Preventing and Treating Migraine Headaches

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By Mike DuBose with Dr. Surb Guram, MD

Migraine headaches are a painful nightmare that can negatively impact individuals’ lives, relationships, and work. Some experience migraines so severe or frequent that they’re effectively disabling! However, because many doctors are not specialists in diagnosing headaches or related disorders, individuals who suffer from migraines often face long, frustrating struggles to find relief. In fact, as noted in a 2013 article in the Journal of Headache and Pain, migraines are frequently misdiagnosed as sinusitis. In another study of 3000 people, 88% percent of the participants who thought they were having sinus headaches were having migraines.

The first step toward minimizing the amount of time you spend in pain from migraines is to find an experienced, competent doctor you trust (preferably, an internist who is a trained medical diagnostician). Once you have located this professional, he or she will likely ask questions about your headaches, their frequency, and your general medical background (family history, other illnesses, etc.). You may be asked to undergo a physical exam or tests to rule out physical factors like sinus problems or muscular issues. Some of the tests that you and your doctor may want to consider include:

  • Blood tests, including a complete blood count (CBC); C-reactive protein (CRP), which measures inflammation; Vitamin D; and thyroid functioning and chemistry screen
  • Angiography of the head and neck
  • Cervical spine x-ray
  • MRI (which is preferable to a CT scan due to lower radiation levels)

Although it is unlikely that the source of your problems is something potentially deadly like a brain tumor, be sure to alert your doctor if you experience any of the following symptoms—they can indicate more serious problems, according to the University of Maryland Medical Center:

  • Severe headache that persists or increases in intensity over the following hours, sometimes accompanied by nausea, vomiting, or altered mental states (possible hemorrhagic stroke)
  • Sudden, very serious headache, worse than any headache ever experienced (possible indication of hemorrhage or a ruptured aneurysm)
  • Chronic or severe headaches that begin after age 50
  • Headaches accompanied by other symptoms, such as memory loss, confusion, loss of balance, changes in speech or vision; loss of strength in or numbness or tingling in arms or legs (possibility of stroke or brain tumor)
  • Headaches after a head injury, especially if drowsiness or nausea are present (possibility of hemorrhage)
  • Headaches accompanied by fever, stiff neck, nausea, and vomiting (possibility of spinal meningitis)
  • Headaches that increase with coughing or straining (possibility of brain swelling).
  • A throbbing pain around or behind the eyes or in the forehead accompanied by redness in the eye and perceptions of halos or rings around lights (possibility of acute glaucoma)
  • A one-sided headache in the temple in elderly people; the artery in the temple is firm and knotty and has no pulse; scalp is tender (possibility of temporal arteritis, which can cause blindness or even stroke if not treated)
  • Sudden onset and then persistent, throbbing pain around the eye, possibly spreading to the ear or neck, that is unrelieved by pain medication (possibility of blood clot in one of the sinus veins of the brain)

Once it has been confirmed that your problem is due to migraine headaches and not another medical reason, your physician may be able to assist you in identifying potential triggers and devising plans on how to avoid them. The strategy may include referrals to other specialists such as a neurologist to determine the cause and treatment of your migraines. They will also have the ability to prescribe extra-potent pain medications that can help to dull the agony caused by migraines, or other prescriptions that can even prevent them.

Popular Preventative Measures

Unlike, say, an infection that can be quickly and easily addressed with an antibiotic, migraines may require actions to prevent the migraine in the first place and additional treatment at the time of the headache. Fortunately, with experience, you will be able to narrow down your migraine triggers (see our previous article at www.mikedubose.com/migrainecauses for some common culprits) and avoid them to minimize the number of severe migraine headaches you endure. Although migraine causes, symptoms, and relief strategies differ by person, the following are preventative measures that you may find helpful:

Try the new preventative injection. In May 2018, the FDA approved a drug called Aimovig, which is the first medication developed specifically to prevent migraines. It comes in the form of a monthly injection and works by blocking a specific protein fragment, CGRP, that has been shown to cause and worsen migraine headaches. The drug, which is intended for individuals who get at least one migraine per month, won’t be able to prevent all migraines from occurring, but it can reduce their frequency by 50% and lessen the severity of the headaches that do happen. It also caused no more side effects than the placebo in clinical studies—a welcome change from previous migraine drugs, which often came with side effects like dry mouth, sexual dysfunction, and mental fogginess. Although the list price—$6900 per year—may be prohibitive for some sufferers, three other pharmaceutical companies will soon be releasing alternative options that work in the same way, so it’s possible that competition may help lower the cost in the future.

