Issue #155 - March/April 2007
Headaches Caused by Hard Pillows?
Q. I am 13 and I suffer from migraine headaches. I think my headaches are caused by sleeping on hard pillows. I have tested the possibility: I slept on a hard pillow one night and then slept on a soft pillow the next night. I woke up with a serious headache when I slept on the hard pillow, but the next night I didn't wake up with one.
I was wondering if there are any pillows made specifically for people who suffer from migraine?
A. I am not aware of any pillows made specifically for people with migraine. However, there are many special pillows made specifically to help with neck pain. You may have a neck component to your headaches since you have noticed a difference with different kinds of pillows.
I recommend you have your healthcare provider evaluate both your headaches and any neck component that may be contributing to them, and discuss a referral to a physical therapist. The physical therapist may be able to recommend an appropriate pillow for you. In the meantime, stick with the pillow that works best for you the soft pillow.
Susan Hutchinson, MD
Headache Center Women's Medical Group of
Irvine Irvine, CA
Indomethacin Causing Kidney Problems
Q. I have had chronic paroxysmal hemicrania (CPH) for about five years and have been taking indomethacin twice a day for it. Since taking indomethacin, I have had no trouble with my headaches.
However, I've now been told my kidneys have gone into decline and I have to gradually stop taking indomethacin. I've tried stopping, but I'm getting the headaches back. Can you suggest another medication I could take that wouldn't be bad for my kidneys?
A. Indomethacin is the drug of choice for chronic paroxysmal hemicrania. Your positive response to it helps to confirm your diagnosis of CPH. Unfortunately, your kidney function now necessitates a change in medication. Other options for prevention include a calcium channel blocker such as verapamil. I reviewed the literature and found another case of CPH being successfully treated with acetazolamide, 250 mg three times a day (Diamox'). There was no evidence in my review that surgery, chiropractic treatment or acupuncture helped CPH.
You may also want to consider consulting a nephrologist to see if there is an alternate explanation for the decline in renal function. Blood loss, high blood pressure and other factors may impair renal function.
Susan Hutchinson, MD
Headache Center Women's Medical Group of
Irvine Irvine, CA
Vomiting with Migraines
Q. I am currently having what I'm pretty sure are migraines. I went a month without having any, but I've had three in the past three weeks. These last attacks have been different because I vomited many times. I've felt nauseated before, but never vomited. Are the headaches getting worse? Are they even still considered migraine?
I do have a prescription, but my doctor told me that it will only work if I take it at the onset of the headache. These headaches came on so fast that I didn't have time to take the medicine, and figured it was too late by the time I thought of it.
A. Migraine often will cycle and one may go several weeks without any significant attacks and then have a series of them. No one is certain why this occurs, but it is a common pattern. Nausea and vomiting are migraine symptoms.
While it is true that the medications used for acute attacks of migraine seem to work better if taken very early in the attack, they will often be effective even if not taken until later. In fact, the early studies of the triptan drugs were all done with patients taking the medication after the headache had become moderate to severe, not at the onset of the pain. Of course, if one is vomiting severely, oral medications will not be very effective. If vomiting is common and comes early in the attack, talk to your healthcare provider about the possibility of taking one of the migraine medicines that come in nasal spray or injection form, along with something for the vomiting.
Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH Confusing
Migraine with Stroke or TIA
Q. Are migraine equivalents ever confused with a stroke or transient ischemic attack (TIA)?
A. It is very easy and quite common to confuse a migraine equivalent with TIA or stroke. Migraine equivalent is a migraine without a headache, but with neurological symptoms that mimic TIA or even stroke. These symptoms may present in the form of visual aura, numbness, tingling, weakness in the extremities or face, or vertigo. Typically these symptoms last from 30 minutes to a few hours, and may migrate to the shoulder, fingers or back, or to the other side. Weakness is not very pronounced and neurological symptoms do revert back to normal.
