Issue #145 - July/August 2005
Migraine and Stroke?
Q. After reading the article, "Is Migraine Increasing Your Risk of Stroke" (July/August 2004), I am in a quandary. As a long-time user of oral contraceptives, I am concerned about the link between their use and an increased risk for stroke. I have been having increasing episodes of migraine attacks during my period, sometimes as many as five migraines over seven days. At other times of the month my migraines occur infrequently or not at all.
During a recent visit, my gynecologist recommended that, to reduce the migraines, I take my oral contraceptive continuously for three cycles, then skip a week during which I would get a period. I would then continue the pattern with three continual cycles on the pill followed by a one-week break.
Now, if having more frequent migraines increases the risk of stroke, then this recommendation would seem to help prevent the increased possibility of stroke. However, if use of oral contraceptives themselves raises the risk of stroke, what should I do - take the advice of my physician and take the pill on a more continual basis as a means of curtailing migraine attacks, or consider stopping my use of the pill altogether?
A. There are some international studies that found that oral contraceptives posed an increased risk of stroke. Interestingly, U.S. studies have not found that association. One possible explanation for this discrepancy in results is that in many countries smoking is not considered a contraindication to using oral contraceptives. In the U.S., smokers over the age of 35 are rarely offered hormonal contraception. A recent review of the medical literature regarding oral contraceptives and stroke concluded that any association was "tenuous at best and perhaps nonexistent."
Smoking, however, changes the picture. A study in the British Medical Journal showed that although non-smoking women on oral contraceptives had no increased risk of stroke, heavy smokers had a 30-fold increased risk.
Fortunately, menstrual-related migraine (as you describe in your letter) is usually migraine without aura. This more common form of migraine has a lesser association - if any - with stroke, whereas migraine with aura does appear to confer increased risk. Data from the Women's Health Study show that among women under the age of 55, migraine with aura increases the relative risk of stroke 74%. While that may sound frightening to those who experience aura, it's important to realize that the absolute risk is quite low. Here's an example to put it in perspective: if the actual risk were 1 in 1000, then a 74% increased risk translates to an absolute risk of less than 2 in 1000 (because increasing the risk 74% would take it from 1 to 1.74)!
Anne H. Calhoun, M.D.
University Headache Clinic
University of North Carolina at Chapel Hill
Teen Suffering Daily Headaches
Q. My daughter, who is 17, has a mild headache all day, every day. She has had an MRI, CT scan, her spinal fluid pressure tested, chiropractic care for her neck, and blood work, all of which looked OK. Do you have any other suggestions?
A. The most common cause of a low-grade persistent headache is a tension-type headache. The teen years are terribly stressful on the human body and mind. The changes in body chemistry and growth have a major impact on many individuals and can contribute to their headaches. This is also a turbulent time emotionally as they move from being children whose lives are directed by their parents and teachers to adults where they become responsible for the decisions they make. With this, too, come many changes in stress hormones and brain chemistry, many of which can contribute to headache pain.
Evaluation by a psychologist may be helpful if there are some specific issues that are contributing to the headaches. Otherwise, treatment of the headaches with medications appropriate for tension-type headache and use of stress-relieving techniques such as biofeedback (which is most useful with this condition) are highly recommended.
Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL
Concerned About Taking Too Many Medications
Q. I often go without a migraine for a few weeks then get a bad migraine for several days in a row. It will come on either in the late afternoon or evening. The odd thing is that I am migraine-free in the day. This pattern can last a week. I take the triptan Maxalt for the pain. I can understand rebound headaches from overuse of medicine, but the first time it occurs, I take one Maxalt. Why would I get another migraine the next afternoon or evening? The next day it occurs I try to go without medicine, but am in such pain I have to take it again. Of course, after a week, I have taken quite a bit of medicine. Then I can go several weeks and not get a migraine.
My doctor has also recommended Zanaflex to take at the onset of a migraine as some of the time I feel muscle pain in my neck. He has also recommended Lexapro, which is normally prescribed for depression, although I don't suffer from depression. I haven't started either yet as I would like some more information on these and am concerned about taking too much medication. I am already taking Depokate, which has helped tremendously in reducing the duration of the migraines.
A. Migraine attacks can last from several hours to several days. For the most part, the medications in the triptan family are only active in the body for about half of a day; therefore the recurrence of migraine is not an unusual event. The longer a migraine has gone on before it is treated the greater the chance that it will recur because of the biological changes that happen in the brain during migraine. Sometimes changing triptans can stop the recurrence, as can making sure the headache is treated at its earliest onset.
As to the time of day, that is an individual factor that varies from person to person. Most migraine sufferers actually get their headaches in the first few hours of the day after awakening.
Regarding the use of adjuncts in treatment, if there is a tension component muscle relaxants or anti-inflammatory agents can be helpful in minimizing headache recurrence with the triptans. Dihydroergotamine is often a good choice for those with migraine recurrence with triptans.
The use of antidepressants has been a mainstay in migraine therapy since the 1960s. Their action on the neurotransmitters, such as serotonin, makes them valuable as potential migraine preventive medications.
Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL
Nosebleeds With Migraine
Q. My boyfriend, who is 21, has been getting migraines for a few years. He takes anti- nausea, anti-inflammatory and painkilling medications for them. He's noticed for a while that every time he has a migraine his nose bleeds. He gets blurry vision, has problems with speech and aura characteristics. He does eat a lot of hotdogs and drink a lot of cola. He also has a big sinus allergy to pollen and dairy. He has been to a doctor who tested him, sent him for CT scans, and then diagnosed migraine.