Take any other doctor-prescribed medications regularly. If you do not qualify for or cannot obtain the migraine injection, your physician may suggest that you consume prescription medications to help prevent migraines (these are referred to as “prophylactic” or “preventative” medicines because they seek to abort the migraines before they occur). They will not necessarily be migraine medicines, but may have secondary effects that will decrease headache frequency. These prescriptions may include certain types of antidepressants (such as amitriptyline or venlafaxine), heart medications like beta blockers (including propranolol or metoprolol) or calcium channel blockers (such as verapamil), and seizure medications such as valproic acid, gabapentin, and topiramate. Be careful if your physician prescribes an antidepressant since they can have serious side effects, especially if you suddenly stop taking them.

It’s important to take any prescription given to you as directed by your doctor (i.e. every day, at a regular time, preferably with food) to ensure their effectiveness. The University of Maryland Medical Center notes, “A preventive medication is usually started at a low dose, and then gradually increased. It may take 2-3 months for a drug to achieve its full effect. Preventive treatment may be needed for 6-12 months or longer.”

Locate a good allergy doctor. Some research indicates that migraines may be related to allergies, so we recommend finding an ear, nose, and throat specialist (ENT) who is trained in assessing and treating these problems. You may be allergic to certain foods, dust, trees, grasses, or other substances without even knowing it! Since sinus issues are also major headache triggers, it can be a helpful part of your treatment program to receive allergy assessment and possibly shots, which relieve allergy and sinus pressure in many patients. Your allergist may also suggest making some changes to your environment (for example, using fragrance-free detergent; placing special covers on your mattress and pillows; replacing fabric curtains with blinds; etc.) that can minimize your contact with the allergens that bother you.

Scrutinize the medications, supplements, and herbs you take. Even seemingly innocent supplements like fish oil can have side effects! (See www.mikedubose.com/prescriptions for more details.) To determine if drug side effects could be a migraine culprit, visit reputable websites like drugs.com or webMD.com and research the herbs, supplements, and prescriptions you take regularly. (Both sites have a “Drug Interactions Checker” function that you can use to find any potentially harmful interactions as well.) You may also want to consult with your pharmacist since they have a more sophisticated software program and training to avoid drug interactions. In extreme circumstances, you and your doctor may eliminate some or all of your non-essential prescriptions and allow several days for them to exit your body to determine if they may be causing your headaches. Then, you will slowly reintroduce the medications, supplements, and herbs to assess their impact.

Reduce stress. Since stress is a major trigger for migraine headaches, decreasing stress can help prevent them—while also improving the sufferer’s health in general. Carefully examine your life, looking for the major sources of past or present worry, frustration, and anger, all situations that cause stress. Start with these non-medical options first.

Exercise regularly. It is a natural form of stress relief that, according to some studies, may be even better than Zoloft for treating depression! According to researcher John J. Ratey’s book Spark, which deals with the links between exercise and the mind, “A massive Dutch study of 19,288 twins and their families published in 2006 showed that exercisers are less anxious, less depressed, neurotic, and also more socially outgoing.” Ratey’s book also described a Finnish study that revealed “those who exercise at least two to three times a week experience significantly less depression, anger, stress, and ‘cynical distrust’ than those who exercise less or not at all.” Because stress and anxiety are major migraine causes, reducing stress through exercise is advisable for migraine sufferers (as long as your headaches are not triggered by physical activity). Regular exercise will also help you sleep better, another factor in preventing migraines.

Obtain adequate sleep. Try to go to bed at the same time every night and sleep for about eight hours. Avoid looking at screens—phones, computers, gaming machines, and televisions—two hours before bed. Try to wrap up any stressful issues like work after 5 PM to give your mind time to relax. Many people find reading to be a calming pre-sleep activity. Make sure the temperature in the room is comfortable (preferably, cool), and run a sleep noise maker or fan for soothing background noise. Don’t take long naps during the day or drink caffeine after 2 PM to avoid sleep difficulties! Eating late in the evening can also keep you up. If you are having problems getting good-quality sleep, your bed could be an issue. Make sure that it is large enough (for two people, we recommend a king size) and that your mattress is firm enough to support your body but soft enough to be comfortable. For more information, the February 2017 issue of Consumer Reports magazine contains an excellent article on selecting beds and pillows, with ratings of several different brands.

