Reader’s Mail: Hypertension and Headache

Q. I was diagnosed with migraine syndrome after a hospital admission with aura, inability to speak and blood pressure of 200/99. Until this experience I was a person who had never had blood pressure above 120. That was three years ago when I was 65 years old. I was put on one aspirin a day and since have had only two slight auras and no other symptoms, except an onset of high blood pressure that my internist is attempting to control with medications, all of which give me side effects I cannot tolerate.

My blood pressure fluctuates from very high to very low during a migraine attack. My doctors don’t believe they are related, but one doesn’t happen without the other. They are treating me for heart trouble with migraines on the side. My question: could this high blood pressure be related to the migraine syndrome, and if so what can I do to overcome it? My diet is a healthy one and I exercise 4-5 times a week. I do not want to be on medications, as I have always been very sensitive to drugs, but of late I can’t see an alternative. Is there one?

A. Hypertension, defined as blood pressure above 140/90, can occur with a severe headache and can sometimes present as a medical emergency with changes in a patient’s mental status and vision. In the most severe cases, kidney dysfunction can also occur. Migraine itself is not a likely cause of hypertension, although sometimes patients with severe pain can experience periodic increases in their blood pressure. In addition to diet, exercise and weight loss, relaxation/biofeedback training is an important component of treating migraine in hypertensive patients. A blood-pressure lowering medication should be initiated in most patients with persistent hypertension to prevent the development of coronary artery disease and stroke. In migraine patients, a good choice for an anti-hypertensive medication would be one that helps prevent migraine as well as treats hypertension. These include beta-blockers, calcium-channel blockers, and angiotensin-receptor blockers (ARB’s).

Patients should discuss their treatment with their primary care physician. Unfortunately, hypertension is usually treated with medications for the remainder of one’s lifetime due to the high risk of cardiovascular disease if the blood pressure is not controlled.

George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL

Hemiplegic Migraine Often Begins in Childhood

Q. My 8-year-old son has had two “episodes” in the last six months that sound like they may be hemiplegic migraines. Both times he was asleep and then awoke with a scream. When we got to his room, he could not sit up, stand or walk (he was floppy) and could not see at all. These episodes lasted approximately 30 minutes and then his motor skills and sight returned completely. He then complained of a throbbing headache right behind his eyes. He wanted to vomit but didn’t (we gave him Tylenolý). He did, however, throw up prior to us getting to his room. He recovered completely and the next day, you would never know it had happened.

We were calling these seizures, but never witnessed any convulsions. Is it possible for an 8-year-old boy who never has regular headaches to suffer from this kind of migraine?

A. Hemiplegic migraine, both the sporadic and familial (genetic) forms, typically begins in childhood and often ceases in adulthood. If there is no first- or second-degree relative with the disorder, then it is called sporadic hemiplegic migraine. Changes in consciousness ranging from confusion to coma are common in childhood cases. Sometimes the hemiplegia may be part of the aura and last less than one hour or may last for days or weeks. The aura is usually followed by a headache. The symptoms are fully reversible and include some degree of motor weakness plus visual, sensory, and/or speech disturbances. The onset of paralysis may be abrupt and simulate a stroke or seizure.

There is also another variant of migraine called confusional migraine. It is characterized by a typical aura, headache and confusion. The confusion can include the inability to maintain speech and other motor activities.

It is definitely possible for an 8-year old boy to suffer from sporadic or familial hemiplegic migraine or confusional migraine. It is important to rule out a more serious disorder including stroke, seizure disorder, etc. A CT scan or MRI of the brain should be included as part of the neurologic workup of a patient with suspected migraine variants.

George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL

What is SUNCT Syndrome?

Q. I was originally diagnosed with cluster headaches, but recently a neurologist suggested that my headaches are SUNCT Syndrome. Could you give me information on this condition and treatment options?

A. SUNCT Syndrome is a headache syndrome characterized by short-lasting attacks of unilateral pain occurring around the eye or supraorbitally (SUNCT stands for short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing). The attacks usually last 5 to 240 seconds in duration. The pain is usually very sharp, but may throb, and is usually associated with significant redness and tearing in the eye. Attacks are very frequent and can occur from 3 to 200 times in a day.

This is different from cluster headache in that the attacks are shorter in duration and more frequent in occurrence. Cluster headache is also a severe pain in or around the eye associated with eye redness and tearing, but it lasts 15 to 180 minutes and usually occurs from once up to 8 times in a day. Treatment of SUNCT has been historically difficult. There are no clear-cut treatment options but some response to antiseizure drugs, such as lamotrigine, gabapentin and topiramate, has been reported.

Nancy Juopperi, D.O.
Michigan Institute for Neurological Disorders
Farmington, MI

Barometric Pressure Changes Triggering Vestibular Migraine

Q. We live in Florida. Every time the rainy season comes I have problems. I have extreme pressure in my ears and my equilibrium is off. I don’t get true vertigo because my head does not spin. I do not usually get nausea. I get weak. I get headaches. I have neck and shoulder stiffness. I get truly frustrated.

