Insight from Dr. Ravitz


Considerations on Cause

Look at the picture of the tree above and let's consider a few words about cause.  

I am always grateful for the explosion of information available to us, and amazed by the amount of research that is done in both the basic and medical sciences.  It is interesting to look at the human being from the outside and how far we have come in unravelling the mysteries of the things we can see from the outside down to the building blocks of life called DNA.   The technology of imaging has allowed us to see tissues, anatomical structures, and even cellular pathways now in ways like never before. Scientists and doctors are constantly performing eloquent experiments to test hypotheses about mechanisms of actions, chemical pathways, and the ways in which genes are turned on an off. 

This had led to drug discovery, understanding of disease course and many other fascinating and helpful discoveries.   But as I continue to practice medicine, I can't help but look at lot of the gray areas and things that we didn't look at in medical school or think about as we followed the path that science has taken.   In most cases, including almost all diseases states and pathological conditions, we are seeing the far downstream effect of a cause that began much much earlier than the effect or disease we see. And as physicians and as a group of scientists and doctors, we continue to treat the effect of the disease and rarely ever get to the cause. Even as we look deeper into the causes and have answers to complex molecular interactions and have mapped and sequenced the entire genome we are often stumped and surprised by what actually turns on and off these interactions and we still don't really know the \"why\" of how genes are turned on or off.   

Heart disease, cancer, lower respiratory disease, stroke, Alzheimers disease, diabetes, kidney disease and suicide are among the 10 reasons that people die in America. The first two, heart disease and cancer account for up to half of those deaths and are chronic long term conditions. In America we spend more money on healthcare than any other country but do not have the longest life expectancies or the best health outcomes. Our treatments and cures are often band aids that we put on a metaphorical fire, but we rarely touch the gasoline that fuels the fire, and almost never get to change or stop the spark that started the entire process. 

I think now a lot about Des Cartes, years after I finished medical school.  Around 1640, he proposed his theory of mind body dualism or Cartesian dualism. It is possible that the theory of mind and body separation started here?   If so the implications are huge and divisive. This theory separates the mind from the body and it has kept these two entities separate. Meaning what goes on in the mind has nothing to do with what goes on in the body.   Is this really possible?  We continue to look for causal agents of things in large studies, but often these don't prove to help us much in the long run.  

I am often up against this in my neurology practice.  A migraine is one of the most common conditions I treat in my practice.  A debilitating condition, it commonly affects women more than men, it is typically a severe one sided headache with light and sound sensitivity and nausea. Many people miss work and life activities with the symptoms.  Interestingly, when we perform CT scans and MRI's looking for the cause of it, the scans are normal more often than not.  In fact, this type of headache is classified and diagnosed by having \"symptoms not attributed to another disorder\".  Meaning, the pain is not caused by bleeding or pressure in the brain for example. Many causes of a migraine have been proposed including blood vessel dilation and contraction, a channelopathy (ie a problem with cellular ionic transport), cortical spreading depression (an electrical excitatatory signal) and muscular tension. The condition is probably genetically determined. The culmination of these well researched theories is that patients with migraine have a very sensitive brain and under certain conditions (that we will discuss in more detail in a different blog) may get a migraine under seemingly normal innocuous circumstances or minimal stressors.   

Time and time again in my practice, I sit in front of patients who have normal scans and ask me:  \"But what is the cause of my headaches?\"

Unfortunately at this time, modern medicine and I as a student of this teaching can not answer that question with certainty.   That is, I do not know the root cause of migraines.   However, I can and will talk more about these headaches and pain conditions including how we treat them, what are major triggers and what the research is discussing.   

Let's look at the picture of the tree again.  If we were standing above the ground looking at the tree, we could see all the branches and leaves that have bloomed, but we can't see the roots under the ground.  They also grow deeply.   As a metaphor for this picture, we can now \"see\" the anatomical structures deep under our skulls with MRI scans and other imaging techniques. We are even able to start to see the ways in which cells work and communicate with each other just like we can see the roots connect to the trunk. But in the case of migraines (and many other things in medicine incidentally) we don't know the true \"Cause\" of why a pain or disease starts.  

We are often not treating the cause of diseases including migraines.  We do however have treatments to make them more tolerable and to go away faster.



the kaiser foundation

\"The headaches\"


Dr. Ravitz


An exploration of Neurology, science, theory and everything in between.

