Headache Diagnosis and Treatment

Dr. Juliette Preston (left), a neurologist with advanced training in treating headaches and migraines, leads the OHSU Headache Center.
Dr. Juliette Preston (left), a neurologist with advanced training in treating headaches and migraines, leads the OHSU Headache Center.

The OHSU Headache Center offers complete care for headaches and migraines. We give you a precise diagnosis, then work with you to develop a care plan for your exact needs. We offer:

  • Expert providers who will help you find the treatments you need to relieve your pain.
  • A two-track approach — to treat your headache pain and to keep headaches from coming back.
  • Fast access for certain migraine patients to outpatient IV treatment.
  • A full range of medications, including the latest targeted therapies.
  • Nerve therapies to block or calm pain signals to the brain.
  • Botox and trigger point injections to help prevent headaches.
  • Effective complementary therapies such as acupuncture.

See our Headaches and Migraines page for information on when to seek a referral or emergency help.

Preparing for your first visit to OHSU

Please fill these out and bring them to your first visit.

We also recommend that you bring:

  • headache diary tracking your headaches.
  • A list of all medications you’ve tried for headaches.
  • A list of questions to ask your doctor.

Diagnosing your headache

You and your headache specialist will talk about your questionnaire and headache diary. You may be asked follow-up questions, such as:

  • What triggers your headaches or migraines?
  • Does anyone else in your family get headaches or migraines?
  • Where is the pain located in your head?

You may have tests, such as:

  • Neurological exam: The doctor tests your reflexes and coordination to see if anything is wrong with your nervous system.
  • Eye exam: The doctor inspects your optic nerves and pupil reflexes.
  • Depression screening: People who get migraines are about four times more likely to have depression and anxiety. It’s a two-way street, with depression and anxiety also leading to migraines.
  • Imaging test: You may have an MRI or CT scan to look for or rule out an infection, tumor or other problem that could be causing your headaches.
  • Ocular ultrasound: We use sound waves from a device outside your body to measure  the coverings of your eye nerves (ocular nerve sheaths). Swelling indicates higher-than-normal pressure inside your head and possibly another condition causing your headache.

Team-based care

Doctors at the OHSU Headache Center work closely with specialists in facial pain, dentistry and pregnancy. See our main Headaches and Migraines page to learn more about our:

  • Orofacial pain clinic
  • Facial Pain Program
  • Headache care during pregnancy

Headache and migraine treatment plans

Headaches are complex, with many possible treatment combinations. At OHSU, your care team will help you find the combination of therapies that works for you. Your care plan may include:

  • A “rescue plan” you can use to treat a headache when it strikes.
  • Preventive medications and other therapies to lessen the number and severity of headaches.
  • Complementary therapies such as acupuncture and meditation.
  • Counseling to help you lower stress or negative thoughts that could be causing or worsening your headaches.
  • Lifestyle changes, such as getting enough sleep.

See our Headache FAQ and Resources page for more information and links.

Tension headache treatments

Many tension headaches can be treated with over-the-counter medications. Relaxation techniques can also help.

  • Over-the-counter pain relievers such as ibuprofen (in Advil, for example) or acetaminophen (Tylenol) can often treat tension headaches.
  • Antidepressants can reduce headache frequency and severity by changing the level of brain chemicals such as serotonin.

Small adhesive sensors are attached to muscles to help you become more aware and better able to control your response to stress.

Therapy such as cognitive behavioral therapy can lessen headaches by helping you lower stress, anxiety and negative thoughts. You can break a cycle in which headaches cause negative thoughts and inactivity, which in turn lead to more headaches.

Acupuncture: Acupuncture places thin needles in the body along lines of energy. Studies show acupuncture can lessen the number of tension headaches in the short term compared with routine care.

Relaxation: Apps, websites and classes can guide you in meditation and mindfulness exercises. Here are a few places to start. Find more on our Headache FAQ and resources page.

Migraine treatments

Treating migraines requires a two-pronged approach:

  • Acute therapy to treat pain when a migraine strike.
  • Preventive therapy to make migraines less frequent and less severe.

Acute therapy

  • An over-the-counter medication with ibuprofen (Advil, for example) or a combination of acetaminophen, aspirin and caffeine (such as in some Excedrin products) can relieve pain.
  • A shot or nasal spray containing triptan can shrink blood vessels and reduce pressure.
  • A medication called dihydroergotamine (DHE) can be given in an IV, shot or nasal spray. At OHSU, patients with a migraine can receive quick outpatient IV treatment with DHE.

