What YOU Can Do To Have Fewer Migraines!

Migraine management requires a team approach.  Excellent results are often seen when patients, families, and providers work together to decrease migraine frequency and severity.  As a migraine sufferer, there are lifestyle changes you might be able to make to help you take control over your headaches.  As a doctor, I have medications that can help; however, the medications will not be as effective if other measures are not taken.

Globally, these measures are the same for every migraine sufferer.  The specifics, however, differ for each person.

“What are those measures,” you ask? 

Keep a headache diary.  To help determine your specific triggers, it helps to keep a diary.  When you get a headache, think about and write down what might have triggered it.  Think about the foods you might have eaten that day, about any weather changes or other environmental triggers.  Think about your sleep patterns, and about any stress or relief from stress.  Think about your exercise, hydration, and diet….and write it down.  This will help you recognize patterns that you might otherwise miss.  If you can identify what triggers your migraines, you can potentially avoid that trigger and the subsequent headache.

Attempt to recognize and avoid triggers.  Triggers for migraines are very patient-dependent.  What causes a migraine in one person might or might not in another.  It is important to try to identify your specific triggers.

Common migraine triggers include:

By ProjectManhattan (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Foods such as:

Chocolate, cocoa, alcohol, caffeine, raisins, certain beans, sauerkraut, garlic, onions, olives, pickles, yeast breads and pastries, processed meats, soy sauce, food with nitrates, nitrites, tyramine, canned soup, MSG, Nutrasweet, ramen noodles, sour cream, buttermilk, cheeses other than American, cottage, ricotta, or Velveeta.

Weather changes

Many people get headaches with changes in the barometric pressure, extreme heat or cold, or in humidity.  These headaches are often attributed to issues related to allergies or sinuses.  The headache can occur just because of the weather changes; they can also be triggered by allergies or sinus congestion.  This is a trigger that you often can’t avoid, but it still helps to know that it exists.

Change in sleep routine

This is a big one for our teenagers.  In migraine prevention, the number of hours of sleep is important, however it is even more important that the sleep hours are regular.  In other words, you need to go to bed and wake up at the same time EVEN ON WEEKENDS.  You might notice that if you go to bed at a different time, wake up early, OR SLEEP IN, a headache will be triggered.  Regular sleep patterns are essential for every migraine patient.

(It is also important to get good quality sleep.  Let your doctor know if you snore or have difficulty sleeping)

Dehydration

 W.J.Pilsak at the German language Wikipedia

Dehydration is one of the most common reason children and adolescents get headaches.  It is important that you remain hydrated through the day.  This often means carrying a water bottle with you through the school day.  This also means drinking water, milk, and occasional juice rather than dehydrating caffeinated beverages.  It is especially important to be vigilant during the summer months and sports seasons.

Skipped meals

Your brain needs nutrients to function.  You will get a headache if you skip meals, and it will be hard for your brain to recover if it is not getting food (and once you get a headache, it’s likely you wont want to eat).  Three meals a day is a MUST and eating small snacks between is ideal.  YOU MUST EAT BREAKFAST, even if it is small.

Stress or relief from stress

Your mind and body are intricately connected.  Your cheeks might turn red when you are embarrassed.  You likely sweat more and shake when you are nervous.  For people with migraines stress can cause headaches.  This can be acute stress, accumulated stress, or even stress related to repressed or unrecognized emotions.  Even more interesting is that you can get a headache as your stress is relieved (for example: weekends, vacations, ending a project or stressful task like presentations, papers, or exams). 

Too much or too little caffeine

Caffeine is tricky.  Drinking a lot of caffeine can give you a headache.  If you are someone who drinks a lot of caffeine, stopping or slowing down your caffeine intake can lead to a headache.  However, if you do not drink caffeine on a regular basis, having caffeine at the onset of a headache can actually help prevent it from getting worse (Excedrin has caffeine in it). 

The recommendation is less than 200mg/day.  That is about equal to 8oz of brewed coffee, a 16oz latte or cappuccino, or 2 espresso shots.  Espresso has less caffeine than a brewed coffee because it is a smaller “dose.” 

Overuse of medications

Using any rescue medicine more than a few times a week for more than a couple of weeks can actually lead to headaches.  This includes Tylenol, Motrin, Excedrin, or any of the medicines that might be prescribed for you to shorten the duration and intensity of a headache when it occurs.

