Sudden hearing loss is a rare condition, but it is more common in people who suffer from migraine headaches, according to just published study by Taiwanese researchers. Taiwan, just like many Scandinavian countries has national health insurance and the large computerized data base allows doctors to perform reliable studies of many medical conditions. This study, which was published in Cephalalgia, an international headache journal, involved 10,280 migraine sufferers who were compared to 41,120 healthy control subjects. Doctors examined ten years worth of records of these people and discovered that having migraines almost doubled the risk of sudden hearing loss (the medical term is sudden sensorineural hearing loss). The incidence was about 82 per 100,000 person-years in migraine sufferers and 46 in those without migraines. They also discovered that having hypertension (high blood pressure) increased the risk of sudden hearing loss. This suggests that the hearing loss may be due to sudden drop in blood supply to the hearing nerves. Surprisingly the increased risk was not more pronounced in patients with migraine with aura since vascular problems are more common in those with auras. Treatment of sudden hearing loss requires immediate visit to a doctor, who takes a detailed history, examines the patient, does hearing tests, and obtains an MRI scan of the brain. Sudden loss of hearing can be caused by impacted wax in the ear, brain tumor and other brain disorders, but usually no such causes are found. If no obvious cause is found, treatment typically involves taking a steroid medication. Acupuncture may also help.
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Many migraine sufferers report that flickering lights and vigorous exercise trigger their migraine attacks. Danish researchers published a study in the journal Neurology , in which they recruited 27 patients who suffered from migraines with aura. Of these 27, 12 reported that flickering lights triggered their attacks, 10 reported that vigorous exercise did and 4 felt that both of these were triggers, while only one felt that these were not triggers for her migraine headaches. These patients were then subjected to bright flickering lights for 30-40 minutes, exhausting exercise for 1 hour, or both. None of the 11 patients who were exposed to bright flickering lights developed a migraine, exercise alone triggered a migraine in 4 out of 12 patients (one migraine with aura and three had migraine without aura), while both types of stimulation together triggered a migraine with aura in 2 out of 7. This is a surprising finding, but it does not mean that patients are wrong about flickering light and strenuous exercise triggering migraines. A more likely explanation is that any particular trigger may require certain additional conditions, such as location which is associated with the expected headache, prior conditioning, such as stress that accompanies exposure to bright light in a certain room, added triggers, such as lack of sleep, alcohol, blood caffeine level, and many other. It is also possible that migraine with aura, unlike migraine without aura, is less likely to be triggered by exercise and flickering lights.
If you are exposed to one of your known triggers, if possible, you should try avoiding exposure to other triggers at the same time since it is often a combination of triggers that brings on a migraine. Regular aerobic exercise is one of the most effective preventive treatments for migraine headaches, so patients who are convinced that exercise triggers their headaches can be advised to start slow and gradually increase the duration and the intensity of their exercise. Ideally, everyone should exercise at least three times a week. Stationary bike or an elliptical machine may not be as much of a trigger as running because jarring of the head could also contribute to headaches. If even mild exercise causes a headache, taking an anti-inflammatory medication, such as ibuprofen or Migralex prior to exercise may prevent the headache. After a few weeks the medication may no longer be needed. Whatever is the trigger, general preventive measures will often reduce their impact. Besides exercise, these include getting enough sleep, learning biofeedback or meditation, taking supplements such as magnesium, CoQ10, and other, Botox injections, and as a last resort, prophylactic medications.
