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Reader's Mail: Compact Fluorescent Light Bulbs and Migraine

Q. I have had hormonal migraines for twenty years. Recently I’ve noticed that the new compact fluorescent light (CFL) bulbs are triggering attacks. I heard that Congress is considering a law to stop the selling of regular light bulbs. I’m not sure what I will do if I can’t purchase regular light bulbs.

A. Studies in children and clinical observation of my patients suggest that the blue wavelengths of light are the portion of the visual spectrum associated with triggering migraine. Fluorescent bulbs emit a higher proportion of blue wavelength light than do ordinary incandescent lights. A couple of options to consider and still be environmentally friendly are: 1. Use daylight spectrum fluorescent bulbs at home. The relative amount of the different wavelengths of light approximate that of good old Mr. Sun, and have less blue wavelength light. 2. Consider light-emitting diode (LED) bulbs. These also should prevent the lighting spectrum issue from being a contributor to your migraines.

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

Choosing a Contraceptive that Won’t Aggravate Migraines

Q. Do you know what type of birth control pill I can take that will not worsen my migraines?

A. It is hard to give you a specific answer because women with migraine do not all react the same to oral contraceptives. Some women have fewer migraines on the pill because they do not ovulate, while others seem to have worsening of headaches with any amount of extra estrogen.

In general, pills with the lowest dose of the estrogen component would be least likely to aggravate migraine. Because the most significant trigger of migraine is the fall in the level of hormones when the pill is stopped (every three weeks in the usual type), many women do better on the low-dose three-month pills. The “triphasic” type of pill, which varies the amount of hormone over the course of the month, should be avoided because the fluctuating levels may have a worsening effect. In theory, contraceptives containing only progesterone should not have much effect on migraine, but I have seen some women for whom even this made their migraines worse.

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

Change in the Pattern of Migraine Symptoms

Q. My migraines have changed pattern and I’m concerned. Until recently, my pattern was to have blind spots—I couldn’t read or judge distances for about five to ten minutes and then horizontal waves of different colors went across my eyes. This lasted for about five minutes. As soon as the waves disappeared I knew I had 15 minutes to get myself ready (feed kids, change diapers, etc.) before the actual migraine started. My migraine headaches last for about two days, though they mellow out over time.

At the beginning of this year, the pattern took a new turn. The vision problem is still the same, but now I get a numb feeling in my left hand, arm and fingers, like they are sleeping. The waves fill up my whole field of vision and now move in all directions. The headache is worse and I feel more nauseated than before.

Do you know why my pattern might have changed? I’m two months pregnant but this new migraine happened before I got pregnant, so I can’t blame it on that. Someone told me it might be a sign of multiple sclerosis.

A. While a change in a pattern of migraine symptoms requires a thorough neurological and physical examination to ensure that there is no other underlying reason, your symptoms are still characteristic of migraine aura. These are not symptoms characteristic of multiple sclerosis.

The change in visual symptoms suggests that the same areas of the visual cortex are still being excited into producing symptoms but now on a larger scale, invoking areas that involve not just the horizontal, but also the vertical quality and invoking more of the visual field. That the symptoms are brief (lasting less than an hour) and resolve spontaneously without outlasting the headache speaks against a more serious problem. The numb sensation, or paresthesia, is again typical of migraine. I can’t be sure from your letter if the numbness involves the whole hand and fingers all at once or spreads from one to the next, which would be the normal evolution in migraine. Again, the brevity of symptoms and return to normal are typical.

In hemiplegic migraine, the individual loses strength, as would occur with a stroke, but returns to normal as the attack resolves. In basilar migraine, the numbness would be in both hands simultaneously as well as having other symptoms.

Therapeutic choices may be limited since you are pregnant. You and your spouse will need to discuss the options with your healthcare provider. Biofeedback has helped control the aura for some people.

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

Who Should Have an MRA?

Q. I have had frequent migraine headaches most of my adult life. I have tried almost every type of daily preventive medication. The medications seem to work for several weeks or months and then the headaches are back to where they were before I started the preventive. Sumatriptan relieves a headache, but I have to be careful not to cause rebound headache by taking it too often.

I have had CT scans and an MRI that have not shown any abnormality. Would it be reasonable for me to ask for an MRA? Since my headaches have been so severe and so consistent throughout my life, I really fear I may someday have a stroke.

A. An MRA (Magnetic Resonance Angiography) of the brain examines the arteries in the head. It is used when there is a suspicion of abnormal vessels, such as with an aneurysm, atherosclerosis or tears in the blood vessels. They’re also commonly ordered when there is a change in headache pattern, or if a patient experiences an explosive headache or a headache with exertion. Speak to your healthcare provider about your concerns so she or he can decide if this test is right for you.

Susan Broner, M.D.
The Headache Institute
New York, NY

Imitrex® Causing Gastric Problems

Q. have been taking Imitrex successfully for several years, but recently it is giving me extreme gastric problems. I get very sick to my stomach and usually throw up. I’ve always depended heavily on Imitrex due to having severe migraines, but this is really intolerable. Should I take a stomach medication along with the Imitrex to prevent gastric problems or should I try another migraine medicine?

A. It is unusual for Imitrex (sumatriptan) to cause vomiting when it didn’t previously. Maybe your migraine pattern is changing. From your note, I assume the vomiting occurs only when taking the Imitrex, which would seem to rule out an underlying gastric problem. I would check for any other underlying factors, such as high blood pressure, anemia, thyroid disease, etc., which might be affecting your headaches.

I certainly think that it would be worthwhile trying another triptan or taking an anti-nausea medication. Many people with migraine who experience nausea and vomiting find that taking metoclopramide (Reglan®) a few minutes prior to taking a triptan helps. Other anti-nauseants may also be effective. I would also consider daily preventive treatment, which will often reduce the frequency and severity of attacks.

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

Experiencing One-Sided Paralysis and Numbness

Q. Two years ago I had what was at first thought to be a stroke. I was completely paralyzed down my left side for about 45 minutes, but the emergency room couldn’t find any signs of a stroke. A couple of days later it happened again, although not as severe, on my right side. This was after a week of some mental confusion and pain in the back of my head (I tried starting my car by turning on my windshield wipers). I was admitted to the hospital, but, once again, they couldn’t find anything wrong. Eventually, a neurologist diagnosed me with hemiplegic migraine and put me on Topamax® as a daily preventive.

Every day since, I have experienced some kind of numbness in my hands or feet. Like clockwork, I go numb before I take my medicine. After I take my Topamax, I feel better. My neurologist ordered MRIs of my brain, neck and spine and found nothing. She said that I should be happy that she couldn’t find anything seriously wrong and that I should just take my medicine and deal with it. I’m miserable, though, and I don’t know who to see for relief.

A. Hemiplegic migraine has certain diagnostic criteria. It is a migraine headache with an aura of fully reversible weakness (i.e., the weakness is temporary and clears up completely) with at least one of the following other auras: fully reversible visual symptoms (like flickering lights or loss of vision), fully reversible sensory symptoms (like tingling or numbness) or fully reversible speech problems. The aura symptoms must develop gradually over five or more minutes. Each aura symptom must last between five minutes and 24 hours.

The headache itself must begin within 60 minutes of the onset of the aura. It must last between four and 72 hours (untreated) and must have at least two of the following qualities: one-sided, throbbing or moderate-to-severe in intensity. With the headache, you must have light and sound sensitivity or nausea and/or vomiting. There is a familial form and a sporadic form of hemiplegic migraine. In the familial form, at least one first- or second-degree relative also has migraine with weakness and possibly cognitive disturbances.

I recommend you see a headache specialist and get a second opinion on your diagnosis and a re-evaluation of the medications you are taking.

Susan Broner, M.D.
The Headache Institute
New York, NY

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