If I could give away a dollar for every time someone had a headache and saw me as a doctor, I would be able to start a small foundation. The incidence of headaches in America runs around 16 percent for migraines and upwards of 30-70 percent for tension type headaches. In some larger studies it has been the 4th leading cause of ER visits. That’s a lot of people having a lot of headaches every year. Is this something new, some new affliction of the modern world?

What do we really know about headaches?

Headaches have been reported since the time of Hippocrates and before. Burr holes, or small holes that were intentionally drilled through the brain have been found in the skulls of mummies from ancient Egypt which are believed to be close to 6000 years old. Scientists believe that these holes may have been early \"neurosurgical\" procedures possibly to alleviate head pain, release fluid, and attempt to anatomically study the brain. Mythological texts have reported detailed accounts of headaches in Ancient Egypt, Rome, and Greece. Meaning, those heroes we read about....complained about their headaches. There are textbook descriptions of migraines and other types of headaches dating back to first century Rome.

What we do know is that headaches are not new for the primordial man being.

It has been more recently, ie in the last 400 to 500 years that we have brought the knowledge from these times and studied headaches in a more scientific and rigorous fashion. While we are able to classify headaches into a structure that helps us to target treatment better, utilize medications in ways that shorten or reduce headaches, have the ability to see tissues and structural anatomy with imaging such as CT and MRI scans in ways we have not in the past, we seemingly have more headaches (no pun intended) and less answers about the root cause of these painful debilitating syndromes. So what does this mean for us modern humans walking around with proportionally big heads?

What do we know in the modern world about headaches?

There have been many proposed mechanisms for the causes of headaches. A genetic predisposition, nerve activation, muscle tension, and other ideas have been proposed, but none that have been able to consistently fully explain why and what occurs. We still don't have clear answers to these questions. I want to use this blog to explore some of these questions, look carefully at what the science has to say and to start to consider other ideas, and thinking can have a pervasive role in our health.


Dr. Ravitz


Telemedicine for Headaches

The team at City Neurology believes that telemedicine is an exciting and modern way for patients to get highly effective specialized care for their headaches. There is already a shortage of Neurologists and in some studies, by 2025 the patients needing Neurologic services will be larger than the supply of Neurologists able to see patients by more than 19%!!!  

What does this mean for patients?

This just represents the number of Neurologists available. There are even fewer headache trained specialists and long wait times to see these doctors. People often go to emergency rooms and to see their primary care doctor only to be told to go see a Neurologist. In 2012 for example, the average wait time was 35 days to see a Neurologist!  That's a long time to suffer with a headache and not get answers to questions or pain relief. This time is increasing according to new studies. Many patients go and wait in an emergency room for hours more than one time because they can't see the right headache neurologist. 

Is telemedicine a safe and effective tool for managing headaches?

A recent study in Norway was published in the journal Neurology, the journal published by the AAN (American Academy of Neurology), the board governing the accreditation of Neurologists in the United States.   The title of the study was FOR HEADACHE, TELEMEDICINE MAY BE AS EFFECTIVE AS IN-PERSON VISIT.

The study was performed by Dr. Muller of the Arctic University of Norway. 201 patients were treated either in person and the other 201 patients were treated utilizing telemedicine for headaches.  

There were no differences between the groups that had the traditional office visits verses those having telemedicine visits based on safety markers and measures of levels of pain before and after the treatments.
In each group, one secondary cause of headache was found, which did not show any difference in the treatment groups.  

What is a Secondary Headache?

A secondary headache is pain in the head that is caused by another condition.  For example, bleeding in the brain causes an extremely painful headache.  It often causes other symptoms including a very stiff neck, but sometimes just causes pain. People are often worried about other causes of headaches. Neurologists and headache specialists are also worried about missing secondary headaches. As doctors, we look for what's called red flags to try to determine which patients are more likely to have something more serious. The study mentioned above had equal numbers of secondary headaches, so it may be just as likely for a doctor to miss something either in person or via telemedicine. Who are good candidates for headache treatment via telemedicine?

  • People who have had headaches for a long time that have been difficult to treat.
  • People who have had been to the Emergency room or have seen their primary care doctor and were told to see a headache specialist or Neurologist.
  • People who have seen many doctors in the past and would like another opinion about their painful headaches.
  • People who are far away from any Neurologists and Headache specialists and have difficulty traveling to see a specialist.  

What is NOT a good person for telemedicine consultations for headaches?

Obviously, telemedicine is not appropriate for all medical conditions.

A new severe headache is not appropriate for telemedicine.

Any headache with other Neurologic findings including fever, inability to talk, or a headache with new visual changes, numbness, weakness or tingling is not appropriate for a scheduled telemedicine consultation.   

