Neurology Outcomes Report


Caring for Complex Cases

Life-Altering Treatment for Headache


Joan Gmora Birnbach

“Headache represents one of the most debilitating conditions in all of medicine,” says Susan W. Broner, MD, Medical Director of the Weill Cornell Medicine Headache Program. “Yet, it remains one of the most underdiagnosed and undertreated.” More than 40 million Americans suffer from severe, disabling headaches.

Dr. Broner, who is dual board certified in both neurology and headache medicine, is internationally recognized for her work in the treatment of headache disorders, including migraine and cluster headaches, as well as a host of unusual headache syndromes.

Joan Gmora Birnbach

“Headache is not a diagnosis, it is a symptom that encompasses a group of disorders,” says Dr. Broner. “The cornerstone of treatment is determining the specific diagnosis, such as migraine, trigeminal autonomic cephalalgias, and other disorders. Some patients have more than one of these disorders and these patients can be particularly complex to treat.”

Dr. Broner’s expertise in the field is what prompted a Manhattan neurologist, well known to Dr. Broner, to refer his patient, Joan Gmora Birnbach, who has been plagued by chronic migraines for many years.

“I had headaches even as a little girl and the migraines started probably in college or law school,” says Ms. Gmora Birnbach, an attorney and mother of two. While traveling in Europe at the age of 22, she was diagnosed with a hemiplegic migraine so severe that it left her partially paralyzed. “I was very lucky and got better, but it took me about a year to get my strength back.”

Over the next two decades she saw a number of neurologists, all very well regarded she says, who managed her migraines with medications, including triptans. These medications, however, sometimes made her nauseous causing prolonged episodes of vomiting. “A couple of times a year, I ended up in the emergency room dehydrated,” she says.

“Throughout this period, Joan was struggling,” says Dr. Broner. “By the time I saw her 10 years ago, her headaches had gotten even worse. She was taking preventative medications that were just not helping.” “While I had a migraine, I was unable to go on with my life,” says Ms. Gmora Birnbach. “The pain was horrendous. I had two young kids and I couldn’t get up. I couldn’t be vertical long enough to make food and take care of them.”

Blocking Pain Signals

“The science of migraine has exploded in the last two decades. Not long ago it was considered a disorder of hysterical people. Now we understand the main piece of the pathophysiology of migraine, which is going to help us identify more targeted approaches.”
– Dr. Susan W. Broner

Dr. Susan W. Broner

Dr. Susan W. Broner

In managing chronic migraine, Dr. Broner first rules out the possibility of a structural or systemic cause. “I then come to a diagnosis and, together with the patient, develop effective strategies that are well suited to the patient’s lifestyle and other medical conditions she or he may have,” says Dr. Broner. “Our goal is to retrain the brain, altering the firing patterns that lead to pain so that patients start having fewer headaches and are more in control. We intervene on neurotransmission in the brain through medications, lifestyle factors, and complementary approaches, which all act to change this very complex neurovascular syndrome.”

Dr. Broner treated Ms. Gmora Birnbach with combinations of oral preventatives, which provided some relief with fewer side effects. She then suggested BOTOX®, which had been FDA approved for chronic migraine in 2010. “I had been involved earlier in clinical trials with BOTOX. The injections worked well from the first or second time for Joan. It has changed her life. When she’s not using the BOTOX, she has headaches every other day.”

The BOTOX regimen calls for 31 injections in the forehead, temple, back of the head, neck, and shoulders every 12 weeks. “We know that BOTOX interferes with acetylcholine release from nerve terminals that normally allows muscles to contract. In migraine, we believe that BOTOX is working in part by inhibiting the release of proinflammatory molecules and neurotransmitters in the periphery, ultimately feeding back onto the brain stem preventing activation of pain pathways,” says Dr. Broner.

“I also have a medication to take when I get a bad migraine and 10 minutes later I can go on with my day,” says Ms. Gmora Birnbach. “The combination of the two has made a huge difference. The migraines don’t interfere with my life any more. I also don’t have the anxiety of fearing what I will do if I get one.”

“I have seen many patients who have tried numerous medications before seeing me,” adds Dr. Broner. “Our comprehensive multidisciplinary approach allows us to introduce new treatment plans to help many of these patients find improvement in their pain. We are excited to be at the forefront of the great breakthroughs that are being made in headache medicine and believe that the new migraine-specific CGRP antagonists coming out this year will provide significant relief for many of those suffering from these painful disorders.”