Post coital headache

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Let us discuss post-coital headache also at times referred to as orgasmic headache. What is post coital headache?  The history is quite typical. This is a throbbing and at times intense headache which comes on at or near the height of orgasm. During coitus as sexual excitement increases, the muscles around the shoulder and neck become tense. There is increased blood flow to the brain and either at the height of the orgasm or soon after the patient complains of throbbing and at times intense holocranial (whole head) headache.

Post coital headache is relatively benign and does not warrant any urgent treatment. As the sexual excitement weans off, the headache too subsides and usually by the time the patient reaches the ER to seek care, the headache is subsiding or already gone. There is though one entity which can mimic a post coital headache in its clinical presentation and which warrants urgent evaluation. This is the headache which occurs when an aneurysm ruptures in the brain. Classically an aneurysmal headache is described by the patient as the ” worst headache of my life“. It is intense, holocranial, throbbing and accompanied by a stiff neck (as you can see the clinical presentation may resemble that of a post coital headache). An aneurysmal bleed though may be accompanied by other neurological signs and symptoms depending upon where the bleed has occurred in the brain and patients are usually obtunded by the time they reach the hospital. An aneurysmal bleed is a medical emergency and needs to be evaluated and treated urgently. Usually a special kind of scan is carried out to localize the site of the aneurysm and then either the aneurysm is coiled or clipped to secure it. I shall discuss the management of aneurysms in a separate post.

Nitin Sethi, MD

A confused mass of “protoplasm”

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The human mind continues to fascinate me. Recently I met a close friend after a long time.  Over dinner and drinks he filled me up on his life. He now had a successful business employing well over 20 people. As we were chatting he said Nitin, I feel I have a problem. I asked what, to which he replied “I think my brain is a confused mass of protoplasm”. Intrigued I asked what did he meant by that.

He answered ” my brain is always working. It never stops thinking. All the time I have thoughts going through my head. What I have to do today, what needs to be done tomorrow. How I wish for just a short while my brain would stop thinking. I am doing one thing but my brain is already thinking about what next has to be done. In the morning I get up to take a shower and as the cold water strikes my face, thoughts race through my mind. Needless and endless thoughts. Do you have any drug which I can take to control my mind?”

I guess the pressures and distractions of modern life has made all our minds (some more than others) confused masses of protoplasm. Our minds are constantly getting bombarded by external images, sense objects, pressures of modern life, all causing a sensory overload which our minds are unable to compensate for. More and more people are burning out at a young age, some willingly and others been forced to opt out of the rat race. Turning to meditation, yoga and solitude to bring this incessant brain chatter under their control. Unfortunately we still do not have any magic drug to switch on and off these thoughts and ramblings of the brain.

Till that happens we continue to suffer the price of modern existence.

Nitin Sethi, MD

Heat sensitivity in patients with MS

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I wanted to just touch on the subject of heat sensitivity in multiple sclerosis patients. MS patients are more sensitive to heat/ temperature as compared to non MS patients. It has been seen they do “poorly” whenever their body temperature is elevated. So when MS patients have fever, they become weaker and their neurological deficits become more prominent e.g. more blurring of vision, diplopia, ataxia and cerebellar dysfunction. Thus infections such as pneumonia and urinary tract infections (UTI) warrant to be aggressively treated with anti-pyretics and antibiotics.

Why does this occur? Well the thinking is that as the temperature of the body increases, it promotes cross-talk among the demyelinated axons and also leads to conduction blocks (block in the conduction of impulses in the neurons). This exacerbates preexisting neurological deficits.

So it follows that MS patients do better in colder environments as compared to warmer places.  Better in winter as compared to the heat of summer. Keeping the ambient temperature of your house a few degrees below “normal” may be worthwhile though there is no scientific data to back this claim.