To establish the diagnosis of migraine equivalent, one has to have migraine with head pain, too. TIA, retinal disease and stroke are ruled out by neurological examination and imaging procedures.
George Urban, MD
Diamond Headache Clinic
Chicago, IL
Tolosa-Hunt Syndrome
Q. I am a 61-year-old female who has been diagnosed with Tolosa-Hunt Syndrome. My regular doctor has never heard of this syndrome and I would like more information. So far, I've been able to out find very little about this disease.
A. Tolosa-Hunt Syndrome (THS) is a relatively rare disorder with estimated incidence of approximately one to two cases per million. It affects males and females equally and usually individuals over age 20. It is characterized by one or more episodes of pain behind or around one eye (orbital or periorbital), which persists for weeks if undiagnosed and untreated. Bilateral pain occurs in approximately 5% of cases. This pain is associated with weakness of one or more eye movements, droopy eyelid, and numbness or tingling in the forehead.
All of these problems are due to a nonspecific inflammation affecting the nerves that provide these functions. This inflammation is of unknown cause. Therefore, the reason you developed THS is unknown. The inflammation is called a granuloma and is readily visualized by a contrast-enhanced MRI. The granuloma is typically quite sensitive to corticosteroid therapy. A follow-up MRI should be performed to determine complete treatment response.
Frederick Taylor, MD
Park Nicollet Health Services
Minneapolis, MN Early
Morning Headaches
Q. Can you tell me what to do for early morning awakening headaches? I wake every morning with pain that goes across my forehead and around the back of my head and neck. Excedrin is the only thing that helps. If the pain is really bad, I take Maxalt for migraines. By evening I feel pretty well, but then it starts all over again the next morning.
I am seeing a neurologist and have an appointment for a second sleep study. The first sleep study I did, I couldn't sleep all night. I seem to be having more frequent nights when I don't sleep.
A. One of the best ways to treat early morning headache is to try to treat the headache preemptively, before it occurs. If your headache has migraine features, there are several options to 'head it off at the pass,' before the headache fully develops. Early morning is one of the most vulnerable times for migraine to occur, particularly between the hours of 4 and 9 a.m.
There are two long-acting triptan medications, frovatriptan and naratriptan, which, when taken at bedtime, may be beneficial in preventing morning migraine. One small study demonstrated that, surprisingly, a little caffeine at bedtime was also helpful in preventing morning headache. I would suggest a very low dose of caffeine, however, such as a cup of weak coffee or tea, in order to avoid interfering with sleep. Taking a gentle headache preventive at bedtime, such as nortriptyline or amitriptyline, may also protect you against waking with a headache, in part by enhancing restorative sleep.
You are wise to exclude sleep disorders such as restless legs or sleep apnea by obtaining an overnight sleep study. A restless night's sleep can cause early morning headache. Treatment of any sleep disturbance may, by itself, be enough to alleviate the pain.
Tarvez Tucker, MD
University of Kentucky Headache Clinic
Lexington, KY
Headache from Exposure to Nicotine
Q. I am not a smoker, but I work in a place that sells tobacco products. I got a doctor's slip for work, which allows me to avoid working in the cigarette area. The smell of the overwhelming odor makes me sick to my stomach and gives me a hammering headache. When I worked in that section, the smell would cling to my clothes and I couldn't get away from it. Naturally, everyone else thinks I am lying when I say that the smell makes me literally sick. Now, however, the company's computer is assigning the registers we work at, so I may have to work in the cigarette aisle. I am fearful for my job and my health. Is there a legal or medical solution that could protect me?
A. You are right that some individuals can get a headache from exposure to substances such as nicotine. I recommend you see your healthcare provider to discuss your tobacco-induced headaches. Another letter from your provider may help prevent you from having to work in the cigarette aisle. If your provider feels it's appropriate, you could be referred to a headache specialist in your area who could further substantiate your tobacco-induced headaches. The medical solution is to avoid exposing yourself to the substance that is causing your headaches and other symptoms. I don't think you need to pursue legal solutions unless your employers are completely unsympathetic to your legitimate medical concern.