If you have addressed these factors and still have troubling getting to and staying asleep, schedule a sleep study supervised by a physician who is trained in sleep disorders. We recommend sleep specialist Dr. Joseph Gabriel, MD with SC Internal Medicine in Columbia, SC. You may have a condition like sleep apnea that is impairing good rest, and a sleep specialist can prescribe medications or equipment to drastically improve your sleep quality. However, be careful about using prescribed or over-the-counter sleep medications—they can be addictive, have side effects, or become dangerous when combined with alcohol or other prescriptions!

Visit a professional counselor. Many people simply cannot handle all life’s stressors and struggles. Seeing a therapist or counselor takes care of the mind just as exercise and a healthy lifestyle nurture the body. If you are anxious, depressed, or overwhelmed to a point where you can’t deal with it by yourself, seek a well-reviewed professional (preferably one who is covered by your insurance). Simply talking about your problems can release some stress immediately, and a trained counselor can also help you decide on paths you can take to live a happier, less anxious life.

A professional therapist may suggest cognitive behavioral therapy (CBT) as a preventative treatment for stress-based migraines. CBT is a practice that strives to reduce behavior patterns by recognizing the thought processes behind them and “disproving” them with help from the therapist. It is often used for chronic pain conditions, and can be helpful for migraine sufferers as well.

Finding an experienced, trained counselor who has a good chemistry with you can be difficult. We suggest you interview counselors until you find the right one. In the Columbia, SC area, we have heard some good patient comments about Dr. Fredric Mau, Ph.D., Marjorie Hightower, Ph.D., and Michael G. Helms, MSW. Psychiatrist Josh Fowler, MD is top-notch!

Keep a “headache diary.” Because triggers differ from person to person, it can be hard to identify which factors are precipitating your migraines. Yes, it is a time-consuming effort to track all you do, eat, and drink, but it’s an important step is tracing the triggers that lead to much greater pain. Start an electronic or hard-copy log where you record the circumstances of your headaches—what you ate, how you slept, if you smelled anything different than usual, etc. Look for patterns. On several occasions, did you drink red wine the night before you experienced a migraine? Did you experience a headache the evening after you were around someone who wears strong perfume or cologne? The longer you keep the diary, the more patterns will become evident, and the more triggers you will know to avoid. Think of yourself as an investigator seeking clues to a crime.

The University of Maryland Medical Center recommends including the following information in your headache diary:

  • Note all conditions, including any foods eaten, preceding an attack. Often two or more triggers interact to produce a headache. For example, a combination of weather changes and fatigue can make headaches more likely than the presence of just one of these events.
  • Keep a migraine record for at least three menstrual cycles. For women, this can help to confirm a diagnosis of menstrual migraine.
  • Track medications. This is important for identifying possible medication-overuse (rebound) headache or chronic (transformed) migraine.
  • Attempt to define the intensity of the headache using a number system, such as: 1 = Mild, barely noticeable pain; 2 = Noticeable, but does not interfere with work/activities; 3 = Distracts from work/activities; 4 = Makes work/activities very difficult; and, 5 = Incapacitating.

Eat and drink cautiously. If your records cause you to suspect that your migraines are triggered by certain foods, remove them from your diet for a predetermined time. If you don’t experience an attack during that time, you may have found one of your migraine triggers! Try reintroducing the item to see if you get headaches again, then removing it to see if the opposite is true. Once you have a solid idea that a food or drink item is a trigger for you, eliminate it from your diet.

Alcohol and caffeine are common triggers for migraines, so keep a special watch on them. Wine also contains preservative sulfites that are known to cause headaches. If you only have one or two drinks but are stricken with a hangover, it’s possible that the bad feeling is actually a migraine. As the American Migraine Foundation says, “Limit and know your limits when it comes to alcohol consumption.” Also, just because one type of alcohol triggers your migraines doesn’t mean that all types will.

Try to keep to a meal schedule. Aim to eat at roughly the same times each day, and don’t go for more than three hours without food. Fasting can increase headache risk since your body’s sugar levels can drop. Drink plenty of water slowly throughout the day so the body can absorb the liquids—dehydration is a major factor in headaches. Consume at least six-eight eight-ounce glasses of liquids (preferably, water) per day, more if you sweat during physical activity or drink alcohol. It helps to keep a 32-ounce non-BPA water bottle with you. If you consume two of these per day, you’ll be very well-hydrated!

