Tag: migraine

Me and my migraine headaches

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Migraine is one of the most common neurological disorder which a neurologist encounters during his or her practice. It is not without reason that it is often referred to as the bread and butter of neurological specialty. My parents are both physicians. My father is a neurologist and mother a pediatrician. Growing up I remember my mother coming back from the hospital and complaining of a throbbing migraine. She would lie down in a quiet dark room and ask me or my sister to press her head. Sometimes she would ask me to tie a “dupatta” (a shawl-like scarf worn by Indian women) tightly around her head in a vice-like grip. She never threw up during a migraine attack, but I remember she was always drained afterwards. My sister is 4 years older than me and when she entered high school and later medical college she too complained of severe migraines.

Following my father’s footsteps, I chose neurology as my specialty. My first recollection of getting migraine headaches is when I was in medical school. During residency training it was not uncommon for me to have a throbbing unilateral headache after an overnight call. By 10 am I would sign-out to my co-resident and head home. I would feel sick and realized quickly that if I ate a good breakfast, took an over the counter non-steroidal anti-inflammatory drug and fell asleep, I would wake up later that afternoon migraine free. I am now in my mid 40’s. As an academic neurologist, I see a wide variety of neurology patients including those who suffer from migraines. I am now able to better appreciate and characterize my own headache disorder. I suffer from common migraines. My typical migraine attack has no preceding visual aura. Just like the textbook description my headache is throbbing, pulsatile with pain radiating to the ipsilateral eye. I am light sensitive though sounds do not bother me as much. Most of my migraine attacks are left temporal. My migraine attacks share some characteristics which have been reported in the scientific literature. Professor Lance famously described the Red Ear Syndrome in migraineurs. Just as he described it, my ipsilateral ear becomes red and burns when I get a migraine attack. Sometimes both my ears become red and the red ear precedes the headache. I do not suffer from the Red Forehead Dot syndrome, a syndrome which I described along with my father. I have noticed things which have not been described in the migraine literature such as that I tend to tolerate my left temporal migraines better than the rarer right temporal ones. When I do get right temporal headaches, I feel very uneasy and irritable. On those occasions you may find me a bit short-tempered. When my migraine does not abort and persists for a long period of time, I develop subtle signs of cerebral dysfunction. I subjectively feel that my speech is off and that I am slurring, my typing skills deteriorate, and I frequently hit the wrong key. Very rarely I feel my balance off.

Over the years I have identified my migraine triggers. Stress at work especially when I am pressed for time and miss a meal is my most common trigger. Others include lack of sleep, dehydration, and red wine. An unusual one is perfumes with strong fruity fragrance. Recently an article highlighted the link between smartphone use and primary headache.  Smartphone use does not trigger my typical migraine attack but when I am having a migraine attack, I am quite sensitive to my iPhone screen and ringtone. Multitasking on the computer and iPhone apps such as answering multiple text messages, e-mails and phone calls all increase the severity of my migraine attack. Overtime I have learnt to adapt to these necessary technological evils. My office computer and iPhone screen brightness are set to low, ringtone to Chimes and the Night Shift turned on from 7:00 pm to 7:00 am. I have my office lights dimmed at all time. Doctors are said to make the worst patients. I am guilty as charged and have resisted a drug for migraine prophylaxis. Recently due to an increase in the frequency of migraine attacks, I started amitriptyline 10 mg at night. The results have been gratifying. My migraine frequency has dramatically decreased but I wake up feeling groggy. My illness has made me better appreciate the impact of this chronic common neurological disease. 

Nitin K Sethi, MD, MBBS, FAAN

White matter lesions, migraine and memory problems: a question and an answer

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One of the readers of my blog wrote in with a question about white matter lesions on brain MRI. Her question and my response to it follows.

