Wednesday 24 October 2018

Dear Dr Nina: I get terrible migraines. Will Botox help?

Picture posed
Picture posed

Nina Byrnes

I am a 35-year-old woman. I have severe migraine headaches which can immobilise me for days. I recently had an occipital nerve block procedure on both the right and left side of my neck. Have you ever heard of anyone having this done, and if so, do you know what the success rate is? Doctors have also suggested Botox. My mother suffered from migraines too before she hit the menopause and they disappeared soon afterwards. Can they be hereditary?

Dr Nina replies: It is estimated that 10 to 15pc of the Irish population suffers from migraine. These headaches can run in families and are more common in women than men. Migraine is not a curable condition. The main goal of treatment is to minimise the impact of migraines on quality of life and lifestyle.

Traditionally a stepwise approach to treatment was advised. This involves starting with simple painkillers and anti-nausea medicine and only adding migraine-specific treatment if this wasn't working. The newer stratified approach to treatment looks more specifically at individual cases of migraine and the impact on an individual's wellbeing and lifestyle.

The most important first step is to get the right diagnosis. I have met many patients who complain of migraine when, in fact, they are suffering from a different type of headache. Keep a diary of the headaches noting when and how often they occur, where in your head they are felt, and note wellbeing before, during and after the attack. Note any other associated symptoms or upset and what medication has been tried. Visit a doctor with this diary. A comprehensive chat and examination will help lead to the correct diagnosis.

If migraine occurs less than twice per month it is reasonable to try simple painkillers at first. Aspirin and Ibuprofen can be effective. It is advised to avoid painkillers containing codeine as frequent use of these can cause analgesia overuse headache. Migraine is often associated with nausea so some anti-nausea medicine may also help.

If the above measures aren't working or headaches are occurring more frequently, your GP may prescribe migraine-specific medicine. The most common of these belong to a group called triptans. They should be taken early in the headache and can be repeated up to once in an attack.

For those who experience regular migraine attack or for whom attacks are severe and disabling, preventive medicine can be prescribed. There are a number of different types. Beta blockers which are a form of heart or blood pressure tablet can be very effective and are the most commonly prescribed. Other options include medication that has also been used for seizures, nerve pain and older antidepressants.

Lifestyle management also has a role. Identify your triggers and avoid these. Ensure you drink plenty of fluids, get adequate rest, avoid stress and exercise regularly.

Those with problematic migraine will be referred to specialist headache clinics. Botox treatments are being prescribed in these centres. This can be of benefit to those with chronic migraine - for example, pain on at least 15 days per month. Botox injections are administered at various locations on both sides of the head. This can help reduce the frequency and severity of migraine pain. Occipital nerve blocks involve injecting local anaesthetic with steroid into the occipital nerve at the base of the head at the back. This too can help reduce chronic migraine pain.

Radio-frequency treatment has been suggested as potentially helpful in headaches emanating from the neck area, but supportive evidence is not strong.

Q: I’m 44 and my periods have failed to arrive the last three months. I’m not pregnant, but I have been quite stressed and upset of late. Could this be it? Or should I have some tests done?

Dr Nina replies: Absent or erratic menstruation can have many causes. Pregnancy is the most obvious one. Any woman in a relationship who misses a period should do a home pregnancy test. If this is excluded other causes can be considered. Stress is another common cause. As stress levels increase a number of hormone changes occur in the body and these can throw off our natural fertility hormones reducing ovulation and thus leading to missed periods. Malnutrition such as that which occurs in eating disorders and over-exercising can also lead to absent or scanty menstrual bleeding. Erratic or scanty menopausal periods are common at the beginning and end of our fertile life. Menopause is, by definition, the end of menstruation but the process itself may start many years before and extend many after. The years leading up to the end of menstruation are referred to as perimenopause and, during this time, periods may change or become more erratic.

Most women will experience one or two missed periods at some stage. If these occur in the absence of other health issues or symptoms then further investigation is not warranted. If repeated menstrual periods are missed a visit to the GP for bloods and examination is advised. Bloods would check for hormone levels and also rule out conditions such as thyroid disease, polycystic ovarian syndrome and other chronic disease that may have an impact on the menstrual cycle. A pelvic examination can rule out infection or any anatomical change in the womb or ovaries.

Perimenopause or stress is the most likely causes for missed periods in your forties. As you have missed three periods at this stage I would advise checking in with your GP for further assessment.

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