 

Nitin Sethi, MD

Complex partial seizures/ temporal lobe epilepsy

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One of the most common type of seizures seen in the adult population is what are called complex partial seizures. As the name suggests these are partial seizures  meaning that only a part of the brain has the seizure (remember in generalized seizures the whole brain has the seizure and hence the patient clinically has a convulsion, read my posts on epilepsy and seizures at http://braindiseases.info). Complex partial seizures differ from simple partial seizures. While in simple partial seizures there is no disturbance in the patient’s level of consciousness (the patient is awake and alert), in complex partial seizures there is an impairment in the level of consciousness. The patient may have his or her eyes open but usually is unable to respond or communicate. He may or may not comprehend if you try to speak to him during a seizure episode.

As many of the complex partial seizures arise from the temporal lobes in the brain, epilepsy of this kind is also referred to as temporal lobe epilepsy (TLE). That said and done complex partial seizures may also arise from the frontal lobes. Seizures arising from the frontal lobes can present with bizzare clinical manifestations, patient may become hyperactive during the seizure and have strange bicycling like movements of the legs. Complex partial seizures are at times associated with an aura. A simple way to define aura is what happens usually before the seizure. Prior to the onset of a seizure, the patient may experience gustatory or olfactory auras (smell of burning rubber, metallic taste in the mouth are the different classical auras mentioned in the textbooks of neurology). Other patients may mention they “feel wierd” or “dizzy”. Others mention a rising sensation in the stomach.

During the seizure apart from impairment in the level of consciousness, patients frequently exhibit what we refer to as automatisms. These are semi-purposeful movements. Examples include lip-smacking, chewing movements, tongue protusion, picking at the clothes (semi-purposeful movements of the hands). These patients may or may not have a “convulsion”. If the seizure spreads and becomes generalized then they go into a convulsion (such seizures are referred to as partial with secondary generalization).

If an adult presents with a new onset complex partial seizure, neuroimaging is warranted. This is because a new onset complex partial seizure raises the suspicion for an underlying structural lesion in the brain such as a cyst or a tumor (though I want to emphasize here that the most common cause of new onset seizures in the elderly is vascular, meaning a previous stroke).

Work-up for TLE includes an EEG, if needed a long term EEG recording (we call this a video-EEG study), imaging studies like CT scan (though the study of choice is what is called a MRI scan of the brain done under the epilepsy protocol). Thin slices are taken to look at the temporal lobes and hippocampus to make sure there is no structural lesion there nor is there any evidence for mesial temporal sclerosis (MTS).

There are many effective drugs for complex partial seizures/TLE. The most commonly used are carbamazepine (Tegretol) and oxcarbazepine (trileptal). If the seizures are refractory to medications, these patients can be worked up for epilepsy surgery (see my post on epilepsy surgery at http://braindiseases.info).

Nitin Sethi, MD

The neurology of aging

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Is aging normal or abnormal/pathological? No one quite knows the answer to that question. What we do know is that as we age, neurological disorders become increasingly common. These may range from well defined neurodegenerative diseases like Alzheimers dementia, Parkinson disease and amyotophic lateral sclerosis to other less well defined conditions like gait disorders, “balance problems”, “forgetfulness and senior moments” and increased propensity to falls. Strokes become more common in the aged brain vessels.

As life expectancy increases and more and more people live past the eight decade, neurological conditions become common and account for substantial morbidity and mortality in the oldest old (above 85). Earlier when the life expectancy was in the 60s, we did not see so much Alzheimers dementia, Parkinson’s disease or brain tumors. People died of other “natural” and “unnatural”  causes before the brain showed clinical manifestations of neurodegeneration.

Is it the norm that as we age, a substantial majority of us are destined to develop dementia?  Clinical studies have clearly shown that Alzhemier disease pathology increases with age and the incidence of the disease becomes increasingly common as one goes past 85 (the oldest old). Other studies suggest that though not all the oldest old show clinical dementia, a substantial majority have cognitive difficulties if carefully tested for at the bedside.

