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What is Botox for migraine?

drsoh@sohheadachecenter.com (Peter Soh) — Fri, 11 Jul 2025 20:13:32 GMT

What is Botox for migraine?

OnabotulinumtoxinA (Botox) is an effective and safe treatment for the prevention of chronic migraine in adults. Botox for chronic migraine (PREEMPT protocol) is administered with a very small needle to 31 areas of muscle around the face, head, neck and shoulders every 12 weeks. The most common reported adverse side effects from the PREEMPT studies were neck pain (6.7%), muscular weakness (5.5%), eyelid ptosis (droopiness) (3.3%), and injection site pain (3.2%). Most reported adverse events were mild to moderate in severity.

A retrospective clinical study that was performed by Dr. Soh at the Hartford Healthcare Headache Center found that more than 50% of patients had a greater than 50% reduction in headache days per month after receiving Botox at six- and nine-months post-treatment. This retrospective study examined adults who were age 65 and older.

What are nerve block injections?

drsoh@sohheadachecenter.com (Peter Soh) — Tue, 01 Jul 2025 23:30:41 GMT

What are nerve block injections?

Pericranial nerve block injections are a minimally invasive procedure that can be safely performed in the clinic setting. Anesthetic, such as lidocaine or bupivacaine, is injected around the nerves of the face and back of head. Nerve blocks can treat acute headache pain, including stopping a prolonged headache, or can also be used as a preventive therapy for migraine headache.

When performed by a trained specialist, series of nerve blocks can be safely given including during pregnancy. In addition to pain relief, nerve blocks can also help improve symptoms of light sensitivity, sound sensitivity, and other bothersome symptoms related to an underlying headache disorder. Nerve blocks and trigger point injections may be used in combination for the management of migraine headache.

What are trigger point injections?

drsoh@sohheadachecenter.com (Peter Soh) — Mon, 30 Jun 2025 12:52:27 GMT

What are trigger point injections?

Myofascial triggers points are taut areas of muscle that can lead to pressure-sensitive areas and muscle pain. Muscle pain involving the neck and shoulders can often be symptoms in patients with migraine, tension-type, cervicogenic, and post-traumatic headaches. Muscle pain can also be common in patients with temporomandibular joint (TMJ) disorder.

Trigger point injections (TPIs) are a minimally invasive procedure that can be safely performed in the clinic. Anesthetic, such as lidocaine or bupivacaine, is injected into the shoulder and neck muscles with the goal of providing headache pain-relief or headache pain-freedom.

When performed safely by a trained specialist, TPIs can reduce the frequency and intensity of headache disorders. TPIs may also be used in combination with nerve block injections around the face and head for the management of migraine headache.

What is hemicrania continua?

drsoh@sohheadachecenter.com (Peter Soh) — Wed, 05 Mar 2025 22:32:05 GMT

What is hemicrania continua?

In the absence of a secondary headache disorder, hemicrania continua is a constant, one-sided headache associated with at least one of the following: eye redness or watering on the same side of the pain, congested or runny nostril on the same side of the pain, swollen eyelid on the same side of the pain, facial/forehead sweating on the same side of the pain, smaller pupil or drooping eyelid on the same side of the pain, a sense of restlessness or agitation, or aggravation of the headache by movement.

The headache is present for at least three months with exacerbations of moderate to severe intensity. Migrainous symptoms such as light sensitivity and sound sensitivity are often seen in hemicrania continua which can potentially lead to a misdiagnosis of migraine.

Hemicrania continua is treated successfully by a non-steroidal anti-inflammatory drug (NSAID) called indomethacin.

What is cluster headache?

drsoh@sohheadachecenter.com (Peter Soh) — Thu, 23 Jan 2025 22:47:51 GMT

What is cluster headache?

Cluster headache are attacks of severe, one-sided pain, usually in or around the eye that last for 15-180 minutes. Attacks can occur from once every other day up to eight times per day, and the attacks happen in groupings or “clusters” that last for weeks or months. Between clusters, symptom-free periods last months to years. During the worst attacks, the intensity of pain is excruciating.

