Perspectives for Better Neurological Care

Dr. Adams
Dr. C. Robert Adams
Board Certified Neurologist
109 N. 15th St., Ste 14, Norfolk Ne. 68701 Phone: 402-371-0226
3900 Dakota Ave, South Sioux City, Ne. 68776 Toll Free: 888-516-2398
Brodstone Memorial Hospital, 520 E. 10th, Superior, Ne. 68978

Migraine Headache Problems

Migraine headache is a common problem which affects over 20% of the population, at least some time in their life. Migraine is a phenomenon including altered blood flow to the head. In many instances there is increased blood flow to the sides of the head in the temple area, behind the ears, and sometimes in the front of the face. Blood flow in the head is sometimes "shunted" or taken away from areas of the brain and diverted to the scalp, sinus areas, ears, and so on. This diversion of blood flow from the brain sometimes causes symptoms resembling a stroke. In particular, there can be loss of vision to one side or sometimes complete lack of vision in one or both eyes. On occasion, there is numbness and tingling of the face and of one arm and in extreme cases a severe paralysis of one side of the body which may last for 12 to 24 hours. Visual warnings of flashing lights (teichopsia) and arcs of color may precede a migraine. Temporary blind spots (scotoma) may be present. More subtle manifestations of migraine can be associated problems of irritability, personality change, sleepiness, nausea, vomiting, and abdominal pain.

A migraine headache can last from a few hours to up to several weeks or longer. In some individuals, migraine becomes more of a "continuous" problem with a "perpetual increased blood flow" to the area of the ears and sinuses. This can cause persistent sinus congestion and a feeling of ear stuffiness with poor eustachian tube drainage.

The features of a migraine can vary in intensity from no pain at all, to a severe excruciating pain which incapacitates the individual and forces them to curl up in a ball in a dark room away from lights and loud noises.

The cause of migraine headaches remains uncertain although there appears to be an inherited or familial contribution in many cases. Many individuals troubled by migraine headaches have had prior problems with motion sickness or car sickness. This suggests an undue sensitivity of their nervous system to external stimuli or change. Factors that can precipitate migraine headaches include ingestion of alcohol, going without adequate sleep, and fasting or skipping meals. Other etiologies include changes in hormonal status as with menstrual periods, or menopause, bright sunlight, and on occasion certain foods. Caffeine excess or deficit, aspartame (NutraSweet, Alcohol (red wine), soy sauce, monosodium glutamate (MSG) as in oriental food, chocolate, brewer's yeast (beer & bread) and nitrates (hot dogs and cured meats) have been implicated as migraine provokers. Migraine headaches tend to come on somewhat unpredictably, not necessarily during times of stress. Sometimes they occur when a person is most relaxed and otherwise happy, as on the start of a weekend or vacation.

Precipitating factors or causes of headaches should be watched for, though are not often found. Some notable etiological or precipitant can be head trauma or neck injury even if in remote past. Chronic neck arthritis can bring on and perpetuate migraines.

Migraine phenomenon tends to occur with a blend into many other varieties of headaches, thus causing some confusion as regards to diagnosis or classification. Some migraine headraces are associated with marked pain in the back of the head and cause a feeling of tightness and tension in the neck. They are sometimes "misunderstood" as being a stress or muscle contraction type of headache. Migraine pain in the sinus area can feel like a "sinus" headache. Many people have a "mixed type headache" with a migrainous component and concomitant symptoms of neck stiffness and aching, as well as sinus congestion with ear pressure.

This varied presentation can be misleading in the consideration of headache management. The confusion is obvious when one considers the "stress" caused by having a headache. It is hard to function when you are in pain.

Migraine attacks can be paroxysmal or nearly continuous for prolonged periods. In persistent, un-resolving headaches, it is important to consider the possibility of other diseases in the head such as brain tumor, sinus or dental infection, neck arthritis or malformations of blood vessels, as aneurysms. If appropriate, x-rays (as CT or MRI imaging) can be done to check out the brain, sinuses, neck and other head structures. However, these tests are sometimes not helpful or cost effective in dealing with or treating headaches. Treatment for bothersome migraine headaches should initially include attempts to eliminate any factors (as alluded to above) which obviously bring them on. Unfortunately, this is usually not enough to eliminate headedness and does not decrease the intensity of headaches when they do occur. Hypnosis, relaxation techniques, biofeedback, and psychotherapy are usually not helpful. These modalities of treatment offer very little for management of severe migraine. A person with a migraine tendency is unfortunately afflicted with a disorder that is most often beyond his or her control. In particular, it often does very little good to confront the person with the headache suggesting that they are such just because they were not able to tolerate stress or have a weak constitution. The pain of migraine and other vascular type headaches can incapacitate the strongest, most well conditioned athlete, as well as, the frail, pale teenager with iron deficiency. The treatment of migraine with medications can often offer the most direct and effective relief in many circumstances. Two approaches need to be considered in treating migraines. The initial "abortive" approach is to try and "stop the headache in it's tracks" by quickly giving medication that gets rid of the headache as it comes on. Unfortunately, migraine headaches are sometimes stubborn in responding even to strong medications and the best one can hope for is to be tranquilized or calmed such that they can sleep until the headache has passed. "Sleeping it off" is not always an option when someone has to continue functioning and does not have the opportunity or leisure to lay down and take a nap. The triptan medication as Imitrex, Relpax, or Maxalt can be very effective in stopping the progression of a migrainous attack. Recurrent use of oral or parenteral narcotic medications should be avoided with migraine headaches. There is a tendency for narcotics to wear off quickly with return of a "rebound" headache such that more narcotic pills or shots tend to be craved. Narcotic medications often only temporarily cover up the headache such that the migraine quickly recurs with a "vengeance".

The second approach of treating migraine syndrome is with drugs including a prophylactic regimen with an individual taking medications every day to try and prevent the headaches from occurring in the first place. If headaches do "break through" with prophylactic treatment, there is hope that they will be less intense and shorter lasting than they would have been if the individual would not have been on the prophylactic drug. Common agents used include beta blockers (Propranolol), calcium channel blockers (Verapamil), antidepressants (amitriptyline, Effexor) and anticonvulsants (Depakote, Topamax). Benefit from taking the drug has to be weighed against side effects and inconvenience with having to be on regular medication. It is imperative to institute drug treatment, either in an abortive or prophylactic regimen, if headaches are severe and frequent enough to decrease the quality of life in the individual who is afflicted.

It is fortunate that the vast majority of migraine headaches sufferers can be relieved of their symptoms after other "curable" conditions are ruled out and dealt with.

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