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Reader's Mail: Are Left-Sided Headaches Worse than Those on the Right?

Q. I have been a migraine and headache sufferer for many years. My migraines have always been right-sided. However, recently some have become left-sided and the pain is much worse than the right-sided migraines were. I once read somewhere that migraines are generally right-sided and that it’s a bad sign if they change to the left side.

I used to take Imitrex for migraines but can’t anymore as I have mitral valve prolapse (MVP) with regurgitation. Imitrex was the only drug that ever really helped me. I can’t take any of the other migraine drugs because of the MVP so I do my best with Fioricet. I have also been told that migraines are one of the symptoms of MVP. This I do not understand as I was diagnosed with MVP ten years ago, but have had migraines since childhood.

A. You’ve heard the saying ‘an old wives’ tale.’ Well, there is no validity that left-sided migraines are worse than right. Certainly, other readers will confirm your history of left worse than right-sided migraines, but likely just as many will say the opposite was true for them. I am more concerned about the recent side shift of head pain. The severity does not necessarily tell us the nature of the headache. If the headache change is less than six months in duration, it would be a good idea to see your healthcare provider for an examination to specifically eliminate worrisome headache concerns. A change longer in duration than six months is very likely not worrisome.

I am unaware of any restrictions on migraine-specific drugs due to MVP with regurgitation. There are such restrictions on coronary disease and other arterial type heart disease, but MVP is not the equivalent of coronary artery disease.

MVP is more frequent in migraineurs and therefore is often termed comorbid or co-associated. There is no evidence that migraine is a symptom of MVP. Any effects of one on the other are purely speculative at this point in time.

Assuming there is no significant history of cardiovascular risks, a migraine-specific triptan or dihydroergotamine is indicated based on your past response and current use of Fioricet.

Frederick Taylor, M.D.
Park Nicollet Health Services
Minneapolis, MN

Migraineur Denied Health Insurance

Q. I was recently denied independent health insurance because I have had a history of migraines, which the company said was a risk factor for stroke. I have had probably a total of 10 migraines in my life starting at age 30. I’m now 38. I have only had one migraine since the birth of my daughter, two years ago. I thought that acquiring health insurance would be simple since I’m in good health, am hardly ever sick, and take pretty good care of myself. When I requested my medical records from the underwriters, there was not even a reference to the headaches since I hadn’t had any episodes for so long.

Can you think of any way to appeal such a decision based on my history of migraines? The insurance company will only consider physician progress records, hospitalization records, diagnostic studies, etc., not physician’s letters or narrative statements. Am I at risk of having a stroke or other serious problem if this is my only medical issue? Should I see a specialist, at my own expense, of course, to determine if I am at risk of stroke?

A. The likelihood of having a stroke related to migraine is extremely small. That being said, migraine is the leading cause of stroke in young people below the age of 50. Recent studies suggest that migraine of a long-standing nature may increase the finding of white matter lesions deep in the brain. The exact nature of these lesions is not understood since the occurrence of these findings does not correlate with abnormalities on neurologic examination for most patients. These spots have no correlation with medications taken, but they do occur more in women and in those who have an aura before their headache attack.

You may be best advised to consult with an attorney who handles issues such as insurance company matters or who might advise you on alternative companies to contact. It is most unfortunate that some insurance carriers make decisions like these, which appear to have little relevance to an individual’s health status.

Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL

Pain Like a Too-Tight Ponytail

Q. I get headaches or a constricting sensation very similar to how one feels when hair is worn pulled back too tightly. It becomes very tender around the top of the scalp and is more sore when I move my hair from one side to the other. It feels nerve related. Could there be a lack of oxygen there?

A. The sensitivity or tenderness around the top of your scalp that you mention is a good description of a common condition called cutaneous allodynia, which is often part of the migraine process. Cutaneous allodynia is sensitivity to a stimuli like a light touch, which, under normal circumstances, would not be painful. This often occurs as a migraine headache progresses.