Susan Hutchinson, MD
Headache Center Women's Medical Group of Irvine
Irvine, CA
Why Am I Taking These Medications for Migraine?
Q. I have been seeing a neurologist for my headaches. I'm wondering if you could shed some light on his decision for me. He first gave me a medication for seizures (Maxalt') and then he put me on a medication for blood pressure (Verelan'). I do not know why he would prescribe these medications.
A. Firstly, many medications are used for more than one purpose. Maxalt is actually only used for migraine, not seizures, and verapamil (Verelan) is used to prevent, or at least reduce, the number of migraines. Virtually all of the medications that are used to prevent migraines were first developed for other purposes and later discovered to help some with migraines.
Mark Green, MD
Columbia-Presbyterian Headache Center
New York, NY
Chronic Headache Has Gone Undiagnosed
Q. I have had headaches for over two years. Multiple neurologists have been unable to diagnose them. Where can I get help?
My symptoms don't fit anything in any headache chart. The headache is daily and lasts almost all day to varying degrees. I wake up with it in the morning or it begins after about 30 minutes. It is almost always a stabbing pain on the top of my head or around it. Medications have failed to relieve symptoms, and, in most cases produce terrible side effects.
A. What you describe sounds like New Daily Persistent Headache (NDPH), a descriptive term for a type of headache that may have multiple causes, which are not as yet understood. Whereas most migraine or tension-type headache begins on a once-in-a-while basis, NDPH starts daily from the get-go and just never lets up. It is not necessarily associated with overuse of medications, and, in some cases, is quite difficult to treat. However, the 'stabbing' quality of your pain is not necessarily typical of NDPH, which frequently has the characteristics of tension-type headache (more of a band-like sensation).
There are reports of NDPH responding to topiramate, valproate and amitriptyline. If you are having side effects with these drugs, you may be able to start them at extremely low doses and very, very slowly increase them over time, possibly taking as much as four to six months to reach an effective dose that doesn't cause adverse effects. You might also consult your neurologist about trying Botox' injections, if oral medications fail.
Tarvez Tucker, MD
University of Kentucky Headache Clinic
Lexington, KY
Birth Control Pills Contraindicated with Complicated Migraine
Q. The article on complicated migraines that I read on your Web site seems to parallel the symptoms that I experience. My main fear is that I am taking birth control pills and your Web site says to avoid them. Should I abstain from taking them? My doctor is well aware of my migraine history and my birth control usage and has never suggested I stop.
I started birth control pills at age 19, but started experiencing migraines well before that. I am now 27 and experience chronic migraines due to a car accident.
A. Complicated migraine is the term used to refer to forms of migraine in which the aura symptoms are prolonged or last into or through the headache phase. These forms include basilar migraine, hemiplegic migraine, retinal migraine and opthalmoplegic migraine. Careful evaluation by a healthcare provider who is experienced in diagnosing these very rare forms of migraine may be important in order to ascertain a proper diagnosis.
The use of estrogens, whether as a contraceptive or post-menopausal treatment, is at least relatively contraindicated in these rare forms of migraine. This becomes increasingly important should you have other risk factors for stroke, such as the use of nicotine.
Frederick Freitag, DO
Diamond Headache Clinic
Chicago, IL
Can Triptans Cause an Aneurysm?
Q. I wonder if you could give me any feedback on the use of Imitrex for migraines. A friend of mine recently had an angiogram where they discovered an aneurysm and had to perform a craniotomy. The neurologist told my friend that Imitrex can cause an aneurysm. I am very concerned about this as I have been using Imitrex for a long time for monthly menstrual related headaches.
A. There is no evidence that Imitrex, or any triptans, cause aneurysms. Do not be concerned about that.
Mark Green, MD
Columbia-Presbyterian Headache Center
New York, NY