Cluster headache pain is also associated with at least one of the following: eye redness or watering on the same side of the pain, congested or runny nostril on the same side of the pain, swollen eyelid on the same side of the pain, facial/forehead sweating on the same side of the pain, smaller pupil or drooping eyelid on the same side of the pain, or a sense of restlessness or agitation. Cluster headache is a rare headache disorder compared to migraine. For unknown reasons, men are affected more often than women.

Can sexual activity cause headache?

drsoh@sohheadachecenter.com (Peter Soh) — Fri, 03 Jan 2025 03:57:52 GMT

What is primary headache associated with sexual activity?

Primary headache associated with sexual activity is a headache brought on by sexual activity that can be severe intensity lasting from 1 minute to 24 hours and/or up to 72 hours with mild intensity. The headache usually starts as a dull ache on both sides of the head and is more often located in the back of the head or throughout the whole head. As sexual excitement increases, the headache intensity can also increase. The headache can also present suddenly with explosive intensity just before or with orgasm. Ruling out other conditions such as a brain bleed, blood vessel tear, or other vessel disorder is needed before diagnosing primary headache associated with sexual activity. This headache disorder is more common in males than in females.

Can exercise cause headache?

drsoh@sohheadachecenter.com (Peter Soh) — Sat, 21 Dec 2024 00:41:45 GMT

What is primary exercise headache?

Primary exercise headache is brought on by and occurring only during or after sustained strenuous physical exercise. The headache lasts less than 48 hours and is in the absence of any other disease process within the head such as a brain bleed, blood vessel tear, or other vessel disorder. Primary exercise headache can occur more frequently in hot weather or at high altitude. Although primary exercise headache can occur in patients with migraine headache, which may also be triggered by exercise, primary exercise headache is a separate headache disorder.

What is tension-type headache?

drsoh@sohheadachecenter.com (Peter Soh) — Fri, 13 Dec 2024 21:44:33 GMT

Tension-type headache

Tension-type headache is typically bilateral, pressing or tightening in quality, and of mild to moderate intensity. The headache lasts from 30 minutes to 7 days. The pain does not worsen with routine physical activity and is not associated with nausea, although light sensitivity or sound sensitivity may be present. If tension-type headache is chronic, or occurring on 15 or more days per month for at least three months, then the headache may be associated with no more than one of light sensitivity, sound sensitivity, or mild nausea.

Tension-type headache is the most common primary headache in the population and is commonly associated with migraine. Tension-type headache can be associated with tenderness in the muscles around the head.

Can fasting cause headache?

drsoh@sohheadachecenter.com (Peter Soh) — Tue, 03 Dec 2024 17:19:22 GMT

What is headache attributed to fasting?

Headache attributed to fasting is a diffuse non-pulsating headache, usually mild to moderate intensity, occurring during and caused by fasting for at least eight hours. The headache is relieved after eating. Headache sufferers have a higher risk of developing headache during fasting than people who do not have history of a primary headache disorder. In patients with migraine without aura, fasting can also be a trigger for migraine headache.

Headache attributed to fasting has been reported in prolonged religious fasting such as during Yom Kippur and Ramadan.

Do headaches occur around periods? What is menstrual migraine?

drsoh@sohheadachecenter.com (Peter Soh) — Tue, 19 Nov 2024 22:25:59 GMT

Menstrually-related migraine and pure menstrual migraine

Menstrually-related migraine without aura is a migraine headache without aura in a menstruating woman that can start as early as two days before first day of menstrual flow and up to two days after the first day of flow in at least two out of three menstrual cycles. These headache attacks can occur at other times of the menstrual cycle as well.

Less common is pure menstrual migraine without aura which is a migraine headache without aura in a menstruating woman that occurs exclusively during the time window of two days before first day of menstrual flow and up to two days after the first day of flow in at least two out of three menstrual cycles. The headache attacks do not occur at other times of the menstrual cycle.

The reason for distinguishing between menstrually-related migraine without aura and pure menstrual migraine without aura is that hormone prophylaxis is more likely to be effective for the latter.