I recommend that you have a healthcare provider further evaluate your symptoms to see if they are part of a migraine headache. If so, migraine-specific medications may help. Watch for other associated symptoms of migraine, like nausea and sensitivity to light, and the level of disability associated with your headaches. Lastly, keep a headache diary and take it with you when you see your provider.

Susan Hutchinson, M.D.
Headache Center Women’s Medical Group of
Irvine Irvine, CA

Preventing Migraines by Preventing Teeth Grinding

<strongQ. What are the National Headache Foundation’s thoughts about the NTI Tension Suppression System, which has been determined to help with migraines?

A. The National Headache Foundation has no official position on the NTI Tension Suppression System. The system is a small plastic device that is worn over the two front teeth at night to prevent bruxism (teeth clenching). The theory is that clenching and grinding may lead to a hyperactivity of the trigeminal nerve and subsequently trigger migraine events. The system is obtainable through dentists. This device is FDA approved for migraine prevention treatment.

Anecdotally, I have patients who find it beneficial and others who do not. I know of no head-to-head trials to determine its statistical superiority. That said, muscle tension is extremely common in the migraine population and bruxism is nearly universal. If the price is right, a trial is likely harmless and may well be beneficial. Another device currently being promoted for acute migraine relief, but as yet without FDA approval, is a splint device called the Best-Bite Discluder.

Frederick Taylor, M.D.
Park Nicollet Health Services
Minneapolis, MN

Migraine Triggered by Contact Lenses?

Q. I was wondering if wearing contact lenses for an excessive number of hours, or wearing contacts period, affects me in getting migraines?

A. I know of no studies that have suggested that contacts play any role in triggering migraine attacks and, in treating migraineurs for over 40 years, I have not noted an association.

However, what does happen frequently is that during a migraine attack, the structures in the head and face may become ‘sensitized’ and the contacts may become irritating. Touching of the head and face, including wearing glasses, shaving, putting on makeup, combing the hair, etc., may become irritating and even painful.

Robert Kunkel, M.D.
Cleveland Clinic Foundation
Cleveland, OH

“Resetting” the Brain from Rebound Headache

Q. I have a 25-year-history of severe migraine. The frequency of attacks increased from two to four migraines per year to about two per month after I was in an auto accident in 1981 (with broken bones and other injuries).

In the last year the migraine pain has become constant and I am taking the narcotic Nubaine in order to function. My neurologist believes this daily dosage is causing rebound headache and is working with me to go off of it. I have tried by myself and the pain I go through is terrible. Six days without the medication was the most I could tolerate.

How can I know that going off of Nubaine, should I be able to, will stop the chronic daily pain I am experiencing? Should rebound be the problem, how long will it take for my pain receptors to function well enough to free me from the need for Nubaine? I am taking Topamax as a preventive and it may be working, but the Nubaine may be masking its effectiveness.

A. There is not a lot known about the mechanisms involved in rebound or medication-overuse headache. Nubaine is not a very commonly used medication in headache, so there is even less known about it.

Not all daily migraine is due to overuse of medication, but the majority of times this seems to be the main factor in the conversion of an episodic migraine pattern into a daily migraine. The severe headaches that occur for the days you are off of the Nubaine do suggest that you are having rebound headaches.

Nubaine is an opiate that binds to several receptors in the brain. Your healthcare provider can obtain detailed information on its pharmacology and actions from its manufacturer.

It is felt by most specialists that it may take two to eight weeks or more for neural receptors to ‘reset’ themselves after the long-term use of an opiate drug. Using ‘bridge medications’ during the withdrawal period may help control the withdrawal headache and other symptoms. Medications frequently used during withdrawal include dihydroergotramine (DHE-45), clonidine (Catapres), nonsteroidal anti-inflammatory drugs, corticosteroids, tizanidine (Zanaflex) and quetipine (Seroquel).

