Q. Yesterday I bent over to do some gardening and, boom, it triggered a migraine with sharp pain in the top right side of my head. That’s the first time a migraine came on that way. I took Imitrex® and it subsided a few hours later. Is this a dangerous situation or is this normal? Can it be from an old head injury? Do I need an MRI?

I’m almost 60 and have had migraines since my 20s. They’ve become worse as time goes on, despite daily nortriptyline and atenolol. I had quite a few acupuncture and chiropractic treatments many years ago for injuries from a car accident, and even months after discontinuing them I still didn’t have any migraines. Coincidence? I want to try acupuncture and chiropractic again.

A. The Vasalva maneuver (holding one’s breath and bearing down) commonly worsens a migraine and can occasionally trigger an attack, as in your case. Bending, stooping, straining, lifting, etc. and even coughing or vigorous sneezing can do this, by causing a momentary rise in the pressure of the veins and fluid in the head.

It is unusual, however, for this activity to trigger a migraine for the first time at your age. If this same scenario recurs, I think you should have an evaluation, including an MRI.

Minor head trauma such as you had may aggravate headaches in individuals with migraine, but I doubt it would cause any permanent problems. Acupuncture can be very helpful in some migraine sufferers. Chiropractic treatment and massage may also help if there is a trigger area in the neck.

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

Screening for Patent Foramen Ovale

Q. My daughter and I read Dr. Ishkanian’s article addressing patent foramen ovale (PFO) in NHF Head Lines 152. He reported on a study in which “closure of the common heart defect in patients resulted in significant reduction or even cessation of migraines.” It appears that the majority of the patients had suffered a neurological event such as a stroke.

My daughter does not meet this criteria, but I am still wondering if she may have a PFO and if closing it would relieve her unrelenting migraines. The frequency and intensity of her migraine attacks have not changed over many years, despite trying medications such as Botox® injections, Topamax® and prednisone, to name a few.

Is there a way to screen for PFO which is non-invasive? We are very interested in exploring different treatments that may allow my daughter to leave her darkened room and return to her life prior to being stricken with migraines.

A. The usual way of screening for a PFO is with an echocardiogram, which is a non-invasive test. Another procedure that can determine PFO is a Doppler “bubble” study, which requires an injection. Sometimes, for better definition of the heart chambers and possible defects like a PFO, a cardiologist will want to do a transesophageal echocardiogram, also known as a TEE. This involves putting the instrument down the throat into the esophagus. I suppose this might be called “invasive” but it does not involve surgery or entering the blood vessels.

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

Right for Patent Foramen Ovale Repair?

Q. I have chronic daily migraine with aura. I had one light stroke which was considered due to migraine. Subsequently, at my urging, I was tested for patent foramen ovale and it was positive. My doctors are reluctant to pursue repair, but I have had enough and I will accept the risks—whatever they are.

A. There is increasing evidence that some people who have migraine with aura will benefit from closure of a patent foramen ovale. Those most likely to benefit are those who have had neurological symptoms as well as migraine with aura.

Double blind studies are currently being done in which some patients will have the defect closed and some will have a catheter inserted but not have the defect closed. This should answer the question as to whether the actual closure of the atrial defect is better than placebo.

There are some risks associated with the repair and that is why some healthcare providers are hesitant to recommend that it be done for migraine until the results of the studies mentioned above are known. Some cardiologists at my institution will not do a PFO closure for migraine. The main risks are cardiac arrhythmias (irregular heart beat) and formation of blood clots.

With your situation and your willingness to accept the risks of the procedure, I would be in favor of you undergoing closure of the PFO.

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

Birth Control Injection Reduced Her Migraines

Q. I started having migraines at the age of 19, but they got much worse after having children. Looking back, I remember that pregnancies were the only time I didn’t have migraines. I recently heard about a birth control injection, Depo-Provera®, that blocks periods for three months at a time. It was worth a try. Since the injection six months ago, my migraines have been cut in half, from ten or more a month down to five. This has helped me and I think it may help others who have tried everything else.

A. It does appear that you are one of the 60% of female migraineurs whose headaches worsen with hormonal triggers. Many women with migraines will get them more frequently around the time of their menstrual period, and the majority of women will have fewer attacks during the second and third trimesters of pregnancy when estrogen is at a higher and more stable level.

The Depo-Provera that you mention is a progesterone compound used primarily for birth control. Hormonal manipulation for headaches can be very unpredictable and is generally reserved as a last treatment resort. I’m glad for you that Depo-Provera has helped. In my experience, I note more women have a worsening of headaches on Depo-Provera and, unfortunately, once it is injected, its effects may last for three months. Therefore, I do not recommend it for my patients.

Loretta Mueller, D.O.
University Headache Center
Moorestown, NJ

Dosages of Supplements Taken for Migraine Prevention

Q. I have been taking supplements (500 mg magnesium, 150 mg butterbur, 400 mg feverfew and 400 mg B-2) for a number of months for my migraines. The supplements were really helping with the frequency and severity of my headaches. For the past three weeks my headaches have been coming more often and the severity is a little stronger. My question is, can I up my supplement doses?

A. There are no studies to address the efficacy or safety of higher doses of these supplements, so I would not recommend increasing the doses. If your headaches remain frequent, your doctor can add a medication that is used for the prevention of migraines.

Mark Green, M.D.
Columbia-Presbyterian Headache Center
New York, NY

Hemicrania Continua

Q. Is hemicrania continua harmful?

A. Hemicrania continua is a relatively rare primary headache disorder (“primary” meaning there is no identifiable cause) characterized by continuous pain on one side of the head (hence the term hemicrania). It is categorized as one of the “indomethacin responsive headaches” because patients almost invariably get relief when treated with regular doses of a nonsteroidal anti-inflammatory medication called indomethacin (Indocin®). The response is typically complete and lasting, as long as the patient remains on the medication (some patients have had no recurrence for extended periods of time even after stopping the medication).

