Migraines

When you talk to them you should make the distinction between taking it while you are still trying to become pregnant and once you are pregnant. All sorts of factors are involved in discussions of this sort such as the regularity of your periods, whether you will become pregnant immediately or whether there will be a matter of doubt for some time, so that you could be pregnant without knowing it.

Cluster headaches are an enormous trouble and nuisance in life and I discuss them more fully in answer to the third question.

I frequently suffer from migraines and headaches. I have a mitral valve prolapse and have recently read that this could be a reason for the headaches and migraines. What is your opinion? Caroline Smith, London

Obviously I don’t know your particular case or how severe the mitral valve prolapse is and what troubles it could be causing to your cardiovascular system. In general it is true that anything which interferes with cardiac efficiency and oxygenation of the blood can give rise to headaches. For instance, and this doesn’t apply to your own case, headaches are often one of the first signs of coronary arterial disease.

I cannot give a specific opinion in your case, but I would also recommend a patient who has migraines to seek specialist advice. There are a few doctors around who have made a lifetime study of migraines and often a simple change in regime can revolutionise a life.

I suffer from cluster headaches and none of the medication I’ve been prescribed seems to work. What’s the best way of coping with them? Name and address withheld

You will be aware of what a cluster headache is; for those other people who haven’t come across them, they are defined as headaches which last from 15 minutes to three hours. They are severe, unilateral and are experienced around the eyes (ie. peri-orbitally or in the temporal region of the head), between the eyes and the ears. They should occur up to eight times in a day and are associated with at least one of the following - shedding tears, red eyes, stuffed up nose, facial sweating, drooping eyelids, or difficulty in focusing. Men have cluster headaches more often than women.

Usually people are aware of something which will trigger a cluster headache. The common precipitating causes of cluster headaches are such things as periods, too little sleep, a heavy meal with rather more alcohol than is usually drunk, and sensitivity to the weather. Many of my patients have told me that their headaches are induced by hot, stuffy weather (humidity and heat), such as we have today. I would suspect that this last week has been hell for cluster headache suffers.

You have had your cluster headaches for a long while. They presumably have been investigated and no other cause has been found for them. The problem is that doctors do not know why people get cluster headaches but it is assumed to have similar causes to those which give rise to migraine.

As in migraine, treatment is divided into three categories. The first is prophylactic – that is finding ways to prevent the headache from occurring and to all intents and purposes this means trying to trace the trigger factors and omitting them. Obviously, it is quite impossible for you to control the weather but you can find out if any foods or red wines, as opposed to white wines, or alcohol in general might induce your headaches.

You need to get your sleep pattern right. Many people find that too much sleep may occasionally induce cluster headaches (or indeed migraine) but the usual trigger is too little sleep, particularly if it is associated with being chased by time. That is to say, when there is inadequate time to fulfil all the jobs and duties you have to do.

There are one or two drugs which people will use to try to prevent attacks. The most common are the calcium channel blockers such as Verapamil and a serotonin antagonist, Methysergide (also known as Deseril).

The second line of treatment is abortive. By that we mean once you feel the attack coming on you take something to try to get rid of it. Sumatriptan is the drug of choice for cluster headaches in this respect. In the UK, Imigran is available either as tablets, nasal spray or an injection. It is worthwhile trying each of the different presentations. Other people try Ergotamine (known as Cafergot) as a means of aborting an attack.

If you fail to prevent an attack and you cannot abort once it starts, the only answer is to take an analgesic. Indomethacin is the drug of choice for this. Indomethacin is one of the non-steroidal anti-inflammatory agents in the same group as Brufen and Nurofen. The trouble with the non-steroidal anti-inflammatory drugs is the side effects of severe indigestion, or even more severe gastrointestinal upsets. A patient will need to discuss this with their own doctor.

I suffered with migraines from the age 13 to 19, and then was migraine free for ten years. However over the last three months they have returned on an average of once every two-three weeks. Is there any reason why they would return? My diet and lifestyle remain the same. Robert Hardy, London

Any patient who has been free of migraine for ten years and then starts to develop it again should certainly see their own doctor to make certain that there are no underlying reasons for it.

Migraine sufferers are not exempt from myriad other causes of secondary headaches and there isn’t a doctor in the world who hasn’t made a fool of themselves by failing to notice that there has been a change in the nature of the headaches and a migraine is no longer a primary problem but a secondary symptom of another condition.

In all probability a patient with your type of history has in fact merely had a recurrence of migraine, which is not at all uncommon, but it should certainly be checked out. If it is migraine you will find that the treatment has greatly improved over the last ten years. The advent of Imigran (Sumatriptan) and other drugs of this group has revolutionised the treatment.