Robert Kunkel, M.D.
Cleveland Clinic Foundation
Cleveland, OH

New Migraine Diagnosis After Age 50 Is Rare

Q. I was recently, at age 51, diagnosed with migraines. I didn’t know what the headaches were and went for several months without diagnosis or treatment. Is it common to have migraine later in life? The women I know who have migraines have battled them since they were young. I didn’t get them until some years after a hysterectomy. No other person in my family has ever had migraines.

I have been placed on 100 mg of Topamax and for the past two months I have suffered no attacks of any kind. Is 100 mg a common dosage or should it be smaller or larger? How is it based? I have had two opinions and am seeking guidance as I am new to this syndrome.

A. The development of migraine after age 50 is rare. It is a situation in which it is important to ascertain that there is not another cause of headache mimicking migraine-type headaches. This would be especially important in a situation such as yours, without a family history of migraine. A thorough examination and appropriate laboratory tests and radiological studies would be part of the evaluation.

Topiramate (Topamax) is the latest medication to be approved by the FDA for the prevention of migraine. In clinical trials about half of all patients on topiramate had at least a 50% reduction in their migraines, around one-fifth had a 75% or more reduction in headache frequency, and about 5% of the group had a complete remission of their migraines.

The recommended target dose for topiramate is 100 mg per day, which is achieved by starting with a dose of 25 mg per day and increasing it in weekly allotments until the target dose is achieved. Many patients will respond to doses lower than 100 mg, while some may require higher doses for optimal results. The safety of the drug is reflected by the lack of an absolute top dose that can be used. While side effects are common when first starting topiramate, events such as tingling, tiredness and alterations in taste almost invariably disappear within the first four to eight weeks of taking the medication.

Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL

Aura’s Shimmering Lights

Q. I suffer from fortification spectra, where shimmering lights float across my eyesight. Are there any medications that are used for this?

A. Fortification spectra are the most common form of the visual symptoms that occur in the aura of a migraine attack. In some persons, they occur without a headache; this seems to happen more frequently as people with migraine grow older. The phenomena usually last 20-30 minutes. By definition, they last less than one hour.

If the symptoms occur frequently, they are treated similarly to frequent migraine, with migraine preventive drugs, such as one of the anti-epileptic drugs or verapamil, which is a calcium channel blocker. If the symptoms do not occur very frequently, no treatment is necessary as long as retinal disease has been excluded. Since the visual symptoms often last only 10-15 minutes, it is difficult to take any medication that works that fast. Some people have found that taking a nitroglycerin tablet under the tongue will promptly clear their vision. This treatment may at times precipitate a headache, though it seems to rarely trigger a full-blown migraine attack.

Robert Kunkel, M.D.
Cleveland Clinic Foundation
Cleveland, OH

Birth Control Pills Contraindicated with Complicated Migraine

Q. The article on complicated migraines that I read on your Web site seems to parallel the symptoms that I experience. My main fear is that I am taking birth control pills and your Web site says to avoid them. Should I abstain from taking them? My doctor is well aware of my migraine history and my birth control usage and has never suggested I stop.

I started birth control pills at age 19, but started experiencing migraines well before that. I am now 27 and experience chronic migraines due to a car accident.

A. Complicated migraine is the term used to refer to forms of migraine in which the aura symptoms are prolonged or last into or through the headache phase. These forms include basilar migraine, hemiplegic migraine, retinal migraine and opthalmoplegic migraine. Careful evaluation by a healthcare provider who is experienced in diagnosing these very rare forms of migraine may be important in order to ascertain a proper diagnosis.

The use of estrogens, whether as a contraceptive or post-menopausal treatment, is at least relatively contraindicated in these rare forms of migraine. This becomes increasingly important should you have other risk factors for stroke, such as the use of nicotine.

Frederick Freitag, D.O.
Diamond Headache Clinic
Chicago, IL

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