 100 mg.  Oral Imitrex (sumatriptan) 50-100 mg, Maxalt (rizatriptan) 10 mg, or Zomig (zomatriptan) 2.5-5.0 mg, Axert (almotriptan) 12.5 mg, or Relpax (eletriptan) 40 mg may be tried at onset of the headache.
  4. Naproxen The headache literature supports using any of the triptans with 2 Aleve (naproxen) 200 mg. These 2 drugs may provide better relief than the triptan alone.  The literature says only naproxen and there is no data for Advil, or Tylenol.
  5. Migraine causes confusion. Many studies reveal that migraine patients do poorly on cognitive testing after the headache starts.  This may relate to the slowness or lack of treatment many patients experience when they just can’t break from what they are doing and take their medication early.
  6. Triptans block the release of inflammatory neurochemicals. That’s how they work, but they have to be taken early in the migraine process before the chemicals are released.  In general, neurochemicals in migraine patients are released 20-40 minutes after the start of the migraine process.  No other drug in the world can do this and that’s why as of 2016 the latest drug approved by the FDA for treating migraine is another triptan—sumatriptan delivered via inhalation.

 

BTD 081616

Tips for sleeping well

Items 1 through 4 are called normal sleep hygiene and should be done by everyone.

  1. Establish a daily sleep/wake schedule. This means keeping a consistent time each day for waking up the morning and going to bed each night.  Try to stay within 30-60 minutes of these times every day.  This includes through the weekend, holidays, and vacations.  In general allow AT LEAST 7 -8 hours of sleep each night.  As we age, we need less sleep, so someone in his eighties may need only 6 1/2 hours, while teenagers may well need 9-10 hours.
  2. Be careful with naps. It’s okay in general to take a short nap after lunch, a siesta, but avoid a long nap.  If you can’t do this on your own, then set an alarm for a brief 15-30 minute nap.  If you have trouble falling asleep at night when you have napped earlier during the day, then eliminate the nap.  Just lie down and rest for 10-15 minutes instead during the day.  If you are the type who “never learned to rest” then, LEARN.  The relaxing response can be taught at any age.
  3. Be careful with caffeine and pseudoephedrine, both of which promote alertness. Caffeine lasts 8 hours.  If you go to sleep at night at 11 pm, then don’t drink any caffeine any later than 3 pm.  Pseudoephedrine is in a lot of over the counter sinus or cold medicines-such as Sudafed, or Tylenol Sinus.
  4. Regular physical exercise promotes sleeping well. The American Heart Association recommends that every body exercise aerobically for 20 minutes 3 times a week to decrease the risk of atherosclerosis.  As a physician I rarely see patients who do manual labor-carpenters, maids-who have trouble sleeping.  Exercise promotes the relaxing response.  A warning here is that some persons get too jived up after exercise to go to sleep.  They should exercise earlier during the day.  Exercise also induces endorphins, brain neurochemicals that reduce pain and promote calming.
  5. A low volume of a high calorie carbohydrate just before bedtime promotes sleep.  I’m talking about something like the proverbial “warm glass of milk.”  This has been studied scientifically and shown to work.  You have to be careful here with the calories and cholesterol.
  6. It’s okay to get out of bed and go to another room for awhile, if you can’t fall asleep when you first try. Then you may read , preferably something not too interesting , technical, or work related, for 10-15 minutes.  However, watching TV or doing housework are not good options.  They’re too stimulating.
  7. Home remedies, vitamins, food supplements, and over the counter sleeping pills don’t usually work for long term sleeping problems. Therefore avoid them.  This includes Benadryl which is in Tylenol PM, other antihistamines, and Chloral Hydrate.  Melatonin is a drug that may rarely work for small subset of patients with insomnia.  Unfortunately, it doesn’t work for everyone.  A dose of 3-12 mg of melatonin may be tried.
  8. Ambien is a class 4 narcotic, hypnotic sleeping pill that has been approved for chronic use. Some patients are drowsy after using it and may be up at night and perform automatic funtctions, like raiding the refrigerator.  Other hypnotics are Restoril.  Rozerem is a non narcotic drug that works on the melatonin brain stem system.
  9. Alcohol and minor tranquilizers (the Benzodiazepine drugs-Valium, Xanax, Ativan)-don’t work that well either because they don’t last all night and are not good long term options.
  10. The majority of patients who have chronic sleeping problems also have psychological reactions or conditions that interfere with sleep. Work directed toward resolving conflicts (psychotherapy) should be helpful. Sleep lab information states that half of patients in America with insomnia are anxious and a quarter of them are depressed.  These are the most common causes of trouble sleeping.
  11. The older antidepressant medications are, in general, safe for chronic sleep disorders. Examples here would be: Elavil (amitriptyline), Desyrel (trazodone), Tofranil, or Pamelor.  All of these drugs have a sedating quality which will allow normal physiological sleep.  They are not addictive or habituating.  They commonly have mild side effects of a dry mouth which improves with therapy.  These are the drugs that may be used for long term sleep disorders.  Trazodone comes as a 50 mg tablet and this works well for the majority of patients with trouble sleeping.  However, if this dose is too high the patient should break it in half and take 25 mg.  A maximum of 150 mg/night may be used.  If the patient doesn’t sleep all night on 50 mg then he should increase the dose by 25 mg /night per week until he sleeps all night.  The same approach may be used with amitriptyline where the dose may be started at 10 mg and can be just adjusted upward by 10 mg/night to about 75 mg until the patient sleeps all night.