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Newer oral contraceptives increase the risk of strokes and other types of blood clots in patients with migraines with aura, according to a study to be presented at the next meeting of the American Academy of Neurology in San Diego in March. We have known for many years that estrogen-based oral contraceptives increase the risk of strokes in women who suffer from migraines with aura. However, most of the studies were done looking at the old contraceptives which contain a relatively high amount of estrogen (such as Ortho-Novum 1/50, Ovral, Ogestrel, and other). It was logical to assume that the newer contraceptives (such as Yaz, Yasmin, Loestrin, and other) with lower amounts of estrogen would be safer. Most headache specialists, myself included, were not as adamant about avoiding the newer low-dose estrogen contraceptives in our patients who had migraine auras. I would always discuss the risk of strokes and other blood clots with my patients and would always suggest using other modes of contraception, but if other methods were not acceptable to the woman or if the contraceptive had other benefits (helped PMS, acne, regulated periods, reduced bleeding, etc) I would not make a big fuss. This new study will make me more insistent on stopping the pill because the risk appears to be even higher with the newer contraceptives than with the old ones. Even the vaginal ring (NuvaRing), which I mentioned in a recent post as a good option to reduce menstrual migraines, carries a higher risk than the old oral contraceptives. The ring has a low dose of estrogen, but it is speculated that the risk is further increased because estrogen is released continuously (with the pill estrogen goes in and out of the body daily). The same may apply to estrogen patches, such as Ortho Evra. The study looked at over 145 thousand women, which makes its conclusions fairly reliable. Another surprising finding of this study is that the risk of blood clots in legs (deep vein thrombosis) was very high – 7.6% in women with migraine with aura and 6.3% in those without aura taking contraceptives.
The bottom line, if you suffer from migraines with aura do not take estrogen-based contraceptives, whether in a pill, patch, or ring, unless you and your doctor decide that the benefits outweigh the risks.
Some features of migraine with aura clearly set it apart from migraines without aura. Aura is present in 15% to 20% of migraine sufferers. Most often it is a visual disturbance, which consists of either gradual loss of vision, starting from the periphery of visual field and moving to the midline. Many people see shimmering and sparkling lights with or without loss of vision and some see things smaller than they are. Sensory aura consists of pins-and-needles, tingling and numbness on one side of the body, often starting with the hand, moving up the arm and then involving the face. Typical aura lasts 20-60 minutes, but it can be shorter or longer. Auras are usually followed by a headache, but sometimes it occurs without any pain. People who have auras are at a slightly higher risk of having a stroke. This risk is magnified by other factors, such as smoking, high-dose estrogen contraceptives, hypertension, diabetes, and high cholesterol.
A recent study by Austrian neurologists published in Headache examined 54 patients who kept a detailed diary and recorded a total of 354 migraine auras. Using a statistical tool called multivariate analysis they discovered that smoking, menstruation, and hunger were likely to increase the risk of having an aura. Holidays and days off reduced the possibility of experiencing an aura. They also found that non-migraine headaches and migraine without aura were more likely to occur during menstruation, psychological stress, tiredness, odors, and were decreased by smoking.
The surprising finding in this study is that the risk of having a migraine with aura was doubled in the first three days of menstruation. The consensus of headache specialists has been that menstrual migraine is typically a migraine without aura, although at least one other study by Danish doctors also reported menstruation as a trigger of migraine with aura.
Aspirin is by far the most effective drug for the prevention of migraine with aura, according to Italian researchers from Turin. They reported on 194 consecutive patients who had migraine with aura and who were placed on a prophylactic medication. Ninety of these patients were on 300 mg of aspirin daily and the rest were given propranolol (Inderal), topiramate (Topamax), and other daily medications. At the end of 32 weeks of observation 86% of those on aspirin had at least a 50% reduction in the frequency of attacks of migraine with aura compared with their baseline frequency, while 41% had even better results – at least a 75% reduction. In contrast, only 46% of patients on other drugs had a 50% improvement in frequency. The probability of success with aspirin was six times greater than with any other prophylactic medication, according to the lead author, Dr. Lidia Savi.
Aspirin is not only effective for the prevention of migraines with aura but also for acute therapy of migraine attacks. In previous posts I mentioned that a rigorous analysis of large numbers of patients showed that 1,000 mg of aspirin is better than 500 mg of naproxen (2 tablets of Aleve) and that 1,000 mg of aspirin was as good as 100 mg of sumatriptan (Imitrex) with fewer side effects.
Many health benefits of aspirin, which was originally derived from the willow bark, are becoming widely known. In addition to helping prevent heart attacks and strokes, aspirin has cancer-fighting properties. You may want to read a very interesting article about aspirin, The 2,000-Year-Old Wonder Drug, just published in the New York Times.
