Migraine diet

Sleep and headaches

Are headaches hereditary

Medication over use headache

Quick self-test for migraine

What is a caffeine withdrawal headache? How to minimize risk

Do you have a sinus headache? Probably not...

About Botox

About Trigger Point Injection

Additional Links

Migraine diet

Many foods trigger or set off vascular or migraine-type headaches in susceptible individuals due to certain chemicals contained in the foods. This is not a true allergy but is food sensitivity. The initiation of the migraine is felt to be related to an effect of these neurochemicals such as Tyramine, Nitrite, MSG on blood vessels. Avoidance of the foods listed below is important in preventing or reducing the incidence of these headaches. MSG and Nitrite (Sodium Nitrite) can be identified on labels of suspected foods. Although some authorities espouse that almost all headaches are triggered by foods, we believe that foods are only one of many types of trigger, and these triggers are only significant in susceptible individuals, not everyone.


  1. Tyramine-
    • a. Dairy Products including Pizza, Macaroni and Cheese, Sour Cream, Yogurt, aged cheese: Cheddar, Gruyere, Stilton, Emmentaler, Brie, Camembert, Gouda, Mozzarella, Parmesan, Provolone, Romano, Roquefort (Blue). Exceptions: Cream, Cottage, and American cheeses.

    • b. Alcoholic Beverages including Beer and Ale, Wine: Chianti, Sherry, Riesling, Sauterine, Red Wine, Champagne, dark or heavy drinks

    • c. Meats including Liver, Dried Fish (Pickled Herring, Cod).

    • d. Others including Vanilla, Chocolate, Yeast Extract, Soy Sauce, Canned Figs, Raisins, Fava Beans.

  2. Nitrites including Hot Dogs, Bologna, Liverwurst, other packaged or processed meats, Bacon, foods containing Glyceryl Trinitrate.

  3. Monosodium Glutamates (MSG) including Chinese Food, Meat Tenderizer like Accent, Tangy Soups, Corn Ships, etc. (Read Labels).

  4. Caffeine including Coffee, Tea, Iced Tea, Cola. Decaffeinated versions are ok.

  5. Nuts including Peanut Butter.

  6. Citrus Fruits and Juices including Oranges, Grapefruits, Lemons, Limes, Pineapples.

  7. Certain other fruits including Bananas, Raisins, Red Plums, Canned Figs, Avocados.

  8. Certain Vegetables including Broad, Navy, Lima, and Fava Beans, Pea Pods, Sauerkraut, Onions, Mushrooms.

  9. Certain Bread Products including Homemade Yeast Breads, Sour Dough Breads, other yeast risen baked goods.

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Sleep and your headache

The relationship between headaches and sleep is complex and poorly understood, but it is commonly observed that it is hard to get control of your headaches if you do not have high quality sleep. Too much sleep, too little sleep and not the right kind of sleep all are contributing factors into making your headaches more difficult to control. Some sleep disorders actually have headache as a common symptom such as sleep apnea and upper airway resistance syndrome (UARS).

Long time headache sufferers generally figure out that they can not sleep too little or too much. Whereas many people can get by with cutting back on sleep time during the week and getting catch-up sleep over the weekend, headache sufferers do better with regular sleep which is typically for adults 7-8 hours.

Normal sleep consists of 4-6 sleep cycles that are about 90 minutes long. Each sleep cycle is composed of stages including deep slow wave sleep and some REM (rapid eye movement) sleep. Workers who do shift work or people who have erratic sleep habits may develop headache problems.

Sleep can actually be a way to relieve headaches, particularly in kids. The instinct to go lie down in a quiet dark room is generally a good one when one has a headache, as sleep can be restorative and often alleviates headache. This is why it may be the case that your doctor may give you some sleep inducing agent that helps with sleep for the difficult times that you have troubling headaches.

Even though sleep can be restorative it is not at all uncommon for headache sufferers to wake from their sleep with a headache. In fact it is said that 50% of migraine starts during sleep. This can make aborting a migraine a challenge, if one wakes up with the headache. Not only migraines are experienced upon arising, and in fact if one begins to have daily morning headaches, this can be medically significant, and may require prompt attention.

Sleeping tips

Seek medical attention if you have: Have a change in headache pattern and have developed daily morning headaches Have loud snoring, breathe holding episodes, choking spells associated with your headaches Frequent insomnia associated with your headaches Fall asleep inadvertently during the day such as when driving a car, talking.

