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Reader’s Mail: Eye Symptoms Common With Migraine Disease

Q. I have recently noticed that the whites of my eyes become less bright, red, or even streaky during a migraine. Is this common? Is it a problem?

A. “Bloodshot” eyes are a fairly common occurence in migraine. About 45% of people with migraine experience at least one so-called autonomic symptom, such as eye tearing, nose dripping or stuffiness, due to increased activity in nerve tissues triggered by migraine mechanisms. Additional symptoms can include eye redness, puffiness, eyelid droopiness, and changes in facial sweating. Eye symptoms alone amount to 40% of the total, while 46% of patients experience eye and nose symptoms. These autonomic symptoms are nothing to worry about and are part of the normal migraine. They’re due to activation of another “module” or area of the brain hard-wired to the pain centers.

This said, it’s always best to discuss symptoms and be examined by your practitioner to increase the likelihood we are all communicating about the same issues.

Frederick Taylor, M.D.
Park Nicollet Clinic
Minneapolis, MN

New Daily Persistant Headache

Q. I was recently diagnosed with New Daily Persistent Headache (NDPH). I woke up with this headache one year ago this week and have visited a number of doctors. Do you happen to have any literature you could recommend that would help me learn more about this type of headache?

A. New Daily Persistent Headache (NDPH) is typically easy to diagnose if the examiner knows the entity. The main diagnostic problem is that NDPH is a relatively rare headache disorder and its characteristics are not commonly understood by many healthcare providers. It is typically one of only four primary chronic headache types that last longer than four hours per day. These four headache types are chronic tension-type headache, chronic or transformed migraine, hemicrania continua and NDPH. Since chronic daily headaches occur in about 4% of the population and all three of the other types are much more common, there is not much educational material readily available about NDPH.

I believe the two best summary reviews are found in Current Pain and Headache Reports from 2003. Both are titled “NDPH” and were written by Todd Rozen, M.D., and Randolph Evans, M.D. A librarian from any local hospital or your healthcare provider’s librarian should be willing to obtain these documents if you provide them with these references: Current Pain and Headache Reports 2003; 7:218-223 and 2003; 7:303-307. These articles are written for medical personnel, so beware!

In brief, NDPH is a headache that occurs without a preceding history of headache and is persistent daily within three days of onset. It often becomes associated with medication overuse, though this overuse occurs only after the daily headache begins and not before. About one in three sufferers had a viral illness preceding the onset of NDPH. The provoker for most cases of NDPH is unknown. There is a long list of possible NDPH mimics that need to be ruled out, so patients need to be imaged and tested.

While there is a refractory form of NDPH, there is also self-limiting form, which eventually goes away on its own. The amount of time you have had NDPH is still within the self-limiting duration, so it may resolve without treatment. No specific evidence currently exists for the best treatment choice, but anecdotal case reports suggest that gabapentin (up to 2700 mg per day) and topiramate (up to 400 mg per day) have been beneficial in this otherwise typically refractory headache condition.

Frederick Taylor, M.D.
Park Nicollet Clinic
Minneapolis, MN

Post-Traumatic Headache Can Be Difficult to Treat

Q. My sister has had massive headaches for the past 10 years. It was thought that the cause was a minor car accident, which also happened about 10 years ago. (She was sitting at a stoplight when a car rear-ended her.) She has had x-rays and MRIs done of her head and neck. The doctors still cannot explain why she gets these excrutiating headaches.

Her primary care physician has called her headaches “suicide headaches.” This seems to truly describe their intensity. Is it possible that the breast implants that she had put in about two years after the auto accident could be the real cause of her headaches and not the auto accident?

A. Post-traumatic headaches can occur after a trauma such as a rear-end motor vehicle accident or a fall. They usually develop within 14 days after the injury. Head, neck and shoulder pain generally occurs within 24 to 48 hours of the injury. Women experience this type of headache more than men in a ratio of approximately 2:1. The headache normally resolves in two months or less. However, many patients experience a chronic post-traumatic headache that can last for months or even years.

