Published July 10, 2019 By Adam Lowenstein

Dr. Lowenstein: Hi, and welcome to the Headache 360 Podcast, I’m your host, Dr. Adam Lowenstein. And as I’ve said many times before, I am a migraine and chronic headache surgeon. I do nerve decompression of peripheral nerves for chronic headaches and migraines.

Dr. Lowenstein: And the purpose of this podcast, that I call the Headache 360 Podcast, is to take different perspectives from different caregivers for patients who have chronic headaches and migraines. And we tend to have varying different experts on our podcast. And today we have the gold standard, today we have Dr. Hussein Ansari. He is the head of the Headache Clinic at the University of California San Diego. He is a very knowledgeable gentleman. He’s a board certified neurologist, he’s a certified headache specialist, and he’s done a world of training. He speaks all over the country on migraine and chronic headaches.

Dr. Lowenstein: He came to California via Ohio and the Mayo Clinic. So, Dr. Ansari, thank you very, very much for joining me.

Dr. Ansari: Thank you Dr. Lowenstein, thank you for inviting me, and I’d be happy to discuss a little bit about migraines. And hopefully this podcast can help some of the migraine sufferers to understand better and get better care and treatment for their migraine headaches.

Dr. Lowenstein: Tell us real quick, a little bit more about yourself.

Dr. Ansari: Sure. Actually you summarized very well, yes. I’m a neurologist, a board certified neurologist and I did my residency in neurology in West Virginia University, and chief residency also there. Then I went to a Mayo Clinic to do extra training for headache and facial pain, and I did my fellowship there. Then I actually, opened up the Headache Center in Akron, Ohio, and was there as a director for the Headache Center for all four years.

Dr. Ansari: And then for the last four and a half years, I joined University of California in San Diego as a director of the Headache Clinic. And I’m basically running the Headache Center here, and also Facial Pain Center. So I have two niche, basically, one is headache and one is the facial pain. And working on both for the last four and a half years here, and trying to help the people with migraine and facial pain here in California.

Dr. Lowenstein: And I should say the way that we first met, I think you worked with Dr. Guyuron in Ohio. And as many of you should know, Dr. Guyuron is the pioneer who discovered that chronic headaches and migraines could be successfully treated without patient surgery. And I’ve known Dr. Guyuron for many, many years, and I would argue he’s one of the best plastic surgeons in history and a true innovator. He’s done some wonderful things and really, really enabled us to help migraine sufferers tremendously.

Dr. Lowenstein: So, Dr. Ansari, as you were speaking at one of his seminars and I certainly was very impressed, and I’m really pleased that we can share some of your expertise with the rest of the world.

Dr. Ansari: Sure. Actually, I knew Dr. Guyuron even before I went to Ohio. I knew him before that, even during my residency I attended his seminars and became interested in this procedure. And for the last seven, eight years, I’ve actually been working with the Plastic Surgery Society, and as you know, they have annual meetings, and this year it will be in San Diego and we will be having another session and cadaver lab. And we did this courses all over the world. Actually a few months ago, we went to Taiwan.

Dr. Lowenstein: Oh, really?

Dr. Ansari: Yes. Migraines surgery course, actually me and Dr. Tutunchi actually went and Dr. Amy Luck. Dr. Guyuron wasn’t able to make it and yes, we were there and over there actually the surgeons are doing this for a few years with very good success.

Dr. Lowenstein: Oh, that’s great.

Dr. Ansari: Yeah, it’s all over the world. And actually we are going to probably Turkey at the end of this year for another international course in this session.

Dr. Lowenstein: Let me just ask you, in your opinion, somebody’s got headaches, at what point do you think that they should start to consider seeing a neurologist?

Dr. Ansari: It’s a very good question. So, patient then has the headache, of course first thing that I need to basically clarify with your audience is the difference between headache and migraine. Because in general population or even in some basically medical facilities, I see they use the terminology headache and migraine interchangeably. While we know migraine and headache is not the same. Not all of the headaches are migraine, and also not all of the migraines have headache. That’s very interesting. Migraine is a complex neurological disorder, and a typical migraine disease has four phases. One is, we call the premonitory phases or prodromal phases, which happen and start before headache. And during that cycle people become tired, fatigued, they yawn a lot, they crave different foods, they become moody. And then about 25, 30% of the patients also gets aura of the migraine.