Question:

I was recently referred to a neurologist by my primary care physician for treatment of my migraines. While migraines have a been a part of my life, they have been occuring with greater frequency of late (10+ per month). To rule out any other cause of my migraines, the doctor ordered an MRI. The MRI revealed 20+ white matter lesions throughout my brain (various locations, various sizes). The neuro was at a loss as to why I had so many. I did inform him that approx 15 years ago I had unilateral ect, and asked if perhaps this had caused it? I also let him know that I was experiencing significant memory issues (forgetting short term and long term memories, and even blanking on spelling my own last name for a minute or two). I asked him if ect could be responsible? The neuro has since followed up with me and has stated that ect could NOT be responsible for the lesions, and was not likely to be responsible for my recent, memory issues. I have been tested for MS, lyme, infection, etc. – all negative. I do not suffer from depression or take any other medications which would cause memory issues. Any thoughts? What else could cause these lesions? Is these any research at all into lesions and ect? I am trying to get into Neuropsych testing to determine the extent of my memory loss. The migraines are now currently being sufficiently controlled with Imitrex.

Answer

Thank you for writing in to me M.  White matter lesions are commonly documented on brain MRI done for various reasons (in your case as a work up of migraines). The differential diagnosis of white matter lesions is broad and varies based on the age of the patient. In “most” adult patients especially those with risk factors for microvascular disease such as diabetes mellitus, essential hypertension (high blood pressure), dyslipidemia (high cholesterol), current or past heavy smokers these white matter lesions respresent small vessel disease (also referred to as microvascular ischemic small vessel disease). Meaning that the small blood vessels in the brain are showing signs of ischemia (lack of blood flow). So when I see extensive microvascular (small vessel) disease on a patient’s MRI scan of the brain what I worry about is the possibility of a stroke in the future. As a neurologist, I then try to identify his stroke risk factors and attempt to modify them. If he has high blood pressure and is not an on anti-hypertensive medication–start an appropriate anti-hypertensive, if he is already taking a blood pressure medication but the blood pressure is still not well controlled then I may need to increase the dose of his medication and/or change it. As per the new Joint National Commission guidelines broadly speaking the lower the blood pressure the better it is (earlier a blood pressure of 140/80 mm Hg was accepted as ” normal”, now we aim for level of 120/70 mm Hg). If the patient’s blood sugar is high (fasting blood sugar greater than 107mg/dl), I would investigate him for diabetes mellitus. For this blood sugar is tested in a fasting state and after meal (post prandial). There are normal values and if the patient’s blood sugar exceeds these normal values, then he has diabetes mellitus. Diabetes mellitus can be controlled by a combination of dietary modification, exercise, oral hypoglycemic medications (pills) and/or insulin injections. If the lipid profile is deranged (high total cholesterol, high low density lipoprotein, high triglycerides and low high density lipoprotein), then again dietary modifications, exercise and lipid lowering medications (statin group of medications such as Lipitor are one example) are recommended.

Now what do white matter lesions represent when they are seen in a young person (like for example in a  young lady 25 years of age)?  The main differential and what concerns most patients and physicians alike is whether this could represent multiple sclerosis. I have written about this before and again want to emphasize that the diagnosis of multiple sclerosis is a clinical one and not based solely on the MRI scan of the brain. The MRI scan always has to be interpreted after taking the history and examination findings into consideration. Also the white matter lesions of ischemic small vessel disease are different from the white matter lesions (plaques) of multiple sclerosis. In multiple sclerosis the lesions have a characteristic appearance and distribution in the brain.

White matter lesions can also be seen in many other infectious (Lyme disease is a good example) and inflammatory conditions (sarcoidosis, connective tissue diseases which cause vasculitis in the brain). Most of these diseases can be identified with the help of a good history and some basic tests.

White matter lesions are also commonly seen in people who suffer from migraines (more commonly seen in women migraine sufferers). Why do white matter lesions occur in migraine patients. While there are many theories of migraine pathophysiology, migraine is a vascular headache and hence the blood vessels are again involved.

Do white matter lesions cause memory problems. Now that is a tough question to answer. When I see extensive white matter disease in a brain MRI, it tells me about the health of the brain and the blood vessels. If a person has extensive white matter disease, the same pathology shall be seen in the blood vessels of the heart. So they are prone to both heart disease and brain disease (stroke, transient ischemic attacks). While Alzhemier’s disease is the most common primary dementia, vascular dementia is exceedingly common too. What is vascular dementia? As the name suggests, it is dementia (memory impairment, problems in multiple cognitive domains) caused due to multiple small strokes in the brain or rather strokes in a strategic location. These strokes occur over a period of time and may be clinically silent (meaning that the patient may not even realise that he has suffered a stroke). The small strokes over a period of time though add up and cause vascular dementia.