At night:

  • Use the bed for sleep and not as a place to do activities such as work or watching television
  • Make sure the bed is comfortable. Most people sleep best in a dark, quiet and slightly cool environment
  • Try to sleep regular and consistent number of hours each night
  • Eliminate stimulants such as nicotine and caffeine
  • Exercise regularly, but not before bedtime
  • Night time sleep might be improved by eliminating naps

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Are Headaches Hereditary?

Absolutely, headaches run in families and the presence of headache in the family is one of the things that helps to establish the diagnosis.

If one looks at children and adolescence almost all have a known family member with migraine. Specifically if one has a single parent with migraine then one’s risk is about 30% and if both parents have migraine then one’s risk is about 70%.

It is important to realize that migraines manifest themselves differently at different ages. For example children might get cyclic vomiting without the headache and older people might get visual auras without the pain, but it is the family history as well as the personal history that often helps with making the diagnosis.

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Medication over use headache

It’s easy to overuse headache pain medication as there are abundant treatments available over the counter. Overuse or rebound headache can be a result primarily of over the counter products, but also of caffeine and some prescription pain medication. While one do not always know if one’s headaches will completely clear up with withdrawal of the offending agent (i.e. true rebound headache) or simply be easier to manage, all headache specialists feel that medication over usage is to be avoided and headache control is easier off of the offending agents. Rebound or medication overuse headache can be a vicious problem to treat. Rebound or overuse headaches often require professional help for detoxification. If you take off-the-shelf or prescription pain medication on more than 2 days a week, or drink 4 or more cups of caffeinated products a day, then you are at risk of developing overuse headache or analgesic rebound headache.

Medication overuse headaches typically last many hours per day and are a steady, pressure type pain all over the head. They may resolve temporarily with another dose of pain killers, but a hallmark is that they are headaches that become unresponsive to the usual dose of pain killers.

If you think you may have medication overuse headache, a headache consultation may be helpful.

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Here is a quick self- test for migraine

  1. Do your headaches sometimes limit your day’s activity, and cause disability?

  2. Do you experience nausea when you have a headache?

  3. Does light bother you when you have a headache?

A “yes” answer to two out of three of these questions could mean that you have migraine and should seek consultation for this condition. A YES answer to all 3 questions makes it very likely that you have migraine. It is possible that you could still have migraine even if you answer “no” to all 3 questions as there are many with atypical migraines, but this test captures a large amount of people who did not realize that they had migraines.

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What is caffeine withdrawal headache? How to minimize the risk

Many people discover that they have caffeine withdrawal headache when they stop drinking coffee. Others are not aware they have this problem but get headaches on the weekend when they wake up late and miss their early morning caffeine fix. Caffeine is ubiquitous and is in many products other than coffee and tea, for example, Extra Strength Excedrin, Mountain Dew, chocolate and no-doz pills.

When does one get caffeine withdrawal headache? If a person is used to ingesting approximately 200 mg/day of caffeine over several months to years, then on a day when the caffeine level drops either through abstinence or a decrease in usage, then one can experience caffeine withdrawal. The headache feels like a throbbing headache, just like a migraine, which may improve if one takes some caffeine.

Rather than experiencing caffeine withdrawal, most headache sufferers would be better off avoiding this by limiting the amount of caffeine they ingest on a daily basis. If they are less dependent on caffeine, then caffeine can actually be used like a medication to abort acute headache.

Typical doses of caffeine found in various foodstuffs:

Food/Beverage Mg
Coffee- based on 5 oz serving  

Instant, regular

Soft Drinks, based on 12 oz serving  

Cola including diet
Mountain Dew
Ginger Ale, Root Beer


No doz
Excedrin extra strength
Fioricet, Fiorinal
Darvon Compound
Norgesic Forte

Chocolate/Cocoa 1 oz  

Baking chocolate
Dark Chocolate
Milk chocolate
Cocoa 6 oz


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Do you have sinus headache? Probably not…

Sinus headache was a term coined by the folks who made Bayer aspirin which gained popularity, but it is a misnomer, few actually have headaches due to their sinuses even though the pain is commonly located over the sinuses. The reason for the pain over the sinuses and the presence of clear nasal drainage has to do with the innervation of the nasal passages with branches of the trigeminal nerve which is irritated in migraine.

