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Reader's Mail: Low Testosterone Levels and Cluster Headaches

Q. I have had bad headaches for years. I was not making any progress with the doctors I was seeing and most of the time the medicines they put me on made me have other health issues. I did some research on my own and read where low testosterone levels could cause headaches. I started working out and purchased some steroids. I took a small amount for six weeks and didn’t have any headaches during that time and for about three weeks after the last injection. I found a new doctor and showed him what I was taking. He warned me about the affects of steroids and had me go off for six weeks. He then tested my testosterone level and it was 65. He prescribed an androgel that did help, but I have started having headaches again. Can you give any guidance?

A. It appears that a small number of men with cluster headaches, particularly if chronic (more than a year with at least two weeks remission), have low testosterone levels and have improvement of their headaches when treated with testosterone replacement. Your testosterone levels are low. I would suggest that you have a thorough workup to determine if you have any other hormonal deficiencies. Low testosterone can be “primary” due to lack of production by the testes or “secondary” due to an abnormality in the pituitary gland. Pituitary gland failure can be associated with other endocrine or hormonal deficiencies. If no underlying cause is found, then you will probably need long-term testosterone replacement therapy, which hopefully will benefit your headaches.

Robert Kunkel, M.D.
Consultant, Center for Headache and Pain Neurological Institute, Cleveland Clinic
Cleveland, OH

Could Allergies Be Causing Migraines?

Q. My daughter suffers with migraines. Her doctor has her on topiramate and amitriptyline and she still has headaches at least once a week. Another therapist suggested that she may have allergies. Could this be possible? Should she also try an allergy medication?

A. Allergic rhinitis and asthma can occur in conjunction with migraine in pediatric patients. Usually, diagnosing and treating the allergies will show some benefit in the overall management of pediatric migraine. However, the headaches can still occur despite being on an effective allergy medication regimen. Sometimes older antihistamines, such as cyproheptadine, can be effective for migraine prevention in younger children, and we frequently use this as a primary preventive agent in our headache clinic. The use of other antihistamines such as cetirizine (Zyrtec®), loratadine (Claritin®) and fexofenadine (Allegra®) has not been shown to prevent migraine in the pediatric population, but can be used to address allergies in conjunction with other migraine prevention medications.

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

Treating Anxiety Associated with Migraine

Q. I have had migraines for approximately 20 years. I have bad months where I have 6-10 days of headaches. The last month has been better since I started on Topamax® for migraine prevention. However, I am feeling anxious and wondering if there is an anti-anxiety medication that is recommended. What are your thoughts about BuSpar® and Paxil®?

A. Paxil (paroxetine) is a serotonin-specific reuptake inhibitor (SSRI) that is indicated for both the treatment of depression and anxiety. BuSpar (buspirone) is specifically indicated for anxiety only. Either medication type is acceptable for the treatment of anxiety.

The SSRI class of antidepressants can be very effective for treatment of anxiety and depression, but is not usually effective for the prevention of migraine. Some of the antidepressant medications that are used for prevention of migraine include the tricyclic antidepressant class, such as amitriptyline, nortriptyline and doxepin. Also, the newer serotonin-norepinephrine reuptake inhibitor class (SNRI), which includes venlafaxine (Effexor®) and duloxetine (Cymbalta®), has shown some benefit in the prevention of migraine.

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

Tyramine Diet and Soy Beans

Q. I am considering trying the tyramine diet to see if tyramine triggers my headaches. I have read articles that say you should avoid all soy products including raw soybeans due to the levels of glutamate that convert to or are close to MSG. As a practical matter, when trying to determine if there is a food trigger, should all soy products be eliminated from one’s diet?

A. I think it is too restrictive to avoid all soy products in an attempt to avoid migraine headaches. Dietary changes for a migraine patient are best done based on personal experience and not by lists of what to avoid. I usually recommend that migraine patients look back for 24 hours leading up to a migraine and make note of what they ate and drank. Once there is a pattern as to a certain food or beverage causing a migraine, then it makes sense to begin avoiding that product. For most migraine patients, greater triggers for migraine include stress, hormonal changes and weather.

Susan Hutchinson, M.D.
Orange County Migraine & Headache Center
Irvine, CA

Could Headache Be Caused by Arthritis Medication?

Q. I have suffered from migraines most of my life. They generally started with the aura followed sometimes by a headache, sometimes not. I could take my medication and they would be gone by the next day.

Recently, I started experiencing a different kind of migraine. I have pressure in my head with a light headache and elevated blood pressure. This headache has pretty much stayed for about the last four months. I’m trying to determine the trigger. About four months before the headache started, my arthritis doctor prescribed Plaquenil®. It takes about three months for Plaquenil to get into your system before you may notice any relief from rheumatoid arthritis symptoms. Could there be any connection between the Plaquenil and the migraine? One other factor is that I am probably in menopause.

A. Since you have had a significant change in your headache frequency, you should be evaluated by your healthcare provider for possible causes. Assuming that no other cause of your headaches is found, you have raised two possible explanations for your transformation from episodic migraine to daily headache. Although not common, headaches can be a side effect of Plaquenil (hydroxychloroquine). Gastrointestinal and skin problems are the most common side effects, with headache and dizziness occurring less often.

The second point you raise is your probable peri-menopausal state. Levels of sex hormones certainly play a role in migraine. Migraine is most common in women between the onset of menstruation and menopause. Headache patterns often change during the time that a woman is having hormonal changes, such as the time just before reaching menopause. The good news is that after menopause, there is often a significant decrease in the prevalence of migraine.

Todd Schwedt, M.D.
Washington University Headache Center
St. Louis, MO

Would Surgery for Mitral Valve Prolapse Help?

Q. I have severe mitral valve prolapse (MVP) as well as migraine with aura. My options are to do surgery for the MVP now or possibly wait another year.

I have read of correlations between migraine and MVP. Over that past two years my migraines have been more frequent than ever and some pretty severe. Could I be having more migraine because of my MVP, which has gradually gotten worse over the last several years? If there is any chance that my MVP has an effect on my migraines, I would choose to do the surgery sooner rather than later.

A. Mitral valve prolapse is usually a benign condition that is found in up to 4% of the general population, with predominance in younger women. There is a higher incidence of MVP in patients with migraine than expected, compared to the general population. However, treating severe MVP with surgical valve replacement is not clearly associated with improvement in migraine. There are no longitudinal, controlled studies evaluating this association.

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

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