Avoid perfumes and other scented products. Many household products like dryer sheets and furniture polish are heavily scented, along with personal care and beauty products such as shampoos and hairsprays. You may be allergic to these scents, causing them to trigger migraines! Fortunately, you can purchase fragrance-free versions of many products at the grocery store, including “free and clear” laundry detergents from well-known companies like All and Tide. The Vanicream brand sells non-scented body lotion, moisturizers, soaps, and sunscreen, as well as hair products under the line Free and Clear. Also, if you have your clothes dry cleaned, place each piece on a separate hanger in the garage for a few days after cleaning to air out the chemicals.

If your migraines are triggered by smells, of course you should stop using perfume yourself…but it can be hard to avoid scents on others! However, don’t be afraid to reach out. Politely ask the people who live with you not to use scented products, colognes, or perfumes in the home. Inform the human resources staff at your office of the issue, and suggest that they enact a “no scents” policy at work (many doctor’s offices already do this). You may want to ask your religious or activity leaders to make an announcement asking people not to wear scents to church or meetings. Many of your friends, family members, and colleagues may not know that you have migraines (or that their smells may be contributing to them), but will be glad to help you avoid scent triggers if you ask for their assistance!

Make environmental changes. There are some triggers—such as bright sunlight or weather shifts—that you can’t avoid entirely. However, you can change how you interact with them! Wear quality sunglasses like Ray-Ban when outside during the brightest hours of the day, and try to stay inside when you know that wild weather is afoot. Try to choose natural over artificial light (which can have hidden flickering that you don’t even notice) whenever possible. For example, some of our staff members turn off their fluorescent office lights and use warm-colored lamps instead, which are more soothing and do not flicker.

If you are female, keep hormones in mind. Many women’s migraines are tied to their hormonal cycles. Manipulating hormone levels can help reduce headache frequency, and some forms of hormonal birth control may help stabilize hormone levels. The triptan medication Frova can be effective against migraines linked to menstruation. Females can also track their migraines in relation to their cycles and know when they are most likely to face an attack.

Non-Conventional Treatments

Non-conventional treatments incorporate practices and remedies from holistic and non-Western medicine that are often overlooked by doctors trained in the United States. Some may have conflicting reports on their effectiveness in terms of migraine treatment, but when you have exhausted your other options, you want to know of anything that could potentially help! Of course, non-conventional medical treatments still impact your overall health (and may interact with traditional medications or treatments), so do not begin or pursue any non-conventional treatment without consulting your doctor first. The following non-conventional treatment suggestions provide alternative ideas if standard approaches to migraine treatment are not working for you.

Incorporate natural herbs and supplements. There are a few naturally occurring plants and herbs that have been used throughout history to prevent and treat headaches, and some recent studies suggest they may still be effective for migraines. Butterbur, a shrub that grows in North America, has been shown in two high-quality studies to reduce the frequency of migraine headaches. Based on these studies, the American Academy of Neurology and the American Headache Society have endorsed the use of an extract made from butterbur root and its underground stem (rhizome) for migraine prevention. However, it’s important to only ingest processed butterbur (one brand name is Petadolex); the unprocessed plant contains alkaloids that can cause liver damage.

Another plant native to North America, feverfew, has been used to ease constipation, dizziness, and headaches. According to the National Center for Complementary and Integrative Health (NCCIH), the official US federal agency for research on non-conventional medicine, “Some research suggests that feverfew may help to prevent migraine headaches, but results have been mixed. However, evidence-based guidelines from the American Academy of Neurology and the American Headache Society suggest that a feverfew extract may be effective and should be considered for migraine prevention.” Feverfew does not have significant side effects, but it should not be taken by pregnant women because it can cause uterine contractions.

Vitamin B2, also known as riboflavin, has been shown to lessen the occurrence of migraine headaches in clinical studies. However, it’s important to take the full dose—400 mg per day—to reduce migraine frequency, according to MedlinePlus, a website created by the National Institutes of Health for patients and families. Taking lower dosages does not seem to have an impact. Fortunately, reports say that there are no side effects associated with taking high doses of riboflavin; because it is a water-soluble vitamin, the body will simply pass whatever it does not absorb. Magnesium also is known to reduce migraines by relaxing blood vessels, but too much can cause diarrhea.