Dr. Ansari: Aura is the transient neurological symptom, which when they happen the first time in the migraine patient could be very scary, because it’s very much like stroke. And a lot of people go to the emergency with the possibility of a stroke. About 25, 30% of the patients have that phase. Then we have the headache phase of the migraine, which most of the people know the migraine just with that phase, while that’s just one of the four phases of the migraine.

Dr. Ansari: And then we have basically the fourth phase of the migraine, which we call the resolution phase or postdrome phase. After a migraine headache finishes, sometimes people feel tired, they can actually feel washed out, and that’s another phase of the migraine. So that’s why migraine and headache is not the same.

Dr. Ansari: So when the people have headache, if the headache has some of the migraine features, so what is the most important feature, or most classic feature of migraine? It’s the throbbing quality, pulsating quality. And usually it starts in one side. And patients either have nausea and or vomiting, or they have light and noise sensitivity, either or. So it doesn’t need to have all three, either nausea and vomiting or light and noise sensitivity. If patients have throbbing severe headache with one of those two features, that’s very likely migraine, not 100% but very likely migraine.

Dr. Ansari: So then if the patient gets those kind of headaches more than one a week, that means four times per month, that patient needs to seek medical attention with either primary care physician, or whereby a neurologist, or a headache specialist. But the problem with headache specialists, of course not all of the migraine patient can see the headache specialist, and the reason is very clear actually. I’ll give you some statistics, in 2018 in the US, we had about 500 certified headache specialists, which actually some of them are not even maybe practicing now. And you have 39 million migrainers.

Dr. Ansari: So 500 for 39 million, so of course, I mean a very small percentage can go to the headache specialists. But the good thing with all the effort that American Headache Society and Migraine Foundation put in the community, a lot of neurologists and even a lot of primary care physician are now familiar with this. And they can help the patient at the beginning. So if the patient with migraine gets one or more per week, the recommendation will be seek medical attention.

Dr. Lowenstein: So, one a week for four weeks or more than that?

Dr. Ansari: Yes.

Dr. Lowenstein: And so, I’m fresh off of a clinical day, and so I just saw a patient who’s only seen their primary care physician. They have not seen a neurologist and then their primary care physician treated them with multiple medications that they didn’t tolerate, which just have ended up in my office. Should I be insisting that they also see a neurologist, or do you think that the level of primary care training at this point can be adequate in some fashion?

Dr. Ansari: Yes, that again, depends on who is the primary care physician. And actually one thing that might be interesting for your audience to know, not all of the headache specialists are neurologists. And so actually-

Dr. Lowenstein: Okay, so whereas… yeah.

Dr. Ansari: We have a lot of non-neurologists who are headache specialists. In fact, the current president of International Headache Society, Professor Edvinsson from Sweden, he’s not even a neurologist, he’s an internist, but he’s the president of International Headache Society, the biggest headache society in the world. So that’s why not all of the headache doctors are neurologists, and not all of the neurologists would like to see the headache patient-

Dr. Lowenstein: Right, that actually-

Dr. Ansari: Or interested in headache patients. So that is the problem. So it depends on who and where they live. For example, in California in Orange County, we have a very good family physician who’s a headache specialist. So she’s better than a neurologist to see because she’s a headache specialist. So again, depending on the location, who is interested and who has some education and training on headache, would be the best person for the patient to see.

Dr. Lowenstein: So you can go to do a headache fellowship, a true headache fellowship as an internal medicine doctor?

Dr. Ansari: As an internal medicine, as an anesthesiologist, as a psychiatrist, for example, a psychiatrist… the head of the Cleveland Clinic Headache Center now, he’s a psychiatrist, he’s a headache specialist. And he’s in the Cleveland Clinic, which one of the biggest headache center. So that’s exactly what happened. Anesthesiologist, internist, family medicine or psychiatrist, they can go and do the headache training.

Dr. Lowenstein: Got it, okay. So we have the differences between headaches and the four phases of a migraine. And certainly if somebody is having a migraine and they’re having four migraines a month, you recommend them seeing somebody. What if they are not having migraines but they are still having chronic headaches? One of my patients today has head pain all of the time, and she also actually has migraines and she can separate the symptoms. But at what point should a non-migraine patient who is concerned about their headaches start seeing somebody?

