Trying to figure out what kind of doctor you should become? Wondering which specialty you should choose? Then SheMD's Why Specialty Series is perfect for you! We're bringing you female physicians sharing WHY they chose their specialty. Today's post is on why Dr. Huma Sheikh chose headache medicine, as well as an introduction to the bread and butter of the field- migraine.
One of my classes in college was about a career in medicine and I ended up shadowing a dermatologist in his office. This is what first peaked my interest. I took the required pre-med courses and applied to a number of medical schools, ending up at one close to home. During medical school, I went through all of the rotations during third year still unsure about which specialty to apply to.
My first rotation in fourth year was neurology on the stroke wards. I was struck by a young 5 year old girl who had choked on an olive and was now on a ventilator. The discussions with the family really pulled me towards this field.
Why did I decide to specialize in headache medicine?
During neurology residency, we would have a weekly outpatient clinic for the residents. During that time, the residents would pick up a patient randomly from the stack of patients waiting.
I remember that everyone would groan when they picked up a patient with a diagnosis of "headache," or "migraine."
The feeling in the clinic was that these patients were just whining or complaining. Most of these patients were young women like myself. I found myself taking on many of these patients because I felt that needed someone who would be willing to sit and listen to them without any preconceived notions about why they were there. This is what first peaked my interest in "headache medicine."
Headache Medicine is a field where most of your time will be spent talking to a patient. It requires a level of empathy and being able to put yourself in their shoes, since most of the history will be about how the headaches are affecting their lives. This is an important aspect of a patient’s story and many times, the patients are looking for someone who is actually willing to listen to them. Many of these patients feel that they have been ignored and accused of “just wanting pain medications.”
One of the things that truly drew me to headache medicine was being able to provide the reassurance that I understand how they are feeling and know that what they are describing is valid. One of the reasons that I may be able to have this approach is that I did develop migraines myself when I was in medical school. I had nights when I was unable to study because I was in bed with the lights off and a tight scarf around my head to help with the pain.
This is what initially drew me to headache medicine and now in the last few years, the field has exploded.
How do I approach headaches?
The most important part of a patient who presents with headaches is the history. One of the most important things to distinguish on the first meeting is whether or not the patient has a primary headache disorder like migraine or whether there is something more dangerous to look for like a tumor. Most of this can be done quickly with a complete and thorough history, but a complete neurological exam is also important.
The most common cause of headaches in the general population is a primary headache disorder- migraine.
This is much more common in women than men, and women are affected most during their reproductive years, which is also when many of them are in the workforce.
It is a genetic neurological disease which is lifelong but its presentation in terms of frequency and severity can wax and wane throughout someone’s life.
What are the symptoms of migraine?
Migraine is a chronic disorder with episodic exacerbations. Each migraine episode can last from 4 hours up to a few days in some cases. There are many different symptoms of migraine. The most well-known is a severe, debilitating headache. However, patients can also have varying degrees of many other symptoms, including nausea, vomiting, sensitivity to light, sound, or smells or even touch. There can also be confusion, difficulty thinking or speaking, as well as fatigue. There are two main types of migraine, migraine with aura and migraine without aura. In those who have migraine with aura, they can experience a neurological symptom either before or during their migraine, these are usually visual but there are also sensory or motor auras.
What causes migraine?
There has recently been a greater understanding of what the underlying pathophysiology is in migraine. The biological basis of aura is caused by a phenomenon known as cortical spreading depression, where one part of the brain cortex becomes activated and depolarizes. This then leads to the release of a number of neurotransmitters, some of which are inflammatory. One of these is called calcitonin gene related peptide or cGRP. cGRP has receptors on the blood vessels located in the meninges, as well as in the body outside of the blood-brain barrier. cGRP has been shown to play an important role in the propagation of migraine. This release leads to activation of the pain pathways including the trigeminal nerve and the pain processing areas in different parts of the brain, including the cortex and brainstem. It has been shown to be elevated during a migraine attack and in patients who develop chronic migraine, the levels are chronically elevated.
Although migraine is a genetic neurological disorder, there is a large environmental component, mainly in the form of triggers.
Environmental triggers are thought to somehow lower the threshold for the initial depolarization event that starts the migraine cascade. Some of the most common triggers are stress, sleep, hormonal changes, and weather changes like rain or heat. Some also describe certain foods or changes in caffeine to be a trigger.
What is the approach to treating migraine?
Given the wide range of symptoms and triggers for migraine, there is a varied approach to treating someone with migraine. The two mainstays of migraine treatment are abortive and preventive therapy. Abortive therapy consists of treating with a medication during a migraine episode. This includes migraine specific treatments like triptans, DHE and cGRP inhibitors that are used to abort a migraine attack. There are also a number of other pain medications like NSAID’s, muscle-relaxers, and rarely opioids that can be used. Medications to treat some of the other symptoms like anti-nausea medications are also used. These can come in a number of forms, including pills, injections, nasal sprays, and more recent neuromodulators that are devices.
The other treatment is preventive therapy, which is used regularly to prevent or decrease the overall number and severity of migraine. There are a number of medications that can be tried, including oral, injections, and IV medications. For the most part, these medications were non-specific, until recently when the cGRP inhibitors were developed. Some common other medications utilized for migraine are onabotulinum-A injections, as well as anti-seizure and anti-depressant medications. Each of these have their own level of evidence and carry some side effects.
The other strategies for treating migraine include attempting to identify triggers to be able to avoid some of them as best as possible. Complementary methods like yoga and mindfulness also have good evidence in the prevention and treatment of migraine. It is also important to address important lifestyle factors that can affect migraine, including disturbances in sleep and other co-morbid conditions.
The overall approach should be a holistic one that takes into all the above factors.
An explanation of what is a migraine cause vs a migraine trigger is important to explain to patients.
If patients have a better understanding of their disease, they are more likely to take control of their headaches and play an active role in treating them.
With all these new medications, treatment options, and better understanding of what causes migraine, it is a great time to be in this field. There are so many things that we can offer our patients that actually make a huge impact on their daily quality of life. When a patient is able to go from a life where they are constantly anxious about their next migraine episode to being able to plan social events in advance, it is a gratifying feeling as a physician.
We are able to make a real impact in these patients’ lives.
For patients who have always felt like they have gotten the “run around” from their doctors to finding someone who listens and truly understands how they feel, it is a huge relief for them. This is one of the main reasons I chose to make an impact in this field.