Why do neurological conditions become more “common” as we age and can we do anything to alter this? Many theories have been propounded. Increased amyloid deposition in the brain has causal association with Alzheimers dementia, in the same vein deposition of iron in the basal ganglia has been postulated to cause various basal ganglia pathology. There is increased oxidative stress in the “aged” brain which leads to free radical formation and damage to the cellular DNA. Genes get switched off or on triggering the disease process. A lot still needs to be learned about the neurology of aging.

While the mechanisms are still been elucidated, is there anything which we can do to change our “risks”. In the absence of good studies most of the data is open to interpretation. Aspirin prophylaxis, modification of microvascular and macrovascular risk factors like hypertension, diabetes mellitis and dyslipidemia (high “bad” cholesterol) all seem to be reasonable interventions. Obesity and sedentary life styles are bad for the brain too. Regular physical as well as brain exercises (neurobics) keeps the brain healthy and increases neuronal reserve. The role of anti-oxidants like coenzyme Q10 and alpha lipoic acid is still been defined. As they are relatively innocuous and free from side-effects, I would recommend them on a case by case basis. Episodes of major depression “hurt” the brain and aggressive treatment with anti-depressants should be initiated early rather than late.

The neurology of aging remains an uncharted territory but there is hope yet.

Nitin Sethi, MD

Alcohol induced dementia/ alcoholic neurodegeneration

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Continuing with the effects of alcohol on the brain, in this post I shall dicuss a frequently asked question by people who consume alcohol, does it cause neurodegeneration? Does alcohol kill neurons/ brain cells?

Let us discuss the entity called alcoholic cerebellar and cerebral degeneration. We now sufficient data to suggest that excessive consumption of alcohol does damage the brain.  Some parts of the brain are more specifically affected, these include the cerebellum. The cerebellum is the part of the brain which controls coordination, balance, gait as well has motor memory (memory for common motor actions performed by the brain). In the cerebellum are cells called the Purkinje cells which are selectively destroyed by alcohol ( the part of the cerebellum most commonly affected is the midline of the cerebellum between the two cerebellar hemispheres. This part is called the vermis of the cerebellum). So in alcoholic cerebellar degeneration we see vermian cerebellar atrophy in CT scan and MRI scans and also grossly if an autopsy is carried out).

So how does vermian atrophy present clinically?

Patients with alcoholic cerebellar degeneration have problems with gait and balance. Their coordination is off and they are prone to frequent falls (we have all seen the walk of a drunkard. While the clinical signs may not be so overt, on clinical examination we can usually pick up the signs of cerebellar dysfunction). Since these patients are prone to falls, they frequently land up in the ERs with head injuries (intracerebral hematoma, epidural and subdural hematoma). See my post on neurotrauma http://braindiseases.info).

Alcohol induced dementia: while this entity is not so well defined as alcoholic cerebellar degeneration, there is ample evidence to suggest that too much alcohol damages the cerebrum and can cause cognitive and memory problems. The thinking is that this is not entirely due to alcohol only. When someone abuses alcohol, he or she also does not consume a good diet and soon becomes deficient in essential nutrients and vitamins such as vitamin  B12 and folic acid. So alcohol induced cerebral degeneration is likely due to nutritional deficiencies.

No one quite knows the answer that if you supplement your diet with vitamins and essential nutrients even in the face of heavy and chronic alcohol consumption, would that prevent the development of alcoholic cerebral and cerebellar degeration. Infact in certain countries of the world a plan was put forward to fortify all alcoholic beverages with vitamins and essential nutrients. One of the problems with this proposal is that it alters the taste of the alcohol. Your rum does not taste like rum anymore!!!

In any case I advise my patients to always drink in moderation and to take 1to 2 tablets of a good multivitamin every day apart from a wholesome and nutritious diet.

Nitin Sethi, MD

Brain tumors: meningioma

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Let us talk here about a relatively common brain tumor called meningioma. I shall try to keep this simple yet cover some important aspects. Meningiomas are brain tumors which do not arise from the cells of the brain (as against glioms which arise from glial cells and other tumors which arise from neural cells). As they do not arise from “brain” cells, they actually are extra-axial in location. By that I mean, they are located outside the brain but inside the skull. So meningiomas do not actually “invade” the brain, on the other hand as they grow in size they press on the brain from outside inwards.