The use of acute anti-migraine medications in patients with episodic migraine (migraine occurring on less than 14 days a month) prevents progression of episodic migraine into its chronic form, according to Dr. Zaza Katsarava and his colleagues in Essen, Germany. They followed 1,601 patients with episodic migraine headaches for two years. None of these patients were taking prophylactic medications and 151 patients took no acute anti-migraine medications. Overall, during the two years of observation, 6.2% of 1,601 patients developed chronic migraines (defined as headaches occurring on 15 or more days each month). However, those who took triptans (sumatriptan and other) had a 66% reduction of risk of headaches becoming chronic, those who took a single pain medicine had a 61% lower risk of chronification, and those who took a combination pain killer, like Excedrin, had a 40% reduction of this risk. This analysis took into account patients’ age, sex, body mass, education level and baseline migraine frequency. A possible explanation for why combination drugs were less protective is that most of them contain caffeine, which is known to make headaches worse. Another very important lesson that can be drawn from this study is that it is important to treat migraine attacks with effective medications because if left untreated these intermittent attacks may become more frequent and even daily. At least two million Americans suffer from chronic migraines and it is likely that in many this debilitating condition could have been prevented by more aggressive and effective treatment of acute attacks.
Read MoreExercise-induced headaches are thought to occur more often in people who do not exercise regularly and my usual recommendation is to exercise regularly, starting with low intensity and short duration exercise sessions. If headache occurs with minimal exertion, I suggest taking Advil (ibuprofen), Aleve (naproxen), Migralex (aspirin/magnesium) an hour before exercise for several weeks. However, it appears that even experienced athletes suffer from what is officially known as a primary exertional headache. Dutch researchers are reporting on the incidence of exercise-related headaches among cyclists in the latest issue of journal Headache. They performed an online survey of 4,000 participants of a very challenging cycling race. Thirty seven percent of them suffered from such headaches at least once a month and 10% had them at least once a week. Women were more likely to have these headaches – 54% vs 44% in men. Older cyclists were significantly less likely to have these headaches. Tension-type and migraine headaches were most common. Headache medications were used by 37% of participants. Extreme exertion was the most commonly reported contributing factor (50%), while some reported that low fluid intake (39%) and warm weather (39%) contributed to their headaches; 26% could not identify their trigger. Another possible trigger not reported in the article is neck strain. Riding sports bikes with low handlebars makes riders strain their neck and trigger a cervicogenic headache.
The authors concluded that these headaches are widely underestimated and may cause many people quit their sports. They also called for research into causes and treatment of exercise-related headaches.
Erythromelalgia is a rare, often inherited pain syndrome which causes pain and redness of hands and feet. I just saw another woman who had both erythromelalgia and migraines. My observation of several patients who had both diseases does not mean that these conditions are connected since migraines are very common in the general population. However, magnesium is known to help both conditions, so it is possible that there are common underlying causes. In fact, a sodium channel mutation which is responsible for erythromelalgia was also found in a family with familial hemiplegic migraine. Magnesium is involved in the regulation of sodium channels (as well as calcium and potassium channels) in all cells of the body. Most people who are deficient in magnesium and suffer from erythromelalgia and/or migraines respond well to oral magnesium supplementation, but a small percentage requires monthly intravenous infusions. We give intravenous infusions to those patients who do not tolerate oral magnesium (get diarrhea or stomach pains), those who do not absorb it (as evidenced by persistently low RBC magnesium levels) and those who prefer a monthly infusion to taking a daily supplement.
Many women are denied therapy with combined (estrogen with progesterone) hormonal contraceptives because published guidelines by doctor organizations recommend against their use in migraine with aura. The concern is that these products might further increase the risk of a stroke that accompanies aura. Stroke risk has been reported to vary directly with aura frequency, and aura frequency in turn has been shown to have a direct relationship to estrogen concentration. With the introduction of increasingly lower dosed hormonal contraceptives it is not clear if these risks are as high as with high-dose contraceptives. These formulations are expected to result in a lower frequency of migraine aura. In addition, continuous therapy eliminates monthly estrogen drops which can be expected to prevent menstrual migraines.
