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Headache Experts - Question and Answer
June 8, 2010
Migraine Headache in Adolescents
Q:Why can’t doctors help sixteen year olds with migraines?
A:Headache, including migraine is common during teenage years. Headache during this period can impact school attendance and academic performance. There are several steps for proper diagnosis and subsequent treatment of the different types of headache that affects teenagers. Treatment includes dietary and life style modifications as well as medications if needed. Care is best received through a Child Neurologist or Headache Specialist. You can contact her primary care giver for referral. Once under care of the proper physician, most teenagers recover and get their headache controlled.
Hossam AbdelSalam, M.D.
Medical Director, Child Neurology
St. Alexius Medical Center
Chicago, IL
IV DHE Treatment for Migraine and Cluster Headache
Q: What do you think of Dr. Peter Goadsby's 5 day treatment with IV DHE for the treatment of Migraine and Cluster headaches at UCSF?
A: The duration of treatment with DHE intravenous has no set duration. It really needs to be judged on the nature of the process being treated as well as how well tolerated it proves. The “traditional” 3 day “Raskin” protocol was not developed with any specific science behind it but rather based on what Dr Raskin and his colleagues noted in their experience. There are some patients who might have great benefit from a single dose others who need more than 5 days. It is not uncommon for some patients to be prescribed rectal suppositories of dihydroergotamine or even capsules of it to take by mouth for a month or longer following an initial 3 day intravenous treatment as a means of resolving chronic migraine.
Fred Freitag, D.O.
Diamond Headache Clinic
Chicago, IL
High Barometric Pressure Migraine
Q:I have had migraines without aura for over forty years. I take Propranolol 80 mg. ER every day. I have been to three neurologists; one in Sayre, PA when I lived in upstate N.Y. in 1995, one in Elgin, IL when we lived there in 2003 and now one from Memphis, TN since we now live in Mississippi. I have been on Topamax which I seemed to be allergic to, Beta Blockers, and Calcium Blockers and Celebrex.
Nothing works for barometric pressure headaches. I used to have terrific menstrual headaches, but I had a hysterectomy and, with my age of 65, I don't have that problem any more. My question is what can I do about the high pressure headaches? It is not a question of what my problem is, but no one seems to know what to do about what I do have.
I have been on Imitrex for years; first the shot and now the 50 mg. tablets. They work, but I have to take them again when the headache comes back after it rains again with unstable weather patterns. I take Vitamin B6, B2, B12, Co Q 10 and Magnesium & Calcium so I am trying everything I know to take. I know to be careful with taking too many analgesics and the Imitrex so rebound is not a problem either since I take as little as possible of Aleve or Tylenol. I am also careful of what I eat and after so many years I know the triggers. My grandmother, mother and brother had these headaches and I passed them on to my two daughters.
A:Headaches triggered by barometric pressure are a challenge for many headache sufferers. Studies have shown that some headaches are triggered by relative humidity, barometric pressure, temperature and precipitation. It’s possible that the change in weather pattern, not the specific weather itself, is the triggering factor. Therefore, there is no specific management strategy for this trigger. You mention several important factors including a strong family predisposition to migraine and your previous trigger of estrogen fluctuations triggering menstrual migraine. So, your sensitive nervous system may respond to changes in weather thus triggering your migraines. The best thing you can do is raise your protective level by healthy diet, avoiding caffeine, having good sleep habits, exercising regularly and managing stress. Preventive medications may also be necessary to reduce your risk of headaches, including those triggered by weather changes. Your healthcare professional can work with you to find the best medication or combination of medications to reduce your headache frequency. And, when you do get a migraine, whether or not it’s from the weather, treat it early to get pain-free. Unfortunately, there is no single simple solution to your headache problem.
Lisa Mannix, M.D.
Headache Associates
West Chester, OH
Migraine Profile and Intensity Change
Q:I suffer from migraines once per month. I also suffer from tension-type headaches. Yesterday, I woke up with a headache (normal for me) and it became worse to the point of pain (level 5 on a scale of 10) so I took a Fiorinal. Steadily my headache worsened throughout the day so I tried another Fiorinal (hours later) to ease the pain. About 1.5 hours after the second Fiorinal, my head started to feel pressure at the point where the neck connects to the head. It became a level 8 out of 10 for pain. I worried it could be a migraine (although normally my migraines do not start like this) and took a Relpax. Decided to take a warm bath for a few minutes, and then laid down in bed with a cold washcloth on my forehead. The pain continued to slowly travel up my head with throbbing on the whole backside of my head, it felt like someone put my head in a vice grip or put large nails through my head on each side. The pain now reached a level 10 and my head felt like it would literally burst. There was less pain if I lay on my back than if I laid on my side. I thought that I possibly should go to the hospital (this was the first time in my life of migraines - 18 years - which I felt I should go to an emergency room). Six hours after the start of this migraine, the pain had moved to the crown of my head and the level had come down to 7. Twelve hours after the migraine started, the pain was now in my forehead. I took a Midol (which sometimes helps my migraines) and laid in bed for two more hours, this is when I finally felt better and could get some decent sleep. At one point through the night I was worried this could be a brain aneurysm. However, I do not have any symptoms.