I have suffered from classic migraines since the age of 12. I am now 37 years old. I appear to be having them less and less, however, during my second pregnancy I had about 15 attacks, but prior to giving birth, I had one nearly every couple of days. Would this have anything to do with blood pressure? Is there anything that works to take the “aura” away? The migraine affects my speech, eyesight, I get pins and needles on the right hand side of my body, legs and arms; my whole face goes numb including my tongue and nose, and it is quite impossible to do anything. The majority of my attacks are at work. Jancine Davies, Madrid

There is a strong hormonal influence to the likelihood of developing migraines or cluster headaches. Many women find that they are worse when they take the Pill, when they are pregnant and before a period.

Your migraine seems particularly severe and I am not at all surprised that a patient with your symptoms finds it quite impossible to do anything. I of course have not examined you and do not know your case but I would make certain that if any of my patients had such severe migraine they were carefully examined by a specialist neurologist, especially a neurologist who takes particular interest in migraine.

These are the type of migraine attacks that would exclude a patient from taking the Pill or HRT.

I experienced sensory migraines when I was younger. I am now 62-years old. A year ago I had migraine-like symptoms, ie. flashing lights and went to see my optician who found nothing wrong. Later however, I was found to have very early lattice degeneration and a small tear in that area for which I had laser retinoplexy. In recent days, particularly in the hot weather and after a long walk, I find the migraine-like symptoms cropping up again. I also have borderline high blood pressure for which I take 2.5 mg enalapril. Solpadeine seems to do the trick. Should I seek further advice on my eye condition or would digital imaging help? Name and address withheld

Many thanks for your letter. I was particularly pleased to receive it as it highlights the change in symptomatology which affects many migraine sufferers are they grow older.

Like you, when I was younger I suffered severe migraines, fortunately only a few times a year. But now I am older, rather older than you are, I never have a classic attack of migraine but I get far more of the sort of problems you have. Occasionally flashing lights, jumping print, inability to read for quarter of an hour or 20 minutes and then it completely clears and there is no headache.

I am told that the improvements in the symptoms of migraine when we reach the older age groups is for the rather unflattering reason that our brains have shrunk and therefore a little bit of cerebral oedema (swelling) doesn’t matter so much as there is room for them to expand in our skulls without rise to splitting headaches and sensory symptoms which we knew so well when we were younger. Likewise older people don’t usually get a headache after drinking, but very probably you never experience this.

I would not expect the retinal problems to be related to your migraine. The other problem you talk about is your blood pressure. I know nothing of course about your case but all patients should remember that whatever their age group the ambition of doctors is now to keep the blood pressure around 130/80.

I never suffered from migraines. However, during the last year I have had a few severe headaches which last for a couple of days. I had my last two attacks in June and July. Could this be as a result of the hot weather or from sitting for long periods of time in front of a computer? Filippo Biscarini, Cremona, Italy

Your headaches don’t sound like classic migraine and could well be as a result of hot weather and tension. If they persist, a patient with these symptoms should see his or her doctor but, at the moment, there is no indication for starting anti-migraine treatment.

I suffer from the occasional migraine (aversion to light), which I treat with pethedine and anti-nausea medication. However, I find that after seven hours, the migraine returns. The more migraines I get, the more difficult it is to treat and it takes two days to recover from the effects. Jos Scotcher, Plettenberg Bay, South Africa

I am sorry to hear about your migraine. Pethedine and an anti-nausea tablet is very unusual treatment for migraine. As with cluster headaches, migraine treatment is divided up into three groups, prophylactic, abortive and analgesic.

Speaking from my own personal experience, so far as migraine is concerned, being the sufferer as well as the doctor I have found that the advent of the beta blockers has revolutionised the situation. Although any of the beta blockers will do, most doctors prescribe Propranolol. I have always preferred to take Atenolol and actually take Tenormin (its proprietary name). Other doctors recommend Verapamil or even small doses of the anti-depressant Amitripeyline. This is not being used for its anti-depressant action but really to utilise its side-effects. I found with my patients that these side-effects of dry mouth, dry eyes, sleepiness, etc are unacceptable.

As with cluster headaches, some people take Methysergide but that can have quite serious side-effects and after six months of continuous use, people need to stop takingn it. In the case you describe, prophylactic treatment would be indicated.

There are four criteria necessary before people go on to prophylactic treatment:

1. There should usually be two or more attacks a month that last for three or more days

2. The drugs used to treat the symptoms of the migraine have proved ineffective

3. The patient is having to use the abortive drugs, ie. Eugogor or triptan more than twice a week

4. The headaches (as in the case of the other correspondent), produces severe neurological problems, such as partial paralysis down one side, loss of speech, eyes sight etc.

So far as the abortive treatment is concerned you don’t seem to have tried any of them. Most people start by trying Sumatriptan (otherwise known as Imigran) but there are many others of this group which are very useful. In the UK we don’t usually give Pethedine, which is an opiate, for pain of this sort. Having said that, I know that this aversion to using one of the opiate group of drugs is not as strong outside the UK as it is in this country. The usual analgesic used worldwide for migraine other than aspirin or one of the other pills of that sort are the non-steroidal anti-inflammatory drugs, of which Indomethacin is usually considered the drug of choice.

