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“More than 10 years ago, I started getting headaches around the time of my period, usually about nine or 10 months of the year,” says Ladies Professional Golf Association (LPGA) Tour Professional Diana D'Alessio. “For me, that meant severe head pain and an upset stomach that began a couple of days before my cycle.”
The NHF is pleased to announce that we have a new director of development. An attorney, Irwin “Mickey” Kesselman has been founding and helping non-profits for 18 years.
Longtime NHF board member Clealand (Clea) Frederick Baker passed away on March 15 at the age of 92. Mr. Baker was devoted to his wife of 68 years and his family, and dedicated to the practice of pharmacy and serving his community. He graduated with a BS in Pharmacy in 1936 and worked for People's Drug Stores in Washington, D.C., before joining the Burroughs Wellcome Company in 1942. He retired from Burroughs Wellcome in 1980 as Vice President of Corporate Planning and Development, a position which included responsibility for addressing company and pharmaceutical industry matters before Congress and with federal regulatory agencies. During thirty-four years living in Durham, NC, Mr. Baker served on the boards of the Chamber of Commerce, the Museum of Life and Science, the Durham Regional Hospital, the North Carolina Society to Prevent Blindness, the National Headache Foundation, First Union Bank, and the Rotary Club.
Each year, the National Headache Foundation gives the Seymour Diamond Lectureship Award to recognize the most significant paper in headache published in the past year. In 2008, Dan Levy, PhD, received the award for his paper, “Mast Cell Degranulation Activates a Pain Pathway Underlying Migraine Headache,” which was published in the journal PAIN.
Seymour Diamond, MD, executive chairman and co-founder of the NHF, explained Dr. Levy's study: “In people with migraine, certain blood cells affect the nerve or pain fibers. If the cells degranulate or lose part of their substance, this can trigger migraine and prolong migraine attacks. Part of this study's significance is that it integrates evidence that migraine is a neurological disorder with a vascular component.”
We asked Dr. Levy to share more about his study, which may contribute to the development of future treatments.
By Dan Levy, PhD, Assistant Professor, Headache Research Laboratory, Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
Although the causes of migraine are unknown, it is generally thought that the pain originates from inflammatory-related activation of the pain-sensing nerves that supply the meninges (the membrane that envelopes the brain), as well as the intracranial blood vessels. Despite a better understanding of the nerve pathway involved in migraine pain, the exact factors that trigger the activation of the meningeal neurons during a migraine attack remain largely unknown. This lack of understanding has severely hampered the development of preventive treatments that could interfere with the activation and triggering of migraine pain.
Our laboratory has recently been investigating the notion that one inflammatory component of the meninges, known as mast cells, may play a role in triggering the activation of the meningeal pain neurons. Mast cells are granulated (or crystallized) inflammatory cells that are implicated in a variety of immune reactions, but are primarily known for their role in promoting allergic reactions. Mast cells contain a host of inflammatory-producing molecules, such as histamine and serotonin, which can also cause pain when released near the terminals of pain-sensing neurons.
Building on Past Research for Tomorrow's Treatments
Given their close association with meningeal pain neurons and blood vessels, as well as their inflammatory properties, it was suggested that meningeal mast cells are involved in the pathophysiology of migraine. In fact, early clinical work suggested that migraine has an allergic component (a view still held by many clinicians today). A seminal study conducted in the 1960s by one of the pioneers of migraine research, the Italian physician Federigo Sicuteri, MD, demonstrated that an injection of the mast cell compound 48/80 into the cranial circulation promoted a hemicranial (one-sided) migraine-like headache, thus indirectly implicating intracranial mast cells in migraine.
Studies conducted in the 1980s by Jean Monro, MD, provided a more causative role for mast cell activation in migraine by showing a potent migraine preventive effect of the mast cell-stabilizing agent cromolyn. Additional evidence further supporting the involvement of mast cells came from studies on the role of histamine in migraine, which showed that plasma histamine levels are elevated during migraine attacks in a subpopulation of migraineurs and that histamine infusion triggers a migraine-like headache in most patients. Recent findings suggest an association between various migraine-triggering factors such as stress and nitroglycerin and the activation of meningeal mast cells.