I hope this helps in answering some of your questions M. My advise to you is to follow up with your primary care physician and the neurologist. They shall help guide your work-up further.

Personal Regards,

Nitin Sethi, MD

When a headache is a pain! About primary and secondary headaches

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When a headache is a pain! About primary and secondary headaches

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

 

Headaches are a very common reason that patients consult a neurologist like me.  The intensity of the headache, its character and duration are some of the factors which determine if and when patients seek medical attention. So in this post I shall go over the different types of headaches and list their main differentiating features.

Broadly speaking we can divide headaches into primary and secondary headaches. Primary headaches are those headaches for which there is no structural/ secondary cause.  For example a migraine headache is an example of a primary headache. The migraine may be severe and frequently disabling but if you scan (CT or MRI) the patient’s brain no underlying structural lesion like a tumor is found. Secondary headaches as the name implies are secondary to a another cause. For example headache due to a large brain tumor or headache due to an infection (meningitis) represent secondary headaches.

Types of primary headaches:

1)      Migraine: common migraine and classical migraine

2)      Tension type headache

3)      Cluster headache

Types of secondary headaches:

1)      Headache secondary to a brain tumor or other masses (space occupying lesions) in the brain

2)      Headache secondary to an infectious and inflammatory process in the brain (example headache associated with meningitis)

Headaches can be a cause of concern and distress. Patients frequently worry that may have a brain tumor. So let us go over some of the signs and symptoms which suggest that the headache is due to a secondary cause . These are the signs and symptoms which should make you seek urgent medical attention:

  1. Sudden onset of severe headache. When asked patients rate their headache as the “worse headache of their lives”. I shall be concerned if I encounter such as patient in the ER, more so if the patient tells me that they have never had a  headache in their life before. When accompanied with other signs such as nuchal (neck) rigidity and depressed sensorium (level of alertness), the question of subarachnoid hemorrhage (SAH) comes to mind. A common cause of non-traumatic SAH is the rupture of an aneurysm or arteriovenous malformation (AVH) in the brain. SAH is associated with high morbidity and mortality especially if the patient presents to medical attention late.

Caveat: Not all “worse headaches of my life” are due to SAH due to rupture of an intracranial aneurysm. Many times (especially if there is a past history of migraine headaches) these patients are suffering from a particularly debilitating/ severe attack of migraine. Thunderclap/ explosive headaches have also been reported at the time of coitus. They are referred to as post coital or orgasmic headache.

  1. Headaches in extreme of ages:  headaches which occur in the extreme of ages (such as in a young child or after middle age especially if there is no past history of headaches) deserve a more closer look. Signs such as neck stiffness or depressed level of sensorium may be masked or difficult to elicit in these age groups. As a neurologist my threshold of investigating these patients with tests such as MRI of the brain and more invasive tests such as spinal tap (lumbar puncture) is lower.

Caveat: small children frequently cannot express headache (meaning they cannot tell you that they are bothered by headache).  Primary headaches such as migraine may be missed in children as a result. The child may be agitated and parents may think he is acting up. So a high index of suspicion has to maintained by the physician to timely identify migraines in small children. Also it is well known that migraine is not “typical” in the pediatric age group. Various migraine variants have been identified in children such as abdominal migraine (the child complains of episodic abdominal pain), cyclical vomiting and so forth.