In addition, exercise has been shown to decrease frequency and severity of headaches

This does not mean you have to go out and run a marathon today.  It requires about 30 minutes of moderate exercise a few times weekly.  This can be walking, light jogging, swimming, yoga, horseback riding, or anything else that gets your heart rate up for 30 minutes.

http://commons.wikimedia.org/wiki/File:Respiracion.jpg#mediaviewer/File:Respiracion.jpg

In summary:

Keep a headache diary

Identify and avoid triggers

Keep life as routine as possible

Keep a sleep routine

Stay hydrated

Eat three meals daily and snacks…..THIS INCLUDES BREAKFAST!

Drink a minimal amount of caffeine.

Exercise a moderate amount at least a few days each week.

For other common migraine triggers, for information on caffeine in foods and beverages, and for more self-help information to include a sample headache diary, please see the “resources” section of my website at www.ocpedsneuro.com

What Does A Migraine Feel Like?

This is an approximation of the zig-zag visual disturbance that I experience as a migraine aura. The picture hardly does it justice! In reality it moves and vibrates, expanding and slowly fading away over the course of about 20 minutes.

Some patients experience an “aura” 5-20 minutes before the onset of a headache.  This sensation usually stops within one hour of the headache starting.  Auras include vision changes such as shimmering or flashing lights, lights surrounding a blind spot, or zig zags.  They can also involve abnormal sensations such as numbness, burning, or tingling.  Less commonly an aura involves focal muscle weakness or problems with speech.

“Classic Migraines” are migraines that involve an aura.

“Common Migraines” are migraines that do not involve an aura and are much more common than “Classic Migraines.”

“Complicated Migraines” are migraines that are associated with additional physical changes; examples include focal weakness, dizziness, loss of consciousness, problems walking, loss of vision, and problems moving the eyes.  When these symptoms are present, the diagnosis of migraine is usually only made after a work up is completed to exclude other causes.

Migraines in children and adolescents tend to last 1-48 hours.  Although headaches are often hard to describe, for migraine-type headaches, children and adolescents are usually able to express a pulsating or throbbing sensation (ie: “it feels like my heart is beating inside of my head”).  In adults, these usually occur on one side of the head, but with children they can occur on one or both sides of the front or sides of the head.  They tend to be moderate to severe in intensity and stop children from their typical fun activities.  Most children and adolescents will seek out a dark, quiet space to sleep as the headaches tend to be aggravated by movement, frequently involve nausea with or without vomiting, and may be associated with sensitivity to light and/or sounds.  Sleep tends to make migraines better.

There are also “pediatric migraine variants” which are unusual events that occur in children, often in families where other members have migraine.  These might look like sudden onset of the child walking funny or falling down lasting a few minutes, or sudden onset of an infant or toddler’s head turning to one side.  It can be stomachaches or vomiting that occur on a recurring basis.  Sometimes children can become acutely confused, usually associated with a headache.  And, oddly enough, some children can have all of the symptoms that are associated with a migraine, but not have the actual headache!  Most of the children with these variants go on to have more typical migraines later in life.

For more information on migraines, feel free to visit the resources section of my website (ocpedsneuro.com)…..and stay tuned to my blog!  More migraine and headache information to come!

Kids Get Headaches?!?!?

Many parents are surprised to find out that headaches are fairly common in children and adolescents.  There are migraine variants that start as young as toddler-age and various headache types that are seen throughout childhood and adolescence.  In fact, about 5-10 percent of children under 12 get migraines and 10-20 percent of adolescents get migraines. 

There are many reasons that children and adolescents get headaches.  Some headaches are caused by external influences on the body (secondary headaches), and some just happen (primary headaches).  Certainly tumors are a cause of secondary headaches and, although not common, are frequently the top concern for parents and providers alike.  Other causes of secondary headaches include head injury, TMJ, bleeding in the brain, increased pressure from fluid in the brain, and infections such as sinusitis, meningitis, dental carries, or even just having a fever.  Examples of primary headaches include tension-type headaches, migraines, new persistent daily headaches (chronic daily headaches), and less commonly cluster headaches. 