Preventive therapy

The U.S. Food and Drug Administration approved three new medications in 2018 to help prevent migraines.

  • Aimovig
  • Emgality
  • Ajovy

All three block a substance called calcitonin gene-related peptides, or CGRP. They have fewer side effects than other migraine medications. Patients use a self-injection about once a month, depending on the medication.

  • Topiramate, an anti-seizure pill, can lower how often you get migraines.
  • Beta-blockers such as propranolol and metoprolol, usually taken in pill form, relax blood vessels to improve blood flow. This helps prevent migraines for many patients.
  • Antidepressants such as amitriptyline and venlafaxine can reduce headache frequency and severity by altering brain chemicals such as serotonin. They can also treat depression and anxiety, which often go hand in hand with migraines.

Trigger point injection: This therapy uses an image-guided injection of anesthetic into a muscle knot. The anesthetic calms the muscle to help prevent headaches.

Botox: Therapeutic injections of Botox in the head, neck and shoulders can reduce the number of migraines for up to three months.

Occipital nerve block: This injection of medication into the scalp at the back of your head can prevent migraines.

Sphenopalatine ganglion block: An anesthetic is given to block nerves behind the nose from sending pain signals to the brain. Usually, patients come to our clinic to have this medication applied through nasal passages.

Vagus nerve stimulation: A handheld device sends mild electrical stimulation to the vagus nerve through the skin on your neck.

Trigeminal nerve stimulation: A stimulator is attached to the forehead with adhesive for 20 minutes a day to prevent migraines. The FDA approved the device for migraines in 2014. It stimulates the trigeminal nerve, which has branches that end at the forehead.

Acupuncture: Acupuncture places thin needles in the body along lines of energy. Studies indicate that acupuncture can reduce the number of headaches with fewer side effects than some migraine medications. Longer-term studies are needed.

Supplements: Vitamins and minerals such as riboflavin and magnesium can help prevent migraines. See our Headache FAQ and Resources page for recommended daily doses.

Cluster headache treatments

Like with migraines, we treat cluster headaches with both acute therapy for an active headache and preventive therapy to lessen the number and severity of new headaches.

Acute therapy

Oxygen therapy: Breathing 100 percent oxygen through a nose or face mask for about 15 minutes can ease a cluster headache.

Medication:

  • Shots, nasal sprays or pills containing triptan can shrink blood vessels and reduce pressure.
  • A medication called dihydroergotamine (DHE) can be given in a shot, IV or nasal spray.

Preventive therapy

  • Verapamil, a medication called a calcium channel blocker, comes in a tablet and lowers blood pressure.
  • Topiramate, an antiseizure pill, can help prevent cluster headaches as well as migraines.
  • Lithium, a mineral, is taken in pill form to prevent cluster headaches.

Trigger point injection: An image-guided injection of anesthetic into a muscle knot calms the muscle to help prevent headaches.

Nerve therapies:

  • Occipital nerve block: An injection of medication into the scalp at the back of your head can help hold cluster headaches at bay.
  • Sphenopalatine ganglion block: An anesthetic keeps nerves behind the nose from sending pain signals to the brain. Usually, patients come to our clinic to have this medication applied through nasal passages.
  • Vagus nerve stimulation: A handheld device sends mild electrical stimulation to the vagus nerve through the skin on your neck. This therapy can lower the number of headaches.

Acupuncture places thin needles in the body along lines of energy. Studies indicate that acupuncture can bring greater pain relief with fewer side effects than medications can. Longer-term studies are needed to verify results, though.

Cervicogenic headache treatments

Treatments for cervicogenic headaches focus on the upper (cervical) spine, where these headaches start. In addition to medications and physical therapy, therapies might include:

  • Medial branch block:  Anesthetic is injected into nerves called the medial branch nerves. These nerves transmit pain signals from the spine’s small facet joints.
  • Radiofrequency ablation: This therapy uses a heated needle to damage part of a spinal nerve that causes pain.

For patients

Location

Parking is free for patients and their visitors.

OHSU Headache Center
Center for Health & Healing Building 1, eighth floor
3303 S. Bond Ave.
Portland, OR 97239
Map and directions

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