Do I need an MRI to diagnose my Headache?

Over the past few years, the number of CT and MRI scans for headache symptoms have been increasing. The increase has concerned experts, and has led to campaigns to stop scans that aren’t needed.

Unneccessary scans can lead to direct health risks (particularly in the case of CT scans), they can lead to more unnecessary tests, wasted money and time, and in almost every case they will not lead to any new treatment.

MRI for Headache?But there are times when MRIs (magnetic resonance imaging) should be requested. Along with concerns that too many MRIs are being done is the concern that doctors aren’t asking for them at the right time. A recent study in the USA indicated that many doctors may not recognize the “red flags” that warn doctor and patient that more investigation is needed.

So – the big question – should I as a patient be asking for an MRI? Or, as a doctor, should I refer a patient to have an MRI?

The answer is complicated. And the decision needs to be made with a lot of knowledge of the context of each patient.

Before a decision is made…

What needs to be done before a final decision is made? First, a proper and complete neurological examination. This means a lot of questions from the doctor to the patient. When did the pain start? What other symptoms are you experiencing? Are the symptoms temporary, or permanent? Are they getting worse?

This will also include medical history questions, and possibly (ideally) family history questions. Do you have family members who suffer from migraine? What other conditions have you been diagnosed with? Any childhood diseases?

One great example is visiting the doctor with a new headache. A new headache is often a good reason for an MRI. However, with a family history of migraine, and a history with related disorders, and symptoms consistent with migraine, an MRI won’t be necessary. But if there is reason to suspect another cause for the headache, or certain symptoms are present – an MRI will be called for.

Other important factors are gender and age. For example, getting headaches for the first time when you’re over 50 is a good reason to consider an MRI.

So even before we look at the warning signs, we have to assume you have a qualified doctor who is asking the right questions.”Red Flags”So what are some of the danger signs that may mean you should be getting an MRI? Here are a few examples.

  • As mentioned above, a new headache (a new type of headache in someone who doesn’t generally get headaches), especially if symptoms have appeared suddenly, is a good reason to call for an MRI.
  • A progressive headache. When symptoms get continually worse, an MRI may be required.
  • Exertion headache. Any headache that seems to come with exertion, such as straining to use the toilet, a sex headache, a headache you get when exercising. This is specifically a headache that appears directly because of exertion – most “exercise headaches” that come from moderate to intense exercise are not the same thing, and will probably not need an MRI for diagnosis.
  • Headaches that change with head position, or that show signs of raised or lowered intracranial pressure. This can be tricky, because a feeling of “pressure” or “fullness” is common in migraine. But hearing sounds, a change with head position, a worsening feeling of pressure – these things may indicate another problem, and an MRI may help with diagnosis.
  • Certain other symptoms, such as neuralgic pain. There are too many other possibilities to list, but one example is shooting, sudden pain along certain paths, certain vision or hearing problems, changes in behaviour and weakness.

And then what?

Even if an MRI is called for at the right time, it’s very likely that it will not show anything and simply confirm that you have a headache condition such as migraine. However, more tests may be called for if something shows up.

Many symptoms that look like something else are actually migraine. Migraine can look like stroke, or brain tumour, or sinusitis. But in certain cases it is worth it to investigate further.

If you are a doctor, this is worth taking at least a few minutes to study further. An excellent place to start is the MedScape article MRI in Headache by Dr. Michael Eller and Dr. Peter J Goadsby.

For more information, check out the links above, and also Most headache-related brain scans aren’t needed from Harvard Medical School and Imaging: Do I need an imaging study for my headache? from the American Headache Society Committee on Headache Education (ACHE).


Dysautonomia and Migraine

Yesterday we took a quick look at dysautonomia symptoms and the relationship between dysautonomia and migraine. Today we’re going to talk a little about what you can expect, and what you can do, if you have both migraine and a dysautonomia disorder.

Migraine and DysautonomiaYour prognosis will vary drastically depending on what type of dysautonomia you have been diagnosed with. As we mentioned yesterday, some types of dysautonomia are progressive, and can shorten your life. Other types are chronic, and never go away completely. Some resolve on their own. Some are severely disabling (limiting your ability to get out of bed), while others are mild.

So it is very important to get a specific diagnosis, and to talk to a specialist who can guide you. There is help available, but you will need patience to find what works and to improve your quality of life.

