Ask the Expert: When a Headache is an Emergency


Lynda is a 44-year-old dental assistant who came to The New England Center for Headache in Stamford, Connecticut, with a one-week history of drooping of the right eyelid, a right-sided headache, and a diagnosis of cluster headache made by her family doctor. Her headache was intense and continuous, and her eyelid drooped more and more over the course of the week.

During my examination, Lynda told me she’d had a right-sided headache six months previously that was so severe she went to an emergency room for the first time in her life. All tests, including a spinal tap, CT, MRI and MRA (magnetic resonance angiogram, used to visualize the heart, blood vessels or blood flow in the circulatory system) were normal and the headache disappeared in about a week. At that time, she did not have a drooping eyelid.

The week before I saw her, however, she experienced the rapid onset of a right-sided, steady, intense pain which did not change. She gradually noticed that her eyelid was drooping. Everything was normal during my exam, except that her right eye was shut. When I lifted her eyelid and asked her to follow my light, the eye could only look to the right.

This finding concerned me. I did not think she had cluster headache, though that condition can be associated with a drooping eyelid, red and tearing eye, or stuffed or running nostril all on the same side as the pain. While these “clusters” of attacks are also quite severe, they last for only a short time (about 45-60 minutes) and reoccur a number of times per day, often at the same time every day, sometimes wakening the patient in the night. Lynda’s headache was constant. Continue Reading

Reader’s Mail Archive: Migraine Questions Answered

Q. I have very frequent migraines. When they strike, they are continual for weeks. The only thing that helps me get on with my life is Imitrex®. I believe my headaches occur mostly from stress and atmospheric changes. However, they almost always come on during the early morning hours and wake me out of sleep.

I have been to several doctors and they have no problem giving me prescriptions for the Imitrex. My insurance company, on the other hand, believes you can’t have more than nine migraines a month (that is how many pills they allow before you pay all on your own). I will take three pills a day when my migraines are in full force. I have been reading about the possibility of people with severe migraines being more susceptible to certain kinds of stroke. If this is true, what can I or should I do to reduce that risk and reduce the migraines? I am 50 years old, in good health, do not smoke, and am not over weight. I have been diagnosed with fibromyalgia. I try to exercise as much as possible, but I’m sure it is not enough; I’m just too tired and it sometimes makes my headaches worse. I have also read about preventive medicines, but I’m concerned about the side effects. I am beginning to feel that I will always be plagued by migraines. I can manage a few but not ones that last for weeks on end. Continue Reading

Spinal Tap (Lumbar Puncture)


Spinal fluid surrounds and protects the nervous system, including the spinal cord, and generally maintains a specific level of pressure. If the pressure is too high, or too low, it can cause headaches. Infections in the brain often require a spinal tap in order to diagnose and identify the organism causing the infection.

In some patients, a spinal tap (lumbar puncture) is done to help diagnose the causes of a headache. Other diagnostic tests, such as a myelogram or cisternogram, require a lumbar puncture. Periodically, a new headache occurs following a spinal tap, which is brought on by standing and improving while lying in bed. This is referred to as a “low pressure headache” and is generally self-limited but sometimes requires a blood patch.


The brain and spinal cord are covered by 3 thin membranes, the dura mater, the pia mater and the arachnoid. These membranes are called the “meninges”. Meningitis is an inflammation of these membranes and the cause is almost always an infection due to a viral agent or a bacterial agent.

Viral meningitis is more common than the bacterial type. Viral meningitis is usually less severe and more benign. Meningitis caused by a bacterial agent can be very serious and can lead death if not treated promptly and properly. The outbreaks of meningitis in young persons in school or college which often make headlines is usually of the bacterial type and hence the concern because it can be a very serious illness. Continue Reading