Dr. Ansari: Okay. Actually the patient that you’re mentioning, has probably what we call, half chronic daily headache. So, chronic daily headache is not a diagnosis it’s a definition, it’s a terminology that we use for the people that have almost daily headache. And most of these people actually, they have a migraine but since their migraine has not been treated or could not be treated for whatever reason, either the headache was intractable or the patient didn’t see the correct provider, they transform to chronic daily headache.

Dr. Ansari: That means, patient has daily headache for example, eight days, nine days they have full blown migraine, but the other days they have a mild headache, a dull headache. And the other thing that’s very common in the patient who has chronic daily headache, they also have medication overuse headache, and that is one of the biggest issue in the community, the medication overuse headache.

Dr. Lowenstein: Can I ask, is that an actual diagnosis?

Dr. Ansari: Yes, that’s actually ICH, the international headache classification, one thing that maybe your audience is interested in, International Headache Society, ICHD had the classification for the headaches that’s online and the pdf form available for everybody. And all different kinds of headaches have been documented there, and it’s very easy to use, even if you’re not a physician, it will be easy to use. That’s called ICHD-3, if you google online, everybody can access.

Dr. Lowenstein: Great.

Dr. Ansari: And medication overuse headache, in section eight in that classification is medication overuse headache. So medication overuse headache, to basically clear for your audience, what does that mean? It means if a patient with a headache takes as needed medication more than certain days per month, and that certain days per month for each class of the medication is different.

Dr. Ansari: Let’s talk about for example, Excedrin. Excedrin Migraine, which is one of the medication that’s extremely overused in the community because when you go to the Costco, I always go and watch those people who bought this Excedrin 500 in one box and it’s just buckets of Excedrin and of course they are using that. And so that is the big problem. If you use more than five to eight days per month of Excedrin, you will develop medication overuse headache, that means your headache will get worse.

Dr. Ansari: But this happens all the time, and in the Excedrin box they never wrote this, that you cannot use this medication more than certain days per month. But if you go to the literature, it always says you cannot take it. The other big issue with medication overuse is the narcotic, opioid medication, Norco, Tramadol. That’s a huge problem.

Dr. Ansari: And the other big problem, particularly in California, for whatever reason, is the medication called Fioricet, which has Butalbital in it. And is very overly used for reasons that I don’t know, actually Fioricet is a medication that in all of the world is abandoned, it’s out of the market. The only place that still has Fioricet is the United States. And that is the medication that very quickly cause rebound, and it’s not even approved for migraine, but a lot of a physicians prescribe it for migraines.

Dr. Ansari: So, these are the people that usually develop medication overuse headache. So they have migraine, then develop medication overuse headache, combination of migraine and medication overuse proceed to chronic daily headache. So probably, your patient had something similar to that. Most of the patients that we see with daily headache or chronic daily headache, they have underlying migraine and then migraine changed to chronic daily headache. And most of the time the reason is medication overuse headache.

Dr. Ansari: Going back to your question, when the patient with non-migraine… We don’t have any basically guidelines that say, “Oh this is who the patient needs to see.” This is basically common sense, if the patient with a headache has enough headache that affect their daily activity, so one of the things that we use in all of the headache centers all over the world, we use the tool, the measurement tool, for the impact of the migraine in the patient’s life.

Dr. Ansari: There’s different measurement tools available, for example, one of them called, MIDAS, one of them called, HIT-6, Headache Impact Test 6, which I use that one in my clinic. So in that, we can measure with numbers the effect of the headache in the patient’s activity or daily life. And if this number is higher than certain, that patient definitely needs to be seen by a physician. So this is common sense, if a patient with a headache has too many headaches that affect their life, even if they don’t take too much medication, they need to see somebody, because it’s basically affecting their daily activity and life.

Dr. Lowenstein: Certainly. And we use MIDAS test ourselves. But I’m not sure that generally people have access to those. We talked a little bit offline before that we’re going to try and do this only for about 40, 45 minutes. I kind of feel like I’ve got six hours of questions about just diagnoses, because I have seen patients who come to see me and they have five different diagnoses from the same neurologist. And so, it’s interesting to me that you were talking about, saying one diagnosis can evolve into another. Does that happen often?

Dr. Ansari: Yes, very often actually.

Dr. Lowenstein: But you’re also seeing, I mean you’re a tertiary care, you’re the end of the line from a medical standpoint. I would imagine that people who see you are being referred because they are not having success with… I don’t want to say lesser [crosstalk 00:18:03].