What is a secondary headache? What are red flags? Why is this important?

drsoh@sohheadachecenter.com (Peter Soh) — Wed, 06 Nov 2024 15:40:33 GMT

Secondary headache

A secondary headache develops in relation to the onset of another disorder that is medically known to cause headache. Some possible examples include brain tumor, vascular abnormality, infection, autoimmune disease, metabolic disturbance, hormonal disturbance, trauma to the head, or medication-overuse. If a headache improves in relation to the underlying disorder improving or if the headache worsens in relation to the underlying disorder worsening (or both), then this would give further support for a secondary headache.

“Red flags” are symptoms or other clinical information that raise suspicion for a secondary cause of headache and can warrant use of further testing such as brain imaging, blood vessel imaging, lab work, and/or eye exam for further evaluation. Some examples of red flags include fever, a sudden maximum-intensity pain, other neurological symptoms, age greater than 50, pregnancy, change in pattern, or progression of the headache.

Although secondary headaches are much less common than primary headache disorders (e.g. migraine, tension-type headache), it is important to further evaluate any clinical red flags to help rule out a secondary headache. If another disorder is the cause of the headache, then identifying and treating the other disorder could prevent further worsening in health and headache symptom.

Are your headache medications causing more headaches?

drsoh@sohheadachecenter.com (Peter Soh) — Mon, 28 Oct 2024 21:07:33 GMT

Understanding medication-overuse headache

Acute medication overuse (AMO) is the overuse of acute or abortive headache medications and can be common among individuals with migraine or tension-type headache who experience frequent attacks. The threshold number of days that defines medication overuse depends on the medication. For opioids, butalbital-containing medications (Esgic, Fioricet), triptans, ergots, or combination analgesics, using 10 or more days per month would be considered AMO. For simple analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, using 15 or more days would be considered AMO.

Medication-overuse headache (MOH) is a secondary headache disorder occurring on 15 or more days per month in a patient with a pre-existing primary headache disorder (such as migraine or tension-type headache), and developing as a consequence of AMO for more than 3 months. MOH usually resolves after the overuse is stopped.

Patients can have AMO but also not meet criteria for MOH because they experience less than 15 headache days per month. Correcting AMO should be under the guidance of a physician or experienced provider, and not performed abruptly, or cold turkey.

What is a headache diary/journal?

drsoh@sohheadachecenter.com (Peter Soh) — Mon, 21 Oct 2024 19:48:20 GMT

Headache diary/journal

To avoid recall bias when trying to remember what happened over the last 90 days, a monthly headache diary keeps patients true to their actual experience. A headache diary is a continuous way for patients to track their symptoms in an organized and simple fashion to better understand the frequency of attacks, headache severity, effectiveness of medications used to treat attacks (abortive therapies); and other data such as days of menstruation and headache triggers (if applicable). Through simple tracking, patients can gain a better understanding of their headaches and empower themselves over their headache condition.

From a treatment perspective, the headache diary provides helpful data for providers to make clinical decisions such as starting a preventive therapy, increasing a preventive therapy, adding a different abortive therapy, or timing therapies for different situations that may be at higher risk for a headache attack.

What are non-pain symptoms associated with migraine headache?

drsoh@sohheadachecenter.com (Peter Soh) — Tue, 15 Oct 2024 02:25:46 GMT

Prodrome and Postdrome

Migraine has associated phenomena that can occur before and after the headache attack.

Hours to days before a migraine headache, patients can have prodrome symptoms which can include various combinations of fatigue, difficulty concentrating, neck stiffness, sensitivity to light and/or sound, nausea, blurred vision, dizziness, food cravings, increased urination, frequent yawning, pallor, or constipation.

Hours up to two days after the migraine headache resolves, patients can experience a postdrome characterized as tiredness, difficulty concentrating, neck stiffness, irritability, or even euphoria.

Understanding the prodrome symptoms of migraine can empower a patient to detect an oncoming migraine headache.

What is migraine aura?

drsoh@sohheadachecenter.com (Peter Soh) — Mon, 07 Oct 2024 15:15:48 GMT

Migraine with aura

These are recurrent attacks, lasting minutes, of one-sided fully-reversible visual, sensory, or other central nervous system symptoms that usually develop gradually, and usually followed by headache and associated migraine symptoms.

