Viewers are asking questions, and the health team is giving answers.

News 4’s Health Team, “Ask a doctor,” finds out what doctors have to say about your questions.

WHAT ARE POSSIBLE CAUSES OF MIGRAINE HEADACHES?

James W Banks M.D.

Assoc Director, Ryan Headache Center

Mercy Health Research

It is not so much as what are the possible CAUSES of migraine as it is TRIGGERS of migraine.  Migraine is essentially due to a sensitive brain that is more easily "triggered" into a state of disequilibrium, or

perhaps another way to say it is that the brain more easily gets overloaded. This state, called "cortical sensitization" can actually start before there is ever any pain, and is when the "aura" of migraine

occurs in the small percentage of people who have migraine with aura. From there starts a brainstem reflex that causes the release of inflammation from around the blood vessels and the trigeminal nerve (which is the sensory nerve for the face and head, and also has close connections to the nerves for the sensation of the back of the head as well as the muscles of the neck and upper shoulders). The more inflammation, the more pain. The more inflammation, the more likely it is for the peripheral nerves to become sensitized, and to be stretched by the now dilated blood vessels along the brain, scalp, sinuses and neck muscles, which just aggravates the pain even more. This can lead to a vicious cycle and the headache progresses by activating other centers in the brain and brainstem that can cause nausea and/or vomiting, sensitivity to light, sound, smells dizziness, ringing in the ears,

difficulty concentrating, speaking, and feeling clumsy. In the most severe attacks, the highest parts of the brain become sensitized/inflamed and leads to a state we call "allodynia", which is simply when things that are not normally sensed as painful or irritating now become so. The best way to describe this "allodynia" is that often

at the beginning of a headache it feels good to rub or massage the head, but when it is really bad (allodynia) people say "don't touch me,  my hair hurts" and note that they don't want to wear glasses, earrings, or are not even sure which way to lay their head on the pillow.  Not every migraine has to be the severe form, the process can start mild and progress only so far either because someone takes some medication, or perhaps the attack aborted on its own. Many people complain of episodic "tension" headache, and/or "sinus" headache in addition to

their "migraine". The best research and understanding of this disease is that if a person can have a milder headache that progresses to a migraine, then in actuality all of their headaches are migraine, it is just that some are not as severe as others. The anatomy of the trigeminal nerve explains how sinuses can become inflamed and swollen and painful as part of migraine, just as it explains how the neck muscles can be tight and stiff and sore, but it is still "migraine". All that to help drive home the point that most people with episodic headaches that trouble them (not necessarily completely disable them) are actually suffering migraine.  These attacks can be TRIGGERED by numerous things, essentially anything that disrupts the normal balance of sensitive brain chemistry. The most common triggers reported are: weather changes, hormone changes (before/with menses and/or ovulation, and particularly during the peri-menopausal years as women have irregular cycles), stress/emotional changes, sleep changes (too much sleep or too little sleep), and chemicals that we may smell, or ingest -- foods are implicated by many migraine sufferers though most state that food triggers are not very consistent. Red wine is often cited as a trigger in North America, but in Europe (where they drink red wines more

often) it is reported that white wine is more likely a trigger. Artificial sweeteners, preservatives (MSG), artificial flavoring and colorings may also trigger migraines.  The key point to all of this is to try and recognize those things that consistently trigger headaches and avoid those, but recognize that most of the time, it is not likely one particular thing that set off the attack, but rather probably several smaller things combined together.

Most migraineurs have seasons of life where they have more headaches and then times when their headaches are less problematic. For some people it is truly seasonal with the spring and autumn equinox being reported associated with increased headaches (but not the summer and winter solstices). There is clearly interaction between the peripheral and the central activation of migraine, it doesn't always start deep in the brain.  For someone who suffers migraine, if the sinuses get irritated (allergies or infection), or if they have neck problems and tense muscles, those may well activate the brainstem more easily and trigger migraine attacks.