 

 

BTD 9/1/06

Caffeine is a drug

The current edition of the Diagnostic and Statistical Manual for Psychiatric Diagnosis (DSM V) states that caffeine is an addictive drugs—in amounts as small as 120 mg/day.  Criteria for caffeine withdrawal: Prolonged daily use of caffeine, abrupt cessation or reduction of total caffeine use, closely followed by headache and one or more of the following symptoms — fatigue/drowsiness, anxiety/depression, nausea/vomiting–, clinically significant distress or impairment in social, occupational or other important areas of functioning.

The diagnostic criteria for caffeine intoxication are recent consumption of caffeine, use in excess of 250 mg a day and the development of five or more the following signs during, or shortly after caffeine use: Restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, or psychomotor agitation.

Approximate amounts of caffeine in various beverages:

Coffee, grande 16 oz Starbucks                      550

Coffee, tall 12 oz Starbucks                              375

Coffee, short 8 oz Starbucks                             250

Redline RTD                                                  250

NoDoz, max strength or Vivarin                     200

7-Eleven Big Gulp cola 64 oz                           190

Coffee non-gourmet 8 oz                                 135

Excedrin 2                                                            130

Coffee instant 8 oz                                                95

Jolt                                                                          711

Anacin                                                                  65

Cola 12 oz                                                           35

Mt. Dew                                                                 55

Dr. Pepper                                                               39

Pepsi                                                                         37

Tab                                                                           46

Cappuccino, 8 or 12 oz                                      35

Expresso Starbucks 1 oz                                   35

Tea, green or instant 8 oz                                    30

Chocolate dark, semisweet 1 oz                       20

Coffee decaf Starbucks 8 or 12 oz                     10

Coffee decaf non-gourmet 8 oz                           5

Hot chocolate or cocoa 8 oz                                5

Chocolate milk 1 oz                                                5

Liquid Speed (amount concealed within a proprietary formula)

Caffeinated water                                                ?

Pharmacologically, caffeine acts as a central nervous system stimulator, a point that is well made by the coffee ad on TV which calls it “the think drink.”  The duration of the effect of the drug is 6-8 hours, but even one drink in the morning will interrupt sleep in some persons.  Caffeine also acts as a constrictor of smooth muscle, which is found in arteries, the bladder, and the colon.  It is the arterial vasoconstrictive action which helps with mild migraine (Excedrin, B.C. Powder, and Vivacin) and may lead to the rebound vasodilatation headache when one withdraws from caffeine.  The smooth muscle effect also acts as a mild stimulant on the bladder, promoting urination and in the colon, a bowel movement.