While hemicrania continua is painful, it is not harmful. However, indomethacin may irritate the stomach, cause ulcers or increase the tendency to bleed. Doses of 75-150 mg twice a day are typical, starting at the lower dose range. Interestingly, the response often occurs within a few days (sometimes after the first dose). If a patient doesn’t have any response after 7-10 days it probably isn’t going to be effective. If there is some response but not complete, we usually recommend increasing the dose to 150 mg twice daily. Patients should be monitored closely at the initiation of therapy and regularly as long as they stay on the medication. James Banks, MD Ryan Headache Center St. Louis, MO

Chronic Headaches after Spinal Fusion

Q. Two and a half years ago I had spinal fusion surgery of the third, fourth and fifth vertebrae. Since then I have suffered with chronic headaches in the back and top of my head. I have been going to a pain clinic and have had two procedures done in which the nerves in my neck, which register pain from that area of the skull, were treated with ultrasound. The first treatment worked for three months. The second didn’t work at all. I’ve tried several pain killers, and the only one that I can function with is a low dose of morphine IV, although I can’t take it at night because it doesn’t allow me good sleep.

My doctor tells me that I have arthritis in my spine, which is putting pressure on the nerves. He wants to implant a stimulator into these nerves to impede the pain signal to my brain. It would include a hand-held device, which would allow me to self administer electrostimulation as needed.

Is this a good and reliable procedure? What are the down sides to it? I’m about at the end of my nerves with this.

A. The relationship between neck pain and headache is a significant one, because of the interaction between the main nerve that carries pain messages in the head (called the trigeminal nerve) and the upper cervical nerve roots that extend from the spinal cord in the neck. Neck pain, in fact, is often a prominent feature of migraine headache.

Treatment of neck pain, however, is often difficult and requires a multi-disciplinary approach. Occipital nerve and spinal cord stimulators are currently under scientific trial for both headache syndromes and cervical pain. I believe more clinical trials will be important to fairly judge their efficacy and safety.

I am concerned about your ongoing use of morphine, particularly since it seems to be interfering with sleep. You may benefit from a combination of therapies including physical therapy with strengthening and relaxation exercises for your neck, medications that can be used safely without the risk of dependency (such as the anticonvulsants gabapentin, pregabalin or topiramate), and muscle relaxants. This multi-disciplinary approach can be overseen by a healthcare provider skilled in the complexities of treating chronic pain.

Tarvez Tucker, M.D.
University of Kentucky Headache Clinic
Lexington, KY

Mother and Three Young Daughters All Suffer Severe Attacks

Q. For at least the last ten years, I have been getting migraines in which I lose coordination of the right side of my body and my ability to walk, stand and communicate. I remember having migraine symptoms as early as four years old. I am now 28-years-old and have four lovely daughters ranging from ages one to five. The oldest three have been getting similar symptoms since their second birthday. They have episodes lasting 14-20 hours long, two to three times a week (on different days just to make it exciting) in which they are nauseous, bump into the wall when walking, sway, drop toys from their right hand, and complain that their legs hurt. Occasionally, they’ve said their heads hurt (always on the left side), but it’s not their predominant complaint. Their speech slows down and sometimes they stop talking altogether.

These episodes have many characteristics unique to children. During these episodes the potty trained ones have accidents, can’t get dressed, and can’t pick up a toothbrush. They can scream for an hour or more in pain, look catatonic and stare at the ceiling, or act extremely anxious and hyper-alert. At points, they can’t understand what I’m saying and get very distressed and disoriented.

What are the possible causes of such a strong genetic link in migraine symptoms? We have an appointment with a pediatric neurologist eight months from now. What can I do in the meantime to help them through these episodes? Tylenol® doesn’t do anything and the pediatrician wants them evaluated before she will prescribe a medication. Is there anything else I can do? We already keep a regular schedule and avoid migraine-triggering foods. I also have each of the girls seeing a counselor. It is so hard watching my children scream or be catatonic, or flailing and saying, “Help me, Mommy.” I try to stay calm, but I still get migraines, too!

A. This is a tough problem, to say the least. I discussed your letter with a pediatric neurologist. He and I both agree that your family probably has familial hemiplegic migraine, but other possibilities include a mitochondrial disorder or other inherited metabolic disorders.

You and the children should have a thorough workup including MRI/MRA, and studies for coagulation defects and vasculitis. The pediatric neurologist also suggests trying to get a brain wave test (EEG) during a spell if possible.

Familial hemiplegic migraine is a migraine disorder where many members of a family all have the same neurological symptoms with their attacks. From your description, this seems to be the most reasonable diagnosis.

It appears that you are doing all you can with your daughters’ diets, getting them adequate rest, etc. I would suggest you keep pushing for an earlier appointment with the neurologist and get on the cancellation list so that the appointment may be moved up.

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

Worried about Serotonin Syndrome

Q. I just started taking Relpax® for my migraines last month, which is working, and I have been taking Zoloft® for the past ten years. I read an article the other day that said that Relpax and Zoloft can cause a deadly condition called serotonin syndrome. Is this true? What should I do? I am very nervous now. I need the Zoloft and I finally found a medication that relieves my migraines.

A. It is true that a serotonin syndrome can occur when certain antidepressants are combined with triptans. Fortunately, this serious interaction is rare. Countless people have been on triptans as well as these antidepressants without any problems. You and your healthcare provider simply have to monitor any side effects.

Mark Green, M.D.
Columbia-Presbyterian Headache Center
New York, NY