Dr. Anne Calhoun and her colleagues in North Carolina examined a database of 830 women seen in a menstrual migraine clinic and identified 23 women who had current history of migraine with aura, had a confirmed diagnosis of menstrually-related migraines, and were receiving extended-cycle (continuous) dosing of a vaginal ring contraceptive. At baseline, subjects averaged 3.23 migraine auras per month. With extended dosing of the vaginal ring contraceptive, median frequency was reduced to 0.23 auras per month after a mean observation of 7.8 months. No at a single woman reported an increase in aura frequency. On this regimen, menstrual migraine was eliminated in 91.3% of women.
The authors concluded that continuous use of vaginal ring contraceptive was associated with a reduced frequency of migraine aura and with resolution of menstrual migraines.
The risk of stroke in an otherwise healthy woman who does not smoke and has migraine auras is higher than in women without aura, but it still extremely small. It is possible that continuous use of very low dose contraceptives, particularly vaginal ring, may not increase the risk of strokes and may even prevent it.
Celiac disease and gluten sensitivity is known to cause or at least increase the frequency of migraine headaches. The recently published study in journal Headache by doctors from Columbia University and Mt. Sinai School of Medicine in New York City examined records of 502 individuals in an attempt to find out the frequency of headaches in these conditions. They looked at records of 188 patients with celiac disease, 111 with inflammatory bowel disease (such as Crohn’s and ulcerative colitis, 25 with gluten sensitivity and compared these to 178 healthy controls. Chronic headaches were reported by 30% of celiac disease, 56% of gluten sensitivity, 23% of inflammatory bowel disease, and 14% of control subjects. Migraine headaches were more common in women and those with anxiety and depression. The severity of the impact of migraine headaches was worst in celiac patients – 72% reported it to be severe, while this number was 60% in those with gluten sensitivity and 30 % with inflammatory bowel disease.
This study confirms previous observations that celiac disease and gluten sensitivity are associated with increased frequency of migraine headaches. The difference between celiac disease and gluten sensitivity was well described in this WSJ aritcle.
Vertigo is a common symptom in patients suffering from migraine headaches. Vestibular migraine is a new category of migraine proposed by German researchers led by Dr. Andrea Radtke. In the current issue of Neurology Dr. Radtke and her colleagues report on the long-term outcomes of 61 patients with this condition. The average follow-up period was 9 years. Unfortunately, 87% of sufferers still had vertigo and in 56% it improved, 29% it worsened and in 16% it remained unchanged. In 21% the impact of vertigo on their lives was severe, in 43% moderate and in 36% mild. Mild hearing loss occurred in 11 or 18% of patients.This report does not mention what kind of treatments were attempted in these patients. It is possible that aggressive therapy with vestibular rehabilitation, possibly acupuncture, magnesium, other supplements and medication can make a difference.
Read MoreProdrome refers to symptoms that precede an actual attack of migraine. Migraine aura also precedes an attack, but it occurs 20 to 60 minutes before the headache and typically consists of visual disturbances or partial visual loss. Prodrome typically is a period of 24 to 48 hours before a migraine attack and it can consist of a wide variety of symptoms. Many people are aware that these symptoms indicate an impending migraine attack, but some are not. Some people tell me that when they feel unusually full of energy, very happy, and creative they realize that they will get a headache the next day. And some realize that what was happening to them was a prodrome only in retrospect, even after having all of the same symptoms repeat themselves many times. Not many people experience prodrome and its features are varied. Here are some of the symptoms reported in the prodrome period:
Depression
Euphoria
Irritability
Restlessness
Hyperactivity
Fatigue
Drowsiness
Difficulty concentrating
Neck or other muscle stiffness
Feeling hot or cold
Increased thirst
Increased urination
Food cravings
Loss of appetite
Yawning
Tearing
Constipation
Diarrhea
Fluid retention
Sensitivity to light and/or sound
If you do experience a prodrome and are aware of it while it is happening, taking an anti-inflammatory medication (Advil, Aleve, Migralex) or, if that does not work, a triptan may prevent an attack or at least make it milder.
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