In a large study of approximately 3500 patients who carried the diagnosis of “sinus headache” were examined by a group of seasoned neurologists, only 5 % were found to have significant sinus disease and the rest were predominantly found to have migraine or other vascular headache.

Sinus headache should be seriously entertained when the individual has thick discolored nasal discharge, pain to palpation over the affected sinus, possibly fever. Although this is not always seen depending upon the location of the sinuses infected this is the more usually scenario. Endoscopic sinus examination or sinus x-rays or CT may be necessary if there is any doubt about the situation.

It is certainly the case that patients may have sinusitis or nasal allergies as a trigger for their migraines. This may be why relief can come from using antihistamines and other sinus preparations; but the best relief comes from specific migraine medications such as the triptans acutely and other preventive medication.

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Botox™ (botulinum toxin A) is one of many of the Botulinum toxins. There are several other that are commercially available, but we will refer to Botox generically as this is the agent most widely used. It has gained popularity in the practice of Neurology since its first approval by the FDA in 1989, but was discovered to have medicinal properties by the American military around the time of WWII in the process of developing biological weapons.

Botox™ was specifically approved by the FDA for treatment of painful dystonic conditions such as blephorospasm (eyelid twitching), torticollis (neck tilting), spasticity (for example as seen after stroke, spinal cord injury, cerebral palsy) and later gained approval for other purposes as well such as wrinkle treatment and, hyperhydrosis. In the course of treating patients for wrinkles it was discovered that treatment also alleviated headaches. For the last 10 years or more many pain specialists have been using Botox™ for treatment of migraine. Botox™ works by blocking neurotransmitter release from nerve endings to muscle, allowing the muscle to relax. As a result, abnormal movements or muscle contractions are decreased.

Individual response to Botox™ is highly variable in part because the method of delivering treatment is customized and there is no uniform protocol that is the standard of care. Hence treatment with Botox is subjective and dependent upon the skills and experience of the operator. For headache numerous small injections are made typically 10-20. Because of the variability in technical skills and treatment strategies Botox™ has been very difficult to study and to demonstrate consistent clear cut effectiveness. We have found that treatment success for our patients has been fairly high and many patients return multiple times for reinjection. In general the benefits of Botox™ start within 2 weeks after injection and last about 3 months. Typically the best response occurs after the second or third series of injections.

Botox™ treatment is not without side effects, but they are rare and transient as the effects of the medication generally wear off after 90 days. After very long term use or large doses of Botox™, there is a slight chance of developing antibody resistance rendering treatment ineffective with this agent, but treatment can still be continued if one switches to another botulinum toxin.

For torticollis, spasticity, and other dystonias, most insurances including Medicare cover the treatment. For other indications, coverage is variable and a pre-authorization from the insurance company is needed if reimbursement is desired. For further policies regarding this matter please feel free to call Andrea Dorsett, our billing specialist.

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Trigger Point Injection

This is a technique that was popularized by the late Janet Travell, MD and her associates working in the 60’s-80’s. She discovered that tight contracted muscles had trigger points, tight ropy bands or muscles or knots that twitch when touched, squeezed or pricked and that caused refer pain into other areas. EMG studies suggest that the muscle spindle is the source of the contraction, and when it is treated successfully it relaxes and the referred pain and tight muscle dissipate. In addition muscle strength is enhanced by treating a trigger point as a contracted muscle is a weakened muscle and a relaxed muscle is a stronger muscle.

The goal of myofascial therapy and trigger point injection is to relax these contracted muscles to alleviate pain. Sometimes despite stretching, strengthening, massage and physical therapy muscles remain contracted and tight. This is why trigger point injection therapy may be helpful. A thin needle is used to pierce the muscle multiple times. The goal is to elicit a twitch response in the muscle. Although some Lidocaine or Bupivicaine may be added to the injection needle, this is only so that the procedure is less painful. Dry needling is also possible without any medication with equally as beneficial effect.

Generally trigger point injection is done as an adjunct to physical therapy. Sometimes it is done diagnostically or as a tool of demonstrating to a patient that their pain is muscular in nature. Occasionally this is done repeatedly when other techniques fail to elicit a long term response, for example in a patient who is already hyperflexible. Trigger point injection generally last 2-4 weeks. Typically patients will be encouraged to do stretches and strengthening of selected muscles to help maintain the pain relief.

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Additional Links

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Greater Washington Headache Center
1101 30th St., NW | Suite 320 | Washington | DC | 20007
202.625.4898 | 202.625.4899 fax

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