My 11-year-old daughter has a history of migraines. Recently we have become aware that they can be triggered by not eating at regular intervals and have managed to stop a few at an early stage simply by making her eat something. What is your experience of this? Name and address withheld

I am delighted that you have written to us about your 11-year-old daughter. When I was a student I was taught that if the headache which couldn’t be induced by starvation throughout the day, “whether relative or absolute”, the cause of the headache wasn’t a true migraine. I know with my own children and now grand children, I can always see migraine coming on in them and if we stop whatever we are doing, have something to eat then as with your daughter, the headache or sometime tummy ache seems to disappear.

Patients with migraine mustn’t go without regular meals and the meals should contain a certain amount of protein. If the sustenance is merely a readily absorbed refined carbohydrate, like sweets or fruit, the headache will come back again within an hour or two.

Choose your snacks with care. Have regular meals and your 11-year-old daughter will avoid some of her attacks of migraine. A most useful letter, thank you.

I have had migraines since about the age of 18. I have tried several types of painkiller but, with the exception of Wigraine (which is no longer available) the side effects (nausea, jumpiness, inability to sleep) are worse than the migraine itself. Are there any other options for stopping them once they start? Mary Gibbons, Minneapolis

Yes, there are masses of drugs which can be tried to abort the attack, or to treat with analgesics if the abortive therapy has failed to prevent the attack from continuing.

One drug we haven’t mentioned specifically is Zomig which is otherwise known as Zolmitriptan. There are a host of drugs in this group which are useful.

You don’t tell us how often you have your migraine but if you are having them more than one or twice a week, they are disabling more than twice a month, it is important to try to prevent them from occurring at all. I always use beta blockers for this.

In answering these questions, I have talked about my own experience but I do think it is important for those patients who have persistent migraine see a specialist. With their immensely greater experience they can think up some small change in lifestyle and prescribe a treatment which may solve the problem.

I am 57 years old and have suffered from migraines for 30 years. I have been taking Imitrex (100mg) for my migraine attacks for about ten years. However, the frequency of attacks has slowly risen and I now take about seven tablets a month, despite the 80mg slow release beta blocker that I take every day. Am I doing any permanent damage to my body and could you recommend a treatment that would enable me to reduce the tablet intake? David Burrell, Tel Aviv

I would not expect that you are not doing any long term damage to yourself with you present regime. I hope you have tried the Imigrane nasal spray, injection or the tablets as the sooner you can get rid of an attack of migraine the better. The very quick absorption from nasal spray or an injection might be helpful.

Although one can never be definite about prognosis, if you are like most people you will find that in a few years your migraines start to become less troublesome. I assume that your blood pressure is well controlled, that you eat regularly, obtain plenty of sleep and don’t over-crowd your days by trying to fit more into them than you can manage. Imitrex is what Imigrane is known as in Israel.

I am 41-years-old and have suffered from migraines for the past ten years. I know that they are related to hormones, as they occur regularly and just before or during my period, when my period has finished and mid cycle. I have tried taking a low dose Pill, but they have all caused severe vomiting. I have taken oral dispersible Zolmitriptan for my migraines for the past year, but am concerned at the number of tablets I need to take per month. I also take 1000 mg of evening primrose oil daily. Previously, I used sumatriptan injections for six years. I feel that my life has been taken over by migraine. I mentioned to my GP about frovatriptan, but she said the triptans are all the same and was reluctant to prescribe it. Can you suggest any other treatment? Name and address withheld

Thank you for your question. I am sorry to hear about your persistent migraine. There is no doubt that the hormonal changes experienced by women as a result of their cycles are closely related to attacks of migraine.

You are wise not to take the Pill. You are taking Zolmitriptan, marketed as Zomig (made by AstraZeneca). The maximum you are allowed is 15mg in 24 hours. As you know, you can also get it as a nasal spray when it is more quickly absorbed and so it might be a better way of taking it, certainly worth a try. I assume that when you were taking Sumatriptan injections you had a very quick response.

As in most branches of medicine it is amazing how one particular drug will suit one person but not another even though the drug belongs to the same group. My own view is that it is therefore always totally legitimate to move around but, like your own doctor, I would not have thought there is likely to be any huge difference in response to Frovatriptan, which is marketed as Migard. Incidentally, Migrard is not recommended for older patients, ie. those over 65.

The usual contra-indications for not taking Zomig are high blood pressure, coronary heart disease, a rather rare form of heart problem known as Wolff-Parkinson-White Syndrome or any other arrhythmia associated with conduction problems in the heart or a history of strokes, even the minor strokes TIAs (a transitory short lived stroke-like attack).

The contraindications to Migard are rather greater, as they include any abnormal liver function tests and peripheral vascular disease – cold nose and hands as a result of poor circulation.

You seem to be getting excellent advice from your doctor and I would recommend that you continue to talk to her and gain from her experience. Discuss with her the possibility of taking some form of prophylactic treatment such as beta blocker.