Lifestyle Changes

In general, you will fight dysautonomia symptoms with changes in lifestyle. Diet changes can be key – drinking plenty of water, increasing your salt intake, avoiding sugar, artificial sweeteners, alcohol, and caffeine, and eating several small meals during the day, for example.

Exercise is important, but can be very challenging for patients with dysautonomia. A gradual increase in moderate exercise is usually planned.

As with migraine, an overall healthy lifestyle will go a long way. But there are some specific changes you may need to make depending on your specific diagnosis.

Other (non-drug) Treatments

Other treatments may include wearing compression stockings and elevating the head of your bed. Sometimes supplements are recommended.

Drugs: A Balancing Act

Sometimes drugs are used for dysautonomia as well, but this can be a very challenging balancing act.

For one thing, some drugs that you may be familiar with can actually lead to dysautonomia, such as some drugs taken for high blood pressure or depression – and yes, drugs for migraine. You may need to take a medication which will contribute to your symptoms, but hopefully you can find something that will have only a small impact (I’m talking about changing to a different but similar medication). Your doctor will need to monitor you carefully. Watch your symptoms, but don’t expect them to go away completely.

If you have a dysautonomia from another disorder, such as diabetes, your treatment will likely focus on the “primary” condition. In some cases, you may take medications for both, but again, it’s a difficult balancing act.

Some medications that may be used in some cases include fludrocortisone, midodrine, and ephedrine. Medications will require monitoring and adjustment over time.

You may need to adjust your migraine medication, because it could be making your symptoms worse. This is another reason why it is helpful to speak to a specialist.

Selected Sources and Resources

Here are some of the key sources I’ve used in these two articles, as well as resources you can use to learn more:


Dizziness – Migraine – Could they be Dysautonomia Symptoms?

If you feel dizzy, weak, or faint when you stand up or get up from lying down, the culprit could be dysautonomia symptoms. And missing the diagnosis could lead to some serious problems.

We’ve been talking quite a bit about fainting and migraine lately, and of course dizziness and vertigo are a constant topic. 25-35% of migraine patients experience vertigo, for example. And as we discussed back in April, migraine patients are more likely to faint in general, though fainting during an attack is not common.

Could there be another condition – such as dysautonomia – underlying this and other symptoms of migraine?

What is Dysautonomia?

Dysautonomia is a disorder of the autonomic nervous system. This relates to many of the things that your body controls automatically, without you thinking about it – things like the function of your heart or bladder.

As is the case with “headache”, dysautonomia is an umbrella term used to describe a problem that may come on its own or related to another disease (such as diabetes or Parkinson’s disease). So if you have “dysautonomia”, the next question would be “which one?”

As is also common with headache and migraine, health providers aren’t always in agreement about what those sub-types should be called. Beyond the terms that actually use “dysautonomia” in the name are terms with words like “hypotension” (low blood pressure) and “syncope” (fainting), “orthostatic” (relating to upright posture) and “postural” (posture related).

Dysautonomia Symptoms

These terms relate to the most common (though not universal) dysautonomia symptom – faintness, dizziness and/or weakness when you sit up or stand up. This happens to everyone under certain conditions, but for someone with dysautonomia the body can’t properly regulate blood pressure, causing it to drop suddenly when you get up.

dysautonomia symptomsOther common dysautonomia symptoms relate to bowel and urinary tract function. For example, diarrhea at night, abdominal pain, frequent urination, or inability to urinate when you need to (or not realizing that you need to).

Fatigue is also common in dysautonomia.

Many of the dysautonomia symptoms listed here will be familiar to migraine patients – brain fog, photophobia or phonophobia, nausea, insomnia, and dizziness, to name a few.

Dysautonomia can be tricky because sometimes the symptoms are hardly noticeable – or may not be present at all. Often patients won’t bother mentioning slight changes in their stool (poop), for example.

Types of Dysautonomia

Some kinds of dysautonomia don’t come directly with another disease – you can call this “primary dysautonomia”. “Secondary dysautonomia”, then, is directly related to another disease, such as diabetes. As with secondary headache, treatment focuses on the main disease.

Dysautonomia may also be degenerative or non-degenerative. Degenerative types get progressively worse over time, and can be fatal. One example would be multiple system atrophy (MSA).

Non-degenerative dysautonomia would include postular orthostatic tachycardia syndrome (PoTS) – which can be very serious and disabling.