This is how meningiomas cause their effects. Depending upon which location the tumor is, as it grows in size it exerts pressure on surrounding structures. Pressure on the surface of the brain may cause seizures (so many patients may present with seizures and when a MRI scan is done the tumor is found), if they are near the optic nerve or tracts patient may present with slowly progressive loss of vision, if near the motor tracts with weakness in the arm and leg, if near the cerebellum with gait and balance problems.

Meningiomas are slow growing tumors and as I stated earlier they usually do not invade the brain (though they may be locally invasive at times and these tumors are called atypical or malignant meningiomas). As these are slow growing, if they are small in size and discovered accidently (as in you went for a MRI for some other reason and a meningioma is found but is not the cause of your symptoms), your doctor may decide not to do anything and just wait and watch and follow you with serial MRI scans. Frequently patients outlive their tumors and die of natural causes without the tumor ever becoming symptomatic.  If for some reason it starts increasing in size and becomes symptomatic then a surgical option can be explored.

So now that we know something about these tumors, we can discuss how to treat them. The treatment option pursued depends upon the size and location of the tumor. If the tumor is the right size and in a surgically accessible location, then it is easy take it out surgically if it is symptomatic. However if the tumor is symptomatic but in a surgically inaccessible location like near the optic nerves then other options like sterotactic radiotherapy may be tried. The management decisions need expert opinion and hence one should consult a specialist.

Personal Regards,

Nitin Sethi, MD

Taking control of your migraines: what can you do as a patient

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Migraines are among the most common of the primary headaches, the other been tension type headaches and cluster headaches. The etiopathogenesis of migraine headache is thought to be vascular and now there are many effective drugs available both for an acute migraine attack as well as for prophylaxis (read my post on headache at http://braindiseases.info). While these drugs are highly effective, many patients would rather avoid taking a drug if they can help it. Drugs have their own side-effects and cost is always an issue.

So is there anything patients can do themselves so as to make their headaches better? In this post I shall list a few of these simple measures, which if followed shall give you a better control over disabling migraine headache attacks.

 Know your headache

what do I mean by that. Well as a patient who suffers from migraine, the single most important thing that you can do is get to understand your migraine.

When does it come on?

Do you have headaches after a hard day’s work?

Do you get a migraine if you keep a late night out?

Does too much stress bring on a headache?

Does too much alcohol give you a headache?

 

If yes then what kind of alcohol gives you a headache the next day. People who have migraines usually get headaches if they consume red wine (white wine goes down better with them).

Do you have any other migraine triggers apart from lack of sleep, overindulgence in alcohol, red wine, old and aged cheese, chocolate, nuts etc.

What gives you relief from a headache?

Does sleep abort the headache?

Does regular physical exercise decrease your headache frequency and severity?

What about other complimentary therapies like yoga, tai-chi, meditation?

Keep a headache diary in which you document your headache episodes consistently for about a month or two. How many times did you have a migraine attack? What brought it on? What made the headache go away? If you keep this diary consistently, you shall soon come to know your triggers for migraine and can then take steps to remedy them.

Nitin Sethi, MD

Seizures associated with alcohol intake

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In this post I thought I shall discuss the effects of alcohol on the brain especially with respect to seizures. Many people drink socially , a drink or two after work is not only relaxing but also enjoyable. But who is an alcoholic or rather when does one have a drinking problem? We doctors use the CAGE criteria as a rather simple questionaire to determine if someone has a drinking problem.

“CAGE” where each letter has a question attached to it and the person has to answer yes or no. Let me elaborate a little.

C–stands for “cutting down”–have you ever felt the need to cut down on your drinking?

A–stands for “anger”—have you ever felt angry if someone has questioned your drinking habit?

G–stands for “guilt”—have you ever felt guilty about your drinking?

E– stands for “eyeopener”–have you ever taken a drink first thing in the morning?