Does the nosebleed have any link with the migraine? Is it dangerous and could it mean something else is wrong?
A. The occurrence of nosebleed is one of the odd events that happen to some migraine patients; the why of it is not understood. It is not a dangerous thing unto itself unless of course the bleeding is heavy.
Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL
Relationship of Seizures and TMJ to Migraine
Q. What happens prior to, during, or after epileptic seizures that trigger migraine headaches? Which nerves are affected?
Also, how is TMJ (temporomandibular joint syndrome) affected by migraine and vice versa?
A. Epileptic seizures occur as a result of spreading electrical activity across the surface of the brain, which is similar to what happens to initiate a migraine attack. The electrical activity triggers the trigeminal nerve of the head to release certain substances that irritate and cause dilation and inflammation of surrounding blood vessels. This in turns causes pain. As to your question about TMJ and its association with migraine, TMJ disease may cause pain and muscle spasm around the joint. This pain input may lower the threshold or the level that will trigger a migraine attack. Additionally, migraine may cause muscle spasms around the head, including the neck and TMJ area, so you are correct in that they may be related.
Loretta Mueller, D.O.
University Headache Center
Moorestown, NJ
Migraines Transformed to Daily Headache
Q. I have had migraines for about 40 years and they are better than they used to be, but six or seven years ago I suddenly developed a pain in the temple area and eye on my left side. It just came on and now I rarely have a day without this pain, which varies from mild to migraine status. Is this part of migraine? If so, is there anything I can do to alleviate this problem?
A. Whenever there is a new pattern or change in a characteristic of headaches, a physician must use his or her clinical judgment as to whether or not a further neurologic work-up is required. A chronic daily headache with migraine qualities such as you describe may be related to your previous migraines. This is often called transformed migraine. We are not sure why episodic migraine transforms into a daily headache pattern, but sometimes it may be due to mild head trauma, a brief viral illness, or overuse of caffeine or analgesics.
Standard daily preventive medications such as a low dose of tricyclic antidepressant drugs, blood pressure pills or anti-seizure 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
Complicated Migraine Can Resemble "Mini-Stroke"
Q. My aunt has a history of migraine headaches. The attacks are getting progressively worse in that lately she sleeps for days at a time. I mean she is dead asleep. Nothing can rouse her. If she does appear to wake up, it is only to talk gibberish and then she's back to dreamland. This last episode (the fourth in 18 months) was especially scary and after two and a half days, my uncle called an ambulance.
She finally woke up on the fifth day in the hospital with no memory of why or how she got there. The first day there she was alternately awake and asleep and her face was swollen almost beyond recognition. The second day she recognized anyone who came to visit, but was childlike in her actions. Half of the time she could follow conversation, the other half of the time she strung unrelated words together as if in a sentence. The third and fourth days brought more improvement and finally on the fifth day she was pronounced cured and released.
While in the hospital she had every neurological test known to man, including a spinal tap. All showed nothing. It was initially thought she had had a mini-stroke and was given something in an IV to treat it. My uncle says that she will continue with this medicine in some form now that she is home. The doctors are not sure if it was a stroke or not.
Other things I know about my aunt are that she is a heavy smoker, has arthritis in her spine, has high blood pressure, had breast cancer and a mastectomy 20 years ago, and had surgery on her carotid artery last year. She takes medicine for her blood pressure and her migraines.
A. Complicated migraine, or migraine associated with transient neurological symptoms, can often resemble the symptoms of a stroke or "mini-stroke." This can include sleepiness, slurred speech, partial paralysis, etc., but the symptoms usually resolve spontaneously. It is important to perform a complete neurological workup including an MRI and magnetic resonance angiogram (MRA) if there is any suspicion of a vascular disorder. Sometimes an EEG (electroencephalogram) may be needed while the patient is in the altered state of consciousness.
It sounds as though all of this has been performed already and that your aunt is already taking migraine prevention medications. Sometimes it is necessary to use multi-drug therapy for better control and prevention of these types of migraines.
George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL
Link Between Headaches and High Blood Pressure
Q. I would like to have someone discuss the nexus of headaches and high blood pressure. I know doctors differ on this. However, I have heard from a chiropractor and a vein doctor who definitely believe there is an obvious nexus.
A. Essential hypertension is the most common form (95% of cases) of high blood pressure and has no specific cause for the elevation in blood pressure. Hypertension is usually independent of a headache diagnosis. In fact, many migraine and chronic headache patients have low blood pressure even when they are experiencing an acute attack of migraine. Most recent studies have not found an association between migraine and hypertension, including the Physician's Health Study in 1995. In 1992, a population study was conducted in Denmark that revealed that there were no differences in the prevalence of migraine or tension-type headaches in patients with high blood pressure and those with normal blood pressure.
However, some patients do experience increases in blood pressure during an acute headache attack in response to severe pain. Also, some treatments for high blood pressure, including calcium channel blockers, may cause headache as a side effect.
There is a specific type of headache that is associated with a diastolic blood pressure greater than 120 mm Hg, called hypertensive encephalopathy, which is considered a medical emergency. It involves severe changes in vision and mental status. It usually requires admission to an intensive-care hospital setting for intravenous blood pressure lowering medications and close monitoring of blood pressure. The headache usually disappears within two days after the blood pressure is reduced.
George R. Nissan, D.O.
Diamond Headache Clinic
Chicago, IL