Also, it is important to be aware of "rebound" headache otherwise known as "medication overuse headache" whereby the medications people take for their acute headaches, if taken too often actually begin to cause the

headaches. This can occur with even OTC medications, particularly those that contain caffeine and/or decongestants as well as with prescription medications, particularly narcotic pain medications and butalbital

containing medications (Fioricet, Fiorinal, Esgic), but it can even occur with overuse of migraine specific medications called "triptans" (Imitrex, Maxalt, Relpax, Axert, Zomig, Frova, Amerge).  The generally

accepted limit of use is no more than 2 - 3 days of acute treatment per week (on average). Some people may take medications for several days in one week and then not take any for a few weeks, which is okay. But to

consistently take acute medication more often than 2 - 3 days per week can cause problems.  Unfortunately, most people say that sometimes the medicines work, and sometimes they don't, and most people are just

trying to get some relief, or trying to keep the headaches from getting too bad just so they can function. But nonetheless, if taken too often, acute meds not only become less effective, they may cause more

headaches.

Preventive medications are medications taken on a daily basis to help reduce the frequency of acute attacks. These medications do not cause "rebound" headaches, but certainly all of them may have some side effects and one medication may work better for one person than another. Trying to find the right preventive, or combination of preventive medications may take some time and trying different ones. In addition to medications to control headaches, there are some lifestyle management steps to utilize (a healthful diet, a regular schedule, regular

exercise, relaxation training, etc.) as well as some evidence supporting the use of certain nutritional supplements.

If someone is experiencing increasing frequency of headaches, or having changes in their headache characteristics, and certainly if new or different things are happening, it is essential to see your physician.

Most headaches can be managed by a primary care provider, but there are times when specialty consultation is necessary. There is a new board certification recognition specifically for "Headache Medicine", but many

physicians who do not have this certification are well qualified to be considered "headache experts". Often, but not necessarily, these are neurologists, but there are several Family Physicians, Internal Medicine, ENT and other doctors who may have special interest and expertise in managing headache. So, if you or your primary care provider think you need a specialist, consider finding a "Headache Specialist".

Why don't doctors give penicillin shots anymore?

Michael Cannon, M.D.

Assistant professor of community and family medicine at Saint Louis

University

SLUCare family doctor

"We used to give penicillin shots for a lot of different types of infections, particularly upper respiratory infections, such as strep throat, and urinary and genital infections. We don't do that anymore for several reasons.

"First of all, we now know that not all upper respiratory infections are caused by bacteria. Some are caused by viruses, and these germs do not respond to penicillin or antibiotics of any kind, pills or shots.  We are now better able to diagnose a bacterial infection, which will respond to an antibiotic, and a viral infection, which won't respond to penicillin. We're not giving penicillin for viral infections it can't fight.

"We're also giving penicillin orally instead of by shot. We give penicillin for strep throat not only to kill the germs, but to prevent a more serious secondary infection called rheumatic heart disease. That takes a 10-day course of antibiotics, given by mouth. By giving a medicine orally, we can stretch out the treatment, which works better in

fighting illnesses.

"And finally, penicillin is not the best antibiotic to treat some of the bacterial infections we used to treat by giving penicillin shots. We now know that some upper respiratory, genital or urinary infections respond better to other antibiotics than penicillin. One shot of penicillin doesn't fit all illnesses."

I have trouble sleeping.  I try everything but nothing helps.

James K. Walsh, Ph.D.

Sleep Medicine and Research Center

232 S. Woods Mill Road

Chesterfield, Missouri 63017

tel: 314-205-6030; fax: 314-205-6025

 Many psychological and physical factors can contribute to poor sleep.

When insomnia occurs it is important to seek medical evaluation especially if the sleep disturbance causes significant distress at night or impairment during the daytime.  It seems as if your sleep problem is severe enough, despite your attempts to improve matters, to be causing you significant distress and sleepiness during the daytime.I recommend that you discuss your problem with your physician or with a physician specializing in sleep medicine. There are treatments available which are effective for most people.

http://www.stjohnsmercy.org/services/sleepmedicine/default.asp