If the person answers yes to these questions, he or she may have a drinking problem. What though is the effect of heavy alcohol drinking on the brain? Does it actually kill brain cells (neurons)? Does it lead to dementia? Can too many drinks cause a seizure?

Alcohol contrary to popular beliefs is a CNS depressant and not a stimulant. Alcohol is rather rapidly absorbed through the lining of the stomach and enters the blood stream from where it is carried to the brain. In the brain, it acts on the neurons and initially causes a loss of inhibition. You loosen up, your speech flows more smoothly and soon you become the life of the party. Well as you continue to drink, alcohol then starts depressing the central nervous system (CNS) . People usually fall asleep soon after consuming alcohol.

But let us get back to how chronic alcohol intake affects the CNS especially with respect to seizures.

I shall discuss this one by one.

Alcohol induced seizures

 

 Heavy alcohol consumption can induce seizures. Alcohol induced seizures are of different types. One is what is commonly referred to as “rum fits”. Let me explain with an example. You are out with your friends celebrating a promotion. Your drink for the night is beer. Your normal “limit” is say 4 beers. But hey you are celebrating and so you end up binging. Before you know it you are on your 10th beer of the night. Right as you are having your 11th beer, your eyes roll up and you have a big generalized tonic-clonic convulsion (see my posts on epilepsy on my website http://braindiseases.info) . This kind of seizure which occurs at the height of binging is what has been referred to as a “rum” fit. I guess it was first described with respect to rum. Any of us can have a rum fit if we drink too much alcohol. You do not need to be an epileptic to have a rum fit, though I feel these kinds of seizures associated with alcohol binging are more common in patients who have an underlying seizure tendency. Thus if you are an epileptic you are more likely to have a rum fit if you overindulge in alcohol as regards to someone who does not have a seizure tendency. Hence I always advise my seizure patients to drink alcohol in moderation. You can drink and by all means enjoy your occasional drink but do not overindulge in this pleasure. Know when to say no and walk out of the bar.

Another type of seizure associated with alcohol is what is called “Alcohol Withdrawal Seizure”. Here the seizure occurs in a different scenario. Usually the person is one who is a chronic alcohol drinker, one who is dependent on alcohol and feels uneasy and restless if he does not drink everyday. Let us now assume he suddenly stops drinking for whatever reason. Maybe he runs out of money and cannot buy alcohol. Usually 24 to 48 hours after his last drink, this patient may have a generalized tonic clonic convulsion. As this seizure occurs in the setting of a withdrawal from alcohol, it is called alcohol withdrawal seizure. It is important that heavy and chronic alcohol drinkers keep this is mind and do not suddenly stop drinking. If a person does decide to quit alcohol he should do it under medical supervision.

Now for the third setting in which seizures might occur with alcohol. Again we have a person who is an alcoholic (heavy and chronic alcohol user). Again for some reason he suddenly stops drinking. Uusally after 72 hours, he starts becoming delirious (confused), he has autonomic dysfunction and is tachycardic, sweating profusely, his blood pressure is up. Such a patient is said to be in what we refer to as “delirium tremens” (DT) . Patient who are in DT may have a flurry of seizures one after the other. DT is a life threatening condition and a patient may die if not treated in time. Usually patients are admitted to the intensive care unit of the hospital. We hydrate them aggressively, we give them medications to calm them down. Lorazepam (Ativan) or other benzodiazepines like chordiazepoxide (Librium) are given to prevent seizures and treat acute alcohol withdrawal.

