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Reader's Mail: Suggestions for Hemiplegic Migraine

Managing Hemiplegic Migraine

Q. My daughter has had hemiplegic migraines since she was eight. I am devastated for her as it is really debilitating. Do you have any suggestions?

A. Hemiplegic migraine is a rare form of migraine that is considered to be one of the more severe types. It is characterized by a fully reversible motor weakness, such as motor paralysis on one side of the body. This precedes the headache and totally resolves within 24 hours. It may be accompanied by numbness or a pins-and-needles sensation. The neurological symptoms usually leave when the headache appears.

The first step in management is a proper work-up to exclude other causes, including mitochondrial disorders that can mimic hemiplegic migraine. If possible, obtain genetic testing to confirm the diagnosis (hemiplegic migraine has a strong genetic component).

Once confirmed, treatment should consist of non-pharmacologic measures such as dietary modification to avoid triggers, regular exercise and sleep, and dietary supplementation, such as magnesium. Topiramate, valproic acid and calcium channel blockers have shown the best pharmacologic results. Triptans must be avoided to prevent severe complications like stroke. Such care is best provided under supervision of a multidisciplinary headache clinic or a specialized neurologist.

Hossam AbdelSalam, M.D.
Medical Director, Child Neurology, St. Alexius Medical Center
Chicago, IL

Are Headaches Hereditary?

Q. During the summer months, I get lots of migraines because of the drop in barometric pressure. Can this be hereditary? My daughter also suffers with headaches.

A. Yes, migraine headache has a genetic predisposition. It does often run in families and it is more common in females who are past puberty. Studies have confirmed that the risk of migraine in first-degree relatives is increased 1.5- to 4-fold.

If your daughter’s headaches are frequent and impacting her daily activities, she needs an evaluation by a child neurologist to decide on best treatment. I would not recommend trying your medications with her before seeing a healthcare provider.

Hossam AbdelSalam, M.D.
Medical Director, Child Neurology, St. Alexius Medical Center
Chicago, IL

Optical Neuralgia a Trial for Family

Q. How would you recommend treating optical neuralgia? My daughter has suffered with pain around the top of her left eye for well over a year that never goes away. It is most upsetting and slowly tearing our family apart.

A. Facial neuralgias are a difficult group of disorders to treat. One type of medication that is sometimes useful is the sodium channel blockers, which presumably work on the more peripheral nerves, slowing the transmission of pain impulses back to the brain. Examples include carbamazepine and lamotrigine. Medications that work more centrally in the brain to inhibit pain transmission include baclofen, gabapentin and pregabalin. Tricyclic antidepressants can be helpful in combination with one of the other two classes of drugs.

Osteopathic approaches can be helpful, too, by reducing secondary muscle tension that can lead to a variety of head and neck pains. Alternative approaches such as acupuncture and training in self-hypnosis have also been shown to be effective. Many times a combination of medications and mind-body approaches turns out to be best for improving quality of life. Understanding and treating other family members who are stressed by the illness are also key to successful management.

Of course, before any therapy is undertaken, it is important to rule out underlying disorders that might be producing the type of pain around the eyes you described. Neurological consultation with appropriate imaging and blood work are central to treatment.

Doug Mann, M.D.
UNC Professor of Neurology
Chapel Hill, NC

Could Worst Headache Ever Be an Aneurysm?

Q. I suffer from both migraines and tension-type headaches. Yesterday, I woke up with what seemed like a normal tension-type headache. I took a Fiorinal® , but steadily my headache worsened until the pain increased to level 8 out of 10. I worried it could be a migraine (although normally my migraines do not start like this) and took a Relpax®. The pain continued to a level 10 and my head felt like it would literally burst. For the first time in my 18 years of migraine I thought about going to the hospital. At one point I was worried it could be a brain aneurysm. It took almost 24 hours to ease up.

Can you please help me understand what kind of headache I had and what I can do next time I have such a headache?

A. It remains a puzzle in the headache world why someone with fairly typical migraine that is easily identified as such will, out of the blue, have a major change in symptom profile and intensity. We often see this kind of change in pattern in migraine sufferers in their 40s and 50s during menopause or with aging, but we also see it at other times for no apparent reason at all.

Sometimes it happens because the factors that lead to triggering a migraine—such as stress, lack of sleep, weather changes, consumption of certain foods, certain phases of the menstrual cycle and even a letdown from stress—pile up, leading to an atypical, severe episode of head pain. An example would be a student who is experiencing the stress of exams, along with poor sleep, too much cheese pizza and the start of her period. If you look back at the time of your bad headache, you may find a combination of such factors. Preventing similar headaches in the future may be a matter of good self care, including adequate hydration, rest and exercise.

The pain medication you mentioned (Fiorinal) is okay but probably could have been taken every two to three hours for three to four doses along with 400 mgs. of liquid ibuprofen. Relpax is a good choice for acute migraine treatment, but it needs to be taken early. It may be taken again within two hours of the first dose if it is less than 70% effective.

If these episodes continue as you have described, it will be important to check your blood pressure during and in between headaches. A neurological consultation to go over your history and medication use, as well as an exam, would be the next step in deciding on other diagnostic tests, preventive strategies and acute pain management.

Finally, major head pain that comes on and intensifies over hours and then fades to no pain is not typical for a bleeding or leaking aneurysm or for brain infection. With an aneurysm, the pain is often sudden in onset and very severe. It is frequently accompanied by a depressed level of consciousness and stroke-like symptoms, such as weakness, loss of speech, nausea, stiff neck and sometimes fever. The pain lasts for days. I don’t think you had a bleeding aneurysm, although if you had shown up at an emergency room with the report of the “worst headache of my life” you would have earned an MRI scan and maybe a lumbar puncture, “just to be on the safe side.”

Doug Mann, M.D.
UNC Professor of Neurology
Chapel Hill, NC

The Who and Why of Migraine

Q. What causes migraine headaches? How many people have them?

A. Approximately 12% of the US population suffers from migraine, and up to 18% of women between the ages of 16 and 40 have migraine. Many patients with migraine have a positive family history of migraine in a first-degree relative.

Migraine is known as a neurovascular disease, meaning that both the nervous system and vascular (blood vessel) system play a role. We believe that the signal for migraine is generated in a primitive part of the brain called the thalamus. The trigeminal nerve also plays a role, and there is excitability in the brain that ultimately leads to the release of inflammatory substances. A number of external factors can trigger a migraine in some patients, from certain foods to barometric pressure changes.

George R. Nissan, D.O.
Co-Director, Diamond Headache Clinic
Chicago, IL



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