I urge all Caffeine addicted patients, migraine patients, Panic Disorder patients, and patients with sleep disorders to taper off caffeine (which, as I said above, is a drug).

BTD 08/03/07

Medication Overuse Headache

The International Classification of Headache III describes Medication Overuse Headache (MOH), old name Rebound Headache, as a syndrome related to overtreating.  Chronic Daily Headache is a term that implies having headache over 15 days a month, 8 of which are like migraine.  A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly.  MOH may come from overtreating with simple pain killers like caffeine, Tylenol or Advil, opioid narcotics, pain killers with barbiturates, or triptans.  Patients typically rotate to different drugs and take many drugs at the same time that may cause MOH.  After awhile the preexisting headache problem, which is usually migraine, but may also be tension type headache, becomes transformed from an intermittent to a chronic headache problem.  It is like what happens to the patient who drinks a lot of coffee every day and then gets a headache when they don’t.  When the brain becomes sensitized to these drugs repeat dosing causes neuro-inflammatory chemicals to be released in the brain which keeps the headache going.

There are two features to this syndrome:

  1. Daily or very frequent headaches which may come with sensitivity to light and sound, nausea, and irritability
  2. This syndrome causes serotonin, a calming brain neurochemical, levels to drop so the patient may also develop anxiety, depression, poor concentration, panic attacks, and insomnia, which also are core symptoms of the disorder.

Drugs that can cause this syndrome are:

Caffeine, such as Excedrin, BC Powder, Vanquish; pseudoephedrine (Sudafed) the decongestant in over the counter sinus meds, such as Tylenol sinus or Advil sinus, or the D in Allegra-D; Ergotamine drugs—Cafergot, Triptans—Imitrex, Maxalt, Zomig, Axert, Frova, Relpax, or Amerge; NSAIDS—(Nonsteroidal Anti-inflammatory Drugs) such as Motrin (ibuprofen, Advil), Naprosyn/Anaprox (Alleve), Miloxicam, and Tylenol; Narcotics—Vicodin (hydrocodone, Narco), Tramadol, Demerol, Nucynta, OxyContin, Tylenol with codeine; Drugs with barbiturates– Fiorinal, Fioricet, Phrenilin, Esgic, generic butalbital.

The International Headache Society criteria for medication overuse headache are:

Triptans or Ergotamine intake >10 days/month (like sumatriptan)

Non-opioid simple analgesics >15days/month (like Tylenol, caffeine, or Advil)

Opioids or Analgesics combined with barbiturates >10days/month

The best treatment for medication overuse headache is stopping the offending drugs, usually on 1 day, or sometimes by tapering over several weeks if the patient has been on a high dose of an opioid or barbiturate for a long time.  Unless the patient is treated with cortisone, also called “Bridge Medication” a terrific headache would come after stopping their pain killers.  The patient should stay off all pain killers on the list above during this time.  Cortisone treatment may be: one or two weeks dose of oral cortisone, as prednisone 20 mg 3X/day for 7 days or Medrol Dosepak, for the chemical brain inflammation.  For spikes of headache DHE given IM or as Migranol nasal spray every 3 hours, or Timidol eye drops, or Alleve may be used for acute treatment of headache.  The time for clearing of MOH varies from several weeks to 1-2 months, depending on the type, amount, and duration of previous medication abuse.  Clearing may be noted by 5 headache free days after which regular acute migraine Rx may resume.   After this the patient should limit painkillers to no more than 2 days/ week for the rest of their life.   Preventive medications such as topiramate, amitriptyline, valproic acid, or beta-blockers should be started to reduce the number of monthly migraines.  50% of patients with MOH have depression, 40% have generalized anxiety disorder (GAD) or panic disorder which may need treatment and 50% of patients with MOH get it again.