  1. Onset of headache in middle age (especially if there is no prior history of headaches): when a middle aged patient comes to me and says he is bothered by headaches for the past 3-4 months, never had headaches when he was in his teens, I pay close attention to him. A thorough neurological examination shall frequently tell me if there is anything “brewing” inside the brain aka does he have a mass lesion/ tumor? As a neurologist I have several tools to help me in this endeavor. I can look for signs of asymmetry: weakness/ numbness on one side of the body, problems with coordination on one side of the body, is the gait steady, are the reflexes symmetrical and so forth. I can further look into his eyes with an ophthalmoscope to see if there is increased pressure inside the brain (remember the eyes are the window into the brain).  Based on my exam, I may or may not order a MRI scan or CT scan to confirm my suspicion.
  2. Headaches associated with fever: are always a cause of concern. Various disease processes such as meningitis (bacterial, viral or fungal), brain abscesses and so forth come into the differential. Patients are admitted into the hospital and further management depends upon the underlying etiology.
  3. Recent onset of headache in an immunocompromised patient: recent onset of headache in a patient who is immunocompromised (example a HIV positive patient or a patient who is receiving chemotherapy for cancer) always warrant a thorough work-up. Such patients are frequently found to have a secondary cause for their headaches. So again my threshold for imaging such patients is low.  My threshold for doing a spinal tap in these patients is also low (provided I am confident that the pressure in the brain is normal).
  4. Headache/ temporal pain  in a patient past 65: temporal arteritis (Giant cell arteritis) is a disease entity which is seen in the elderly and is due to inflammation of the temporal arteries. Patients may not complain of headache per-se. When you examine them you find they have tenderness over the temporal arteries and the artery may feel beaded and thickened.  It is imperative that temporal arteritis be identified in a timely fashion and treated otherwise the patient may suffer loss of vision.

In the next post I shall talk about the primary headaches.

White matter lesions on MRI–a question and some answers

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I thank one of my readers Sandy for writing in.  Sandy asks some important questions. As a lot of you may be dealing with some of the same issues as her, I am reproducing her question here. My answers to her query follow.

Again thank you Sandy for writing in.

Sandy

Dear Dr.

In june I experienced some very unusual headaches that felt think electrical shocks throughout my head. One night I experienced the worst headache of my life in my forehead only. It lasted all night and in the morning it was better; however I experienced dizziness and if I bent over a swell of pain would radiate through my head. A week later I experienced an eye problem and was told that it was uveitis. Because uveitis can be caused by a virus or autoimmune problem, I immediately began testing for an autoimmune problem. During this testing I continued to experiece overall nerve pain in by head (forehead, temple, back of head) as well as neck pain, should nerve pain through fingers, neck, ankels), joint & chest pain. The only positive test result showed a high ANA test of 1:640 but all other blood tests(c-reactive protein, RF, Sed Rad, SM etc..) were normal. I also had an MRI and the radiologist noted several tiny foci white matter in the frontal lobe area. He indicated that it is may or may not be of clinical significane but could be small vessel ischemia disease or possible dymlienation. I wonder if there is a correlation to the several headache I had in my forehead with the MRI results. My neurologist initially said I had occpital headaches and is normally caused by a pinched nerve; but after receiving this MRI, I don’t think he has it right. I feel the headaches and vision problems along with the other symtoms correlate together. Should I be concerned about this MRI. I don’t feel that this is MS because I’m not having muscular/walking issues; but greatly concerned that if these headaches continue, cognitive problems could occur. Your opinion would be greatly appreciated.

From MRI white matter lesions: does it represent MS?, 2008/09/26 at 2:24 PM

 

Dear Sandy,

                      thank you for writing in. Your case history is intriguing, since I do not have all the details my assessment is severly limited.  I can though tell you that white matter lesions are commonly seen when patients undergo a MRI study of the brain. Some of the times these white matter lesions (also referred to as white matter hyperintensities (WMH), this is because they appear as bright white spots on the MRI) are incidental findings and may have nothing to do with the reason the MRI was done in the first place. Let me explain. Lets assume you come to see me since you have being lately experiencing headaches. I order an MRI because I want to rule out a brain tumor. MRI result comes back. There is no brain tumor but incidentally note is made of several scattered white matter hyperintense lesions. Likely in the case I describe above, the WMHs are incidental findings and not the cause of the patient’s severe headaches.

So what do these white matter lesions represent? Many diseases can cause white matter lesions in the brain MRI.  One of the diseases usually mentioned in MRI reports is multiple sclerosis. Patients rightly get scared that they may have MS. While multiple sclerosis is characterized by white matter lesions (we call them plaques in the case of MS) which are scattered in the brain, I want to re-emphasize that not all white matter lesions represent MS (see my website for more details http://braindiseases.info). In the case of MS, the plaques are scattered in the brain in a particular way. Moreover if you do not have any signs or symptoms of MS (your examination is normal), more than likely the white matter lesions do not represent MS. The diagnosis of MS is clinical, at times supplemented by tests like MRI brain, CSF/ spinal fluid examination and evoked potentials.