Dr. Ansari: Yes and no, because I also see different kinds of first or second hand patients who actually refer from UCSD primary care or internal medicine family. So those are the patients that didn’t see anybody, I basically see them.

Dr. Lowenstein: Okay.

Dr. Ansari: But I see them as a first hand or second hand, but when I see them, “Okay, what are you doing?” “I’m using Excedrin for 20 years every day.”

Dr. Lowenstein: Got it. And so, okay well, I could talk to you about what to do with that kind of patient. But let me ask you another question that I frequently get asked, the term cervicogenic headache.

Dr. Ansari: Cervicogenic headache, yes. It’s a separate diagnosis, again both in ICHD-3 and also in ICD-10, we have the separate code for that and separate diagnosis. This is actual diagnosis. Those are the people that their headache started from the back of the head, might have some migrainous features, and most of these people have history or whip lash injury. That’s a separate diagnosis. But also we have other diagnosis in ICHD-3 we call cervicogenic migraine.

Dr. Ansari: So we need to differentiate between cervicogenic headache and cervicogenic migraine, because treatment is totally different.

Dr. Lowenstein: Interesting.

Dr. Ansari: And the cervicogenic migraine is more common than cervicogenic headaches. Cervicogenic headache is not very common, although it’s maybe overly diagnosed, or also underdiagnosed. A lot of time I see the patients, they actually have cervicogenic headache, but they’re diagnosed with migraine, and I see the other way. So these are two headaches that mimic each other. It’s not very easy, they really need a good detailed history and exam to differentiate between cervicogenic migraine and cervicogenic headache.

Dr. Ansari: But cervicogenic migraine by far is much more common than cervicogenic headache. If you look at the migraine patients, about 70% of the migraine patient have what we call occipital triggers, that’s the part that you probably talk more in the surgery part. But about 70% have that occipital trigger, and that means their headache started from occipital or neck area or radiates to that area. And those patients can be mistaken with cervicogenic headache.

Dr. Ansari: So this is two separate categories but they have some overlap and sometimes the diagnosis is not easy. And it’s very good history, exam and also nerve block or facet injection that we do to differentiate between cervicogenic headache and cervicogenic migraine.

Dr. Lowenstein: And then differentiating both of those from occipital neuralgia, can you make some comments on that?

Dr. Ansari: Yes. Occipital neuralgia also is the diagnoses that this one is certainly over, over diagnosed. Most of the time, if you see in the neurologist’s note, in the pain doctor’s note when they put occipital neuralgia, the main reason is because they want to get the nerve block, and it’s much, much easier to put that as a diagnostic code to get approval from insurance.

Dr. Ansari: So that that is one of the reasons, and I don’t blame them because you don’t want to fight with the insurance and say, “This patient had migraine and I want to do occipital nerve block, insurance a lot of time does not cover that, because say that’s experimental. But if you put occipital neuralgia they will cover it. So that that is one of the reasons that it’s overly documented at least.

Dr. Ansari: But on top of that, also it’s overly diagnosed and why? Because when we talk about the neuralgia in general, neuralgia means paroxysmal pain, that means sudden onset, sudden termination, lasts few seconds up to two minutes. And it feels like jabbing, jolting, electric shock pain, that is neurologia. So if a patient has the pain in the back of the head, which is occipital, and had that quality, jabbing, jolting, split second, starts with maximum intensity and then finishes abruptly, very quick, if a patient has pain in occipital area with that quality, that patient we can label as occipital neuralgia.

Dr. Ansari: And it’s not uncommon in the patient with migraine that also feel they have the migraine headache in the occipital and on top of the migraine headache, sometimes they feel that jab and jolt. That can happen in the migraine patient. But occipital neuralgia as a purely and primary diagnosis is not very common. It’s a rare condition usually seen in elderly who have a lot of arthritis in the cervical spine area, or a lot of time they have the rheumatologic disease, rheumatoid arthritis or something. In those people, I see a lot of occipital neuralgia as a pure diagnosis without migraine.

Dr. Lowenstein: Okay. And so all these things are separate, but can coexist, that sounds right?

Dr. Ansari: Yes.

Dr. Lowenstein: And then, we’re not just talking about this general subset of diagnosis which I’m just very interested in, because it’s a large part of my practice. But you can have occipital triggers for any of these diagnoses?