Primary headaches are much more common than secondary.  Although primary headaches can be disabling, in general they do not cause harm.  Secondary headaches, on the other hand, may have detrimental effects if not diagnosed early.  As a pediatric neurologist, I am trained to determine the cause of headaches and to treat primary headache disorders.

How do I do that?  By talking with and examining my patients (why I love neurology).   If there are any “red flags” in the history or physical exam that make me concerned for a secondary headache, I use neuroimaging (MRI or CT scan) to help me with my diagnosis. 

Treatment for headaches is tailored to the underlying cause.  Clearly, if there are external influences, such as tumors or infection, the treatment is to address those.  Primary headache treatment is often more complex and less straight forward as it is specific to each patient.  There are times when treatment is quick and easy, but more often than not, treatment requires lifestyle changes on the part of the patient, sometimes in combination with medications.  When medications are used, they often take up to two weeks to have any affect and up to 2 months to achieve their full effect. 

Although headaches are often scary for families, more often than not they are treatable and not caused by something big, bad, or ugly.  Unfortunately, sometimes it takes time to find the best course of treatment for an individual's headache.  I stay in close contact with my headache patients until their pain is resolved.  Although it often takes time, headache management is very rewarding as patients tend to become empowered by understanding their individual triggers and how to manage their lifestyle to decrease headache occurrence.  In addition, in the long run (and sometimes immediately) medications do tend to be effective when used for the right patient at the right dose for the right amount of time.

For more headache resources and information, feel free to visit the resources section of my webpage at ocpedsneuro.com......and stay tuned for my next blog entry!

What Is a Pediatric Neurologist?

Pediatric Neurologists are pediatricians, and occasionally adult neurologists, with special training in the pediatric nervous system.  This includes disorders of the brain, spinal cord, nerves, and muscles.  We have pediatric training (2-3 years), followed by 3 years of specialty training in pediatric and adult neurology.  We are taught by many experienced pediatric and adult neurology staff.  More importantly, we are taught by every patient that we encounter from the day we begin our training. 

The heart of pediatric neurology is in the interactions with our patients and their families.  In fact, this is one of the things that I love most about my job. Frequently, with a detailed history, and a thorough examination (which usually  involves playing with children), I can reach a diagnosis without needing to do a lot of other testing.  I may need to use other resources like rating scales, EEG, MRI, CT scans, or labs to confirm, establish, or rule out other diagnoses; but, in general, I get to use my hands, my skills, and my interactions with patients over all else. 

Pediatric neurologists diagnose and treat disorders of infancy, childhood, and adolescence.  These disorders include:

ADHD,

autism,

cerebral palsy,

bell’s palsy,

developmental delay,

epilepsy and spells other than epilepsy,

headaches including migraine,

concussion/traumatic brain injury,

intellectual disability,

developmental delay,

movement disorders,  including tics and Tourette Syndrome,

muscle disorders,

neurocutaneous disorders including tuberous sclerosis and neurofibromatosis, nerve and neuromuscular junction disorders including myasthenia gravis,

We also often identify and help determine the most appropriate place and type of treatment for neuropsychiatric disorders that might accompany these.  We tend to work closely with many other talented and trained healthcare professionals who are experts in their field, including psychologists, occupational therapists, physical therapists, speech therapists, psychiatrists, and occasionally, if needed, with neurosurgeons (People commonly ask if pediatric neurologists do surgery; the answer is we don’t!)

I am happy to answer any questions you might have about myself, pediatric neurology, or your child.  I have also tried to make my website a useful tool for parents and physicians with concerns related to pediatric neurology.  Please feel free to contact us at Pediatric Neurology of Orange County: 949-495-9600 for further information or to set up an appointment for your child.

How I Became A Pediatric Neurologist In Orange County

As a child, I remember everybody wanting to become a doctor, a veterinarian, a fireman, a policeman, or a superhero.  We grew up, developed new interests, and many people chose other paths.  For the most part, my path has been straight and narrow from that early age.