A lot of work has been done to determine the significance of white matter lesions. The thinking now is that they represent ischemia (lack of blood flow) in the small blood vessels of the brain. Hence they are also at times referred to as ischemic small vessel disease. Hence these lesions are more commonly seen in the MRI of patients who have cerebrovascular risk factors like hypertension, diabetes and high cholesterol as well those that smoke. Their incidence increases as we age (meaning you are more likely to see them on the MRI of someone who is 60 and above rather than someone who is in his 20’s).

They have been reported in the MRI of patients who suffer for migraine. The reason they are more commonly seen in migraine patients is again not fully elucidated but the thinking is that migraine is due to vascular causes and hence WMHs are more common in these patients.

While I cannot comment of your case in particular, you have a positive ANA though rest of the autoimmune markers are negative and your ESR is low. I would rule out the usual suspects, vasculitis though remains in the differential and it would be reasonable to make sure you do not have any underlying vasculitic etiology.

Your last question is important. Though there is no direct correlation between the extent of WMHs in the brain and the development of cognitive decline, as I stated earlier they become more common as we age. People who have extensive white matter disease in their MRI frequently do exhibit cognitive deficts when carefully tested for. Whether this represents a form of vascular dementia is not clear.

I would advise you to follow with your PMD and neurologist. They would be the best people to guide further diagnostic workup and treatment.

Personal Regards,

Nitin Sethi, MD

Analgesic overuse headache

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Analgesic overuse headache

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Recently I saw a patient in the hospital who had complaint of constant severe daily headaches. She was a 34-year-old otherwise healthy African American woman who first developed headaches at the age of 15. At that time she used to get throbbing hemicranial (one half of the head) headaches which were accompanied by nausea. At times she used to throw up if the headache was particularly bad. During the headache episode she complained of light sensitivity (bright lights bothered her, we refer to this as photophobia) perferring to lie in a quiet dark room. Sleep usually aborted her headache attack. She was correctly diagnosed as suffering from common migraine (this is migraine which is not associated with aura) and treated with Inderal (propanolol-a beta blocker). Later she started using Imitrex (a triptan) whenever she had an acute migraine attack. Around the age of 18, she developed pelvic inflammatory disease for which she started using ibuprofen.

At the time of her current presentation, she said her headache character had changed. Now instead of having episodic migraine attacks, she had a headache “all the time”. She was taking 4-6 pills of ibuprofen a day and 8 to 10 Imitrex pills a month.

This brings us to the topic under discussion “analgesic overuse headaches” also at times referred to as “medication overuse headaches”. Research has shown that about 1% of the general population experiences medication overuse headache and the condition is thought to occur due to an interaction between a therapeutic agent (in this case an analgesic) used excessively by a suspectible patient.

The overuse of anti-migraine drugs and analgesics gives rise to a mixed picture of migraine-type and tension-type headaches that occur at least 15 days a month. Patients start taking more and more analgesics to treat the headache and this sets up a vicious cycle of headache-analgesic-headache-analgesic.

Chronic daily headaches due to overuse of analgesics are particularly difficut to treat.  Analgesics are discontinued (some patients of course have worsening of their headache during this time). To keep headaches under check during this time (when the analgesics have been discontinued), the doctor may prescribe a low dose tricyclic antidepressant such as Elavil (amitriptyline). The headache usually resolves or reverts to its previous pattern within two months after discontinuation of the drug (analgesic).

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

MRI white matter lesions: does it represent MS?

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MRI white matter lesions

Many times I get consulted by patients or their relatives when their MRI brain report reads multiple scattered white matter lesions seen. The radiologist’s report usually further reads that these can be seen in primary demyelinating conditions like multiple sclerosis or in vascular disorders. Patient’s and caregivers are naturally worried when they get this MRI report and do not know what to do and how to proceed further. So I thought that here I shall talk about these white matter abnormalities seen on the MRI. What is their significance? Do they represent evidence of multiple sclerosis?