Dr. Ansari: For which one? For the occipital neuralgia and cervicogenic headache?

Dr. Lowenstein: Correct, and cervicogenic migraine.

Dr. Ansari: Cervicogenic migraine, yes, they have occipital triggers. That’s why they feel the pain in the occipital area. But cervicogenic headache and occipital neuralgia are not. They’re in a separate category, and the treatment of those two is basically facet injection or occipital nerve block. So for cervicogenic headache, diagnosis made by blocking, local anesthetic block of the facets, mainly C2/C3 area.

Dr. Ansari: And for occipital neuralgia, is diagnosis based on blocking of the occipital nerve, either lesser or greater occipital.

Dr. Lowenstein: I have seen and successfully operated on patients with all of these diagnoses, and it seems that while some of them may be under or over diagnosed, from somebody who’s not as specifically trained as you are, it seems that there’s a lot of ambiguity between all of these different diagnoses.

Dr. Ansari: Yes. In fact there is, because sometimes as I mentioned, could be overlap. Cervicogenic migraine and cervicogenic headache sometimes have very similar features, just with good and detailed history, we can differentiate it. Occipital neuralgia also can be seen in migraine a lot. The patient had migraine with occipital trigger and on top of that they feel that jabbing, jolting. And the reason that you had the success is because the patient that you operated probably was migraine patients with occipital trigger and sometime they had occipital neuralgia, e.g real occipital neuralgia or just documented in the chart because of basically insurance purposes for nerve block.

Dr. Ansari: That’s probably why you were successful, because the most common… if you see 10 patients with occipital pain and headache and things, at least nine of them will be migraine. Maybe one of them will be cervicogenic headache or pure occipital neuralgia, even less than one. I don’t have any statistics, but that’s why statistically when you’re operating those patients, then you’re operating migraine patients most likely.

Dr. Lowenstein: Right, okay. And it’s because people come to see me and I’m sure my peers as well. And it is kind of rare that people get to our office and don’t have successful blocks. And I think you’re right, I think most of them have the diagnosis that is favorable for that. So, we’ve got lots of different diagnoses obviously for head pain and we haven’t even gotten into the whole world of facial pain. But let’s just say if somebody comes to you with migraine symptoms and they’re qualifying with the four phases of migraine et cetera, and they’re having this more than four times a month, what are the first steps of your kind of diagnostic regime? What are you going to do?

Dr. Ansari: Okay, before we talk about that, the four phases do not necessarily happen in all of the migraine patients, some migraine patients really have that headache phase as a prominent phase and none of the other three phases. But most of the patients have prodromal and postdrome, and again 25, 30% of the patient also have aura.

Dr. Ansari: In terms of the patient diagnosis, one thing that is very important, migraine is purely clinical diagnosis. There is no blood test, there is no imaging that we need to do to basically diagnose the migraine. So it’s all history. And a headache history and exam for a new patient, at least take 45 minutes.

Dr. Lowenstein: Yeah.

Dr. Ansari: It’s in no way sooner than that, actually after these many years doing headache, still my new patient appointment time is 60 minutes. There’s no way I can diagnose sooner than that, because you have to ask a lot of questions, the patient needs to fill out the questionnaire. So based on that history and exam that I do in the first session, with 99.9% confidence, you can diagnose the migraine.

Dr. Ansari: Really we don’t need any tests. We don’t have actually any tests, because sometimes I see the patient that come and see me say, “Yeah we saw a neurologist and they told me we’re going to do MRI to diagnose your migraine.” We don’t have such a thing. MRI is not diagnostic for migraine, and neither are any other tests. We don’t have-

Dr. Lowenstein: How many of your patients come in insisting on some kind of imaging?

Dr. Ansari: A lot. That is another issue. That’s another big issue that actually we have, and we can talk about just this for five hours.

Dr. Lowenstein: Yeah, I know, there’s so much to talk about.