In our study, we examined more directly whether meningeal mast cells can indeed interact with nearby pain neurons. We speculated that an interaction in the neuroimmune system (the immune system and the parts of the nervous system that modulate immune response) brought about by the release of pain-causing molecules from meningeal mast cells could cause a potent activation of the meningeal pain neurons with subsequent activation of the migraine pain pathway. We recorded the change in the activity of the meningeal pain neurons in rats in response to the local release of molecules from meningeal mast cells, using compound 48/80, the same drug used earlier by Dr. Sicuteri.
Cells Activate a Vicious Cycle
Our results showed that, indeed, the release of inflammation-producing molecules from mast cells can cause persistent activation of the meningeal pain neurons, an effect that can last for a number of hours. In a complimentary study, we used the mast cell stabilizing agent sodium cromolyn (the same drug used by Dr. Monro) as a migraine preventive agent and found it was able to completely block the effect of compound 48/80.
Our data provides, for the first time, evidence of the direct interaction of mast cells with meningeal pain neurons. It suggests that meningeal mast cells are involved in a bidirectional communication in which they can become activated by pain neurons but also activate them in return, causing a vicious cycle that likely enhances migraine pain. The notion that meningeal mast cells might become activated by factors that precipitate migraine points to their potential involvement in the triggering mechanism of migraine pain itself. Targeting mast cells, as well the action of their pain-producing molecules, may provide new ammunition for migraine prevention.
Q. My child has headaches that occur every month. They're mild, but he also vomits frequently and intensely for several hours. Are these migraines or something else?
A. It sounds like your child may have cyclic vomiting syndrome (CVS), a frustrating and challenging, but not life-threatening, condition that is a migraine variant. CVS is characterized by explosive, recurrent, prolonged and severe attacks of vomiting with no other underlying cause.
This condition typically begins in a preschool- or elementary school-age child who is otherwise completely well. The episodes of vomiting start abruptly at any time of the day, though most commonly early in the morning. Vomiting occurs many times an hour, often every 10 minutes, gradually slowing down in intensity over a period of hours to days. The vomiting resolves on its own and almost instantaneously.
During the spell, children are described as appearing pale and are sensitive to noise and light. They often want to be left completely alone in a dark room. They may also complain of a headache and a stomachache, though it is the vomiting that is the most troubling symptom. Their bowel movements may become loose or they may have actual diarrhea. They appear sleepy during and after the vomiting. Due to the frequent vomiting, a child may quickly empty his or her stomach and then vomit bile, which is a green color. Infrequently, a child may have blood in his or her vomit, which is usually from irritation of the esophagus from frequent vomiting.
The bouts of vomiting can recur weekly or monthly and the spell is often predictable to the day and, at times, the hour of onset. The episodes of vomiting can be triggered by stress (tests, divorce, homework), excitement (vacations, birthdays), motion sickness, certain foods and viral illness. In between, the child appears completely well.
There is often a family history of migraines and many CVS patients transition to having migraines themselves when they get older.
This condition is still frequently misdiagnosed, which means its true incidence is still not known. Unfortunately, there is no single test or procedure to help make the diagnosis. The stomach flu or food poisoning are often diagnosed with the initial bout of vomiting until the spells recur. Despite increasing awareness of this condition, diagnosis is typically delayed two to three years after onset of symptoms. The diagnosis is made after careful review of the patient's history, along with the exclusion of other causes of vomiting such as neurologic and gastrointestinal problems.
Once a diagnosis is made, treatment includes anti-vomiting and migraine medications during the bouts of vomiting and, if the spells are frequent, a medication to help prevent them. In case the vomiting is very severe or lasts days, intravenous fluids may need to be given to prevent dehydration. We have also started looking at non-traditional treatment options, such as certain vitamins and stress management therapy, to help prevent these spells.
The diagnosis, evaluation and treatment of CVS are typically coordinated by a gastroenterologist and neurologist. More recently, metabolic specialists have become involved in the evaluation. Certain medical centers have created CVS diagnosis and treatment specialty clinics.
A protocol for appropriate diagnosis and management has been developed by the National CVS Association Medical Advisory Board and is available through their Web site, www.cvsaonline.org.