White matter signal changes on the MRI essentially means that on the MRI, the white matter  showed some scattered bright spots. White matter in the brain refers to the fiber tracts that carry information to and fro from the brain.

My first question when somebody asks me what next and what does this mean is to ask them why was the MRI done in the first place. If the MRI was done because there was a clinical suspicion of multiple sclerosis then these white matter lesions may indeed have significance and may represent radiological evidence of MS plaques. Let me explain this with an example. You go to your doctor, you have signs and symptoms that suggest MS (example you may have had an attack of optic neuritis), when the doctor examines you he is able to elict signs in the examination compatible with a diagnosis of MS, then he orders an MRI to see if you do have evidence of white matter lesions in the brain. In a case like this the presence of white matter lesions/ signal changes in the MRI is obviously important. Here it likely does suggest the presence of MS. That said and done I again want to re-emphasize that the diagnosis of MS is made on the basis of clinical history of previous attacks, CSF (spinal fluid) examination and MRI, not just on the basis of the MRI alone. Also there are certain criteria which have to be satisfied on MRI to make a definite diagnosis of MS. These radiological criteria for MS include the number of lesions on  the MRI, their location and their size.

Thus it is important to remember that a person who is noted to have white matter lesions on a brain MRI does not necessarily have MS. White matter lesions can be seen in numerous other conditions and they are more commonly seen as we grow older. The thinking behind this is that they represent microvascular ischemic changes in the brain (the smaller caliber blood vessels in the brain showing signs of ischemia or decreased blood flow). Hence these white matter abnormalities on MRI are more commonly seen in patients who have microvascular and macrovascular risk factors such as a history of hypertension, diabetes and high cholesterol (dyslipidemia/ bad lipid profile).

White matter signal changes on MRI may also be seen in patients who have infectious and other inflammatory conditions. They have been reported in the MRI of patients with a history of migraine headaches (migraine too is a vascular disorder and that may explain the connection).

So I want to end by saying that the presence of these white matter signal changes on brain MRI has to be correlated to the history, clinical examination and other ancillary investigations. Your doctor shall help you in going about this in a methodical manner. I repeat these white matter lesions do not suggest MS in each and every case they are found.

 Dr. Sethi

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Headache

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Headache

 We have all suffered from a headache at some point in our life. Thus headache is among the most common neurological disorder seen in the out patient neurological clinic. I shall discuss headaches under 2 headings:

1) Primary headaches such as migraines (both common and classical), tension type headache and episodic cluster headaches.

2) Secondary headaches such as headaches associated with brain tumors, temporal arteritis (giant cell arteritis), headaches associated with subarachnoid hemorrhage and meningitis.

 

Primary Headaches:

 

1) Migraine: migraine is the most common primary headache disorder. It commonly starts in adolescense and affects women more than men. Migraine is of 2 types:

a) Common Migraine: this is the common variety of migraine in which the headache is not accompanied or preceeded by any aura. Patients usually have complaint of episodic headaches which have a typical character. Headaches are typically unilateral (though the headache may shift from side to side in different episodes) and are accompanied by nausea and vomiting. Patients may complain of dizziness and also usually are sensitive to bright lights and loud sounds at the time of their headache. Sensitivity to loud sounds is called phonophobia and that to bright lights is referred to as photophobia. During an acute attack patients usually feel and look sick and prefer to lie in a quiet dark room. Shaking the head makes the headache worse. Sleep naturally aborts an attack with patients waking up headache free.

b) Classical Migraine: this is migraine with aura. Patients experience an aura at the onset of the headache. The aura is usually visual and patients may complain of seeing bright flashing lights or spots/ halos in front of their eyes (referred to as scintillation scotoma or fortification spectra). Many different types of visual auras have been described, you can see the pictures of some of them by googling scintillation scotoma and looking under images.

 

2) Cluster headache: this is another type of primary headache disorder which predominantly affects young to middle aged men. Episodic cluster headache is characterized by episodes of intense unilateral headache usually around the peri-orbital area (pain is centered around the eye) associated with nasal congestion, lacrimation (tearing from the eyes) and nasal stuffiness. The headache usually awakens the patient at the same time every day and may be so intensely uncomfortable that some patients have been known to commit sucide. These episodes of daily headache may last for a few weeks and then abate spontaneously only to recur at a later date.