You can find some types of dysautonomia listed here.

Dysautonomia and Migraine

Headaches and other migraine symptoms are common in dysautonomias. You would think that researchers would have noticed the connections between migraine and dysautonomia – and you would be right. Recently we discussed the link between migraine and Parkinson’s. Patients with dysautonomias have noted headache and migraine attacks as common symptoms or comorbid disorders.

In research, links between migraine and certain types of dysautonomia have sometimes been obvious, though at other times there seems to be no connection at all. This is not a surprise, since there are many kinds of migraine just as there are many kinds of dysautonomia.

But at the end of the day, it is common to suffer from migraine attacks as well as dysautonomia symptoms. Why the two are sometimes connected is not clear.

Do I have Dysautonomia?

It is very important to get a specific diagnosis if you can – and that goes for both migraine and dysautonomia, which are both umbrella terms.

If you’ve noticed problems with weakness and dizziness when you get up, and it happens consistently, you’ve been blessed with a big clue. If some of the other symptoms above sound familiar, you may have more clues. (Sometimes there are few, very mild, or no symptoms at all.)

Your doctor will want to know as much as possible about your symptoms, even if they are mild. Then she will want to do some tests.

The tilt-table test is key. The patient will lie on a table which will (you guessed it) tilt at varying degrees to test symptoms and blood pressure.

Other tests may include breathing tests, gastrointestinal tests, bladder function tests, and sweat tests. Read more here.

To be continued…

We will continue our discussion of dysautonomia tomorrow, looking at what you can expect if you’re diagnosed, and what challenges you may face especially if you have headache and/or migraine at the same time.


A Review of Icekap

Back in March I posted some information about “Icekap”, a “hat” with ice packs that can be used for conditions like migraine and insomnia. That may not sound like an astounding product at first, but it actually generated a huge amount of interest from our readers.

Andrea Jones, the founder of Icekap, was kind enough to send me an actual Icekap to try – so here’s a review.

Initial Observations

Taking my first look at the Icekap, I was impressed with the quality. This is not something that’s been thrown together. The material is soft. There are three ice packs, an extra “fleece sleeve” for one of the ice packs, and a bottle with 5ml of essential oil.

Actually using the Icekap

Ice pack for Icekap

Sliding in the ice pack for the posterior pocket.

Just reading the information on the Icekap website, this is the part I was a little confused about.

So what I did was put the three ice packs in the freezer. When I was ready to use the Icekap, I took them out. There are three “slots” on the inside of the cap. You can just turn it inside out and slide the ice packs in. It won’t fall out because of the way the pocket is designed.

3 ice packsThe first large one goes in the back, where it will cool the back of your neck. The second large one slides into a pocket on the top, to keep the top of your head cool. Finally, the long skinny one goes across the front, to cool your forehead. With the skinny one you have the option of putting it in an extra “case” so it won’t be quite as cold.

The Icekap then slides easily onto your head.

Icekap strapOn either side is a strap, which you can either leave loose or attach (velcro-type fastener), depending on how tight you want the cap to be.

The regular size Icecap (more on sizes in a moment) weighs about 640g once it’s all assembled together (if you use every piece). But it’s balanced and comfortable and didn’t feel heavy to me.

That’s it! You can press and knead the ice packs a bit to make sure they’re comfortable and where you want them to be.

The essential oil is basically a little bonus. It’s a mix of lavender peppermint in a coconut oil base. If you want, you can apply two or three drops onto your neck or wrists or even use it in a diffuser.

Pros and Cons of the Icekap

Oddly enough, my biggest complaint is that the Icekap is VERY cold. Now that is obviously what some people want, but let me explain a bit more.

The ice pack on your forehead is particularly pressed against your skin. Now there is more than one layer of material there, so it’s not like you’re going to get frostbite. But if you have a larger head (mine is about average, I think!) and the regular size Icekap, you may find it pressing quite a bit and so very cold.

I think the second time that I tried the Icekap the packs weren’t quite as frozen, so it was a little better.

Obviously this will vary with the temperature of your freezer. And the solutions are simple – in fact, it’s probably better to have the packs a little too cold than not cold enough.

First, you can add the extra sleeve for the pack in front. You can adjust the pressure somewhat. You can put the Icekap on for less time, and then repeat (that’s what I did, and it worked fine). Actually, you won’t want to have it on for more than 15 minutes to half an hour at a time.

