Both of Dr. Daniel’s Neurology textbooks: Migraine and Transient Global Amnesia can be found at Amazon.com
Britt Talley Daniel M.D.
7777 Forest Lane Suite B-220
972 566-4556
Dallas, Texas 75230
Approximately 40% of persons who have migraine will have stress or anxiety issues. The most common medical diagnosis here is called generalized anxiety disorder which may be abbreviated as GAD. Migraine and GAD are comorbid which means that they occur more likely statistically together than would be expected. Migraine is said to be a genetic problem while anxiety is discussed as familial.
Many persons will say, instead of admitting anxiety, that they have “pressure or stress or worries” but all these are really about the same thing. The DSM-IV is the large standard diagnostic text book from the American Psychiatric Association which lists psychiatric diagnoses and the check list below details how a doctor might diagnose GAD.
DSM-IV Criteria For the Diagnosis of GAD (Generalized Anxiety Disorder)
The patient experiences excessive anxiety and worry
The anxiety is difficult to control
The anxiety is on several subjects
Symptoms occur for more days than not (or > 50% of the time) for the past six months
The patient experiences significant distress or social impairment (withdrawn, sees no one)
There may be at least three ancillary symptoms:
Ancillary Symptoms
Restlessness/mental tension (time pressure)
Fatigability
Poor concentration
Irritability (for intrapersonal relationships)
Muscle tension (tension in neck, shoulders, back, teeth clenching or grinding)
Sleep disturbance
Exclusions
Focus of anxiety/worry is not another disorder (for example, panic disorder)
Not part of a mood disorder, psychotic disorder, or pervasive developmental disorder
Not substance related
Not organic
DSM-IV= Diagnostic and Statistical Manual of Mental Disorders, fourth edition
BTD 10/30/09
Britt Talley Daniel MD
Migraine Aggravating Factors/Triggers
Many patients refer to “migraine triggers” but ICDH II differentiates between a migraine trigger which is something that causes an attack within 24 hours, like red wine inducing a migraine, and an “aggravating factor” like stress which builds up over weeks to produce migraine.
Chabriat, et al,[i] wrote in 1999 in Headache on “Precipitating factors of headache. A prospective study in a national control-matched survey in migraineurs and non-migraineurs.” They screened prospective factors in a migraine and non-migraine group of patients who kept a diary for a 3-month period. The most frequent precipitating factors in both groups were:
“fatigue and/or sleep, stress, food and/or drinks, menstruation, heat/cold weather, and infections in both groups.”
Kelman[ii] writing in Cephalalgia in 2007 on “The triggers or precipitants of the acute migraine attack” listed stress at a frequency of 79 % and food at 26.9 %. The table of frequency of individual migraine triggers from his article was:
Trigger Frequency
Stress 79.7%
Hormones (in women) 65.1%
Not eating 57.3%
Weather 53.2%
Sleep disturbance 49.8%
Perfume or odor 43.7%
Neck pain 38.4%
Light (s) 38.1%
Alcohol 37.8%
Smoke 35.7%
Sleeping late 32.0%
Heat 30.3%
Food 26.9%
Exercise 22.1%
Sexual activity 5.2%
Kelman is not going by ICDH-II here which refers to stress as an “aggravating factor”, not a “trigger.” However, his list is interesting and I keep a copy of this article in my office to hand out.
Another observation here is that many patients will focus on the different foods that may aggravate migraine and not recognize stress in their lives which is the most aggravating feature of migraine.
(972) 566-4556
Allodynia with migraine and medication overuse headache
Allodynia comes from the words “allo” which means “other” and “dynia” which means “pain.” Clinically it refers to pain produced by a non-painful stimulus, such as touch. Allodynia is an uncomfortable heightened sensitivity to touch. Normally it doesn’t hurt to touch the head or the brow or the temple, but during the late stages of a migraine or during medication overuse headache, a simple touch to the head or temple may be perceived as painful. This is like a sunburn. Normally if I touch my arm it doesn’t hurt but after a sunburn at the beach, my arm is painful to touch. This is what allodynia is like.