Visual aura is the most common type of aura and may start as a zigzag figure or geometric pattern in a convex (sickle or C-shape) form that may gradually spread right or left and leave varying degrees of relative scotoma (blind spot) in its wake.

Sensory aura can be a sensation of pins and needles moving slowing from a point of origin and affecting a greater or smaller part of one side of the body, face and/or tongue. Numbness may follow and could potentially be the only symptom.

Less frequent aura symptoms are speech disturbances, motor weakness, retinal disturbance, and brainstem symptoms with no motor weakness.

Two important characteristics of aura is the gradual spread over at least five minutes, and that the symptoms can be positive (for example, flashing lights in the vision, or pins and needle feeling in the hand). This is important to distinguish from transient ischemic attacks (TIA) which can also mimic migraine aura.

Aura without headache can occur but is less common than migraine with aura.

What is a migraine headache?

drsoh@sohheadachecenter.com (Peter Soh) — Tue, 01 Oct 2024 21:28:18 GMT

Migraine without aura

Migraine without aura is a recurrent headache disorder manifesting in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea and/or light and sound sensitivities.

Chronic migraine is headache occurring on 15 or more days per month for more than 3 months, which, on at least 8 days or more per month, has the features of migraine headache. Episodic migraine is less than 15 headache days per month.

Migraine headache is second highest cause of disability worldwide and affects more than 12 percent of the population.

Dr. Soh's radio interview

Wed, 17 Jul 2024 22:58:39 GMT

Dr. Soh discusses migraine and weather changes on 1110 KFAB weekend news radio .

David Nabity: I saw an article in the Omaha Herald that talked about a study linking extreme heat to migraine headaches. Evidently, the University of Cincinnati did a study that basically says that when weather changes and gets hotter, people have more migraine headaches.

Are people really getting migraine headaches as temperature goes up?

Dr. Soh: Migraine headaches are associated with many different factors. It could be genetics, it could be due to environment, to diet, sleep disruption, stress, and in the literature there is some data that shows that fluctuations in temperature, humidity can be a trigger for headache or migraine headache. However, there's multiple things that could happen at once that that could trigger a migraine headache.…So this study was based off diary data from about six hundred patients, and they tracked headache along with the different changes in weather in their regions, and they noticed that every ten degree change in temperature, there was an increased number of headache days. And this is approximately over a twenty-eight week period…it's really that change in temperature, that daily change in temperature.

David Nabity: Tell me what is a migraine headache?

Dr. Soh: A migraine headache is a headache that by criteria is four to seventy-two hours that's either untreated or treated unsuccessfully. It'll have two of the following four characteristics (1) one-sided unilateral, (2) moderate to severe intensity, (3) throbbing, pulsating pain, and (4) pain worsened by movement. And at least one of the following two: (1) Light and sound sensitivity and/or (2) nausea and/or vomiting.

David Nabity: What I thought the article was saying is is hotter climates could create it more. But you're saying what they're saying is that if you're used to normal temperature pattern and then that temperature pattern increases no matter where. You could be in Alaska and you're used to thirty degrees right and then it goes to fifty, that could trigger it?

Dr. Soh: So the study looked at barometric pressure changes, dry bulb temperature, humidity, relative humidity. So these are all things that you want to look at more into detail. But this is just a kind of a correlation they're seeing, and there's no data to say that being in a hot temperature consistently worsens headache disorders. Clinically, what I see in practice, patients who are exposed to cold temperatures can be a trigger, so we got to look at both extremes. And I think the study is looking at the changes in temperature, but the news article may have not been stating it that way. So that's my interpretation.

David Nabity: Well, what do you do for somebody that has migraine headaches?

Dr. Soh: Well, migraine headaches they can either be very debilitating a few times a month or up to thirty days a month. So it depends on first of all, is the diagnosis correct? Is this patient really having a migraine headache? And if they're not, we got to think about secondary causes or headache disorders. And there are other disease processes that could be manifesting themselves as a headache disorder; like a brain tumor, vascular abnormality, infection, autoimmune causes, hormone imbalances, and metabolic disturbances.