Dr. Ansari: But one thing about the imaging, yes we don’t have any imaging to diagnose and we do not need imaging for basically diagnosis. Now-

Dr. Lowenstein: And imaging can be problematic sometimes, right? Because you can find things that-

Dr. Ansari: Exactly, that’s my point actually. Because sometimes we argue with some of our colleagues that say, “Oh I’m ordering MRI for all of the patients.” What’s the problem? “The patient becomes more… basically no worry for the patient and the patient becomes more confident and reassured.” But actually in fact in the real world, it’s not that, actually that sometimes is exactly the opposite. The patient gets MRI and you see the things that you don’t need to see. And that causes a lot of problems, and this problem is a real problem. One problem is, yes the patient gets some MRI or imaging, and now we have this 3 Tesla imaging, which basically picks any small detail in the brain, and there’s cavernoma. That is the finding that a lot of people have, and with 1.5 Tesla sometimes we are not able to get it, but with 3 Tesla we get all of those small cavernoma.

Dr. Lowenstein: Higher resolution.

Dr. Ansari: Yeah, it’s very detailed. And then, the patient becomes worried. Some of the patients are really worried about that. And some of these imaging actually, if you show the patient, for example, there is one of the incidental finding that you see a lot in the MRI of the brain, is the arachnoid cysts. It’s a big cyst in the brain, which looks really ugly, and if you show that one to the patient… I’m a physician, if I see my brain with that big cyst, I cannot sleep at night.

Dr. Lowenstein: Yeah, sure that, yeah, it’s a scary thing, right?

Dr. Ansari: That’s scary, it looks scary but it’s benign, it’s a congenital thing, the patient is born with that. And then no matter how much you reassure the patient, some worried patients go to the wrong direction. I cannot tell how many patients I’ve had that had operation on the brain for this incident alone.

Dr. Lowenstein: Oh my gosh, wow.

Dr. Ansari: We call it incidentaloma. And so yeah, they have the brain surgery and that is not good to open somebody’s brain for no reason. That’s why getting the imaging is not always reassuring and good. Plus forget about the financial thing that’s put in the community and blah blah. But even for the patient reassurance and safety, it’s not a good thing. If the diagnosis by history makes the diagnosis a migraine, we don’t need anything. And in fact, if you look at International Headache Society classification, it doesn’t say that you need to get any test to diagnose the migraine. Just pure clinical diagnosis.

Dr. Lowenstein: All right, so you know, I’ve seen yet another problematic situation where you have patients who are frantic because they have a completely normal MRI. And so, they have chronic migraines, and they’re so intent on finding a reason that when their MRI does not show some horrific tumor, they’re even more distraught, because they’re just so desperate to find something to show for it.

Dr. Ansari: Yes, exactly. And the other thing with the imaging, sometimes they find this incident, for example, the meningioma cavernoma, and then the radiologist has a generic basically, dot phrase in the note and say, “Follow up MRI indicated.” So I see sometimes the patient that they’re having MRI 15 years every year MRI for the same finding, because they say you have to repeat it. And they just repeat it, they just repeat it. So that’s happened.

Dr. Ansari: One thing about your question, and your previous question or previous sentence about this patient basically insisting to find the reason, one thing that sometimes I joke, there’s a quote from one of the famous headache specialists, Dr. Goadsby from UK, and he says, when a patient asks me why I have this headache or migraine, he says, I told the patient it’s because you picked wrong parents. Migraine is a genetic disorder, so why you have it, is because you have the gene. That’s the simplest answer.

Dr. Lowenstein: You know, it’s interesting again, I’m afraid that we’re going to trail off and that it’ll be late, late at night, two o’clock in the morning and we’ll still be talking. But, I had a patient like that last week, and it seems to me, and I’m interested in your perspective here, that just like some people have big noses and some people are six foot two and everything is genetic, but I’ve seen patients who have these genetic predispositions, a lot of those times I see anatomic reasons at least for their triggers.

Dr. Lowenstein: So this young man I operated on last week, and this may be a little more technical for some of our listeners that we haven’t reviewed this kind of thing, but he had a super orbital foramen that was almost an inch and a half long. And so he had this long, long compressive tunnel for a super orbital nerve that was causing compression of that nerve. And I’m thinking, well, that is just like the shape of his nose. Many of his siblings or many of his family might have that same kind of… it’s not even a deformity, it’s just a normal variant, but it’s unfortunate normal variant that can cause pain in those nerves and subsequently migraines. Do you have an opinion about that? I mean I-

Dr. Ansari: Yes, actually this is a very interesting question, because it’s one of the biggest debate that we have with our ENT colleagues. So people with migraine… In general population we have a lot of people who have an atomic variant of the septal deviation or conscionable loads of which again is medical term, or contact point, and a lot of other stuff. So if a patient with conscionable load or CVR septal deviation contact point does not have migraine gene, all that anatomic variant can cause for the patient could be some breathing problems, right? But if that patient had migraine gene that the same anatomic variant can cause migraine, because this is a migraine patient have the sensitive brain, sensitive nerve, and that anatomic variant can trigger, play as a trigger point for the patient with migraine. And again, this is a big debate because a lot of times when we talk or document in our note, ENT colleagues say, “No, no, this has nothing to do with your headache.”