Allodynia can be divided into: tactile allodynia-pain from touch or light pressure like a belt or bra strap, mechanical allodynia-pain from motion across the skin such as light massage or the touch of fabric, and thermal allodynia-pain from heat or cold that makes the limbs feel needle like, sharp pain.
The pain of allodynia can be provoked by combing or brushing the hair, shaving, showering, wearing glasses, or earrings. The pressure of a strand of hair may feel like the jab of a hot knife. Allodynia is the migraine patient who notes on the third day of headache suffering that it hurts her to brush her hair or lay her head on the pillow.
Allodynia occurs mostly in long duration episodic migraine attacks or in patients transformed to medication overuse headache by overtreatment of headache with analgesics. The duration of migraine is 4-72 hours, as defined by the International Classification of Headache 2004. Migraine is generally an episodic, paroxysmal disorder occurring at most 2 times a week. One can easily see by doing simple math that multiplying 72 hours or 3 days by 2 equals 6 days. This is why periodic migraine rarely occurs more than twice a week. Daily headache or headache 3 or 4 days a week is usually Chronic Daily Headache (CDH), a syndrome defined as >15 headache days a week. About 70% of persons with CDH have a common headache syndrome from overtreating with analgesics, caffeine, or triptans called Medication Overuse Headache. Also read my article on the subject of Medication Overuse Headache on this blog.
An attack of migraine has 4 stages: 1) trigeminal activation, 2) neurochemical release, 3) arterial vasodilatation, 4) central sensitization of the thalamus in the brain. In general patients with an attack of migraine are at stage 3 in two hours and after two hours they are in stage 4. Thus, patients with long-duration (headaches lasting more than several hours) episodic migraine attacks spend most of the time in stage 4 central sensitization. The general thinking is that all patients with medication overuse headache are continuously in stage 4 central sensitization. Both of these circumstances can produce allodynia.
With episodic migraine the allodynia clears when the headache ends and the offending neurochemicals are metabolized and excreted. The same thing occurs during treatment of medication overuse headache when the patient is detoxed off of analgesics, caffeine, or triptans. In time the offending neurochemicals are metabolized and consequently the headache clears.
BTD 10/29/09.
Dallas, Texas
BETABLOCKERS
Betablockers are “Vasonormalizers” which prevent dilation and constriction of arteries. Adrenaline is made in two varieties: Alpha—which works on the lungs, and Beta—which works on arteries, thus, the name betablocker. The archetype betablocker drug is Inderal, known generically as propanolol. This drug works to block some of the effects of adrenaline on arteries. Other Betablockers that may be used are: Corgard (naldolol) and Tenormin (atenolol).
Indication:
Inderal has been approved by the Federal Drug Administration for the treatment of a large variety of medical problems which includes: Migraine, Benign Essential Tremor or Familial Tremor, Hypertension, Angina (the chest pain heart patients with coronary artery disease get), Cardiac Arrhythmias.
Dosing
Inderal comes in a short term (4 hour lasting) dose usally given 3 or 4 times a day or in LA (long acting-24 hour) once a day form. Common doses are 80-320 mg/day. For younger patients with migraine or tremor the dose may be discontinued safely at a low dose such as 80 mg/day, while older patients with heart disease and higher doses should have the dose tapered slowly.
Side Effects
Inderal is usually well tolerated and has few side effects, although like all drugs it has two pages of small print listing possible side effects. One potential side effect is that a small number of patients may develop the so called “Inderal tired syndrome” after they start the drug, usually in the first week. If this symptom develops, then the drug should be stopped and another betablocker selected. Betablockers may worsen depression or asthma and should be used with caution with these medical conditions
Duration of therapy
How long the drug has to be given is not known at the beginning and depends on the clinical indications. For tremor Inderal is usually given long term for years or life. For migraine I commonly encourage the patient to consider using the drug for 3-6 months at first and then reassess on follow up. Daily preventive drugs like betablockers may be offered to migraine patients if they are experiencing at least 3-4 migraines a month. The general effectiveness for migraine prevention is reduction in number of migraines by 50%. Many patients are able to get off the drug if their headache diaries show that their number of events is low, although some patients with bad migraine should continue.
