Expert says pain medicine, neurology both have solutions for headache, facial pain sufferers

Do you have the occasional migraine, or have you been experiencing them for a while? Does your headache include debilitating facial pain? Are you actively being treated and getting relief? Or are you trying to figure out who might be best qualified to treat your condition?

If you’re not getting seen by a doctor, today is a great day to take that first step!

Depending on your insurance, the first move is generally to your primary care provider, who can aid in some way to referring you to a “lifesaver,” a.k.a. a neurologist and / or a pain management specialist.

If you hadn’t thought about pain management for migraine – the information below might lead you in a successful direction. As was recently confirmed to me, a pain management specialist can treat and aid in your headache / facial pain wellness. It might be especially helpful to know if you live in an area that has a limited number of neurologists or pain management specialists, you can go in either direction.

Dr. Bryan Marascalchi, an assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine explains the overlap in pain medicine and neurology and the relief migraine / facial pain sufferers can achieve from utilizing either or both.

“Migraine is kind of in half of the domain of neurology and pain medicine,” Marascalchi explained. He differentiated the active roles of each, “Where neurology takes the forefront for a lot of the medication management, pain management doctors also prescribe some of the medications, but mainly [a patient would get medications] through a neurologist.”

As you know, I’ve received Botox for migraine for several years and it’s given me my life back. I’m no longer hugging the floor and canceling endless family and friend commitments. I was pleased to learn from Marascalchi and share with you that “pain management physicians can [also] do procedures like Botox injections, that can reduce the frequency and intensity of migraine headaches and also do things like occipital nerve blocks for occipital neuralgia that contribute to headaches.”

Nerve blocks are “procedures that can help prevent or manage many different types of pain including facial pain.”*

“They are often injections of medicines that calm down irritated nerves,” said Marascalchi. “They can be used for chronic pain relief as well as total loss of feeling if needed for surgery.”*

“Nerve blocks can be used to manage chronic, or long-term, pain …. Severe acute, or short-term, pain such as with surgery or traumatic injury. Nerve blocks ease pain by offering immediate relief.”*

As Marascalchi notes, it’s an “interesting thing, because it’s a combined approach between pain and neurology to treat migraine and facial pain.”

In his practice, Marascalchi has seen and treated patients who experience facial pain “which often is very debilitating and they have very complex disorders that are challenging to treat from trigeminal neuralgia to SUNCT.”

Trigeminal neuralgia is a chronic pain condition affecting the trigeminal nerve, which carries pain from the face to the brain.

SUNCT (short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing) is “a rare form of headache that is most common in men after age 50.”**

Marascalchi said that “SUNCT is half headache condition, half facial pain.” He emphasized this is one of those debilitating disorders like cluster headache that as a pain management specialist “when you treat [them], it’s life changing.”

The conditions are identifiable by symptoms of “bursts of moderate to severe burning, piercing, or throbbing pain, usually on one side of the head and around the eye or temple.”** Research has shown that the “episodes” range from 5 seconds to 4 minutes. “Individuals generally have five to six attacks per hour.”**

Our autonomic nervous system (ANS) responds by inducing watery eyes, bloodshot or red eyes (caused by dilation of blood vessels, i.e. conjunctival injection), eyelid swelling, increased pressure within the eye on the affected side, nasal congestion and more. The ANS functions involuntary and reflexively and regulates functions of our internal organs (stomach, intestines, heart) as well as controls some muscles within the body.

Pain management specialists have a variety of procedures and solutions to alleviate headache conditions, “from different nerve blocks to medications to treat” patients. “And there are so many headache categories such as cluster headaches, occipital neuralgia, migraines, SUNCT, and hemicrania continua,” said Marascalchi. “Cluster headaches are terrible and are also known as suicide headaches.”

An aspect I really admire about Marascalchi is his dedicated approach to helping patients improve their lives. And that includes outside of medications and procedures. He said many individuals have shared a variety of ways in which they find relief from their headache and/or facial pain.

“I have patients who swear by diet modifications,” he said. “People with cluster headaches have told me that avoiding processed, smoked, and preserved foods such as those with nitrites, avoiding alcohol or monosodium glutamate (MSG) as well as ketogenic diets, magnesium supplements, and juice meal replacements heavy on vegetables and ginger, made a life-changing impact.” Then, there are patients who have credited medications and procedures to having a better quality of life.

One of my favorite statements of Marascalchi’s is, “What works for one person doesn’t work for another. You kind of find this cocktail. You can get relief from each of those three categories: the non-medical, the pharmaceutical, and the procedural. It’s just grabbing what you can from each of them and optimizing it. And putting it together in one package to treat it.”

Taking migraine sufferers as an example, it’s common to hear that chocolate or coffee can trigger one person, another it’s bright sunlight and barometric pressure.  For relief, maybe it’s a cool ice pack, a nap, or being seen in the pain management specialists’ office for a nerve block.

Healthy eating is always helpful. The “cocktail” I swear by pulls from each category: non-medical (healthy lifestyle, mindfulness, regular sleep schedule), pharmaceutical (Cambia on an emergency basis), and procedural (Botox for migraine and nerve blocks when needed).

The treatment you apply to your life (think all categories) “has to be mixed. It has to be combined. It has to be optimized across different options that you have.”

Marascalchi likened it to “ordering off a menu.”

“You’ve got an appetizer, first course, second course, third course and dessert and you’re trying to pull from each of them to make a full meal to get the pain relief. And everyone is going to order something different when they go out to eat.”

We all have different bodies, different health conditions, and different likes.

If you have experienced your first warning sign (or are having continuous indicators and struggles) of a facial or headache condition, it’s worth getting a thorough evaluation by a pain management specialist and/or neurologist you trust.

In closing, Marascalchi said, “One message I try to get across: For so much of what we do in medicine there is no one thing that is either immediate or permanent. It’s always just something that has to be continuous or take time.”



Dr. Bryan Marascalchi serves as an assistant professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine.  In the pain management division, he specializes in treating patients with persistent pain in the spine, complex regional pain syndrome, disc pain, sciatica, and neuropathic pain, in addition to more. Marascalchi is also an innovator in his field, having helped develop the Pneumico Ventel™ and the Pain Scored platform.

Coming next:  Silence can be medicine for the busy mind

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