Long ice pack with fleece sleeve

Long ice pack with fleece sleeve

Actually, the packs are very adjustable. You don’t even need to use all of them – you can easily wear the cap with only one or two packs where you want them. With the extra cover, you can use the long pack separately – I tried it, for example, on the back of my neck all by itself. It also works over the eyes if yours are feeling hot and swollen.

Now this problem would probably be solved with a large size Icekap. I would encourage the average and large men out there to go with the large for sure. It’s very adjustable, so it’s easier to make it more snug than to loosen it.

If anything, it was smaller around for me than it was up and down. But you can actually pull it down partway over your eyes to help block some light.

In fact, it’s reversible! You can wear it with the larger ice pack at the front (just turn the Icekap around) and have the cool and dark right over your eyes. Nice!

The packs themselves are excellent quality (I’ve tried quite a few different kinds – even reviewed one here). They didn’t get hard, and are easy to “knead” a little to the softness and shape you want them.

I also tried heating one – ten seconds at a time. Just knead it a little and let it sit for a couple of minutes so the heat is distributed throughout.

The material of the Icekap itself is soft and stretchy, and easy to adjust.

The ice packs are not hard to put into the Icekap. However, you might want to consider putting them in ahead of time, putting the whole cap in a freezer bag, and putting them all in the freezer together. That way you don’t have to mess around with assembly in the middle of a migraine attack. Again – they’re not hard to put in, but during a severe attack the easier and faster the better.

This is not a fashion cap you’ll want to wear out on the town, but it has the feel of a topper for a Yukon winter when you’re just getting the dog sled ready. :)

The essential oil is also an excellent bonus (and I’ve tested a lot of those too). Lavender and peppermint are two of the most popular oils for aromatherapy for migraine, and the go well together. Of course, not everyone will want to use the oils during an attack, but if not putting them into a diffuser at bedtime would be lovely.

Final thoughts…

Overall, I’m happy with the Icekap, I will continue using it, and I do recommend it. It does seem to be better than just using ice packs, because you can adjust the “cold therapy” against your head and keep it there even as you roll around in bed or move around the house.

I didn’t try it later on at night, but I suspect it would be a huge help for someone with insomnia. Grab it from the freezer and put it on, just for five minutes, and chances are you will sleep a lot better. You could even pull out the ice packs afterwards and put them in your pillow, although I think using the Icekap itself is far more effective. I hope to give it a try one day soon.

Thanks again to Andrea for the sample! If you would like an Icekap of your own, check out the official Icekap website. For more details and a video, you can also read my previous post, Have You Tried the Icekap for Migraine?.James in an Icekap

Oh, you wanted a picture of me actually wearing the Icekap? *sigh* Fine – just a little one. :)


Stroke and “Common” Migraine: A Genetic Connection?

We’ve known for a long time that there is a connection between stroke and migraine. But a new study seems to confirm at least a partial genetic basis for that connection. But there are some surprises.

The meta-analyses, published in Neurology earlier this year, compared thousands of cases of migraine along with thousands of cases of stroke and control patients. Their study looked for genetic similarities in the groups with various types of migraine and stroke, especially known genetic characteristics of either disease.

As expected, there was significant overlap.

Now we’ve mentioned the genetic connection between migraine with aura and stroke in the past. But the strongest connection in this study was between two types of stroke and migraine without aura. (That’s right, without aura.)

So what types of stroke had the most overlap?

➸ First, large artery stroke. Large artery strokes are a type of ischemic strokes, and it’s just what it sounds like – a large artery (which brings blood to the brain) is blocked.

➸ Second, cardioembolic stroke. This type, also an ischemic stroke, occurs when the heart pumps impurities (clots) into the cerebral vessels (blood vessels that supply the brain), causing a blockage and damaging brain tissue.

Recent research has allowed us to differentiate further between these and other types of stroke genetically, and so comparisons like these, although by no means precise, are becoming easier.

For now, this study further confirms that there is at least some genetic basis for the connection between stroke and migraine without aura – and so perhaps with most or all types of migraine. Further research needs to be done, but research needs to go beyond what seems to be the common tendency – to focus on migraine with aura.

For most of us, the advice remains the same – don’t panic, but watch your symptoms, get the best migraine treatment you can, and do what you can to lower your risk of stroke and heart disease.

Selected sources: