by admin | Jun 20, 2011 | Migraine Survival
Could a Headache Diary Help with Your Headache Diagnosis?
Keeping a headache diary can be helpful in a number of ways. If you record enough detail, it can assist you in identifying your triggers. It doesn’t take long to jot down time of day, weather conditions, and factors such as stress, menstrual cycle, or other suspected triggers. Recording response to medication can also be useful to your health care provider.
If you have not yet been diagnosed with a specific headache type, keeping a record of the location, duration, frequency, and type of pain you experience can be very helpful to the physician who evaluates you.
If you are trying to identify food triggers, a food diary kept along with a headache diary can also be useful. There are many different headache diary formats available, varying in detail. Some people prefer an electronic diary app and others prefer a paper diary or calendar. This is a simple paper one to get you started. download pdf
by admin | Jun 20, 2011 | Types of Headaches
Could Your “Sinus Headache” Be a Migraine?
Of course it is possible for the migraine sufferer to develop a sinus infection, especially if you also have seasonal allergies. In fact, many suspected sinus headaches are migraines.
Here’s how that works: the sinus cavities are lined by sensitive tissues whose nerves are fed mostly by a branch of the trigeminal nerve. This is the same nerve responsible for migraine headaches. When you have sinus congestion, it can confuse the nerves and cause what is called referred pain, sending pain to distant areas in the face and head, away from the sinuses themselves. So, sinus headaches may cause pain that is not in the sinus region, and migraines can cause pain that is in the sinus region. Just to make things even more confusing, some migraine sufferers experience nasal congestion or watery eyes with their migraine attacks. This is because the trigeminal nerves can release neurotransmitter chemicals that cause blood vessels to dilate, which is why your eyes get red and watery and your nose gets congested.It isn’t clear why this happens more to some people and not to others with migraine.
The Sinus, Allergy and Migraine Study investigated 100 subjects self-diagnosed with sinus headaches. They were then evaluated by headache specialists, and 63% were diagnosed with either migraine with aura or migraine without aura, and 23% with probable migraine. Only 3% actually had sinusitis. Interestingly, 62% reported that exposure to allergens was a significant headache trigger. Although the symptoms can overlap, these general guidelines can help somewhat in telling migraine and acute sinus infection apart. Sorting out chronic sinus headache is more difficult, especially if there is also another type of chronic headache present.
SINUS INFECTION
These are the major features of a sinus infection:
Usually bilateral
Fever*
Discharge thick, yellowish-green*
Diminished or absent sense of smell*
Minor factors:
halitosis (bad breath), cough, headache, dental pain, ear pressure, fatigue
Facial pain or pressure—more likely to be non- throbbing
Sinus CT or direct examination positive
MIGRAINE
Features of a migraine headache:
Often (not always!) one-sided*
No fever
Discharge thin, clear if present
Heightened or altered sense of smell or avoidance of odors
Occasional symptom: watery, red eyes Facial pain or pressure—more likely to be throbbing or pulsating*
Diagnosis based on symptoms.
*Major features of each disorder.
Sinusitis occurs in 15% of the population— and that is even higher than migraine, unless we take into consideration the possibility of overdiagnosis of acute sinusitis in the migraine population.
Contact Point Headache
As if this were not confusing enough, there is another headache type called Contact Point headache. This occurs when you have a deviated septum or bone spurs in the nose, and the bone from the center of your nose comes in contact with the sensitive tissue on the other side of your nose. This can cause headaches that can feel very much like a migraine.
What Should You Do About Sinus Pain and Congestion?
If you think you have allergies causing allergic rhinitis, or allergies triggering your migraines, it might be worthwhile to see an allergist. Specific treatment of allergies may reduce your migraine frequency.
If you think you have a sinus problem, it may be worthwhile to see an ear, nose, and throat physician (the technical name is otorhinolaryngologist). Treatment of a mechanical problem like a deviated septum, bone spurs, or other physical sinus problems can be helpful if you truly do have chronic sinusitis.
Gastric reflux can also be a cause of chronic sinusitis.
Be careful about treating yourself with over-the- counter sinus medications, especially if you do so on a frequent basis. This can result in rebound rhinitis, causing more nasal congestion than you might otherwise have had. They can also cause rebound headaches if used frequently. It is always best to see your doctor for examination, particularly since this can be such a confusing diagnostic challenge. One thing is for sure, though—antibiotics are not the best treatment for migraine! So don’t just pick up the phone and ask for a prescription. If there is any doubt, go in and be seen.
Reference:
1. Rozen TD. Intranasal contact point headache. Neurology. 2009;72(12):1107.
2. Behin F, Lipton RB, Bigal M. Migraine and intranasal contact point headache: Is there any connection? Current Science Inc. 2006;10(4):312-315.
3. Behin F, Behin B, Behin D, Baredes S. Surgical management of contact point headaches. Headache. 2005;45(3):204-210.
4. Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Study (SAMS). Headache. 2007;47(2):213-224
by Christina Peterson, M.D.
updated June 20, 2011
by admin | Jun 19, 2011 | Comorbidity
Migraine Sufferers Have an Increased Risk of Cardiovascular Disease
For several years, there has been increasing evidence of an increased risk of heart disease and stroke in migraine sufferers. The risk is clearly increased in migraine with aura. Whether or not there is an increased risk in migraine without aura has been less clear. Several large studies have now been done, and we have more information about this.
In the Womens Health Initiative study, 2006, women with migraine with aura were found to have about twice the risk of cardiovascular disease as were women without migraine, or women with migraine without aura.
Also reported in 2006 was a study of men with migraine. Over 20,000 men, 1449 with migraine, were followed for 15.7 years. Information regarding aura was not available. Migraineurs in this study were younger than controls, and more likely to have high blood pressure or a cholesterol of 240 or more. They were also less likely to smoke or use alcohol.
Men with migraine in this study had a higher risk for major cardiovascular disease than men without migraine.
Cardiovascular disease (CVD) means heart disease, including heart attack (myocardial infarction), stroke, or other types of vascular problems due to arterial atherosclerosis.
Recent Studies of Migraine and Cardiovascular Disease
Reykjavik Study
The Reykjavik Study, reported in 2010, looked at a large number of people with one or more migraines a month, and followed them for 26 years. They found that both men and women with migraine with aura were at increased risk of CVD, regardless of whether or not they had classic cardiovascular risk factors (smoking, high blood pressure, high cholesterol, or diabetes.)
In this study, the excess ten-year risk of all-cause mortality at age 50 was 1.2% for men and 0.6% for women. The risk associated with migraine was less that the risk associated with hypertension, smoking, or diabetes. The study authors stated, “The absolute risk is low, and the focus should be on conventional risk factors, such as hypertension, smoking, and adverse lipid profile, for reducing the risk of cardiovascular disease, regardless of migraine status.”
GEM Study
The Genetic Epidemiology of Migraine Study, conducted in The Netherlands, looked at 863 migraine sufferers, 111 with migraine with aura only, 396 with migraine without aura only, and 81 with both migraine types. The average age was 42, and 53% were women.
This study found that the risk for cardiovascular disease over a ten year time span was < 1% in about ⅓ of all study participants. However, it was twice as high in migraine with aura and for non-migraine headaches. The risk elevation was higher for women than for men with migraine with aura.
All migraine sufferers had an increased risk of CVD compared to those with non-migraine headaches, but for migraine with aura, the risk was double compared to those with non-migraine headaches. The diagnosis of high blood pressure was more likely in all migraineurs. A maternal history of early heart attack (myocardial infarction) was associated with all migraine sufferers, while a paternal history of early MI was found in men with all migraine types.
Women who have migraine with aura were more likely to have had gestational hypertension. Female migraine with aura sufferers were also more likely to use oral contraceptives.
The authors of this study commented “Migraineurs, particularly with aura, have a higher cardiovascular risk profile than individuals without migraine.” They went on to comment:
“Further research is warranted to determine why migraineurs have these risk factors more frequently than nonmigraineurs and the nature of the additional mechanism that predisposes these individuals to early-onset cardiovascular disease.”
Other Studies
In a paper by Dr. Marcel Bigal, Dr. Tobias Kurth, and their colleagues, the authors have pointed out that the association of migraine with aura and cardiovascular disease could be due to several things. One possibility is that some of the migraine with aura patients were incorrectly diagnosed with TIA (transient ischemic attack) instead of migraine aura. The studies done have been large enough, however, that this is unlikely to be affecting the overall results. It is also unlikely that migraine medications are causative.
Another possibility is that one disease leads to another, and that migraine could lead to stroke or brain lesions because of repeated episodes of cortical spreading depression. We do not yet know for certain if this is the case.
It is also possible that there are shared genetic factors or shared environmental factors that account for the association between migraine with aura and cardiovascular disease. For example, migraine and heart disease risk genes could be on the same chromosome.
It has been found that migraineurs (of all types) had higher glucose levels as a group, as well as an insulin resistance pattern in 65% (as compared to 19% in the control group. Migraine sufferers were also found to have a higher rate of retinal blood vessel narrowing (retinopathy), even after controlling for age and cardiovascular risk factors.
The authors of this study noted, “Most migraine patients have migraine without aura and are at no or little increased risk of CVD. Accordingly, most patients with migraine should be reassured instead of being frightened.”
Most of the same authors also participated in a more recent study involving 9107 migraine subjects and 10,000 controls. This showed an increased rate of MI (myocardial infarction) and claudication (leg pain due to arterial narrowing) in all migraine sufferers, but only found an increased rate of stroke in migraine with aura.
How does cardiovascular disease affect the body in migraine?
Why would migraine itself be a risk factor for cardiovascular disease? There are many reasons, and more than one could be a factor. We know that people with migraine have a higher rate of what are known as “prothrombotic factors,” which are things that make your blood more likely to clot. (These include things like von Willebrand factor, factor V Leiden, endothelin, and others.)
It also appears from these various studies that migraine sufferers may have an increased rate of elevated cholesterol.
Migraine researchers have noted that migraine is a complex disorder, and may not be the same biochemically or genetically in various migraine sufferers. The mechanisms behind cardiovascular disease in migraine are as yet unclear, and may themselves be complex.
What Should You Do As a Migraine Sufferer?
Most migraine sufferers will have a low risk of heart disease or stroke. The risk of cardiovascular disease due to migraine with aura is still less than the risk of cardiovascular disease associated with other risk factors, such as uncontrolled high blood pressure, diabetes, smoking, or elevated cholesterol. While some studies showed no risk in those who had migraine without aura, other studies suggested an intermediate risk for heart disease as compared to those without migraine.
The best thing to do is to control known cardiovascular risk factors. Keep your blood pressure under control. Don’t smoke. If you have elevated cholesterol, work with your doctor to find the best way to control it. Keep your blood sugar well controlled if you are diabetic, and keep your weight under control to lower the risk of developing diabetes.
Future studies will likely tell us more about this connection between migraine and cardiovascular disorders—and what to do about it.
References:
1. Scher AI, Terwindt GM, Picavet HSJ, et al. Cardiovascular risk factors and migraine: the GEM population-based study. Neurology. 2005;64(4):614-620.
2. Schurks M, Rist PM, Bigal ME, et al. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ. 2009;339(oct27 1):b3914-b3914.
3. Gudmundsson LS, Scher AI, Aspelund T, et al. Migraine with aura and risk of cardiovascular and all cause mortality in men and women: prospective cohort study. BMJ. 2010;341(aug24 1):c3966-c3966.
4. Bigal ME, Kurth T, Hu H, Santanello N, Lipton RB. Migraine and cardiovascular disease. Neurology. 2009;72(21):1864 -1871.
5. Kurth T, Schurks M, Logroscino G, Gaziano JM, Buring JE. Migraine, vascular risk, and cardiovascular events in women: prospective cohort study. BMJ. 2008;337(aug07 1):a636-a636.
6. Kurth T, Gaziano JM, Cook NR, et al. Migraine and Risk of Cardiovascular Disease in Men. Arch Intern Med. 2007;167(8):795-801.
7. Kurth T, Gaziano JM, Cook NR, et al. Migraine and Risk of Cardiovascular Disease in Women. JAMA: The Journal of the American Medical Association. 2006;296(3):283 -291.
8. Bigal ME, Kurth T, Santanello N, et al. Migraine and cardiovascular disease. Neurology. 2010;74(8):628 -635.
By Christina Peterson
updated 6-19-11
by admin | Jun 17, 2011 | Comorbidity
Fibromyalgia
Fibromyalgia is a chronic pain syndrome which manifests as chronic widespread pain. The pain is in the muscles and soft tissues, not in the joints. Specific tender points must be present for more than three months before the diagnosis is made.
Fibromyalgia is a central nervous system disorder. The chronic pain is associated with central sensitization, which can make pain processing in the brain occur more easily.
Depression is vey common in fibromyalgia. Between 50% and 70% of fibromyalgia patients have a history of depression. Major depressive episodes occur in 18-36%. Sleep disorders are almost universal in fibromyalgia. Metabolic syndrome is also more common, occurring in five times as many women with fibromyalgia than those without. Elevations in total cholesterol and LDL have been found to be associated with fibromyalgia in women.
Fibromyalgia and Migraine
Estimates of migraine or chronic headache in fibromyalgia range from 30% to over 50%. An epidemiologic study of headache in fibromyalgia was conducted, and 63% of fibromyalgia patients were found to have migraine. Only 8% met criteria for medication overuse headache.
In a study of 92 consecutive migraine patients who were assessed for fibromyalgia, 22.2% of female migraineurs (and none of the men) were found to have fibromyalgia. Migraine severity and characteristics were similar in both those who had fibromyalgia and those who did not.
A questionnaire-based survey, which asked which of several conditions migraine sufferers had been diagnosed with by a doctor, found that musculoskeletal conditions, including fibromyalgia, were increased in migraine sufferers. Migraine with aura sufferers were more likely to to have comorbid conditions than were those who had migraine without aura. Women with migraine were more likely than men to have comorbid conditions.
What is the fibromyalgia-migraine connection?
Hypothalamic neuroendocrine dysfunction has been proposed as a brain mechanism common to both fibromyalgia and migraine. Both conditions also share the mechanism of central sensitization of pain neurons.
While you may read that the transformation of migraine to chronic migraine results in fibromyalgia, this idea has not been borne out in formal studies. In an epidemiologic study, there was no difference in migraine severity or other migraine characteristics in fibromyalgia sufferers with migraine and migraineurs who did not meet diagnostic criteria for fibromyalgia. Not all fibromyalgia sufferers also have migraine. And not all chronic migraine sufferers also have widespread chronic pain.
Many migraine sufferers have a condition called allodynia (also called cutaneous allodynia) during migraine attacks. Allodynia means that a touch that is normally perceived as just that–pressure or touching–is experienced as painful. Usually allodynia is confined to the head and neck, but can involve other areas of the body as well. Allodynia is generally episodic and does not occur all the time, although it can be frequent in chronic migraine sufferers. Allodynia is not the same thing as fibromyalgia.
In some studies, allodynia has been reported in up to 80% of migraineurs during attacks. A recent study of 1413 migraine sufferers found severe cutaneous allodynia to be more likely in those who had two or three comorbid pain conditions (IBS, chronic fatigue syndrome, or fibromyalgia).
Fibromyalgia, Migraine, and Other Comorbid Conditions
If you have both fibromyalgia and migraine, you are more likely to also have anxiety and depression. Correlations have also been made between fibromyalgia, migraine, and irritable bowel syndrome.
The association between fibromyalgia and tension-type headache is even stronger than the association with migraine.
References:
1. Ifergane G, Buskila D, Simiseshvely N, Zeev K, Cohen H. Prevalence of fibromyalgia syndrome in migraine patients. Cephalalgia. 2006;26(4):451-456.
2. Le H, Tfelt-Hansen P, Russell MB, et al. Co-morbidity of migraine with somatic disease in a large population-based study. Cephalalgia. 2011;31(1):43 -64.
3. Tietjen GE, Brandes JL, Peterlin BL, et al. Childhood maltreatment and migraine (part III). Association with comorbid pain conditions. Headache. 2010;50(1):42-51.
4. Tietjen GE, Brandes JL, Peterlin BL, et al. Allodynia in migraine: association with comorbid pain conditions. Headache. 2009;49(9):1333-1344.
5. Valença MM, Medeiros FL, Martins HA, Massaud RM, Peres MFP. Neuroendocrine dysfunction in fibromyalgia and migraine. Curr Pain Headache Rep. 2009;13(5):358-364.
6. de Tommaso M, Sardaro M, Serpino C, et al. Fibromyalgia comorbidity in primary headaches. Cephalalgia. 2009;29(4):453-464.
7. Bradley LA. Pathophysiologic mechanisms of fibromyalgia and its related disorders. J Clin Psychiatry. 2008;69 Suppl 2:6-13.
8. Sarchielli P, Di Filippo M, Nardi K, Calabresi P. Sensitization, glutamate, and the link between migraine and fibromyalgia. Curr Pain Headache Rep. 2007;11(5):343-351.
9. Tietjen GE, Herial NA, Hardgrove J, Utley C, White L. Migraine comorbidity constellations. Headache. 2007;47(6):857-865.
10. Cole JA, Rothman K, Cabral H, Zhang Y, Farraye F. Migraine, fibromyalgia, and depression among people with IBS: a prevalence study. BMC Gastroenterology. 2006;6(1):26.
11. Sakarya ST, Akyol Y, Bedir A, Canturk F. The relationship between serum antioxidant vitamins, magnesium levels, and clinical parameters in patients with primary fibromyalgia syndrome. Clin Rheumatol. 2011.
12. Bigal ME, Kurth T, Hu H, Santanello N, Lipton RB. Migraine and cardiovascular disease. Neurology. 2009;72(21):1864 -1871.
by Christina Peterson, M.D.
updated June 17, 2011
by admin | Jun 12, 2011 | Comorbidity
What is Mitral Valve Prolapse?
Mitral valve prolapse occurs when the leaflets of the valve between the left atrium of the heart and the left ventricle are too large, or the strings (chordae tendinae) that connect them to the heart wall are too long. This causes them to close unevenly and bulge back into the left atrium (the upper chamber of the heart). In most cases, the valve still functions as it should. In a few cases, it may leak blood. This is called mitral regurgitation.
Mitral valve prolapse affects between 3%-10% of the population. About 60% of individuals with MVP have no symptoms. Mitral valve prolapse is also called click-murmur syndrome, Barlow’s syndrome, balloon mitral valve, and floppy valve syndrome.
Mitral valve prolapse, or MVP, is more common in people who have connective tissue disorders such as Marfan’s Syndrome or Ehlers-Danlos Syndrome, in people with Graves Disease, or in polycystic kidney disease. About 40% of people who have MVP also have a condition known as dysautonomia, a disorder of the autonomic nervous system. Dysautonomia can cause a variety of conditions that affect heart rate, blood pressure, and other bodily functions.
Symptoms of MVP
Symptoms of MVP can be brought out by stresses on the body like pregnancy, a viral illness, or major life stresses. MVP symptoms include chest pain, dizziness, palpitations (especially when lying on the left side), fatigue, shortness of breath with exertion or when lying flat, lightheadedness, and chronic low energy. In the infrequent, more severe cases of MVP with mitral regurgitation, symptoms of congestive heart failure can occur, with swollen legs and arrhythmia. Only in the most severe cases is valve replacement surgery necessary. Medical treatment is available for arrhythmia. The majority of people with MVP do not require any treatment.
Mitral Valve Prolapse and Migraine
A 1984 study of 100 migraine patients and 100 controls who all underwent echocardiography and clinical examination found that 11% of the control group and 25% of the migraine group had evidence of mitral valve prolapse. A larger, older study found that 27.8% of migraineurs had MVP. A study of only migraine with aura patients found a 15% rate of definite MVP, and 16% of probable MVP.
Why is there a connection? This is not known for certain. One theory is that blood platelets are damaged by the floppy valve leaflets, releasing serotonin from within the platelet. Serotonin is one of several chemicals in the body that has been implicated in the cause of migraine.
References:
1. Spence JD, Wong DG, Melendez LJ, et al. Increased prevalence of mitral valve
prolapse in patients with migraine. Can Med Assoc J 1984;131:1457–60.
2. Litman GI, Friedman HM. Migraine and the mitral valve prolapse syndrome. Am
Heart J 1978;96:610–4.
3. Amat G, Jean Louis P, Loisy C, et al. Migraine and the mitral valve prolapse
syndrome. Adv Neurol 1982;33:27–9.
by Christina Peterson, M.D.
updated June 12, 2011
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