Sumit Parikh, MD, Co-Director of the Cleveland Clinic Neurogenetics/Neurometabolism Clinic and the Cyclic Vomiting Syndrome Center, Neuroscience Institute, Cleveland Clinic, Cleveland, Ohio.
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Case Studies in Headache: Occipital Headaches |
by Alan M. Rapoport, MD,
Clinical Professor of Neurology,
The David Geffen School of Medicine at UCLA, Los Angeles, California, and founder and Director-Emeritus of the New England Center for Headache, Stamford, Connecticut
The Case
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. LyndaÕs headache was constant.
Discussion
A recent onset, intense, one-sided headache with neurological findings is always a red flag that suggests a more serious problem in the brain. Even though Lynda's tests were normal, I decided to admit her to the hospital for an emergency angiogram. For this test, a catheter is placed in an artery in the groin and threaded up the arterial tree until it reaches the carotid artery in the neck. Then a dye is injected and x-rays are taken. This results in a better view of the blood vessels in the brain than with an MRA scan.
We discovered a small aneurysm pressing on the third cranial nerve at the base of her brain, which was causing her pain, drooping eyelid and paralysis of the right eye. The next morning, Lynda had an operation to clip the aneurysm. She came through the procedure well and her eye problems resolved over a six-week period.
Lynda did not fit the criteria for cluster headache and because her headache was recent in onset, severe and associated with neurological findings, she needed urgent evaluation, in spite of previous negative studies.
An aneurysm is a small out-pouching of a blood vessel with a thin wall. If an aneurysm ruptures, it causes a hemorrhage in the brain and the outlook is often dismal. If an aneurysm is discovered before it ruptures, and it is larger than 4-5 mm in diameter, it is often treated with either surgery or a coiling technique, whereby a small set of threads is introduced via a catheter to cause a firm coagulation that prevents future bleeding. If the aneurysm is smaller than 4 mm, it is usually observed.
While most headaches are not cause for alarm, if you have a new onset, one-sided, intense headache with neurological symptoms like numbness, weakness or eye symptoms, it may be a medical emergency and should be attended to immediately.
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Readers' Mail, NHF, 820 N. Orleans, Suite 411,
Chicago, IL 60610-3132 or NHF1970@headaches.org.
Thunderclap Headache
Q: I have been living with daily migraine headaches for the past eight years. Then, a few months ago, I got a headache with pain so intense that my whole left side went numb along with my vision. I spent two separate times in the hospital. I still have a daily headache. I am also in physical therapy once a week to help my left side; my vision is still blurry in the left eye.
I have had an MRI of my head along with blood work, and seen a neurologist, neuro-ophthalmologist and an ophthalmologist but have found no obvious cause. I am very frustrated as I just want relief from the pain. I would like to know what caused this to happen.
A: It sounds as if you may have had an episode of what is called “thunderclap headache.” This is a severe, sudden headache that reaches its peak intensity in a few seconds. It is occasionally associated with a ruptured aneurysm, but that is usually diagnosed with symptoms of a stiff neck, loss of consciousness and blood in the spinal fluid. The majority of time this headache is benign and does not reoccur.
I hope you had a MRA and a spinal tap to rule out a small bleeding episode that may have occurred. It would be too late now to find blood in the cerebral spinal fluid.
-Robert Kunkel, MD, Cleveland Clinic, Cleveland, OH
Chronic Headache Not Likely Sinus
Q: The information on your Web site about sinus headaches says: “most people who think their headaches are sinus in nature are actually experiencing a vascular type of headache.” What is that?
I have had nasal surgery that failed. I take Zyrtec® and two nasal sprays daily, along with allergy shots weekly, yet my headaches still persist. I have seen an Ear, Nose and Throat (ENT) specialist who recommends I try surgery again, but with the last failure, I am doubtful it will work. My headaches have been coming a few times a week yet an MRI shows no infection or blockage. I am tired of only finding relief by going to bed.
