Issue #144 - May/June 2005
The Search for a Cure
Q. As a migraine sufferer, I have read everything I could find on headaches. I believe my migraines are caused by a number of factors including hormonal fluctuations, fatigue, stress and digestive problems. Recently I discovered a report called "An Innovative New Treatment for Migraine" by Dr. Sergey A. Dzugan. He reported 100% success by using natural therapies to restore balance to the hormonal, sympathetic and parasympathetic systems, the pineal gland and intestinal absorption.
There is also a plastic surgeon in my area advertising surgical treatment for migraine headaches, based on the theory that if Botox injections in the forehead muscles give temporary relief, then removing tiny muscles in the back of the neck and temple area can permanently relieve migraines. What do you think?
A. Most folks are constantly looking for definitive causes and treatments for their headaches. Unfortunately, most headaches are a chronic condition that can be adequately managed, but not cured. I would be very wary of anyone who boasts of total cessation of headaches.
There is some scientific evidence that Botox may be effective for the prevention of migraine headache; however, the data is modest at best in double-blinded studies. As for other alternative approaches, there have been small studies that showed some efficacy with melatonin, Coenzyme Q10, and riboflavin (B2) for migraine prevention. There also have been several studies showing modest benefit with feverfew and butterbur root. We must remember that these supplements are not FDA-regulated and may contain various chemicals. "Natural" does not necessarily mean it is safe, and many of our prescribed medications are derived from natural products.
Loretta Mueller, D.O.
University Headache Center
Moorestown, NJ
Benign Intracranial Hypertension
Q. I suffer with benign intracranial hypertension (BIH). I have had carbon monoxide poisoning and was wondering if this could have caused the condition. I am partially blind as a result of BIH. Any advice would be greatly appreciated.
A. Benign intracranial hypertension, or pseudotumor cerebri, is a disorder of elevated spinal fluid pressure, usually occurring in women of childbearing years. A headache is the primary presenting symptom, but patients can experience double vision and visual loss due to paralysis of the sixth cranial nerve. More than 90% of BIH patients are obese and are women. The mean age at the time of diagnosis is 32 years. The likelihood of carbon monoxide poisoning causing the condition is very low. There are several medical disorders that are more likely to be associated with BIH including Addison's disease, hypoparathyroidism, arterio-venous malformations, and diseases that obstruct drainage of the veins. It has also been reported following the use of excessive vitamin A or the antibiotic tetracycline.
George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL
Computer Screen Triggering Migraines
Q. I'm convinced that my migraine headaches (with symptoms of blindness, light auras, dizziness, vomiting and pain, in that order) are caused by looking at my computer display, which is a CRT (cathode ray tube) computer monitor. I'm thinking that flat panel display technology may be a solution because of its improved fidelity, resolution and refresh frequency rate. Has anyone researched this?
A. I don't know of any specific studies on the various aspects of the effects of the CRT on triggering migraine. Migraine is an inherited condition so the CRT is not the "cause," but certainly many patients feel it is commonly a trigger of attacks. Patients with migraine tend to be adversely affected by visual flickering, strobe effects, glare, etc.
I strongly suspect that reactions to computer displays are an individual matter and that there are no guidelines that will fit all migraineurs. It would be a matter of trying various monitors to see which is less irritating. I agree that a flat screen with LCD (liquid crystal display) would probably be more tolerable.
Robert Kunkel, M.D.
Cleveland Clinic Foundation
Cleveland, OH
Migraines Stopped During Chemotherapy
Q. Although I have a 39-year history of debilitating migraines, for the majority of the time that I was on an aggressive chemotherapy regime my migraines stopped altogether. Because I was given a mix of chemo medications and adjuvant chemical therapies, it would be impossible for me to know if it were a single drug or the combination that brought about such relief. Now that I have been off the chemo for an entire year, I can tell it is out of my system because the migraines have returned. Frankly, cancer was a whole lot easier to deal with than frequent migraines!
Perhaps others have encountered this in all the research that is done, but I've never heard or read anything about it. Has any research been done in this area?
A. There have been occasional reports such as yours, but I don't think there have been any studies done on the effects of chemotherapeutic agents on migraine. Drugs such as leuprolide and tamoxifen, which are used to control some cancers, have been reported to be helpful in some individuals with migraine. Their benefit seems to be due to suppression of female hormones.
Robert Kunkel, M.D.
Cleveland Clinic Foundation
Cleveland, OH
Migraine Associated with Anxiety and Depression
Q. Have any studies been done that link migraine and anxiety disorders?
A. Migraine and especially chronic daily headaches are highly associated with depression and anxiety. The reason for this link is unknown. In many cases, headaches are the result of frequent anxiety attacks or a permanent anxious state; in other cases, patients react to frequent migraine with increased anxiety. There are certain neurotransmitters implicated in both anxiety and migraine, which may be why they are comorbid disorders. In addition, antidepressants and tranquilizers used to treat anxiety can also be very effective in the treatment of migraine.
George J. Urban, M.D.
Diamond Headache Clinic
Chicago, IL
Sudden Explosive Headache Worrisome
Q. Monday of last week, I was talking to someone when I felt a slight pressure in my neck and face. Approximately one minute later I felt like someone had hit the back of my head with a baseball bat. Then my head felt 10 times its normal size. The pressure was unbelievable - it felt like my whole head was going to explode.
By the time I got to the doctors 10-15 minutes later, I could not walk unaided. I was crying from the extreme pain. I had double vision, could not stand light, and was sick to my stomach. My blood pressure was 185/108. I had all the tests at the hospital and they all came back negative. I was given morphine four times and it still didn't help. Then they gave me Toradol by IV and that made the headache manageable. Wednesday night, I was tired so I lay down and instantly felt the baseball bat to the back of the head and all other symptoms, along with a blood pressure of 189/108. At the hospital they said it was a severe migraine.
