Reader's Mail Archive #170 - September/October 2009
Q: Since my periodic migraines of four a month suddenly jumped to twenty a month, my neurologist has been giving me Botox® (botulinum toxin) injections. This has cut my migraines to eight a month. The Botox injections have to be renewed every three months. However, I had to pay for this specialist out-of-pocket because he was not covered by my HMO. My insurance also refused to pay for Botox injections on the grounds that Botox is considered “experimental” for migraine and tension-type headache. I plan to appeal this decision. I wonder if you know of any studies that I could cite that dispute the fact that Botox treatment for chronic daily headache is still considered “experimental” or if you have any other suggestions as to points I can raise to strengthen my appeal. I’m sure that there are many people like me who would be helped by Botox injections, but can’t get it covered by their insurance. A: You are facing a common dilemma with insurers not covering certain treatments. There should be an appeals process, which you and your healthcare provider can pursue. Most providers will assist in this appeal process. Keep in mind, your insurance company (whether a private for-profit plan or a government plan) is primarily interested in controlling expenditures, not in what may be best for any one individual. There is more and more data being published on the use of botulinum toxin for migraine and chronic headaches. Citing the data, however, may not be as compelling as being able to demonstrate marked reduction in other healthcare costs you incur after getting treatment with botulinum toxin, should you note marked improvement. Paying out-of-pocket for one or two courses of treatment may well be a valuable investment for you. James W. Banks, MD, Ryan Headache Center, St. Louis, MO Q:I have had headaches for five years and they’ve now become almost constant, though some are more severe than others. Most of the time Imitrex® helps, but the headaches always return. I also have an aching pain in my forearms and I have tension in my neck and shoulders. Is it normal for a 30-year-old woman to have this many aches and pains? A: No, it is not normal for a 30-year-old woman to experience headaches and body pains so frequently. However, chronic headaches and pain are more frequent than most people realize. This does not mean you need to just tolerate the pain. There is recent evidence to suggest headaches can lead to more headaches. In some people who experience episodic migraines, the headaches can transform to chronic daily headaches. Also, if you are using Imitrex every day, you may be experiencing medication overuse headaches (rebound headaches). You likely need a daily preventive medication to stabilize your headaches and help you out of the medication overuse pattern. Your body pains may indicate that you have fibromyalgia, which is a condition that can occur more frequently in individuals with migraines. Often the treatment for both conditions overlaps. Make an appointment with your healthcare provider to specifically discuss your headaches and body pains. Jennifer Bickel, MD, University of Kansas, Kansas City, KS Q: My daughter has been suffering from cluster headaches for three years. She averages 62 headaches each year. She has had to leave two different work positions and give up her dream of becoming a nurse due to these crippling headaches. My daughter has no insurance and needs help. She’s tried Botox® and went through 10 different medications. The family nurse practitioner that she sees feels that my daughter needs to be put in the hospital when she is having an attack and have tests run, but without any insurance it’s impossible. A: Cluster headache can be quite debilitating and the pain is often excruciating. Hospitalization, however, is generally not required for either the treatment or work-up of attacks. The diagnosis is made on the basis of the symptoms and timing of attacks. Although your daughter has tried 10 different medications, it is not clear whether any of these medications were those that have been identified as most successful in the prevention of cluster headache. Your daughter might benefit from consultation with a headache specialist or a neurologist who understands headache. Christina Peterson, MD, The Oregon Headache Clinic, Milwaukie, OR (To locate a headache specialist in your area, check out the NHF’s Physician Finder on our Web site, www.headaches.org. The NHF also has free lists of physician members for most states. Call 1-888-NHF-5552 to get a copy.) Q: Over the last three years I have had cluster headaches on the left/backside of my head, which always begin at 3 a.m. The only way I can get relief is to stand up. Typically, I have mild back and neck pain the night before; the stronger the neck pain is, the more painful the headache. I have had acupuncture, chiropractic sessions and physical therapy, but nothing works. What advice can you give me? A: Although your headache warning is in the neck, it is unlikely that the cervical spine is the cause. Therefore, chiropractic treatment or physical therapy would not be of benefit for the treatment or prevention of cluster headache. Cluster headache is felt to originate in the brain. It is suspected that it is associated with the hypothalamus area of the brain, which controls body temperature and circadian cycles. This may account for the regular timing of attack occurrences. It is not clear why your cluster attacks are improved by standing up; other cluster headache sufferers have reported relief with exercise, but this is presumed to be due to increased oxygen intake. High-flow oxygen is sometimes prescribed for the treatment of cluster attacks. If your attacks are frequent, you may wish to pursue the possibility of preventive medications. Christina Peterson, MD, The Oregon Headache Clinic, Milwaukie, OR Q: Do you know what type of birth control pill I can take that will not worsen my migraines? A: It is hard to give you a specific answer because women with migraine do not all react to oral contraceptives the same. In general, pills with the lowest estrogen dose would be least likely to aggravate migraine. Some women have fewer migraine attacks on the pill because they do not ovulate, while others seem to have worsening of headaches with any amount of extra estrogen. Many women do better on the low-dose three-month pills, because the most significant trigger of migraine is the fall in the level of hormones when the pill is stopped (every three weeks in the usual type). The “triphasic” type of pill, where the amount of hormone varies during the month, should be avoided in migraine because the varying amount of estrogen may have a worsening effect. In theory, contraceptives containing only progesterone should not have much effect on migraine, but I have had some patients for whom even this type of pill made their migraines worse. Robert S. Kunkel, MD, Cleveland Clinic, Cleveland, OH Q: Can you tell me if there are any diagnostic tests that can be done on a patient that would rule out the diagnosis of occipital neuralgia? A:There are no tests that will prove or disprove occipital neuralgia. The diagnosis is based on clinical features and is usually confirmed if pain relief is achieved with numbing and/or anti-inflammation injections around the nerve (occipital nerve block). Typical features of occipital neuralgia include stabbing or electrical shock-like pain starting in the back of the head on one or both sides (depending on whether one or both occipital nerves are involved). The pain may radiate to the front of the head or behind the eye. The scalp is sometimes tender to touch. Occipital neuralgia is usually caused by injury or irritation to the occipital nerves, which radiate from the neck to the scalp along the back of the head. Loretta Mueller, DO, University Headache Center, Stratford, NJ
Appealing Insurer’s Refusal to Pay for Treatment
Daily Headaches with Body Pain
Forced to Give Up Dream Because of Cluster Headache
Cervical Spine and Cluster Headache
Choosing an Oral Contraceptive
Diagnosing Occipital Neuralgia