A: Indeed, several studies have shown that most people complaining of “sinus headaches” are actually suffering from migraine, which is considered a vascular headache. That you have had so many interventions and testing focusing on a “sinus” or “nasal” cause for your headaches, yet still have them, suggests that you have migraine and probably transformed migraine or chronic daily headache (headache 15 or more days per month). More often than not, chronic daily headache is due to overuse of medications taken to relieve the headaches. In such situations, preventive medicines are rarely effective. I recommend that you seek a consultation with a headache specialist.
-James W. Banks, MD, Ryan Headache Center, St. Louis, MO
(To find a headache specialist in your area, check out the NHF's Physician Finder at our Web site, www.headaches.org. The one-step search will help you locate a specialist in your area. The NHF also has free lists of physician members for most states. Call 1-888-NHF-5552 to get a copy.)
Preventing Headaches
Q: I suffer from chronic migraine headaches. It has been five years since I started taking nortriptyline as a daily preventive medication. It has helped tremendously, decreasing the number of migraine attacks from three or more a week to two to three times a month. When I experience a migraine attack I take Imitrex®, which usually helps within 20-30 minutes.
My question is: is it time for me to get off the nortriptylene and try biofeedback? I've found that drinking two glasses of Gatorade and heating my hands and feet helps sometimes, but I am helpless when the attack starts so suddenly. Is there a way to recognize the early pre-headache symptoms so I can start my preventive routine?
A: There is no right amount of time to be on a daily preventive medication. Migraine is a chronic medical disorder like high blood pressure. It just does not up and disappear for most people and so may require treatment for a prolonged period. On the other hand, we also know that the successful treatment of migraine with medication can produce a prolonged period of remission allowing patients to discontinue their medication for at least some length of time. The longer the migraines have been quiet, the better the chance that stopping the medications will be successful and the migraines won't flair up again.
Some people with migraine have well-defined auras that announce the coming of a migraine attack or subtler, but also reliable, symptoms called premonition. The premonitions occur from several hours to a day before the migraine and take the form of such symptoms as a change in energy level (up or down), change in mood (happy or sad), or food cravings (like chocolate). These are among the most common symptoms, but not the only ones. If the symptoms are reliable, they can be used to predict attacks, making the preventive strategies more effective. However, in the absence of an aura or premonition, it may be more challenging. Biofeedback may be a worthwhile nonpharmacologic treatment to complement the nortriptyline and improve relief.
-Frederick Freitag, DO, Diamond Headache Clinic, Chicago, IL
Hormonal Migraine Headaches
Q: I am pretty positive that my migraines are hormonal. My doctor has put me on Cenestin® 0.45 mg (an estrogen supplement). My migraines are now gone during my period, but I consistently get a five-day migraine two weeks after my period even while I am on the Cenestin. Do I need to increase the dose?
A: If you are taking Cenestin daily, I am not surprised that you still experience a post-ovulatory (mid-cycle) migraine. it is expected that you would still have this migraine, since Cenestin inhibits neither ovulation nor menses. But I am surprised that you have not had a migraine with your period recently. I suspect that this is simply a fortunate, but chance occurrence.
What might work better for youÑand prevent both the post-ovulatory and menstrual migraineÑis extended-cycle therapy. There are a number of ways to accomplish this, but some commercially-available regimens include Seasonal® or Seasonique®. Seasonique adds back 10 mcg of a synthetic estrogen during the period week (the 13th week of the pill-pack). In my experience, 10 mcg is usually not sufficient to prevent an estrogen-withdrawal migraine during the menstrual week, so I add Cenestin 0.9 mg (in addition to the 10 mcg in the Seasonique pack) during those 7 days.
Alternatively, other 30 mcg oral contraceptives can be used as “active-pills-only” for extended periods of time. Patch or ring contraceptives are also effective when used in extended regimens (such as OrthoEvra® or NuvaRing®).
-Anne H. Calhoun, MD, University of North Carolina, Chapel HIll, NC
Migraine and Birth Control
Q: When I originally started taking birth control pills, I would get tension headaches for a week and a half that would turn into migraines. My doctor suggested trying a hormone patch the week I was on the placebo pills. I tried the patch, but it did not improve my headaches. I was next put on Loestrin®, but my migraines got worse, affecting my vision and causing numbness and dizziness. The last few months my migraines have been debilitating. My doctor would like to put me on Seasonique®.
