Science CaféHope for Headaches: A Conversation with Headache Expert Peter Goadsby
By Jeff MillerJune 6, 2008
Anyone who has ever suffered from an intractable headache can understand why the ancients used to remove segments of the skull to let the evil spirits and the bad vapors escape. We don't know, of course, whether trepanation, as this form of surgery is called, actually worked. But the desperate maneuver underlines the suffering of the victim.
Peter Goadsby
Neurologist Peter Goadsby, MD, PhD, director of UCSF's Headache Center and a world expert on this common and often debilitating ailment, knows your pain. He sees it every day, sometimes in children as young as 5 years old. Worse, he sees the unnecessary frustration of patients who have endured misdiagnoses and missed opportunities for relief.
Indeed, if there is any single message Goadsby wants to trumpet, it is hope - hope that the brain imaging of headaches as they occur will lead to better therapies; hope that the right diagnosis can lead to interventions that offer some relief; and hope that regular routines, an evening-out of the ups and downs we all experience, can defuse the power of various headache triggers like bright light, noise and stress.
For all his compassion, though, Goadsby has no time for what he considers foolish North American assumptions that many types of food are primary headache fodder, nitrate-laden hot dogs being the one obvious exception. Part of beating headaches, he insists, is knowing the truth about them.
Podcast Transcript
Jeff Miller: Hello I’m Jeff Miller and welcome to a special edition of Science Café, today’s conversation with famed expert Peter Goadsby, director of UCSF’s Headache Center, begins with a question-- do headaches serve some evolutionary purpose?
Peter Goadsby: There’s no evolutionary purpose we can see for the primary headaches, and let me make the distinction that there are two types of headaches broadly-- there are those called primary headaches, where headache where headache is the disorder, migraines would be a great example of that, and there are secondary headaches, where the headache is due to some thing happening li8ke an infection or a bleed or a tumor.
I can understand why getting a warning about an infection or a tumor growing in the head is a good thing, I can see a benefit to that, but for the primary headaches it’s very difficult to understand what is attractive about having one in three adult western females stricken by migraine.
Miller: Is there anyone in the world who has probably not experienced a headache, do you suppose?
Goadsby: There are two sorts of people – there are those who have primary headaches and have them relatively frequently in varying severities, and there are a small group of people who never seem to have a headache, they seem to be very lucky.
Miller: Truly, there is a small group that never has a headache?
Goadsby: Yes there’s a small group of people who will tell you that they more of less never have headaches.
Miller: Do you suffer from headaches yourself?
Goadsby: No.
Miller: Anyone close to you?
Goadsby: Oh yes.
Miller: Was that the prompt to get into this field of study or was it some other reason?
Goadsby: The prompt to get into headaches was a lecture that my mentor gave many years ago about migraines. I found the explanation unsatisfactory, and it was the first thing in the medical school curriculum that ever struck me as interesting, and I’ve been interested in it ever since.
Miller: What would you list as some of the common causes you mentioned, structural damage and the like that causes pain, but the other kinds of headaches, stress, food, allergies, lack of sleep, what would be other things on the list maybe?
Goadsby: All things you describe, pretty much, are migraine triggers. The commonest form of disabling or troublesome headaches in the Western world is migraine. Now, many migraine sufferers think that what they have is normal, because migraine is substantially inherited, and in their families it is indeed normal. So the typical migraine sufferer will have headache triggered by change, change in sleeping habits, eating habits, change in the weather, change in levels of stress, too much or too little stress, and some particular triggers like alcohol. Many migraners think of all that as just normality, and it is for them, but in reality most of that is migraine.
Miller: So how about this classification of sinus headache, cluster headache, menstrual headaches, there’re all different types, correct, or are they all triggering the same mechanism?
Goadsby: Those headaches have distinctions: Cluster headache is a particular type of primary headache, it mainly affects men, and of all the cluster patients I’ve ever seen it is the most severe form of pain known to man or woman. You mentioned sinus headache – sinus headache is vastly over diagnosed in North America, largely because some of the symptoms that occur in migraines, such as eye watering, or nasal stuffiness, redness or irritation around the eyes and nose can occur in migraine and occur in sinus headaches. Menstural headaches or almost invariably menstrually triggered migraine.
Miller: And how about a class of headache I learned about fairly recently, the pressure headache, the one caused by intracranial hypertension. Is that often overlooked, do you suppose?
Goadsby: There is a class of headache associated with either increases or decreases in intracranial pressure; it’s one of the so-called secondary headaches because there’s a cause that’s clearly identified. I think it’s like most forms of headache struggles to get diagnosed, although in terms of commonness it’s nothing like migraine.
Miller: You mentioned severity of pain earlier with the cluster headaches, how do you rate this, obviously pain is a subjective experience, you’re not experiencing it as a clinician or researcher so how is this classified and how do you know where it falls on the gauge of pain?
Goadsby: I think the most useful gauge of pain is the degree of disability that the problem affords, so if you have an attack of migraine for example, you can’t get out of bed, or you can’t get to work, or you can’t take the kids to school, you can’t fulfill social obligations, you can’t do anything, then you’re highly disabled. It really doesn’t matter what the level of pain is in some abstract sense because as you say, it’s a highly individual thing.
What’s crucial is the impact of the headache on a person’s life. When you take a productive, young, well person who is stricken for a day, that’s a very severe illness. And the disability is the big measure of that.
Miller: What is your research revealing at this point?
Goadsby: We have a broad research program we’ve set up here at UCSF with fundamental research looking at the mechanisms of actions of drugs and the development of new medicines in the treatment of migraines. We have a strong component of brain imaging where we’re interested in trying to see what’s happening in migraine and cluster headache in the human brain during the attacks, and that’s probably been the most exciting thing we’ve been doing in the last few years back in London and begun to do here because it actually gives us a window onto these attacks which otherwise one couldn’t see.
And the third leg to our stool is clinical care. It’s terribly important to evolve a really high quality clinical program both with in-patients and out-patients, so that we can really look after all the people who come along with disabling and troublesome headaches.
Miller: So is the ultimate goal better drugs or some other kind of therapy?
Goadsby: Our mission statement is to make the world a better place for people with primary headache disorders. We’re going to do that by increasing understanding which is probably the most crucial thing that we could leave to our children, a better understanding of the disorder. In the short term, certainly I’d like to be involved in meds and development, and I have been involved in meds and development, but if I leave one thing behind, I’d like to leave behind a world that treated people with headache problems much better than it currently does.
Miller: Do headaches increase with age?
Goadsby: In general terms no, most headaches get better with age, certainly migraine gets better around the time of the mid to late 50s. A terrible thing about the disorder is it really strikes down people in their young and productive years.
Miller: What is the worst case you’ve ever seen personally?
Goadsby: I’m sad to say I have seen dozens of worst cases. I have seen 5-year-olds with dreadful headache problems that have been attributed simply to school avoidance and silly ideas like that. I’ve seen adolescents have their entire life’s preparation ruined. I’ve seen young mothers who couldn’t look after their children and I’ve seen people who run oil companies who could buy the building we’re sitting in and can’t buy themselves a decent day without disabling headaches. These disorders don’t respect age, social economic status – what they do is strike down people over a range of our society.
Miller: So when they come to the UICSF Headache Clinic, what can you actually do for them?
Goadsby: The first and most crucial thing to do for someone with a headache problem is to make sure to get the diagnosis right. A proportion of people we see, simply the diagnosis was wrong, and if you don’t know where you’re going you’ll always be lost, sop that’s the first thing I can do. We can make sure the patient understands their disorder as best we can with the current information so that they can take some control of the problem for themselves, and then we can optimize the management of their problem through non-pharmaceutical approaches or through pharmaceutical approaches.
Miller: Is there any advice you have for people who suffer from headaches that are not the totally debilitating kind – some foods to avoid of things they can do – and in answering that, inevitably the question comes up about things like acupressure, etc., are they of any value?
Goadsby: The first piece of advice I’d give to anyone with headaches is don’t give up; don’t think there’s nothing that can be done, because there’s almost no one for which nothing can be done. The second piece of advice – and this is good general advice for migrainers, is to try to even your life out: Regular sleep, regular exercise, regular meals, a bit of regular grief, not too much and not too little. Regularity will help you a great deal. There’s not much to be made of this food myth, so to speak. Alcohol and perversely, hot dogs, which is less of a problem in most of the world but is a funny problem here. There’s a little bit of the nitrate problem in many types of hot dogs and that produces a little bit of an issue for migrainers -- so the main thing I say to migrainers is just get some regularity, give yourself some time in your life, don’t give the time to everyone else around you, as generous as you might want to be, and try to even the highs and the lows out, that’s generally good advice.
You mentioned acupressure and acupuncture, I think the substantial benefit of those types of therapies is around giving time to the individual – they’re almost like relaxation therapies. It’s been reasonably clearly shown for example in acupuncture, that it doesn’t matter where in the head you stick the needle so long as you stick a needle in the head, so the idea that there are traditional points where the acupuncture should be done doesn’t stand up to any analytical basis. The problem with those types of therapies is what is consistent with the idea that they’re related to simply, broadly speaking, taking time for yourself and getting some level of relaxation, reduced stress, is that when you stop doing them there’s no carry-over effect.
Miller: Last question, how many patients are you seeing now at the Headache Clinic here at UCSF?
Goadsby: We see a large number of patients at the clinic every week, have quite an active clinical program, but we’re still building up, and happy to see more.
Miller: Okay, thankfully I’m not one of those people, Peter, thank you for joining me on Science café.
Goadsby: Thank you.
Last modified: July 31, 2008