Last year my doctor thought migraine medications would help. Well they did not. I went to an eye specialist. He said no problems with the eyes. We know it has to do with pressure – the minute the barometric pressure changes I am not well. I have also traveled and when in high altitudes I have similar problems.

I have had sinus surgery (which we thought might be the cause). I was better for about two years, but am worse again. The ENT said my nose is clear. I have taken Sudafed, anti-motion medications and Tylenol. I even tried earplugs. Any suggestions?

A. You bring up a very interesting problem: vestibular migraine. When you experience ear pressure and poor equilibrium you may be experiencing a migraine aura. This is then followed by headache and neck and shoulder stiffness typical of the headache phase of migraine. You may also get nausea but not usually. You already know some of your triggers: changes in barometric pressure (with the rainy season) and altitude change. These are typical migraine triggers. Vestibular migraine is really just being recognized as an entity of symptoms involving the central and peripheral balance systems in patients who experience migraine. Symptoms may or may not be associated with headache at the time of their occurrence. Often the use of migraine preventives is the best treatment. These may include antiseizure drugs and blood pressure medication. You would need to be on the medication for a minimum of six weeks at the appropriate dose to see an effect.

Nancy Juopperi, D.O.
Michigan Institute for Neurological Disorders
Farmington, MI

Worried About Slow Heart Rate

Q. My son suffers from migraines almost every day. Do you know if the headaches affect vital signs in serious ways? His pulse has been extremely low during his headache, 45-47, blood pressure is 133/88-138/84. I am extremely worried and wish to have him examined by a doctor who knows what he’s doing.

A. By all means have your son examined by a physician. You can begin with your primary care provider first and see where that leads. To sum up your problem, your son has a near daily headache with bradycardia (a heart rate less than 60 bpm). This can happen for a variety of reasons including benign headache, such as migraine or cluster headache, when the autonomic brain, which controls heart rate and blood pressure, is affected. However, slow heart rate with severe daily headache can be seen for more serious reasons, and these should be ruled out by a physical exam, lab tests and brain imaging before you are satisfied with a diagnosis of benign headache.

Nancy Juopperi, D.O.
Michigan Institute for Neurological Disorders
Farmington, MI

Clonidine for Migraine Prevention

Q. I have had migraines since I was 38. I have tried all kinds of treatment, yet I still struggle with them. Last week, my local doctor prescribed something new: clonidine in the 1 mg. strength. The directions are to take 1-3 per day as needed. I take one at a time when I think a headache will be starting. I also take Maxalt for migraines. Since I started the clonidine, I’ve reduced how much Maxalt I take so I don’t use it daily anymore.

I have two questions for you:

  1. Is there anything you can point out about clonidine use for treating migraines?
  2. What is your current position on Botox injections for headache treatment?

A. Clonidine is sometimes used as a preventive treatment for migraine as well as for detoxification from narcotics to reduce withdrawal symptoms. It is an anti-hypertensive agent that reduces sympathetic tone. Sympathetic tone is a constant wave of nerve impulses generated in the autonomic nervous system (which controls all inner organs, blood vessels, glands, etc.). Increased sympathetic tone causes rapid heartbeat, sweating, diarrhea, nervousness and other symptoms typically experienced during the withdrawal from narcotics. Botox is used for both migraine and tension-type headaches. The results are variable, but in some studies efficacy has reached up to 60%. In my opinion, Botox can be effective, but I also believe that it has been misused for inappropriate indications and used more frequently than recommended.

George J. Urban, M.D.
Diamond Headache Clinic
Chicago, IL

Preventing Early Morning Headaches

Q. I read an article on “early morning headaches,” but unfortunately it didn’t say how to prevent them. Are they preventable?

A. Early morning headaches per se are preventable only be preventing the migraines themselves. The most common time of day for migraine to begin is in the early morning hours. The combination of a lowered pain threshold in the early morning hours and increased adrenalin levels “primes the engine” of migraine. Since sleep is critical for migraine patients, a good nightýs sleep, starting and ending at around the same time each day, tends to be best.

Good sleep hygiene is also important. If your partner says you snore, or stop breathing at night, then a visit to your healthcare provider and/or a sleep lab may be in order. If you are overweight, then the first order of business may be to lose some pounds. This often helps with snoring and sleep apnea. Being overweight has also been linked to an increased tendency for migraine to become chronic. Caffeine avoidance is very important since it can not only disrupt the quality of sleep, but is one of the leading causes of medication overuse headache characterized by headaches occurring in the early morning hours.

Finally, if you are taking a preventive medication for your headaches, ask your healthcare professional if it might be more effective against morning migraines if you took the medicine prior to going to bed. This is sometimes the case.

Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL