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Reader's Mail: How Long Is Botox Effective?

Q. I have suffered with migraines lasting a minimum of five days at least once every month for most of my life. I am taking propranolol, nortriptyline and topiramate to help prevent these headaches and I take Imitrex injections for the pain. Taking the Imitrex has been particularly dangerous for me because I suffer from high blood pressure and take lisinopril, but there has been no other recourse.

Then this past April I had a couple of Botox (botulinum toxin) injections for the migraines. Since then, I have not suffered with another migraine. This is the first time I have been migraine-free for this long for as long as I can remember.

My question is, how often should Botox injections be repeated to prevent migraines from reoccurring?

A. I am pleased to hear that you responded so well to botulinum toxin injections. Many patients receiving botulinum toxin injections have a reduction in the number of migraines and can eventually decrease the amount of other headache medications that they require. Hopefully this will allow you to limit or discontinue the use of triptans, especially in light of your hypertension. In general, the effects of botulinum toxin last about three months. However, there is variability among patients. I recommend that you keep a headache diary in order to monitor the duration of effectiveness for you. Then you will be able to make an informed decision regarding the optimal interval with which you should have repeat injections.

Todd Schwedt, M.D.
Mayo Clinic
Scottsdale, Arizona

Finding Help When Money Is an Issue

Q. I have very bad migraines and have them so often that I have had a hard time holding a job. I have no health insurance or job and recently I had to go to the emergency room the pain was so bad. I have lost my job, home, everything. I am living with my mother right now or I would be on street. My mother paid for me to see her doctor and he gave me some drug samples, but they won’t last long and my mother can’t afford to buy my medicine.

I need to know if there is anyplace I can get help. Are there any studies in my area that I could participate in that might help me?

A. It certainly sounds like you are having a rough time. Getting better control of your headaches may be one important aspect of improving your situation. Since your headaches are contributing to significant disability in your life and resulting in emergency room visits, you certainly need to address methods of headache prevention and treatment. As you mention, this is more difficult in the absence of medical/prescription insurance.

However, I do have some suggestions. Try to avoid your headache triggers. These may include certain foods, missed meals, changes in sleep patterns, alcohol, excessive caffeine, and mental stress. If lifestyle changes are inadequate, medications may be necessary. Many pharmaceutical companies have programs for patients with financial needs. Check the Web sites of companies that make the medications your doctors have recommended for you. Also, taking the medications, including over-the-counter medications, as soon as possible may help make them be more effective. This will reduce the overall number of doses you need to take and will keep you out of the emergency room.

As you allude to, patients enrolled in clinical trials may receive medications free of charge. Consider checking with headache centers, university hospitals in your area, and the National Institutes of Health internet site (http://clinicaltrials.gov) for trials for which you may qualify. The National Headache Foundation also lists drug research studies on its Web site (www.headaches.org) as well as pharmaceutical company patient assistance programs.

Todd Schwedt, M.D.
Mayo Clinic
Scottsdale, Arizona

Editors Note: For more information about low-cost or no cost medications see the news brief on page xx regarding the Partners for Prescriptive Assistance (PPA) program.

Short-Lasting Headaches

Q. For the past few days, I have been having a strange headache that comes and goes.

Every 5-10 minutes I get a numbing type of pressure across the top of my forehead. It is not particularly painful. It just concerns me that is has been going on for so long. The pressure (numbness) lasts about 10 seconds.

A. Although the information provided is not adequate for a specific headache diagnosis, it seems that you are suffering from one of the short-lasting headaches. Headache types that have been given this designation include cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), idiopathic stabbing headache, trigeminal neuralgia and hypnic headache. Usually patients with these headaches report severe pain of a boring or stabbing quality. Some of these headaches are associated with autonomic (non-headache related) features, which include nasal congestion, runny nose, redness of the eye, tearing, swelling and even drooping of the eyelid.

You should see your healthcare provider about these headaches. Often, patients with headaches of this type require magnetic resonance imaging (MRI) of the brain. Once a diagnosis is made, treatment recommendations specific for your headache type can be made, if necessary.

Todd Schwedt, M.D.
Mayo Clinic
Scottsdale, Arizona

Benign Intracranial Hypertension

Q. My sister has been suffering from headaches and neck pain for some time. Approximately two weeks ago, she started to have double vision. We took her to the hospital where they tested her eyes. Her eye test was clear and therefore she had to undergo an MRI scan. The doctors suspected a tumor due to excess pressure behind her eyes, which by now had forced her left eye inwards and she had become cross-eyed.

The MRI scan showed that she did not have a tumor and after some research she was then diagnosed with benign intracranial hypertension (BIH), which the hospital had not seen before. She had a lumber puncture and it was a bad experience, with a lot of pain and worries about her blood pressure rising. She was told she might have to have another one. After three more days in the hospital she was discharged, still with a turn in her eye and double vision. She is still suffering badly if not worse than before with headaches, double vision and nausea, and she is very weak. We are extremely concerned and do not know what to do or where to go, and we feel we are not getting the help and support from the hospital that she needs.

A. Benign intracranial hypertension (BIH), or pseudotumor cerebri, is a disorder characterized by headaches, swelling of the blind spot of the eye (where the optic nerve leads from the retina to the brain) and vision disturbances, including double vision and, more seriously, vision loss. The disorder generally affects women more than men, particularly women in their 30s who are overweight. Symptoms are caused by increased pressure in the cerebrospinal fluid, but why this occurs is not fully understood. Other causes of her symptoms must be ruled out before the diagnosis is made. These include brain and spinal cord tumors, cerebral sinus thrombosis and side effects of certain medications, among others.

Treatment for BIH is aimed at reducing the pressure, either with medications or serial spinal taps (lumbar punctures), and often a weight loss program is initiated. Close neuro-ophthalmogic follow-up is necessary to help guide and follow treatment as permanent visual loss can occur. Patients who don’t respond to standard medical therapy may require surgical intervention.

I recommend you see a good neurologist to ensure that other causes of her symptoms are ruled out and that she gets appropriate treatment. If you do not know of a neurologist, a good starting point is a local teaching hospital or medical school.

Susan Broner, M.D.
St. Luke’s Roosevelt Hospital Center
New York, NY

Setting Limits on Taking Triptans

Q. I currently take Zomig as prescribed by my doctor and I have a question regarding the medication. I have had more headaches this month than normal and have had to take eight Zomig tablets so far this month (one 2.5 milligram tablet on eight different days). I’m wondering if there is a limit to how much of the 2.5-milligram dose you can take in a month?

A. Daily limits have been set for Zomig and other triptans. However, as these medications should be used only episodically, manufacturers have not set monthly limits. This being said, migraine sufferers should avoid taking triptans more than two days per week on a regular basis because of the concern of medication overuse headache (rebound headache).

Further, any patient continually experiencing frequent and/or disabling headaches should discuss a preventive medication with their healthcare provider. I suggest you speak to your doctor to ensure there are no other causes of your worsening headaches and to see if you are a candidate for preventive therapy. Also, a diary that tracks your headaches and treatment response is a useful tool to help you and your doctor find the right treatment for you.

Susan Broner, M.D.
St. Luke’s Roosevelt Hospital Center
New York, NY

Headaches Worsened by Lying Down Cause for Concern

Q. I have sporadic headaches that worsen when I bend over or lie down. I’ve had an MRI in the past and it was fine. I was tested for allergies and started receiving allergy injections 18 months ago. Up until the past few weeks or so I was fine, but now the headaches are back. What else could it be? I must mention, I did hit my head two weeks ago pretty hard dodging a bug that flew in my face. Think that could be the culprit?

A. Although these headaches may be benign, there is a high level of suspicion for an underlying disorder in any patient who reports headaches that worsen with bending over and lying down. Sometimes, such headaches are associated with elevations of intracranial pressure. Although abnormally high intracranial pressure may have no identifiable cause, it may be secondary to another problem.

There are a large number of possible causes for positional headaches. Head trauma is included although it is not one of the most common causes. Other possibilities include idiopathic or benign intracranial hypertension (pseudotumor cerebri) and mass lesions. You certainly need to be evaluated, and an MRI scan of the brain with gadolinium (contrast) is necessary. You may require other tests as well, but your healthcare provider will need to make this determination after you’ve been evaluated.

Todd Schwedt, M.D.
Mayo Clinic
Scottsdale, Arizona

Weather Induced Headaches

Q. I have suffered from various types of headache pain for the past 60 years. For the last eight years, I have lived in Florida. We are threatened with thunderstorms almost daily and with them comes migraine pain. Can you recommend any form of prevention or treatment for me to discuss with my physician?

A. The majority of migraine patients report one or more headache triggers. These may include mental stress, fatigue, certain foods, missed meals, menstruation, alcohol, changes in sleep patterns and weather changes. Some patients claim that they can predict weather changes by their headache pattern.

The best treatment for patients with identifiable triggers is to avoid them. When this is not possible, there are other types of headache treatments that can be considered. A comprehensive treatment plan for patients with chronic headaches is advisable. There is no single medication that prevents migraine attacks precipitated specifically by weather changes. However, if you and your physician can find an effective prevention medication, your susceptibility to weather changes and other triggers will be diminished.

Todd Schwedt, M.D.
Mayo Clinic
Scottsdale, Arizona

Triptans Not Advised with Ischemia

Q. During the last half year my wife has been suffering from severe stomach pain, especially after eating. The apparent reason is a condition called non-occlusive mesenteric ischemia. I have read that there have been cases that arose from the use of Imitrex. My wife suffers from daily headaches and Imitrex has been the only drug to help her. She has been taking Imitrex for a number of years.

I have a number of questions. Will all the triptans have the same effect? Is there any good alternative? Is there any logic in changing triptan drugs on a periodic basis in order to prevent vasospasms? Is there any logic in the use of witch hazel ointments or patches for shrinking cranial blood vessels? Is it possible that the reality is actually reversed and the headaches are actually caused by a basic underlying general circulatory problem?

A. Non-occlusive mesenteric ischemia is caused by a decrease of blood flow to the gut, which can happen for various reasons. All triptans, including Imitrex, constrict blood vessels and could therefore potentially worsen the ischemia so it should not be taken unless approved by your gastroenterologist. Changing triptans, therefore, would not be of use.

I recommend that your wife consult a headache specialist to evaluate her daily headaches, ensure she has an appropriate diagnosis and find alternative non-triptan therapy. She should also speak to her gastroenterologist about the possible reasons for her diagnosis in case there may be a systemic disorder that may also be contributing to her headaches. I don’t know of any studies supporting witch hazel ointment in the treatment of migraine.

Susan Broner, M.D.
St. Luke’s Roosevelt Hospital Center
New York, NY

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