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Migraine

In August 2008, our guest expert in Le Club's Ask the Expert segment was Dr. Marek Gawel, a Toronto-based neurologist at Women’s College Hospital, Rouge Valley Health System and at Sunnybrook Health Sciences Centre, associate professor of medicine (neurology) at the University of Toronto and president of Headache Network Canada, a web based resource for patients.

Dr. Gawel graduated in medicine from Cambridge University in 1971.  After his internship he did a residency in neurosurgery, medicine and neurology in Cambridge and Vancouver.  In 1975 he joined Charing Cross Hospital as a research fellow in neurology and subsequently became a lecturer in neurology.  While there, he worked at the Princess Margaret Headache Clinic, and was one of the winners of the Harold Wolff award in 1981.

In 1987 he joined the staff of Sunnybrook and Women’s College Health Sciences Centre as a consultant neurologist.  He sat on the professional education committee of the Heart and Stroke Foundation of Ontario from 1984 to 1996. Dr. Gawel has been involved in numerous clinical trials on headache, stroke, and ALS, as well as research in cerebral blood flow in cluster headaches. 

He was the chairman of the 1995 International Headache Society Congress held in Toronto, was the vice president of the Migraine Association of Canada, and is past president of the Canadian Headache Society. 

Dr. Gawel has authored 46 publications on migraine and is a co-author of the Guidelines for the Diagnosis and Management of Migraine in Clinical Practice. His other area of interest is in the field of ALS, and he founded the Neuromuscular Clinic at Sunnybrook Health Sciences Centre.

Here are Dr. Gawel’s  answers to your questions on Migraine:

Q: Does the weather affect when you get a migraine?

A: There have been a number of studies linking weather change and the onset of migraine. One done in south eastern Ontario by Nursall and Phillips showed that the onset of headache was linked to a particular type of weather (Phase 4, about to rain or snow, with low clouds) but not atmospheric pressure.

A study in Calgary linked migraines to a certain wind velocity (more than 38 km/hour) during a Chinook. A study from Ottawa was unable to link emergency room visits to any weather variable.

The tendency to implicate weather also varies from country to country, for instance in Belgium – where the weather is very variable – patients almost never blame the weather.

Another factor often blamed is barometric pressure, but this has never been confirmed in studies, and it must be remembered that the pressure in an airplane is lower than anything ever found on the ground.

 


Q: Are there any new modalities in treating occipital-cranial nerve pain syndrome, which is identical to migraine pain, but worse? The only treatment given to me has been Marcaine injections through my skull.

A: Occipital neuralgia is still treated with injection of local anesthetic and Depomedrol around the occipital nerve, not through the skull. An operation to cut the C2 ganglion can be performed in resistant cases. Drugs such as Lyrica or Neurontin may also help.

 



Q:
My husband has now experienced perhaps his fifth "ocular" migraine since last winter. While he's learning to recognize the symptoms, it’s sometimes difficult to pinpoint when it’s about to come on so abruptly. What can be done before and during one of his migraines? He's 33 years old now, without a prior history of headaches. Should we be concerned? Should we insist that his family doctor send him to a specialist of some kind? Thank you very much for your attention. 

A: By ocular migraine do you mean migraine with aura? The aura is a visual disturbance such as a shimmering circle or loss of part of the visual field lasting about 20 minutes, followed by the headache. Sometimes people have what is called ophthalmologic migraine when they get double vision. It is important for me to know which type you mean. Migraine with aura is sometimes associated with a small hole in the heart called a patent foramen ovale (PFO). I am interested in patients with this condition as we are investigating the relationship between these two types of migraine.

 


Q: I have been getting headaches and migraines as far back as I can remember. It comes from my mother's side of the family. Her father got them, one of her sisters gets them, as well as one of her brothers and all of his children. I am the only child of eight to get them constantly like my mother. I was wondering how can I go about looking into a way of managing them. I am almost 19 years old and don't know who I should see specifically for this.

A: This is a big question, and the best way I can help is to direct you to the Headache Network Canada (HNC) website. This is a website we set up in conjunction with the Canadian Headache Society (CHS) as a resource for patients. Ultimately, we plan to make it a resource for physicians as well. Migraine does run in families. One form, known as familial hemiplegic migraine, has been traced to a CACNA 1 (calcium channel) gene on chromosome 19. It is possible to produce genetically altered mice which stagger and appear to have headaches. (These are known as ‘wobbler’ mice.)

