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Reader's Mail Archives Issue
#165 - November/December 2008
We welcome your letters; please limit them to one page.
We reserve the right to edit them. Send your letters to:
Readers' Mail, NHF, 820 N. Orleans, Suite 217,
Chicago, IL 60610-3132 or NHF1970@headaches.org.
Looking for Help with Cluster Headache
Q: My husband has been suffering with chronic cluster headache for almost five years. He has been on just about every medication there is and finally took himself off all but Imitrex® injections and pain medications.
We found that the preventive medications didn't stop the headaches but kept him “messed up” even when he wasn't having a headache. His headaches last over an hour (usually several hours), even with the use of Imitrex and pain medications. He is pitiful really. He tries to live his life as normally as possible, but it becomes increasingly more difficult.
Recently, I saw an article on the use of baclofen for cluster. What are your thoughts on this?
A: The treatment of chronic cluster is challenging. Even when patients go into a remission, they are prone to recurrence despite ongoing treatment. In some cases, previous therapeutic approaches that had failed can again become effective. Aggressive medical therapies to try to interrupt the cluster headaches, such as dihydroergotamine or histamine, have been used with success. Some patients have undergone surgical procedures as well.
The use of baclofen, a medication originally used for relief of spasticity in multiple sclerosis, has proven useful in trigeminal neuralgia and, in one study, 12 out of 16 patients who were treated with this agent at doses of 15 to 30 mg per day had resolution of their cluster headache cycle within a week. Several of these patients took the treatment again at a later date when their cluster headaches recurred and had success again.
Frederick Freitag, DO, Diamond Headache Clinic, Chicago, IL
Headache from Sex and Physical Activity
Q: My boyfriend is 46 years old and often suffers headaches during sexual intercourse, especially if he hasn't had or it has taken a long time to get an orgasm. The headache usually disappears in a few minutes when he relaxes and has a rest. He has noticed the same kind of headache after other physical activity, such as working with heavy weights.
A: Orgasmic headaches are benign headaches that are not uncommon. They may happen during or after an orgasm in both females and males. Usually, they have a sudden onset, severe intensity and last a relatively short time. They can be very disturbing, especially when they happen the first time. Indomethacin usually helps when taken before sexual activities. Some patients need psychological counseling.
These types of headaches should also be investigated for the possibility of a ruptured aneurysm (which can happen during sexual activities). A CT or MRI of the brain should be performed to rule out bleeding in the brain. Please, have your boyfriend see a neurologist.
George Urban, MD, Diamond Headache Clinic, Chicago, IL
Treating Chronic Daily Headache, Fibromyalgia and More
Q: I have had chronic daily headaches and migraines with aura for years. I also have fibromyalgia, TMJ (temporomandibular joint syndrome) disorder and irritable bowel syndrome (IBS). All of these involve chronic pain. I take Relpax® for the migraines, which helps a lot with the aura and works okay for the headache. I also take Cymbalta® for depression, but haven't noticed any pain relief from it. The only other medication I seem to tolerate is Advil®.
Since I have a headache “24-7”, with no beginning or ending, I never really know what causes it. How many pain relievers (like Advil) do you have to take to get a rebound headache? I never take more than two a day, but I wonder if taking them for several days makes my headache worse. I want to do anything I can to prevent an already difficult situation from getting worse.
A: Chronic daily headaches are commonly associated with fibromyalgia, TMJ, IBS and other chronic pain disorders. The treatment for all those disorders is even similar. However, there is always a risk that overuse of pain medications will cause rebound headache, tolerance (a need for higher and more frequent dosing) and/or dependency.
Opioid-type analgesics, caffeinated products, barbiturates, triptans and ergots are known to be the main cause of rebound headaches. There is a debate as to whether nonsteroidal anti-inflammatory medications (such as Advil and Aleve®) may also be responsible. I think that you should seek help from a headache clinic, where these issues can be addressed.
George Urban, MD, Diamond Headache Clinic, Chicago, IL
(To find a headache specialist in your area, check out the NHF's Physician Finder on 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.)
Aura Incident Is Troubling
Q: I have had migraines since 1959, most often without aura but sometimes with aura. I am now 73 years old.
In February, while I was working on the computer, I had an aura and took an Imitrex. Then, as I tried to read the computer screen, I found the words made no sense. I could read the letters of a word, but had no idea what the word was or what it meant. I didn't have any numbness, tingling or blurred vision.
I had not eaten breakfast and thought it might be lack of food, so I went to a local fast food place. When I tried to order, all that came out of my mouth was a jumble of noise (word salad if you will). Finally, I got my order and sat in the car to eat. While I ate, I read signs in the area to see if I could read and understand them. As time progressed, I was able to read and understand the signs so I went home.
When my son heard he immediately took me to the hospital where I received all types of tests. I was admitted to the cardiac unit because it was thought I may have had a TIA (transient ischemic attack) . However, I never did have a complete MRI. I was told to follow-up with a neurologist, who told me I had an uncommon form of migraine. Unfortunately, I donÕt remember the name of the migraine.
He did not believe I had a TIA and instead prescribed vitamin B12 injections. Do you have an opinion?
A: The incident you describe is concerning. Migraine auras occur in about 20% to 30% of migraineurs and last for 5 to 60 minutes. Most auras are visual, but speech and sensory abnormalities can occur. Sustained weakness would be very disturbing. Clearly, food deprivation or certain types of food can be migraine precipitants.
Your case is troubling since I suspect you never had such symptoms before and the circumstances trouble you, as they should. You describe what neurologists call visual agnosia or alexia: you had trouble perceiving the letters you were looking at or understanding the words. Additionally, it sounds like you had a period of expressive aphasia (unable to use words). The symptoms occurred after taking Imitrex, a drug that constricts blood vessels and is contraindicated if there is a history of TIAs or stroke. A TIA is possible. Furthermore, Imitrex is not designed to prevent a headache when one is experiencing an aura in the absence of headache pain.
The neurologist might have mentioned the term complicated migraine, which should negate further use of Imitrex or other triptans. This was not just an ocular migraine or acephalalgic migraine (aura without the headache) I am afraid. You need to follow up with your neurologist or seek a second opinion from a headache specialist. A complete MRI and maybe an MRA of the brain may still be warranted along with a more detailed neurologic work up.
Michael Franklin, MD, St. Petersburg Neurology Clinic, St. Petersburg, FL
Aspartame Triggering Headaches?
Q: I get sick of well-meaning friends, relatives and colleagues and their insights into why I get migraine headaches. I just smile and check your Web site. The most recent idea was that aspartame, the artificial sweetener, is the cause of my headaches. If I would just stop using it, it was suggested, all my problems would go away. I did a search for an article regarding aspartame, however, and couldn't find one.
A: There are multitudes of migraine triggers. Triggers can be physical, psychological, biological, food, medications, etc. However, not every migraine sufferer is able to recognize his/her own trigger(s). Most of the time, migraine attacks occur without any pattern or stimulus.
Dietary factors have been recognized as common triggers (though not the cause) of migraine in susceptible people. Chocolate, aged cheese, nuts, nitrates and MSG are just few from the long list of food items. Aspartame, the artificial sweetener, has been known to induce migraine attacks in some individuals. In a study published in Headache (1989 Feb;29(2):90-2) investigators concluded that aspartame may be an important dietary trigger of headache in some people. In another study, published in NEJM (volume 317:1181-1185), aspartame was not found to be a precipitant for migraine.
Individuals who suspect that aspartame may trigger their headaches should avoid it for at least two to three weeks to see if the frequency of their headaches is reduced, and then reintroduce it to see the result.
George Urban, MD, Diamond Headache Clinic, Chicago, IL