Dr. David Buchholz published Heal Your Headache in 2002. While controversial, the book is still the #1 best seller on Amazon for headaches. I checked in with Dr. Buchholz to find out which of his recommendations still stand, which he’s changed his position on, and why he continues to take other doctors to task. In Part 4 of this 4-part series, I asked him why he thinks his book was controversial, and how patients can best work with their doctors for successful treatment.
In your book you talk about headaches and migraine as one continuous spectrum, with migraine as the underlying mechanism.
You state that virtually all headaches are a form of migraine. Other doctors segregate migraine as a neurological disorder, one very different than a headache. Your thoughts?
The concept of migraine being one mechanism capable of producing a wide variety of headache is actually pretty widespread. Migraine is a neurovascular mechanism, with a central nervous system (brain) disposition at its root. A part of the issue, which is well established, is that nerves (especially the trigeminal nerve) are involved, and they cause blood vessels to become swollen and inflamed. Everyone has the same physiology—it’s why we all get headaches—but some people are naturally more sensitive than others.
If you read the ENT literature, it is now widely held that most chronic sinus headaches are due to migraine. That’s a prime example of movement in the right direction. But in practice these patients are still too often being labeled as having sinus headaches and are treated incorrectly with sinus medications, antibiotics, allergy shots, and even sinus surgery. The literature, at least, is moving in the right direction.
Most recommendations say that triptans can be taken up to two days per week, but more than that will cause rebound headaches.
You recommend only two days per month. Why are your recommendations so much stricter?
First of all, people will cross any line you draw. Second, it’s based on my clinical experience that individuals using rebound-producing drugs more than two days per month remain resistant to migraine-preventive steps. Neither doctors nor patients want to believe that the limits should be stricter. It would seemingly make their jobs and their lives more difficult. It’s hard to tell people what they don’t want to hear.
Another aspect is human nature. Many healthcare providers have a dim view of headache patients. They have an expectation that they will be chronic complainers, no matter what. People are routinely misdiagnosed, and/or given the wrong treatment. So then people don’t gain effective control of their headache problem, and doctors throw their hands up in the air and say, “Oh well, just as I expected.” There is a lot of blaming the patient.
Rebound medications thwart the effectiveness of preventive measures, both through dietary changes and possible preventive medication a patient might require down the road. So you continue to ply the “failed headache patient” with quick fixes to get them out of your hair. That all-too-common scenario becomes a self-fulfilling prophecy.
What have you learned about Meniere’s disease and migraine since the book came out?
The majority of people who I see who have been diagnosed with Meniere’s don’t have it, never had it, and always did have migraine. They present to their primary care physician with dizziness or vertigo and get a Meniere’s diagnosis even when they don’t meet established criteria. Instead they usually have vestibular migraine. Even my patients who do fit the diagnostic criteria for Meniere’s, I’m not convinced that it’s anything other than migraine.
How do you treat these patients?
I’m not impressed with the response I’ve seen to dietary salt restriction and diuretics for presumed Meniere’s patients. I treat them for migraine and they respond well.
You are really passionate about helping your patients.
Yet one of the critiques of your book by migraine advocates is that it seems like you talk down to patients and blame them for their illness. Do you think this is a valid critique or a misunderstanding?
I appreciate you giving me the chance to address this, because I do think it’s a misunderstanding. I really believe that among migraine advocates, our interests are aligned, it’s just that our approaches are somewhat different.
There are two sections of my book that are the focus of that critique. In the Introduction of the book, I talk about other clinicians who routinely talk down to patients. I heard one doctor refer to patients as “pain weasels.” That’s wrong. The heading that reads “Blaming the patient” is in reference to doctors like him, not to my approach.
I think that in general healthcare providers have failed when it comes to headache care, and that’s what I’m saying needs to change. But some readers seemed to misunderstand and thought those were my views about patients.