I have always felt uneasy about taking a birth control pill that would reduce my periods to only four a year. Also, the research I've done says that having a history of migraines with aura can double your risk of having a stroke. I am extremely concerned about starting Seasonique with the bizarre symptoms and migraines I have had with Loestrin. I really don't know what to do. I am only 25, but with my history of migraines I don't want to risk my overall health.
A: I appreciate your concerns. Having migraine can increase, ever so slightly, the risk of stroke. Having migraines with aura about doubles that risk; though still very rare, it is a cause of concern. The pill increases the risk of stroke more significantly. Experience with the pill over the decades has pointed out that the higher the dose of the estrogen the greater the chances of a stroke, but even with the low-dose pill there is a level of risk.
The development of new neurological signs or a change in them (as you experienced) when starting an oral contraceptive is not a favorable sign, but rather a red flag that it may be best to part ways with the pill. While Seasonique has an even lower estrogen dose than Loestrin, it could still exacerbate your migraine and, given the increased stroke risk, is probably not worth the risk for you. That said, the overall approach that was originally taken an estrogen supplement during the week off the pill or around menses, or using a continuous oral contraceptive can be tremendously beneficial for some women with migraine associated with their menses.
-Frederick Freitag, DO, Diamond Headache Clinic, Chicago, IL
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Mission Statement
The NHF exists to enhance the healthcare of headache sufferers. It is a source of help to sufferers’ families, physicians who treat headache sufferers, allied healthcare professionals and to the public. The NHF accomplishes its mission by providing educational and informational resources, supporting headache research and advocating for the understanding of headache as a legitimate neurobiological disease.
Vision Statement
The NHF will be the premier educational and informational resource for headache sufferers, their families, physicians, allied healthcare professionals and health policy decision makers. The NHF will advocate for headache sufferers. The organization will employ the most effective means to disseminate information and knowledge to headache sufferers and non-sufferers.
TO TOP| BROCHURES (Prices include postage & handling. For 11-20 brochures add $2. For 21-75, add $3. For more than 75 brochures, please call for information.) |
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| NEWLY UPDATED - The Complete Headache Slide Chart Lists 21 different types of headaches, their symptoms, precipitating factors, treatment & prevention. |
$2.00
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| The Headache Handbook 8-page brochure with information on causes, types of headaches, & available treatments. |
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| About Headaches 16-page in-depth look at headaches, tips on when to seek medical advice, treatments, etc. |
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| About Stress Management 16-page brochure discusses stress management techniques and how to locate help for managing stress. |
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| About Relaxation Techniques 16-page step-by-step instructions for relaxation methods such as meditation, deep-breathing & visualization. |
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| About Over-the-Counter Medications 16-page brochure explains the potential risks and precautions to take with certain medications, how to read medication labels, & other valuable information. |
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| How to Talk to Your Healthcare Provider About Headaches 8-page brochure on when to seek help for a headache problem, keeping a diary, & working with a doctor. |
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| Alternative Therapies & Headache Care 20-page guide to the vast array of alternative headache remedies & methods. Recipient of a Silver Award from the National Health Information Awards. |
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| New Perspectives On Caffeine And Headache: Straight Talk For Headache Sufferers 20-page brochure summarizes and explains the most recent information about the unique relationship between caffeine and headache. |
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| Keeping Track of Your Migraine Patient Diary 36-page logbook has detailed calendars to keep track of headaches & associated symptoms. |
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| Women & Migraine 16-page brochure offers facts, tips and coping strategies for women suffering from migraine in all phases of life from pregnancy to menopause. |
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| Talking to Your Headache Doctor 12-page guide to enhancing communication with your doctor to get the best information & help in developing an effective treatment plan. |
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| A Patient’s Guide to Headaches 16-page brochure on types of headache, with a focus on migraine including dietary triggers, the phases of migraine, medications, & alternative treatments. |
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| A Patient’s Guide to Migraine Prevention & Treatment 18-page guide includes causes and phases of migraine, drug and non-drug approaches to treatment and prevention, and a diet for migraine sufferers. |
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| NEW ITEM - A Patient Guide to Menstrual Headache 16-page brochure offers facts, tips and coping strategies for women suffering from menstrual migraine. |
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