I have migraines with aura, but never the pain like these two attacks. I am wondering if this is unusual for a migraine. I talked to people who are migraine sufferers and none of them have had a migraine like this one. Since my attacks, I have felt tired and drugged out, with a loss of appetite. Some food tastes different. I'd really be interested in your perspective on these strange headaches. Two in three days is too much for me!
A. Sudden onset of an explosive headache can be indicative of intracranial bleeding from an aneurysm. Therefore, every effort should be made to rule out this cause. Incapacitating, explosive headache associated with high blood pressure also can be a result of pheochromocytoma (a tumor associated with hypertension). Talk to your healthcare provider about those possibilities.
George J. Urban, M.D.
Diamond Headache Clinic
Chicago, IL
Is Daily Pain Part of Migraine?
Q. I have had migraines for about 40 years now and they are getting better, but over the last six or seven years I have developed a pain in the temple area and around my eye on the left side. I have been told that this is a normal migraine thing. It just came on and now I rarely have a day without this pain, which varies from mild to migraine status.
Is this a part of a migraine? If so, is there anything I can do to alleviate this problem?
A. A chronic daily headache with migraine qualities such as you describe may be related to your previous migraines. This is also called "transformed migraine." Whenever there is a new pattern or a change in the characteristics of headaches, a physician must use his or her clinical judgment as to whether or not a further neurologic work-up is required. We are not sure why episodic migraine "transforms" into a daily headache pattern, but it may sometimes be due to mild head trauma, a brief viral illness, or overuse of caffeine or analgesic medications.
Standard daily preventive medications such as a low dose of older antidepressant drugs, blood pressure pills, or antiseizure medications may work effectively in treating this headache condition. Seeking the help of a headache specialist would be advised.
Loretta Mueller, D.O.
University Headache Center
Moorestown, NJ
Endometriosis and Migraines
Q. My 29-year-old daughter is having surgery to treat endometriosis. She has been a migraine patient for over 10 years. What correlation between endometriosis and migraines have you observed, if any? Hormones definitely play a heavy role in her migraines, as well as in the pain from endometriosis.
A. In my own practice, 17% of my menstrual migraine patients carry a diagnosis of endometriosis. I suspect that figure underestimates the true prevalence, however, as many women have endometriosis for years before their chronic pelvic pain is diagnosed. In a recent study from the National Institutes of Health, 57-75% of young women with chronic pelvic pain had migraine.
You are quite right that hormones play a role in both menstrual-related migraine and endometriosis. In fact, I consider a co-diagnosis of endometriosis to be an indication to use hormonal prevention for both conditions. One option is to use continuous active-pill-only oral contraceptives for extended periods of time. It is important to pick a pill with a relatively heavy progestin component and an adequate overall potency in order to block ovulation. Your daughter's healthcare provider could determine if she's a good candidate for this type of therapy.
Anne H. Calhoun, M.D.
University Headache Clinic
University of North Carolina at Chapel Hill
Impact of Hysterectomies on Migraine
Q. I would like to know if women who have hysterectomies notice a decrease or increase in their incidence of migraine occurrence. And is there any relationship to whether or not the ovaries are removed?
A. This is an area of some debate. A study published last year in Headache found that in China, migraines became less frequent after menopause - unless the woman had a surgical menopause. Then, they claimed, the risk of migraine was greater. But when you look more closely, that study had a major flaw: 81% of these Chinese women who had "surgical menopause" weren't menopausal - they still had one or both ovaries! They were premenopausal from a hormonal standpoint.
What I have noticed from over 20 years of treating hormonal issues in women is that migraines get better after menopause. This includes natural menopause or when it is due to removal of ovaries. However, if a woman enters menopause with chronic daily headache, migraines often get worse due to the superimposed sleep disruptions of menopause. I have never recommended hysterectomy for prevention of migraine.
A complicating issue is whether - or what type of - estrogen therapy is used after ovaries are removed. Gaps in estrogen concentration can produce estrogen-withdrawal migraines whether they are due to interrupted therapy or unintentional fluctuations from interactions with other drugs.
Hysterectomy without removal of ovaries offers no mechanism by which the operation would be expected to affect menstrual migraine, and my observations support this. It simply makes it more difficult to "time" specific preventive strategies.
Anne H. Calhoun, M.D.
University Headache Clinic
University of North Carolina at Chapel Hill
Adjusting Oral Contraceptives to Reduce Headaches
Q. What type/brand of oral contraceptives do you recommend for headache sufferers, specifically those with "common" migraine possibly related to the menstrual cycle? I'm presently taking a pill called Kariva.
A. If a woman has menstrual-related migraine with her natural cycle, there is no hormonal contraceptive that will decrease that risk. The drop in estrogen that occurs with the natural cycle is equal to the drop in estrogen with the lowest-dose oral or patch contraceptives. Those lowest-dose products include Kariva, the 20-microgram pill you mentioned.
Two options for your healthcare provider to consider are (1) an extended active pill regimen (such as Seasonale) that delays the period for 12 weeks but increases the estrogen drop when it does occur, or (2) supplementing with estrogen during all 7 days of the placebo week. This would be like taking 7 of Kariva's light blue pills during the last week instead of only 5. With Kariva, there is a placebo pill on days 22 and 23.
Anne H. Calhoun, M.D.
University Headache Clinic
University of North Carolina at Chapel Hill