The headaches associated with trauma can be difficult to prevent and treat, and usually require multi-drug prevention therapy. Stress management, biofeedback training, exercise and psychological counseling may be helpful for long-term management. It may be beneficial to refer the patient to a headache specialty center that can employ a multi-disciplinary approach to managing the headaches. The breast implant procedure is not a likely cause of this type of headache.

George Nissan, D.O.
Diamond Headache Clinic
Chicago, IL

Role of Patent Foramen Ovale

Q. I am a 47-year-old male and have had migraines about once a week for over 20 years. I almost always get complete relief from triptans, but suffered an embolic stroke eight years ago and would prefer not to take them.

A seemingly unusual characteristic of my headaches are that after 24-36 hours on one side of my head the pain dissipates, but then begins on the opposite side and lasts another 24-36 hours. Does this characteristic suggest a specific trigger that I could avoid or possibly a specific medication that I could use preventively? I’ve tried restricting my diet and have taken verapamil, amitriptyline, riboflavin and magnesium, all without results.

A. Your pattern of having an attack on one side that clears and then appears on the opposite side is quite common in migraine. It doesn’t mean anything specific. Your having had an embolic stroke makes me think of recent reports about patent foramen ovale (a hole in the membrane between the two upper chambers of the heart). Closure of this hole in persons with migraine who have had a stroke has reduced the number of headaches for many of them. I assume that you had an echocardiogram as part of your workup to find the source of the embolus. If not, you should talk to your healthcare provider about having one done. The foramen ovale usually closes shortly after birth, but apparently fails to close in about 25% of people.

There are other preventive drugs, such as anti-epileptic drugs or beta-blockers, which might be worth trying.

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

Could Tension-Type Headaches Be Triggering Sinus Infection?

Q. I suffer from daily tension headaches. Usually ibuprofen curbs them, although I try not to take it every day to avoid the rebound problem. Sex is a trigger as is a stressful job.

My question is this: do you know if tension headaches play any role in chronic sinusitis? I am under the care of an ENT (ear, nose and throat specialist) and allergist, but I am beginning to wonder if the underlying cause of my inflammation is actually the factor that triggers my headaches and not allergies?

A. I don’t think there is any connection between tension-type headache and “sinus.” There is a condition known as vasomotor rhinitis that causes congestion and irritation of the membranes in the nasal and sinus cavities. This condition is not uncommon in migraine and is due to dilation of the vessels in the membranes. Patients are aware of congestion, runny nose and sometimes sneezing. Tension and stress, as well as weather changes, pollution and inhalation of chemical irritants, can also cause this condition. Sexual activity is associated with increased blood flow and nasal congestion is quite common during sexual activity.

The underlying problem seems to be an over-active autonomic nervous symptom. This is a very common part of migraine but less so with tension-type headache.

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

Testing for Allergies as a Headache Trigger

Q. In an article entitled “Allergy and Headache,” I read the following: “There are many individuals who have respiratory allergies that contribute to or cause headaches arising from their nasal passages or sinuses. Examination and diagnostic tests can isolate and specifically help to resolve these problems for most patients.

“At times migraine and other headache patients may get headaches related to allergic problems like these. They may even provoke an increase in their normal headaches or migraines because the allergic headaches lead to reflex contraction of scalp and facial muscles, increased pain, and other physiologic changes that provoke their headaches.”

Can you give me more information about the types of diagnostic tests I should be requesting? Which doctor performs these tests?

A. Even though allergies are seldom responsible for headaches, I would recommend you talk to an allergist. He or she is the one who would do allergy testing. Also you would need a CT scan of the sinuses and an MRI of the brain.

George Urban, M.D.
Diamond Headache Clinic
Chicago, IL

One-Sided Headaches

Q. I have suffered with one-sided headaches for about two months. I have been to several doctors – one said it was tension, the other said it was caused by a strain in my shoulder and occipital neuralgia. Now I am scheduled for a CT scan. My symptoms are moderate to severe headaches that never go away. It feels like they start in my left ear, go up behind my eyes and into the left side of my temple. I am so sick of them. Any suggestions?

