MIGRAINE- A COMPLEX HEADACHE

Migraine – A complex headache

What is migraine?

Migraine is a condition characterized by frequent episodes of headaches, associated with nausea or vomiting. Commonly, migraine headache is experienced on one side of the head around the temples and occasionally may shift from one side to the other. It arises from a combination of blood vessel enlargement and release of chemicals from nerves that are in close proximity to these blood vessels. During a migraine attack, the artery located just under the skin of the temple and outside the skull enlarges causing release of chemicals that cause an inflammation and further pain. This also triggers the sympathetic nervous system to react with feelings of nausea, vomiting and aversions to light, smell and sound.

Different types of Migraine:

In clinical practice, doctors see patients with two kinds of migraine viz migraine with aura and migraine without aura.

Migraine with aura: This is also known as classic migraine, and here the patients feel sensory symptoms (aura) 10-20 minutes prior to the attack. An aura is described as seeing hazy or flashing lines or blind spots in the centre of vision. Patients with classic migraine may also experience mental fuzziness and unclear speech. Almost 1 in 5 migraine sufferer experiences an aura.

Migraine without aura: This is the most common migraine and the patient in this case does not experience an aura although all other symptoms and factors for the attack are similar.

What triggers a migraine?

A migraine trigger is different for each migraineur and what acts as a trigger for one, may not start a headache in another. Some of the most common migraine triggers are –

• Changes in weather and especially summer heat
• Sensory disturbances such as strong smells, flashing or fluorescent lights, extreme and continuous loud noise

• Certain food items such as over fermented cheese, alcohol, red wine, nuts
• Stress and anxiety
• Sleep pattern disturbance
• Erratic meal timings and fasting 

What to do during a migraine episode?

For some patients it is difficult to differentiate between migraine and normal headache. Taking over-the-counter pain killers do not help relieve a migraine headache. If the headache is experienced on one side of the head along with nausea and vomiting, lasting 4 hours or more, then one needs to immediately consult a general physician. 

What are the treatment options available for migraine?

There are two levels of treatment options available for treating migraine.

Preventive treatment: Identifying and being aware of the triggers and trying to avoid them completely is one way to prevent migraine attacks. Maintaining a migraine diary and recording history helps tremendously to prevent a migraine attack.

Drugs for treating migraine: There are several classes of drugs that are used to treat a migraine headache. Although these are actually prescribed for other conditions such as depression, blood pressure, or allergy, experience shows that they can also halt a migraine headache.

What is the outcome in cases of Migraine?

Migraine attacks are at its peak in the age group of 25-55 years. Therefore as one grows older, the frequency of attacks gradually diminishes. For most patients, avoiding known triggers and following a therapeutic regimen works best to overcome migraine headache.

SUMMER HEAT AND NEUROLOGICAL PROBLEMS

SUMMER HEAT AND NEUROLOGICAL PROBLEMS

Summer is here and temperatures are starting to rise. Summer has its share of fun, with lots of delicious mangoes and frequent trips to ice cream joints. However, it also brings with it, its share of problems. Here, I would discuss the neurological problems that may get worse with summer heat.

1. Migraine- Migraine is a condition characterized by frequent episodes of headaches, associated with nausea or vomiting. Headaches in migraine patients are triggered or exacerbated with a number of factors, heat being one of them. It is common to have severe headache with every outing in the scorching sun. So, it is better to avoid going out during the hottest parts of day- 12 noon to 3 pm. Also, one can use umbrella to avoid direct sunlight.

2. Multiple sclerosis (MS)- MS is a disease that affects central nervous system (brain, spinal cord and optic nerves). In this disease, there is damage to the myelin sheath, the covering of the nerves. The symptoms in MS patients get worse with increased heat, as after exposure to summer heat, hot water baths, strenuous exercises, etc. The symptoms noted are blurred vision, fatigue, weakness and cognitive dysfunction. So, patients with MS should avoid heat exposure.

3. Heat stroke- Heat stroke occurs if body temperature rises to abnormally high levels on exposure to heat for prolonged duration. Generally, our body tries to regulate temperature with sweating, increased thirst, etc when exposed to heat. However, these mechanisms may fail when exposed to high temperatures for prolonged periods. Symptoms of heat stroke include high temperature, headache, nausea, weakness, muscle cramps, confusion, and in severe cases, unconsciousness and coma may also occur.

4. Brain stroke- Exposure to heat can lead to dehydration, thereby, increasing the chances of a brain stroke. Brain stroke may lead to paralysis due to blockage of blood supply to a part of brain.

5. Epilepsy- Heat can be a trigger for seizures. Some people experience an increase in seizure frequency during summer months. In children below the age of six, febrile seizures are common, where they get seizures during an episode of high fever. Also in adults, high fever can trigger an episode of seizure. There is a special type of epilepsy, where the person gets a seizure after taking hot water bath; this type of epilepsy is referred to as “hot water epilepsy”.  The increase in seizure frequency may be due to loss of anti-epileptic medications through too much sweating or perspiration in hot weather.

Strategies to beat the summer heat:

• Stay indoors as much as possible, especially during the hotter parts of day,
• Use umbrella to avoid direct sunlight exposure,
• Stand in shade,
• Use AC or fan, when indoors,
• Drink plenty of water and juices to keep yourself well hydrated.

DR.  SUDHIR KUMAR MD (Medicine) DM (Neurology)

Senior Consultant Neurologist,

Apollo Hospitals, Hyderabad, India.