Patients who have had a rum fit, an alcohol withdrawal seizure or even DT do not warrant long term treatment with an antiepileptic drug. These patients do not have epilepsy. If they abstain from drinking in the future it is more than likely that they may never have a seizure again in their lifetime. However there are a few patients whom we feel have a high risk for seizure recurrence, in such patients we may prescribe antiepileptic drug therapy for some time (the duration of the therapy varies depending upon the history, examination findings and the results of investigations like EEG and CT scan or MRI brain)

I have tried to give an overview of the kinds of seizures associated with alcohol intake. Like I stated earlier one need not be an epileptic to have seizures associated with alcohol intake. I try to explain this to my patients as follows. The brain has a threshold for the amount of alcohol it can tolerate. This threshold varies from person to person. If you drink above that threshold, the brain does not like it and one way it reacts is by having a seizure. This “threshold” is lower in patients who have an underlying seizure tendency. In these epileptic patients, a small amount of alcohol may induce a seizure. Also if you mix your drinks or combine alcohol consumption with other recreational drugs like cocaine you are creating the ideal grounds to have a seizure. Certain medicines like antibiotics also lower your seizure threshold and hence should not be used along with alcohol.

Patients with epilepsy should discuss about alcohol consumption with their doctors because at times we doctors do not initiate this discussion of our own. If you have seizures my advise to you would be to drink in moderation and not exceed your limits.

Nitin Sethi, MD

The healthy brain

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As a neurologist, I see the diseased brain everyday. Patients suffering from acute and chronic debilitating neurological conditions like strokes, uncontrolled seizures, brain tumors, Parkinson disease and ALS. The devastating toll of neurodegenerative conditions like Alzhemiers dementia is enormous. They affect not just the immediate patient but also family and friends.

It seems to me that as doctors we talk a lot about the brain in disease (the diseased brain) but precious little about the brain in health (the healthy brain). Why this fascination with the brain in disease? Why do we not invest more in keeping the brain healthy.

There is so much literature out there about how to keep the heart healthy. Take a low cholesterol diet, exercise regularly, keep your blood pressure under control, eat fish and keep your stress low to keep your heart healthy. What about the brain’s health?  Can we extrapolate data obtained from studies done on the heart and apply it to the brain? Are the heart and brain alike? Is their physiology the same? What is good for the heart, is it also good for the brain?

At the expense of making cardiologists really angry I would like to point out here what was once told to me by my friend. The only function of the heart is to keep the brain alive!!! To pump blood to the brain so that the supercomputer, the masterboard of the human body can work smoothly. The heart and brain are not alike and what is good for the heart need not be good for the brain. The blood vessels of the heart and brain do not work in the same way. The human brain is far more intricate and complex and there is still precious little we know about it.

The decade of the brain came and went. True there has been an explosion of knowledge in the field of neurosciences but we still have miles and miles to go. I think we have reached the stage when we pretty much know everything about the heart, we can open blocked blood vessels, bypass coronary vessels and hey even transplant the heart. A few nicks here and there and out pops the old heart and in goes a new one. But what about the brain? Can we even dream of transplanting a human brain? One can imagine a neurosurgeon trying to connect billions of synaptic connections, so that the new brain works just like th old one. It is the brain which defines us, makes us what we are, the seat of our emotions, memory and intelligence. How would we make sure that the new brain still houses all the old information?

As you can see there are more questions than answers at least with our current degree of understanding of the human brain. So till we learn more, we should as doctors and patient advocates talk more about the brain in health. How do we keep this supercomputer healthy? For every one lecture a neurologist gives about treatment of stroke, he should give ten about stroke prevention. We need good quality research to figure out what foods does our supercomputer like (what are these brain foods, how much is good and how much is bad). How much sleep and down time this supercomputer needs? Does it like complementary therapies like yoga, meditation and tai-chi? Does neurobics help in keeping it hale and hearty.

An ancient Indian text says and I quote “ YOUR BRAIN IS YOUR BEST FRIEND. DO NOT HURT HIM FOR WHOMSOVER OR WHATSOEVER”

Emotions that define us as human beings such as love come from the brain. The rush one feels as he sees his beloved, the longing, the pain all come from the brain. Hmm I even propose that instead of having a arrow through the heart to display cupid, we should have an arrow through the brain, after all that is where the love center is.

So lets take a pledge to keep our brains healthy. There is no better gift we can give ourselves than a healthy brain and mind.

 

Nitin Sethi, MD