 

3) Tension type headache: this is a rather common type of primary headache disorder. More commonly seen in women, tension type headache is characterized by holocranial headache (the whole head hurts) or the patient may complain of tightness or a vise like sensation around the head (especially the nape of the neck).

 

A point to remember is that patients may have 2 or more types of headaches. For example a person suffering from migraine may also admit to having tension type headaches.

 

Pathophysiology of Migraines: Let us now discuss what causes migraines. The brain itself is insensitive to pain. Let me give a rather crude but effective example. If you take a knife and drive it through the brain, you shall feel no pain. The pain sensitive structures in the brain include the blood vessels which course through the brain, the venous sinuses (think of them as large reservoirs where the venous blood in the brain drains to) and the meninges. The meninges or the covering of the brain are richly supplied by nerves and hence are very sensitive to pain. Thus when one has inflammation of the meninges (condition referred to as meningitis), one has pain in the nape of the neck and headache.

There are many theories to explain the pathophysiology of migraine headaches, the one most accepted is referred to as the trigeminovascular hypothesis. According to this hypothesis, the blood vessels in the brain are innervated by branches of the trigeminal nerve. During a migraine attack, initially the blood vessels constrict (go into a spasm) and then dilate. That is time the patient complains of a throbbing headache, characteristic of a migraine. The pain is referred to the distribution of the trigeminal nerve (this nerve supplies the skin of the face) hence the complaint of pain in the temple and around the eyes. Hence migraine is rightfully thought to be a vascular condition.

 

The diagnosis of migraine is clinical (that means your doctor shall be able to make the diagnosis without ordering major tests). If there are elements in the history which are atypical for migraine then your doctor may order an imaging study such as an MRI scan of the brain. Usually this is done when there is a suspicion of a brain tumor.

Other atypical signs include:

1) weakness or numbness on one side of the body.

2) new onset headache in the middle aged or elderly.

3) headache associated with projectile vomiting (remember migraine too can be associated with nausea and vomiting).

4) headache which first presented with a seizure.

 

Once the diagnosis of migraine is secured then the question of treatment arises. There are a couple of aspects in the treatment of migraine which demand attention. The first is the treatment of an acute attack (you are suffering from an acute migraine headache, how to abort the attack and relieve the pain? What medication is the most effective? What if the medicine does not abort the headache attack?).

The second is the prophylatic treatment of migraine (treatment initiated so that you never have the attack in the first place).

There are different medications used to treat the acute attack of migraine and those for prophylatic therapy. I shall discuss them one by one.

 

Treatment of acute migraine attack: 

An acute attack of migraine can be debilitating. Effective treatment which quickly aborts the headache is the need of the hour. Any of the common pain-killers like aspirin, acetaminophen (tylenol), ibuprofen (motrin) is effective in the treatment of an acute migraine attack. The secret for the drug to be effective is that they should be taken right at the onset of the headache. Let me explain, you feel the migraine starting-a dull aching around the eye, the typical aura–if you take the tablet right now then it shall abort your headache. But if you decide to wait and the migraine attack evolves further into a classical unilateral throbbing headache with sensitivity to light and loud sounds, it is more than likely that either the pain killer shall not work or for it to work you shall have to take more than usual amount of the medication (more pills to break the attack). Also remember that most patients during a migraine attack feel nauseous and some may even throw up so it may be hard to keep the pill down.

 

Now we have more effective and migraine specific medications available. These medications which are commonly referred to as TRIPTANS include medications by the name of sumatriptan  (brand name Imitrex),  rizatiptan  (Maxalt), naratriptan (Amerge, Naramig), zolmitriptan (Zomig), eletriptan  (Relpax), almotriptan(Axert, Almogran), and frovatriptan (Frova, Migard). The triptans are 5HT 1D and 1B receptor agonists (meaning that they act on the serotonin receptors in the brain to exert their anti-migraine effects).  They are available in the tablet form to be taken orally (by the mouth). Some like sumatriptan can also be administered via the sub-cutaneous route (under the skin) or via the nostril as a spray. This is specially advantageous when the patient is having nausea and is throwing up. Your doctor may prescribe you a triptan. The various triptans differ from one another in their speed of action, side-effects and their efficacy. So if you do not have a positive response to one triptan, it is still worthwhile trying out another.