Stop the following drugs:

Do: the migraine lifestyle—www.doctormigraine.com

Take:  For prevention 10 mg amitriptyline every night for the next few months, a drug which can decrease migraine by 50 % and promote sleep, or propranolol, topiramate, or Depakote (not for fertile women.)

For acute treatment either Migranol Nasal Spray every 3 hours as needed, or DHE 1cc Intramuscularly every 6 hours as needed, or Timidol eye drops 0.25% sol, 1 in each eye as needed for headache, may repeat in 1 hour, or if too expensive—take Alleve (naproxen) 200 mg every 12 hours once or twice a week.

For reduction of brain inflammation- either 20 mg or prednisone 3X a day for 7 days or a Medrol dose pack.

For nausea use either Zofran 4 mg every 4-6 hours or Phenergan 25 mg orally every 4-6 hours.

Be patient with this problem, it takes a while to improve and the time depends upon how long you have taken the offending drug and which drug you have used.  For example, 3 weeks of overtreatment with caffeine or Advil may take 2-3 weeks to clear, while 12 months of butalbital 2-3/day may take 2-3 months.

Try to regularize your life during the detox time—rest your eyes and your body, but don’t sleep during the day (maintain a normal sleep/wake schedule.)  Stay hydrated with fluids.

Other treatments that may help headache are ice packs, lying down with your eyes closed for a short rest, prayer, and mild exercise.  Don’t develop the practice of treating every headache with medication, try to bear through some of them without treatment.

Migraine in the brain has 4 stages: 1 Trigeminal activation, the sensory pain fibers in the fifth cranial nerve send pain to the face or back of the head, usually on one side, 2 within 20-40 minutes the ganglia in the brain of the trigeminal nerve and the arteries start to release 3 toxic neurochemicals which last 3 days and inflame the brain and dilate the arteries,3 arterial vasodilatation occurs with the pulsing blood from the heart stretching the chemically inflamed arteries, 4 the thalamus, which is the pain center of the brain is inflamed by the chemicals and migraine process usually about 3-4 hours into the headache causing severe headache and allodynia (the head is sensitive to touch.)

BTD 02/26/16

BTD picture and biography

Image may contain: 1 person, playing a musical instrument and guitar

Britt Talley Daniel MD is a practicing neurologist from Dallas, Texas. Trained in medicine at the University of Texas Medical Branch in Galveston and in Neurology at the Mayo Clinic, Dr. Daniel served his country as a staff neurologist LCDR, USNR at Balboa Hospital in San Diego, California at the end of the Vietnam conflict. After this he was on the senior staff as a neurologist at Scott and White Clinic in Temple, Texas and an Associate Professor of Neurology at Texas A&M University Medical School. Moving to Dallas to start a private practice, Dr. Daniel taught at the University of Texas Southwestern Medical School as a Clinical Associate Professor of Neurology. Currently he is a member of the American Academy of Neurology, the American Headache Society, and the American Association of Neuromuscular and Electrodiagnostic Medicine. His EMG lab has been declared an Accredited Laboratory of Exemplary Status. Married and with 5 grown children, Dr. Daniel is a lifelong folksinger and guitar picker. He is also the author of 5 medical textbooks: Migraine 1st and 2nd editions, Transient Global Amnesia, The Mini Neurology Series: Volume 1 Migraine, Volume 2 Carpal Tunnel Syndrome, and Volume 3 Panic Disorder. He has written a transgenerational novel about a medical family from England who relocates to America aboard the haunted Titanic, entitled: Titanic: Answer from the Deep. He has published 2 stories about a mystery solving physician entitled: The Mysteries of MacArthur Donne, Book 1 And If Thine Eye Offend Thee, Book 2 The Case of the Organic Chemist.
Please, if you read any of my books, review them on Amazon. I would really appreciate it.
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