If there is any urgent question, always consult your nearest emergency room.  

GO TO THE EMERGENCY ROOM or dial 911 for these emergencies.


Dr. Ravitz


Let's talk about the M-word.

The explosion of research in migraine is in stark contrast to way that migraine was treated in the past. If you have every had a migraine or know someone who has had migraines, it is not your simple headache. It can affect many organ systems (more on this below) and is often a debilitating condition that sends people to the ER.

Doctors diagnose migraines clinically, that is; we listen to a patient and base the diagnose almost solely on the symptoms a person has. There is no imaging test or blood test that will confirm the diagnosis of migraine. We often get pictures of the brain and run other tests to make sure that we are not missing something more serious such as a brain aneurysm or tumor.

The clinical criteria for migraine is as follows (the criteria doctors use to make a diagnosis of migraine):

A person has at least 5 painful attacks lasting from 4 hours to 3 days. The pain has 2 out of 4 qualities:

1. a pulsing or throbbing quality
2. one sided pain (unilateral headache)
3. moderate to severe pain
4. pain is worsened by regular physical activity (ie walking up stairs or bending over).

During the headache there is either nausea or vomiting, and light or sound sensitivity. These headaches CANNOT be explained by anything else. This means there is no bleeding in the brain or other problems to explain the pain.

Fast facts about migraines:

Migraines are a significant cause of disability, missed work and emergency room visits. They are much more common in the active working years (ages 15-55). Lost productivity has been estimated at 5.6 billion dollars because of missed work and restricted activity.In one study almost 24 percent of females age 21-30 experienced a migraine in a year. Migraines are more prevalent in woman affecting them two to three times as much and hormones likely play a role in this phenomenon. One third of patients require bed rest during a headache.

What causes migraines?

There is a lot of mystery surrounding the true cause of migraine headaches. Many theories have been proposed regarding migraine headaches, but none have been proven. Migraine tends to run in families and there is clearly a genetic component to them. Some of these theories explain the pain pathways that occur during a migraine but the root cause of why they occur is still unknown.

Some of the pathways involved in migraine include:

-Activation of peripheral trigeminal nerve branches. These branches directly innervate and affect the brain blood vessels and the surrounding covering of the brain that is called the dura mater. Both the dura mater and the blood vessels can \"feel\" pain and cause pain to be registered as a symptom in the brain. The actual brain substance does not experience pain. These nerve branches also send pain signals into the blood stream including glutamate, substance P, and CGRP. These painful substances can make the head more sensitive to pain and it takes the body time to \"clear\" out these particles that are involved in inflammation and excitation. An \"inflamed\" and \"excited\" brain is primed to feel pain and \"wired\" to set off a cascade of patterned events. In this case, a migraine.

-plasma extravasation- This process describes the process by which the nerve receptors in the brain release more painful substances into the blood and circulation, thereby furthering the pain process.

-\"Sensitization\" describes the process by which nerves become more reactive and can feel pain by something that usually doesn't cause pain. For example a gentle touch of the scalp may be painful in a patient that has migraine, but not in a person who doesn't have migraine. There are many levels of this pain process that may be affected by this process. In effect, the pain tends to make more pain!

-Imbalances in brain neurotransmitters such as Serotonin have been seen experimentally in migraine brain pathophysiology. This is the target of some of the medications specifically for migraine. Overall, a migraine brain is more excitable and affects other parts of the brain that control a variety of functions in the body including balance, wakefulness and sleep, reactions to normal stimuli, thinking processing speeds, mood, and appetite. More on this in future blogs.

Why are migraines often under diagnosed and are under treated?

Migraines are less common then tension type headaches (discussed in a separate) blog, but have more far reaching symptoms. These headaches have specific treatments and sometimes can be refractory and not respond to simple treatments that work for some milder types of headaches.

Neurology is a highly specialized field and within that field, headache medicine has grown into a field onto itself. So even some Neurologists are not familiar with the newest treatments for headaches. Headache specialists have spent a long time learning the nuances and art of treating headaches. There is trial and error in finding the right medications for treatment and patients need to be educated carefully about their condition.

Migraine is an episodic condition; meaning it tends to come and go. Patients often go to an emergency room or see their primary care doctor after they have had the symptoms. Often they get treatment that puts them to sleep or they are told to see a specialist. The wait times for these types of doctors can be months. Consulting a specialist online such as City Neurology is an appropriate way for a headache specialist to assess symptoms, schedule follow ups and get you on the right track for migraine care.


Dr. Risa Ravitz