Hope for Headaches: A Conversation with Headache Expert Peter Goadsby

Photo of woman with headache

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.

Photo of Peter Goadsby

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.

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Health Guide: Headache
New York Times




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

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

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

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

Miller: Okay, thankfully I’m not one of those people, Peter, thank you for
joining me on Science café.

Goadsby: Thank you.