 

Another medication effective in the treatment of an acute migraine attack is DHE or dihydroergotamine. DHE is usually given intravenously (via a vein) but as compared to the triptans it has more side-effects and hence is not the first choice to treat an acute migraine attack. You may be given this medication if you land up in the emergency room with a bad attack of migraine that has not responded to the conventional pain-killers and triptans.

 

Other medications which are also effective in treating an acute attack of migraine include the opioids (morphine and codeine containing drugs). We as doctors avoid using these drugs because of their significant addictive potential. Patients may get addicted to their use and then start abusing the drugs.

 

Prophylatic therapy for migraine attacks: The idea behind migraine prophylaxis is to use a medication which prevents the migraine headache from coming on in the first place. If you can prevent an attack of headache from happening then you do not need to treat it. Makes sense you would say!!!

There are many different classes of drugs which have demonstrated efficacy in migraine prophylaxis. Let us discuss some of them. Some of the commonly used drugs for migraine prophylaxis are those that belong to a class called beta blockers. Drugs included under this class  commonly used to treat migraine include Inderal (propanolol). The tricyclic antidepressants are also commonly used and are effective in migraine prophylaxis–drugs such as Elavil (amitriptyline). Recently a number of anti-seizure drugs have demonstrated their efficacy in migraine prevention. Topiramate is one such drug which had gained much popularity in recent years. It is marketed under the brand name Topamax. The calcium channel blockers are also used. A popular drug in this class used for migraine prophylaxis is verapamil.

Changing your lifestyle and identifying your migraine triggers is the key to achieving good control of these disabling headaches. Common migraine triggers are:

1) Lack of sleep

2) Too much sleep–lets assume you normally sleep for 7 hours a night, now one night you oversleep–it is possible you may wake up with a headache.

3) Alcohol intake–migrainers have a more sensitive brain and thus if they drink too much, it can trigger off an attack. They are especially sensitive to red wine and it is best to avoid it.

4) Certain foods act as migraine triggers–commonly implicated are aged cheeses and chocolate.

5) Excessively stimulating environment–example you go to a rock concert:  loud music, bright lights, a beer here and there–the perfect migraine combo.

6) STRESS ! STRESS ! STRESS!  

Doctors frequently ask their patient’s to maintain a headache diary. This is basically a diary maintained by the patient in which the patient documents each and every headache attack. What precipitated it, what brought on relief from the headache, things eaten around that time etc. If you maintain a good headache diary for a month, you shall be able to identify your migraine triggers and thus avoid them.

SPECIAL TYPES OF MIGRAINE HEADACHES

1) Familial hemiplegic migraine–as the name suggests it is familial, meaning that it runs in the family. In this special type of migraine, patients usually develop episodic hemiplegia (weakness/ numbness on one half of the body) around the time the headache attack occurs. The hemiplegia resolves once the attack of migraine is over. Familial hemiplegic migraine is thought to occur due to vasoconstriction (spasm of the blood vessels of the brain).

2) Retinal artery migraine–as the name suggests, here the migraine process involves the retinal artery and does presents with visual symptomatology.

3) Basilar artery migraine–here the migraine process involves the basilar artery or its branches in the brain-stem. Patients have sign and symptoms reflecting involvement of the artery and superficially it may seem that they are having a stroke.

4) A number of migraine variants have been described in young children. Young children may not have the classical headache, or they may be unable to express that they are having headaches. A few of the migraine variants described in children include:

a) benign paroxysmal vertigo—children have episodic attacks of vertigo and may throw up during an attack.

b) abdominal migraine-children present with episodic abdominal pain.

c) alternating hemiplegia of childhood–here children have weakness which shifts from one side of the body to the other.

 

 

“Your  mind is your best friend and your worst enemy”

Lord Krishna in the Bhagavad Gita

Contact me at :

neurologistnyc@yahoo.com