Making the Decision to See a Headache Specialist
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A common question that arises for headache patients, including migraine, is when to see a headache specialist as opposed to continuing to have their primary health care provider be the one managing their headaches. As a headache specialist, I have put together a list to help you decide when it is time to see a specialist for your headaches.

  1. Are you comfortable with the diagnosis given for your headaches? For example, if migraine headaches are your diagnosis, does it make sense given what you have read and know about migraines? Are your headaches throbbing, worsened with activity, associated with nausea, sensitivity to light and/or noise, and are there predictable triggers such as stress and for women, menses? Perhaps you are wondering if your headaches are cluster or tension or you are worried about a brain tumor. If there is any doubt of your headache diagnosis and your primary care provider is not open to helping you make a specific headache diagnosis, then it is time to ask for a referral to a headache specialist (often is a neurologist but not always; many internists and family physicians like myself have gone back for extra training and are headache specialists).
  2. Are you satisfied with your treatment? For headache episodes, are you headache free and back to full function in 1-2 hours? Are you being offered oral and non-oral treatment options including nasal spray and injectable options for when your headaches are severe and/or associated with nausea/vomiting? Does your primary care provider seem up-to-date with the “triptan” class of migraine specific medication or are they resorting to non-specific pain medications such as hydrocodone (Vicodin; Norco); butalbital containing medications (Fioricet; Fiorinal); or telling you to simply take over the counter medications such as Ibuprofen or Naproxen or Acetaminophen?
  3. Is there a changing or worsening pattern to your headaches? Are there new neurological signs or symptoms such as loss of vision, confusion, slurred speech, tingling on one side of your body with your headaches? Are you having a new type of headache that is different than your normal headache? Is your headache frequency much greater than it has been? Is the severity and/or duration of your headaches increased? Answering yes to these questions necessitates a re-evaluation of the diagnosis; an evaluation to discover the reasoning for the worsening pattern; and may require neuro-imaging with a CT or MRI of the brain and/or referral to a headache specialist. If your primary care provider does not seem interested in your worsening pattern of headache, it is time to see a specialist!
  4. Is medication overuse/rebound headache an issue that is not being addressed? It is well-known that taking an acute medication such as Sumatriptan (Imitrex) or Butalbital (Fioricet) or Hydrocodone (Vicodin) or Excedrin can cause medication overuse headache (rebound headache) if taken more than 2 times a week on the average. If this is your pattern and your primary care provider is not equipped to address this issue and offer you options on how to get out of rebound, including getting more aggressive with preventive options, it is time to see a specialist.
  5. Is your primary care provider aggressive with offering preventive treatment options?Preventive treatment for headaches, including migraine, should be offered for as few as 2-4 headaches a month if they are severe, prolonged, and associated with significant disability. A daily preventive medication with an anti-epileptic such as Topamax or Depakote or an anti-hypertensive such as Inderal or an anti-depressant such as Elavil or Effexor or Cymbalta should be offered. Also, if your headaches are 15 or more days a month of migraine, then Botox should be offered as a treatment option. Botox has been FDA-approved for Chronic Migraine since 2010 so your primary care provider should be aware of this treatment option. If you need a more aggressive preventive option, then ask your primary care provider to refer you to a headache specialist.

In summary, if you are not comfortable with your headache diagnosis or your headache treatment, then you need to see a headache specialist. Don’t suffer in silence with underdiagnosed or undertreated headaches. Get the care you need and live the life you deserve as free of headache as possible!

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