 


Q: I have heard claims that Botox is being used to successfully relieve migraine pain. Is this true?

A: Over the last eight years, we have done four studies of Botox in headache, some at Women’s College Hospital. The outcome has been that there is no demonstrable benefit of using Botox to treat tension-type headaches or episodic migraine (fewer than 14 attacks a month).

There is, however, benefit in using it to treat chronic migraine. The problem is that the placebo response (to injections of saline) is very high, so that the Botox has to have a very big therapeutic effect to appear better than placebo.

However, I have had patients returning for Botox every three months for years. The mode of action is uncertain, but probably it blocks the adhesion of Synaptosomes carrying Calcitonin Gene related Peptide (CGRP), a potent transmitter in the pain system to the synaptic membrane, which prevents the  transmission of pain impulses. The website called The Neurotoxin Institute has a lot of information about this.

 



Q:
My first migraine ever was at age 27, at six weeks pregnant. Wine is also a trigger for me, but for the most part they appear to be hormonal. I am just now having menopausal symptoms (at age 52). Could I expect less migraines post menopause? Why do migraines, in some cases, diminish once women are post menopausal?

A: Migraines are often related to hormonal fluctuations. Perimenstrually they are related to the fall of estrogen. They may get worse at menopause and improve afterwards, although exact reasons are not known.

 


Q: Is it true that pain from a migraine is always limited to one side of the head? Can pain from a migraine provoke pain in the eye or to the eyes?

A: Migraine is often felt on one side of the head; some say that the name is derived from the term ‘hemicrania,’ which is a term sometimes used to describe a headache that affects one side of the head. However, migraine headaches can also involve the whole head. The nerves that supply sensation to the inside of the head, and to the upper part of the outside, represent the first division of the trigeminal nerve, which is the ophthalmic (of the eye) nerve. Hence, sensations arising anywhere in the head can be referred to behind the eye.

 


Q: I am 48 years old, pre-menopausal, am still taking birth control pills (anovulants) and I've had migraines for about two years. I used to have episodes of migraines in my 20s (with episodes where I got the impression that I had lost my sight) but did not have migraines in between these two time periods. I have tried alternative methods to try and solve the issue - acupuncture, homeopathy, massage and chiropractic – but only medication seems to works. I have taken Maxalt, and more recently, Imitrex (because the other one is less effective). However, when I read the warning on the medication box, I get worried because there is a history of heart disease and stroke in my family. I am looking for more alternatives – what can you suggest? Can I hope that they will go away again, like they did once?

A: The drugs you are using are in the class known as Triptans. They can cause constriction of blood vessels including those in the heart. A recent meta analysis has demonstrated the general safety of these drugs, although anyone with a definite history of heart disease should avoid them. Alternatives include the NSAIDS such as Naproxen.


Q: Sometimes my nose seems stuffy when I am getting a migraine headache, and then runs when the headache starts to diminish in severity. Is this common? I assume these are migraines because they are severe, I see haloes around lights, have light and noise sensitivity, nausea, etc. However, sometimes I find that it’s impossible to tell the difference between a bad sinus headache and a migraine. Are there some specific hallmarks between the two? Can a treatment designed for one also help the symptoms of the other?

A: Autonomic symptoms, such as tearing and runniness of the nose, do occur in a number of headache syndromes. Many of the headaches labelled ‘sinus’ are, in fact, migraine and respond to migraine drugs. There is an overlap in symptoms, but migraine has other features such as light and sound sensitivity. Some drugs intended for sinus disease, such as antihistamines, can also help with migraine.

 


Q: I have suffered from migraines since puberty, and I am now 44 years of age. The headaches have almost disappeared. Most recently, I have been experiencing a sharp head pain when achieving orgasm. Most times, this leads to a migraine that lasts several hours. I have hypertension, but it is well controlled with Avalide. Could you tell me why this happens, and what I need to do about this? Thanks.

A: You are describing orgasmic or exertional cephalalgia. This can happen out of the blue, for reasons not known, but you have to exclude an intracranial aneurysm or other arterial abnormality. This would be done with either magnetic resonance (MRI) or CT angiography.

 

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