David Nabity : Lime disease?

Dr. Soh : Yes, lime disease can have a symptom of headache. So I think seeing your physician or your health care provider if you're having headaches that are preventing you from going to work, preventing you from being social, keeping you inside the house, that's when you need to talk to a doctor or health care provider. Now, what do we do after we make the diagnosis correctly. Because it's a clinical diagnosis, there's no brain imaging, no blood work to say, ‘hey, you have a migraine disorder.’ This is all clinical through extensive history. To rule out the secondary causes, we might use lab work, you might use imaging and other tests, but once we have that ruled out, then we think about your clinical history. We make the diagnosis based off the criteria I had mentioned. And if you do have migraine, there can be chronic migraine, which is fifteen or more headache days a month, or episodic which is less than fifteen. And there's different treatments for that. There's medications, there's vitamins, there's lifestyle changes and other things that we can do to address the headache.

Co-host (Peter): So I'm also curious too, and I've always wondered this. So I've heard migraines can come from all ranges of things, from brain tumors and stuff that are mortally, a very serious disease physically but also mentally. How much or how many migraines would you say, or maybe a percentage of it as a result of physical malady? And maybe it's similar to that, or it's a mental stress or mental health or something like that.

Dr. Soh: So, just to clarify, migraine is a neurological disorder of the brain. It's a primary headache disorder. So the brain can get hyperactive, the vessels, the nerves that supply the vessels can get sensitive, and that's really coming from the brain itself. A headache due to a tumor would be a secondary headache cause so that would not be a migraine headache. And actually, in chronic migraine, up to fifty percent of patients have depression and or anxiety and so stress is a big trigger. And so that's why I was making the analogy.

Co-host (Peter) : So what sort of drugs do you give people that have migraine headaches?

Dr. Soh : I first like to make the diagnosis and then ask patients what their goals are and expectations, and depending on how chronic or severe their headaches, I give them options based off their lifestyle, their preferences, and their medical needs.

Co-host (Peter): Well Tylenol is not going to do anything for it, right?

Dr. Soh : Actually, Tylenol one thousand milligrams. I'm not saying that this is for every patient, but that can be used for acute relief.

David Nabity: What do you get if you take two Tylenol? That's a thousand milligrams?

Dr. Soh: Right, doubles five hundred milligrams each. Five hundred milligrams is extra strength Tylenol.

David Nabity: So two of those can be - I didn't realize that. I thought it was one hundred milligrams. I would just do that weak stuff then.

Dr. Soh: But you know, talking to your primary care doctor or your physician really is the best thing to do when you're trying to treat your headache especially if they're debilitating. And that's what I would recommend first. The unfortunate thing is we don't have enough specialists out there or providers to treat patients because migraine headache effects twelve percent of the population. So that's approximately thirty nine million people in the US.

David Nabity: Wow. How much of that can just be caused by your neck being out of alignment and needing a chiropractic adjustment?

Dr. Soh: There can be myofascial components to headache, being the muscles get tight. There can be some neck disease in the spine that could be related to…

David Nabity: Yes, yeah, and when you say neck disease, what do you mean?

Dr. Soh: So disease in the cervical spine or muscles that are tight in the neck that can be a trigger for headaches. And there can be what they call a cervicogenic component. So it's actually a very complex problem that is a brain issue. But because there's a lot of pain sensory

fibers that are going around the face, the neck, the muscles, this can be linked to the headache disorder and make the symptoms worse or manifest its symptoms as being pain in that area, even though the pain is actually a brain disorder and the brain has no pain receptors inside the brain, but the covering of the brain around the vessels, those are the pain receptors.

David Nabity : I'm really curious as to your perspective in your opinion on chiropractic as a treatment for migraine? Do you think you can help or is that more of a no-no for you?