Email: drsudhirkumar@yahoo.com

Appointments: 0091-40-23607777/60601066

MANAGEMENT OF EPILEPSY IN PREGNANCY

MANAGING EPILEPSY IN PREGNANCY

Epilepsy is a common illness and therefore, we commonly encounter women with epilepsy (WWE), who are either pregnant or contemplating pregnancy. There are a lot of apprehensions and misconceptions regarding managing epilepsy in this group of WWE. Here, I wish to highlight some of the important aspects of managing epilepsy in women who are planning pregnancy or are currently pregnant.

1. If a woman is seizure-free for at least two years, she can consider withdrawing anti-epileptic drugs (AEDs) under the supervision of neurologist, and then plan for pregnancy.

2. If a woman has seizures, it is better to continue AEDs during pregnancy, as the risk to the baby is several times higher with seizures, as compared to that with AEDs.

3. Sodium valproate has the highest risk to the developing baby, and it should be avoided in pregnancy.

4. AEDs such as levetiracetam, lamotrigine, oxcarbazepine, topiramate, etc are safe and may be continued during pregnancy.

5. The lowest effective dose of AED should be used.

6. Try to use only a single anti-epileptic drug, if possible.

7. Folic acid vitamin supplements should be used in pregnancy.

8. The dose of anti-epileptic medication may have to be increased during the last three months of pregnancy.

9. CT scan of brain should be avoided, as far as possible, during pregnancy, as radiation exposure due to it may harm the baby.

10. MRI brain is reasonably safe for baby, especially after the first three months of pregnancy. So, if needed, it may be performed.

DR SUDHIR KUMAR MD DM (Neurology)

Senior Consultant Neurologist,

Apollo Hospitals, Jubilee Hills, Hyderabad-500096

Email: drsudhirkumar@yahoo.com

For appointments: 0091-40-23607777/60601066

Common Adverse Effects of Anti-epileptic Drugs

Common Adverse Effects of Anti-epileptic Drugs

Introduction

Epilepsy is a common condition and it is routinely treated with anti-epileptic drugs (AEDs). It is important to continue AEDs for a long time, even life long in many cases, in order to remain seizure-free. Seizure freedom depends on taking appropriate anti-epileptic drug, at a correct dose and interval, everyday for a long period of time.

When one takes drugs for long time, we need to be aware of the possible side effects. The currently used anti-epileptic drugs have been well studied in clinical trials and data about their safety and possible side effects are well known.

My aim, in this article, is to briefly summarize the common side effects of commonly used AEDs. Early recognition of side effects is important to minimise any harm due to AEDs. 

Side Effects of Phenytoin (Dilantin, Eptoin, etc)

Phenytoin is one of the commonest AED used and also among the oldest drugs. It is used in all age groups.

The main advantage is its availability in injection form; so, it is also used in emergency situations.

The other advantage is that the full dose can be started on day 1 and there is no need to start at low dose and gradually increase the dose (as we need to do with carbamazepine, oxcarbazepine, lamotrigine, etc).

Side effects of phenytoin injection- if injection is rapidly given, it can lead to low blood pressure and cardiac arrest. Also, severe drowsiness can occur.

With the use of phenytoin tablets, the following side effects should be watched for:

• Imbalance while walking,
• blurred vision,
• increased facial hair,
• coarse facies,
• thickening of gum,
• skin rashes. 

Gum hyperplasia due to phenytoin use

Side effects of Carbamazepine (Tegretol, tegrital, mazetol, zeptol, Zen, etc)

Carbamazepine is useful in partial or focal epilepsies and can be used in all age groups. Syrups are available for use in children. However, injection forms are not available, which prevents its use in emergency situations.

Common side effects include:

• Dizziness,
• Drowsiness,
• Imbalance while walking,
• Skin rash,
• Lowering of sodium level (hyponatremia)

The first three side effects can be minimised if carbamazepine is started at a low dose and the dose is gradually increased over a period of days. 

Oxcarbazepine have similar side effects, however, the incidence is lesser than that of carbamazepine. 

Side Effects of Sodium valproate (Depakine, Valparin, Encorate, Valprol, etc)

Sodium valproate is effective in controlling generalised epilepsies, juvenile myoclonic epilepsy (JME), absence seizures, etc. 

Common side effects of valproate include:

• Weight gain,
• Tremors of hands,
• Hair loss,
• Liver toxicity,
• Menstrual irregularities,
• Increased incidence of polycystic ovary disease,
• Pregnancy-related complications.

Sodium valproate should be avoided in patients with liver disease.

Also, it should not be used in women who are pregnant or are planning pregnancy. 

Side Effects of Levetiracetam (Keppra, levipil, levera, etc)

Levetiracetam is a newer AED and is effective in controlling various types of seizures. It is safer than most of the older AEDs. It has injection form, so, it can be used in emergency situations. Also, it is safe in all age groups and can be used in pregnant women too. 

Side effects to be watched for while using levetiracetam are:

• General weakness,
• Sleepiness,
• Aggression and behavioural changes,
• Occasional skin rashes. 

Side Effects of Lamotrigine (Lamictal, lamitor, lametec, etc)

Lamotrigine is also very effective AED, and can be safely used in children as well as pregnant women. 

Side effect to be watched for with lamotrigine use are: 

• Nausea, vomiting, 
• dizziness,
• sleepiness,
• imbalance while walking,
• skin rash

The dose of lamotrigine should be very gradually increased to avoid skin rash.

I hope you find this article useful. Feel free to contact me at the details below. 

Dr Sudhir Kumar MD (Medicine), DM (Neurology)

Senior Consultant Neurologist

Apollo Hospitals, Hyderabad, India.

Email: drsudhirkumar@yahoo.com

Phone: 0091-40-23607777 (to fix appointment for consultation)

online consultation: http://bit.ly/Dr-Sudhir-kumar