Another “vitamin-like substance” that may help is Coenzyme Q10 (CoQ10), according to the Migraine Trust. This antioxidant occurs naturally in meat and oily fish, but in amounts smaller than are typically effective as a migraine preventative, so supplementation is necessary in those who use it to treat their headaches. The Migraine Trust noted that, in one study where participants took 150 mg of CoQ10 per day, “migraine attack frequency after 4 months of treatment was reduced at least 50% in 48% of patients as compared to 14% for placebo.” No adverse side effects were noted in any of the patients. However, if you are on a blood thinner, consult your doctor before taking CoQ10.

Seek an experienced acupuncturist. As NCCIH explains on its webpage dedicated to analyzing acupuncture for pain relief, “Acupuncture is a technique in which practitioners stimulate specific points on the body—most often by inserting thin needles through the skin. It is one of the practices used in traditional Chinese medicine.” Several studies, including one published in the Journal of the American Medical Association in 2017, have shown that acupuncture can relieve certain types of chronic pain, and this may also be true for migraines and tension headaches. In fact, some insurance companies, like United Healthcare, provide coverage for acupuncture.

Only seek treatment from a licensed acupuncturist who uses sterile needles, since incorrectly performed acupuncture can lead to harmful side effects like infection and punctured organs. Most states require a license or certification to practice acupuncture, with the standard being a diploma from the National Certification Commission for Acupuncture and Oriental Medicine. Some traditional medical professionals, such as internal medicine physicians and dentists, are also expanding their treatment options to include acupuncture. When considering any acupuncturist, be sure to ask about their license, training, and experience. Some health insurance plans will even cover acupuncture! In Columbia, SC, we recommend Dr. Li Huang (www.drlihuang.com), a former ER surgeon from China. In an interview with Dr. Huang, he noted, “In some cases, we use acupuncture and chiropractic therapies if needed to cure or manage migraines. It often takes about 12-15 treatments of about 45 minutes per session.” 

Explore biofeedback therapy and relaxation training. According to the American Migraine Institute, “Biofeedback and relaxation training typically yield a 45% to 60% reduction in headache frequency and severity,” which is a rate comparable to many prescription medications! In biofeedback therapy, electrodes are attached to the patient’s skin. The electrodes monitor different biological processes (such as muscle tension and body temperature), which a therapist watches on a screen and can show to a patient. With the help of the therapist, the patient can learn to reduce their anxiety and lower heart rate by controlling breathing, lowering body temperature, and relaxing their muscles. The most dramatic results in terms of migraine reduction occur when biofeedback is combined with medications such as propranolol. One of the drawbacks of biofeedback is that it requires time (several hour-long sessions per week for a period of months), but a positive is that it has no known side effects.

Meditation, where you sit silently, breathe deeply, and focus your thoughts, can be helpful in calming the mind and body. Yoga, a series of stretches that are accompanied by measured breaths, is also very calming (with the added bonus of increasing muscle flexibility and strength). Tai chi is a Chinese practice combining mindful breathing, movement, and meditation that has similar qualities and goals to yoga. All these activities can help individuals whose migraines tend to be triggered by stress to reduce tension in their bodies and minds, thus reducing the chances of a headache. There are many yoga and meditation DVDs and online courses available (some for free!), or you can seek out a yoga studio or local recreation department for in-person instruction. Chinese cultural centers are often good places to find tai chi classes.

 

Consider Botox. Injections of botulinum toxin Type A, known as Botox, are often used cosmetically to smooth out facial wrinkles…but they can also be a surprising helper in the fight against migraines! Botox injections block pain networks in the brain, and they were approved by the Food and Drug Administration (FDA) as a migraine treatment in 2010. The injections, which must be taken about every three months, may help reduce the severity and frequency of attacks in those who suffer chronic migraines (more than 15 headaches per month). If you pursue this treatment, you should obtain the shots from a doctor who is trained in administering them specifically for migraines—and not for wrinkles or facial drooping!

When an Attack Is Happening

Unfortunately, it is not always possible to prevent migraines, but the more often you experience them, the more familiar you will become with your body’s signals that one is on the way. You may even have an “aura,” a warning in the form of impaired vision, dizziness, or other physiological signs. When you feel a migraine beginning, take some non-medical steps to try to avoid the pain:

Relax. Go to a dark room where you can avoid hearing loud noises. Ask not to be disturbed, turn off all electronics like phones, and lay down in a comfortable place to rest. If you can sleep, the Mayo Clinic advises doing so.

Apply an ice pack and some pressure. Ice is an anti-inflammatory and can help numb the throbbing pain associated with a migraine attack. Try placing one against the side of your head that is affected. Some people also report relief when they firmly massage the scalp or put pressure on the temples.