Dr. Soh: I get a lot of questions about that. There's not really a standard treatment for chiropractors. And one thing I say to patients when they do get care from chiropractors, I just say let's avoid any sudden movements of the head or neck because that sudden movement going left and right can cause a vessel dissection. The studies don't show a high incidence, but it is a possibility, and I don't have good data to say that chiropractor is actually helpful for treating headaches. Some patients do get relief from the chiropractor treatment in a safe manner, and because it's not standardized, I just give them the warnings and let them know, ‘Hey, if you're doing it, just be careful of this.’

David Nabity : So I noticed you brought this article about Caitlin Clark, the basketball star and she deals with migraines all the time, I guess.

Dr. Soh: And this is great because you know when celebrities and celebrity athletes who have migraine and let the media know, it reduces the stigma because migraine is an invisible disease.

David Nabity : And it's probably embarrassing, right for somebody to keep saying, I got a headache again, I got a headache again, headache again?

Dr. Soh: And this is why education is important for the public, so that this is a real disease that's disabling. And Caitlin Clark almost had a triple double apparently, I think she missed it by one rebound. In her postgame interview, she mentioned she has migraine and the lights and sounds from the stadium obviously makes it worse. And then during the game her adrenaline kind of helps her out, but after the game it just it's really impacts her negatively, but she plays through it.

David Nabity: This is just nice that you have a superstar athlete who can say, look, I'm dealing with migraine and people get more of awareness and maybe more comfortable with the diagnosis. How about how about little ones? You know, a mommy and a daddy can have a baby and there's this crying all the time. How do you figure out whether a little baby has migraine?

Dr. Soh: So that's a great question. There's actually headache specialists who are pediatric headache specialists. They go through different training than adult headache specialists. Patients can have headache before they are even talking. And a lot of patients I have will have headaches since they're as early as they can remember. And I think Caitlin Clark also mentioned she grew up with headaches growing up from younger to older. So it affects all populations, all ages. Economically, it's a huge impact. The huge population it affects is women more so than men, about three to one ratio, and usually that twenty to forties age range, when that's a very productive age range

in terms of work and raising families. So you could see the huge impact it has on not just quality of life, but economic impact. When we're missing a day of work or a social activity, it's a big toll on society and it's actually number two in disability in the world, behind low back pain, and that's measured in disability adjusted life years.

Co-host (Peter): So man, I'm so glad we talked a little bit about Tylenol, but besides that, what kind of treatment plans can you offer? And the research I'm sure it's an ongoing thing. It's a science. It's always evolving and developing stuff. So what are you looking at in helping these people who have suffered since childhood or maybe just recently developing this.

Dr. Soh: Thanks for circling back, Peter. The medications can range from vitamins like magnesium, riboflavin and, CoQ10. There can be preventive therapies if you're trying to prevent the headache attack…

Co-host (Peter): And these supplements can actually make a difference in this?

Dr. Soh: Yeah, the studies have looked at magnesium and three hundred eighty milligrams a day. I usually recommend four hundred to eight hundred milligrams nightly. And this is making sure this is done in a safe way that patients have no adverse side effects. But those can help with migraine. We have medications that were made for other conditions like high blood pressure, seizures, depression, and the mechanism of action actually helps with migraine headache. This is before the new medications came out. So even though I prescribe medication that's a seizure medication, it doesn't mean I think the patient has seizures, but that mechanism of action can actually help with the actual migraine headache. Then we have newer medications that came out over the last four to six years, and these block a molecule called CGRP. CGRP stands for calcitonin gene related peptide, and it's been found that this can be elevated in headache attacks. And so these new generation medications that are either injectable or by pill they can actually help reduce their frequency of headache attacks or treat acutely. And so there's not really one right therapy. Each patient is different.

David Nabity: You have to custom design it. Well listen, Peter, how can people get a hold of you?

Dr. Soh: The best way right now is going on the website, sohheadachecenter.com. They can read about the services we provide, read about if this is right for them, and then make an appointment through the website.

David Nabity: All right, well, listen, I appreciate you being here this morning. I'm sure there's somebody listening and like, ‘you know what that's got to be what I have and I need to do something about it.’ So I appreciate you being here.

Dr. Soh: I appreciate it really much.

David Nabity: All Right, we're going to take a break.