Can you please help me understand what kind of headache I had and what I can do next time I have such a headache? Normally, Relpax works in 1-2 hours for my migraines, but since the pain did not go away until after 7 hours then I am convinced this was not a migraine.
A:It remains a puzzle in the headache world why someone with fairly typical migraine that is easily identified as such will out of the blue have a major in symptom profile and intensity. We often will see this kind of change in pattern in migraine sufferers in their 40s and 50s during the menopause or just with aging. But we also see it at other times for no apparent reason at all. Sometimes it happens because the factors that lead to the triggering of migraine, such as stress, lack of sleep, weather changes, consumption of certain foods, certain phases of the menstrual cycle, and even a letdown from stress such as the first day of a vacation, pile up, leading to an atypical, severe episode of head pain.
An example would be a severe headache with some atypical features for migraine appearing in a student experiencing the stress of exams, along with poor sleep, too much cheese pizza and the start of her period. If you look back at the time of your bad headache, you may find a combination of such factors. Preventing similar headaches in the future may be a matter of good self care, optimal dietary choices including adequate hydration, rest and exercise.
To treat the pain you described is complicated if you have nausea and vomiting which I did not see listed in your symptoms. I think the pain medication you mentioned is OK but probably could have been taken every 2-3 hours for three to four dosings along with some liquid Ibuprophen, 400mg. Relpax is a good choice, needs to be taken early and may be taken again within 2 hours of the first dose if less than 70% effective.
If these episodes continue as you have described them, a check of your blood pressure during and in between headaches is important. A neurological consultation to go over your history and exam and medication use in detail would be the next step in deciding on other diagnostic tests, preventive strategies and acute pain management.
Finally, major head pain that comes on and intensifies over hours and fades after 4-7 hours back down to no pain is not typical for a bleeding or leaking aneurysm or for brain infection. With an aneurysm, the pain is often sudden in onset, very severe, frequently with a depressed level of consciousness and stroke-like symptoms such as weakness, loss of speech, nausea, stiff neck, and sometimes fever. The pain lasts for days. So I don’t think you had a bleeding aneurysm, although if you had shown up at an emergency room with the report of the “worst headache of my life” you would have earned an MRI scan and maybe a lumbar puncture, “just to be on the safe side”. That approach is very appropriate given that the docs in the ER don’t really know you as a patient and need to rule out major illness as part of what they offer.
Thanks for your question and good luck.
Doug Mann, M.D.
UNC Professor of Neurology
Chapel Hill, NC
Headaches From Degenerative Disc Disease
Q:What can be done about headaches that appear to come from degenerative disc disease? I am awakening with a headache early in the morning or shortly after arising.
A:Degenerative disc disease as a primary cause of headaches is not very common. There are two types of joints in the neck. The discs rest between each of the vertebrae and serve, if you would as “shock absorbers”. The second set of joints are facet joints which are off to the sides and these are the ones that all motion. They are similar to the “knuckle” joints of the fingers. Wear and tear is the most common reasons for the shock absorbing discs to degenerate and they do so in the lower part of the neck usually with the discs between the 6th and 7th cervical vertebrae. There is no direct neurologic connection from this area of the neck to the brainstem centers that are involved in headache pain. However the facet joints get the most wear and tear between the 4th and 5th vertebrae. At this level, at least in some there are connections from the peripheral nerves that serve this part of the neck and the brainstem centers for headache.
Treatment of all of these issues is aimed at reducing inflammation, often the NSAID group of medications, physical therapy aimed at improving motion and strength of the adjacent muscles and manual therapies performed by a variety of practitioners from physical therapist to doctors of chiropractic medicine (DC) to doctors of osteopathic medicine (DO).
There are a variety of headaches that can occur first thing in the morning. These may include severe uncontrolled hypertension and sleep apnea but also the early morning hours are the most common time for migraine attacks to begin.
Fred Freitag, D.O.
Diamond Headache Clinic
Chicago, IL