Try over-the-counter medications to reduce pain. Especially at the beginning of a migraine, when the discomfort is not too severe, over-the-counter pain medications like ibuprofen, 325 MG aspirin, or acetaminophen can provide relief. Note that individuals respond differently to these drugs, so you may find that one works and others don’t. You have to experiment a bit to determine what works for you. However, if you are taking over-the-counter pain medications more than three times per day, the Cleveland Clinic suggests seeing a doctor for prescription pain medications. Taking too much acetaminophen can cause liver damage, while consuming too much ibuprofen or aspirin can irritate the stomach. Also, taking medications for headaches more than three days per week can lead to a “rebound headache,” so you want to ensure you’re not overusing pain pills.

Turn to prescription medication for more intense discomfort. For severe pain, you will need to take a stronger pain medication, which can be prescribed by your doctor (who may also prescribe medications to treat the other symptoms of migraine, such as nausea). A group of drugs called triptans are the most commonly suggested type of prescription painkillers for migraines. According to Consumer Reports, triptans “significantly reduce pain within two hours for most people,” and as a bonus, they fight other migraine symptoms like nausea and light sensitivity. Triptans come in a number of forms, including injections, patches, suppositories, pills, and nasal sprays. For people who cannot tolerate triptans, ergots are an alternative option. Ergot medications are vasoconstrictors, meaning that they restrict the flow of blood to the brain. They are available in injection, nasal spray, suppository, and pill form. Smoking should be avoided when taking ergot medications.People with heart disease cannot safely take triptans or ergot.

When other options fail, make an appointment at a migraine specialty center. If the treatments you try under the supervision of your regular doctor prove ineffective, it may be time to visit a physician who specializes in migraine headaches. You can find a headache specialty center in your state or region using the Migraine Research Foundation’s online database of Comprehensive Headache Centers (see http://migraineresearchfoundation.org/resources/find-a-doctor/comprehensive-headache-centers/).

Although you may have to spend some time and money traveling to one of these centers, you will find specialists who are very experienced and knowledgeable regarding migraine headaches, so it can certainly pay off in terms of quality-of-life improvement! When going to any doctor, be sure to take all your medical records and a listing of your prescriptions, over-the-counter drugs, supplements, vitamins, and herbs you take.

The bottom line: Science has not yet pinpointed the exact cause of migraine headaches, so they can be tricky to prevent. Determining the unique causes for each individual requires substantial investigation, and you may need to do much of the work yourself (in collaboration with your selected health professionals). However, helpful preventative measures do exist, and they can assist many migraine sufferers in reducing the frequency and severity of their attacks. When a migraine is unavoidable, prescription medications can also help reduce the agony. As time moves forward, researchers will uncover more ways to fight these painful headaches, but until then, consider our tips—along with the advice of your physician and other professionals—for maximum chances of relief!

You may read the other segment of this two-part series, “Migraines: More Than Just Headaches,” at www.mikedubose.com/migrainecauses.

About the Authors: Our corporate and personal purpose is to “create opportunities to improve lives” by sharing our knowledge, research, experiences, successes, and mistakes. You can e-mail us at katie@dubosegroup.com.

Mike DuBose received his graduate degree from the University of South Carolina and is the author of The Art of Building a Great Business. He has been in business since 1981 and is the owner of Research Associates, The Evaluation Group, Columbia Conference Center, and DuBose Fitness Center. Visit his nonprofit website www.mikedubose.com for a free copy of his book and additional business, travel, and personal articles, as well as health articles written with Dr. Surb Guram, MD.

Dr. Surb Guram, MD is a board-certified internist and a graduate of the University of South Carolina School of Medicine. He is a partner with the SC Internal Medicine Associates in Irmo, SC and has practiced internal medicine in the Midlands for the past 30 years. See www.scinternalmedicine.com for more information on Dr. Guram and his practice.

Katie Beck serves as Director of Communications for the DuBose Family of Companies. She graduated from the USC School of Journalism and Honors College.

© Copyright 2018 by Mike DuBose—All Rights Reserved. You have permission and we encourage you to forward the full article to friends or colleagues and/or distribute it as part of personal or professional use, providing that the authors are credited. However, no part of this article may be altered or published in any other manner without the written consent of the authors. If you would like written approval to post this information on an appropriate website or to publish this information, please contact Katie Beck at Katie@dubosegroup.com and briefly explain how the article will be used; we will respond promptly. Thank you for honoring our hard work!

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