A. One-sided headache or side-locked headache lacking side shifting narrows the spectrum of headaches you are likely to suffer from. The most common one-sided headache is migraine, but that typically side-shifts. Migraine is side locked in only 10% of cases and this suggests the need to think about underlying brain abnormalities, though they typically are not found. The migraine I refer to is not constant, however, but rather intermittent.

Constant side-locked headache, especially in the temple region, creates consideration for hemicrania continua. The headache is moderate in severity most of the time, but peaks of severe, migraine-like pain intermittently occur accompanied by cranial autonomic symptoms. These autonomic symptoms are typically very limited in severity or may not even occur, but can include slight nasal congestion, tearing, eye redness, facial puffiness, etc. The symptom that most strongly supports such a diagnosis is that of a sense of a foreign body in the eye with peaks of pain.

Other diagnoses involving side-locked headache are the trigeminal autonomic cephalagias (TACs). The most common TACs are cluster headache, which is not a continuous headache, and chronic paroxysmal hemicrania, which also is not continuous, but the 10-30 minutes headaches can be so frequent that patients describe them as continuous. It is critical to be clear whether the pain is constant. If it is, you should be evaluated for hemicrania continua and be treated with indomethacin, unless it is absolutely contraindicated for you. Finally, side-locked headache that is not responsive to indomethacin deserves to be assessed for cervicogenic headache. This is a headache disorder that originates from the cervical spine itself, while the aforementioned disorders originate from the brain. Your history of occipital neuralgia, which is a grab-bag term of disorders overly diagnosed and often misdiagnosed, particularly suggests this entity. If the problem originates in your spine, typically certain postures or head positions will affect the headache.

Definitive diagnosis requires an expert practitioner who is familiar with selective facet blocks. Selective facet blocks are diagnostic anesthetic procedures performed under fluoroscopic X-ray guidance. With the proper expertise and experience, the practitioner directs a needle to specific structures of the neck and anesthetizes them to determine whether the pain can temporarily be completely eliminated. If the pain is eliminated it strongly suggests the source of the pain has been identified. Radiofrequency neurotomy, a microwave-type procedure, might follow if the block does find the source in the neck.

Frederick Taylor, M.D.
Park Nicollet Clinic
Minneapolis, MN

A Reader Suggests Solutions to Computer Screens Triggering Headaches

I would like to reply to the Readers’ Mail question in the May/June 2005 newsletter titled “Computer Screen Triggering Migraines.” Yes, CRT (cathode ray tube) computer screens can and do trigger migraines in susceptible people. But you can reduce this or avoid it altogether by setting your refresh rate to 75mHz or higher, assuming your monitor and video card will allow it, or by switching monitors.

I suffer from migraines and notice a huge difference between the monitors at work and my monitor at home. I did a lot of research before purchasing my monitors. All of them are Viewsonic brand, which I feel is the best and the only one I’ll trust my eyes to for CRT-style monitors. The difference in monitors is so great that I can work on my computer at home for 14 hours straight with no migraines, but can’t work on a Hewlett-Packard monitor from work for more than one or two hours without triggering a migraine. I even brought a monitor home from work and put it on my home computer to see if it really was the monitor at fault or some other factor in play.

I’m a computer engineer and I really research things. The 75mHz refresh rate is only one factor. The other factor, I believe, is the amount of shielding in the monitor. The Viewsonics adhere to the tougher German standards and are much better shielded for radiation than other monitors are. Yet another factor is the dot pitch the smaller the better, so .26 or .25 is good. With LCD monitors, brand is not quite as important. LCD monitors are not a panacea, though. They are not always crystal clear and as such can cause eyestrain leading to migraines. Despite the fact that the LCDs don’t have the flicker to worry about, the eyestrain factor can be just as bad if you work long hours on the computer.

Caroline MacDowell
Tampa, FL

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