Dr. Ansari: So that is a challenge but is exactly your point. People with Migraine or Migraine gene, they have predisposition to a basically have any normal anatomic component as a trigger. Another basically good example for this predisposition will be the people who they never had migraine and the migraine started after slight trauma to the head. I cannot tell how many patients I have, female you know, a house wife female come and say, “Oh, I never had headache. I hit my head in the cabinet in the kitchen and I got headache after that.” So guess what patient had migrant to predisposition. Gene of the Migraine was silent, then with the trivial trauma, that activated and patients start their migraine and then that they think that is the trauma or something is causing for the Migraine. In fact it’s not it’s just triggering points for the migraine.

Dr. Ansari: So you question exactly true anatomic variant in the patient with Migraine can play as a trigger point, certain for one a certain type of migraine which we called Hemiplegic Migraine, we have the gene, there’s a three gene identified the chromosome and gene identified but that is for Hemiplegic Migraine. But for other migraine also the genetic library is there is a too big center that’s running. One of them in his Mayo Clinic in Rochester which I was trained and my former program director and he has probably the biggest migraine genomics library, and they looking at the gene of the Migraine and they identify and they working on that. If this publish, which will be hopefully in the next 10 years will be huge in the Migraine board.

Dr. Lowenstein: That will be huge, huge. But there’s no current like we have tests for breast cancer that we would run on somebody who might be susceptible to breast cancer. We don’t have a blood test to send that would be diagnostic for Migraine for making that extra point?

Dr. Ansari: No, just for hemiplegic.

Dr. Lowenstein: Just for hemiplegic, okay.

Dr. Ansari: We do have and we sent often because that’s very disabling type of a migraine, patient become completely plegic actually a full hour or so. So for that we have the test, a commercial test for the other type, not commercial, but there is actually there’s, I mean there’s multiple type of the gene identify for Migraine and that’s why different people with Migraine had the different type of the headache, different symptom. Why some of the people get severe light sensitivity, some does not. Some people get severe nausea, vomiting, some does not. So because of different gene.

Dr. Lowenstein: I’m really hoping to have you back on another, if not several more episodes, but I’d love to talk about a drug therapy with you. I’d love to talk, I mean we can talk about narcotics alone for several hours.

Dr. Ansari: We can talk about the facial pain and sinus headache, which is another big issue that I see in my clinic. And we definitely can educate your audience about the term sinus headache more.

Dr. Lowenstein: That’s fantastic. So at this point I’m going to say thank you very much and to my listeners, I will say, think of this as a pause and we’ll definitely get a Dr. Ansari to talk about several other things in the future. But for now thank you so, so much for spending the time with us and I really do appreciate it, and I hope we can do this again.

Dr. Ansari: Thank you. Yeah, certainly we will do it.

Dr. Lowenstein: Hey everybody, this is Dr Lowenstein once again, and I have two last things to ask you. Firstly, the thing that you can do for fellow headache sufferers is to please remember to subscribe into Radar Podcast, the more ratings and subscriptions that we get, the more visit visibility that we get and the more listeners that will be able to find us, the more help and information we can provide to the huge population of people who suffer from headache pain.

Dr. Lowenstein: Secondly, please remember that the treatment of headaches of all types is very individualized. The purpose of this podcast is not to give medical advice. So please use the information here on this podcast, and elsewhere that you hear on the Internet to broaden your knowledge, but consult with your physician before acting on any information that you hear on podcasts, or youtube or anywhere on the internet. I as a physician, don’t necessarily endorse the opinions or practices of my guests and if you have particular questions that you would like to consult with me directly about, please call our headache surgery center. Our number is 805-969-9004 or email us at and my staff will set up a consultation to discuss your specific case. Thanks and best wishes from all of us here at Podcast 360.

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