Treatment strategy
Inderal (propranalol) would be a good preventive drug choice for a patient with both migraine and essential tremor, but a poor choice for the patient with migraine and depression.
BTD 10/12/09
Caffeine is a Drug
The current 1994 edition of the Diagnostic and Statistical Manual for Psychiatric Diagnosis (DSM IV) added a new drug to the list of known addictive drugs—Caffeine, in amounts as small as 120 mg/day. Criteria for caffeine withdrawal: Prolonged daily use of caffeine, abrupt cessation or reduction of total caffeine use, closely followed by headache and one or more of the following symptoms — fatigue/drowsiness, anxiety/depression, nausea/vomiting–, clinically significant distress or impairment in social, occupational or other important areas of functioning.
The diagnostic criteria for caffeine intoxication are recent consumption of caffeine, use in excess of 250 mg a day and the development of five or more the following signs during, or shortly after caffeine use: Restlessness, nervousness, excitement, insomnia, flushed face, diuresis, gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, or psychomotor agitation.
Approximate amounts of caffeine in various beverages:
Coffee, grande 16 oz Starbucks 550
Coffee, tall 12 oz Starbucks 375
Coffee, short 8 oz Starbucks 250
Redline RTD 250
NoDoz, max strength or Vivarin 200
7-Eleven Big Gulp cola 64 oz 190
Coffee non-gourmet 8 oz 135
Excedrin 130
Coffee instant 8 oz 95
Jolt 711
Anacin 65
Cola 12 oz 35
Mt. Dew 55
Dr. Pepper 39
Pepsi 37
Tab 46
Cappuccino, 8 or 12 oz 35
Expresso Starbucks 1 oz 35
Tea, green or instant 8 oz 30
Chocolate dark, semisweet 1 oz 20
Coffee decaf Starbucks 8 or 12 oz 10
Coffee decaf non-gourmet 8 oz 5
Hot chocolate or cocoa 8 oz 5
Chocolate milk 1 oz 5
Liquid Speed (amount concealed within a proprietary formula)
Caffeinated water ?
Pharmacologically, caffeine acts as a central nervous system stimulator, a point that is well made by the coffee ad on TV which calls it “the think drink.” The duration of the effect of the drug is 6-8 hours, but even one drink in the morning will interrupt sleep in some persons. Caffeine also acts as a constrictor of smooth muscle, which is found in arteries, the bladder, and the colon. It is the arterial vasoconstrictive action which helps with mild migraine (Excedrin, B.C. Powder, and Vivacin) and may lead to the rebound vasodilatation headache when one withdraws from caffeine. The smooth muscle effect also acts as a mild stimulant on the bladder, promoting urination and in the colon, a bowel movement.
I urge all Caffeine addicted patients, migraine patients, Panic Disorder patients, and patients with sleep disorders to taper off caffeine (which, as I said above, is a drug).
Consider what the migraine expert, Dr. Marcelo Bigal, wrote in October 2009: ”The role of caffeine in the evolution from episodic into chronic headaches is of enormous interest, due to wide populational exposure to caffeine. In the population, individuals with chronic migraine are more likely to be high caffeine consumers while they had episodic headaches, as compared to individuals that did not develop chronic migraine. Abrupt withdrawal of caffeine in individuals with chronic migraine is associated with rebound headaches, further supporting the importance of this substance as a risk factor.” http://www.discoverymedicine.com/Marcelo-Bigal/2009/10/12/migraine-chronification-concept-and-risk-factors/
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