I grew up in San Diego where I was involved in leadership and mentoring activities throughout my elementary, junior high, and high school years. I was drawn to math and sciences, though I loved learning in general.  I have always found great joy in making a difference in other peoples’ lives.  I remember an activity at a leadership camp as a teenager where each person in the group was given a candle.  One person’s candle was lit.  This person passed the flame to the person next to them and this continued until everyone’s candle was lit, creating a vast amount of fire and light.  I identified with that flame and I still enjoy using my energy and light to create brightness and fire in people around me.  I knew that I wanted to change the world by affecting one life at a time and from an early age I knew that would happen through becoming a pediatrician

Through my Physiological Sciences major at UCLA, I was able to dive deeply into the amazing works of the human body.  I loved that there was order and a reliable flow of events leading to life and our ability to eat, breath, think, move, and live.  I found myself drawn to neurology- from the big picture nervous system down to the tiny synapses and channels at the nerve and muscle junction.  Looking back, I see this is where my future career started to take shape.

After working for a year as a clerk in an emergency room in San Diego, I ventured outside of California, to an osteopathic medical school in Kansas City.  I was drawn to osteopathic medical schools because of the emphasis on the whole body working together to create health or illness- and the need to think about the body as a whole when making diagnoses and treatment plans.  From the first day of class, we used our hands and minds to touch patients in order to learn about function and dysfunction.  Here my interest in neurology grew, as much of our diagnoses comes thorough physical examination.

I thought I would return to California after four years of medical school.  Before leaving for school, I went to lunch with a friend who suggested I look into the Army’s competitive Health Professional Scholarship Program.  Although it sounded somewhat  “crazy,” I talked to a recruiter and a few days later my application to the scholarship was in.  I was drawn to the idea of taking care of soldiers’ children in addition to the fact that I would complete medical school without debt. I had no idea of the immense impact the military would have on my life and my career

I completed a three year pediatric residency in Hawaii from 2002 to 2005 at Tripler Army Medical Center.  With my fellow residents, we experienced all aspects of pediatrics with the added component of military life. As we rotated through various specialties in pediatrics, I found that I was continually drawn back to neurology, where I enjoyed the patient and family interactions more than any other specialty.  We were involved in the highs of bringing babies into this world and the lows of seeing young lives taken.  As military physicians, we saw mothers and fathers deployed from their families, and the resilience of those left behind. 

For my first job as a board certified pediatrician, I served as the Chief of Pediatrics and sole pediatric provider in a busy practice in Fairbanks, Alaska for one year.  That year of general pediatrics allowed me to gain confidence in my clinical skills and helped me understand the plight and joys of being a general pediatrician.   As a provider in Alaska, I still found myself continually drawn to neurology and I further developed my skills in the initial recognition and treatment of neurologic and neurodevelopmental disorders.  That time also helped me understand the role and value of subspecialists- both for patients and for primary care providers. 

While in Alaska, I was selected for a competitive fellowship in pediatric neurology, which I completed at Walter Reed Army Medical Center in Washington, D.C from 2006-2010.   I gained expertise in all areas of pediatric neurology, through my mentors, patients, and colleagues.

On completion of fellowship, my first job as a board certified pediatric neurologist was at San Antonio Military Medical Center in Texas from 2010-2013. I had the opportunity to continue to teach and to hone my skills and expertise as a child neurology specialist there.

During this time, I was chosen to serve as the neurology consultant in Iraq for six months, which included serving as the concussion/traumatic brain injury expert for the country.  This time helped me learn to rely on my expertise and knowledge to treat patients with varied neurological diagnoses, learn to function independently and confidently and at times with limited resources.  All of these experiences helped prepare me as I worked toward my ultimate goal of opening this private pediatric neurology clinic.

In opening my pediatric neurology private practice, my primary goal was to create an office that welcomes families and children of all ages, and I hope you’ll feel that from the moment you first interact with me.    Being a new pediatric neurologist in the area has allowed me to have a fairly open schedule—which means I can schedule an appointment with your family relatively quickly. I am able to personally guarantee that we will have adequate time to review your child’s history, to perform a detailed (and fun) physical exam, and have a complete discussion about your child’s diagnosis and plans. 

As my family and I integrate into the area, I am already enjoying serving the Orange County Community. I look forward to working with you and your family and am certain that South Orange County and the surrounding areas will come to know me as a caring, compassionate, and expert pediatric neurologist.

A New Practice, A New Blog

I am hoping to introduce myself, clarify the role of a child neurologist, and to educate and inform families through this, my first ever, blog.