15 ms·

So as to not bury the lede: I'm not giving medical advice, but I wonder how many people's migraines are worsened by the Valsalva maneuver? How many would be pr

So as to not bury the lede: I'm not giving medical advice, but I wonder how many people's migraines are worsened by the Valsalva maneuver? How many would be prevented with a daily low-dose aspirin? I had my first migraine (with aura) as a teenager. What a scary thing for you to lose proper vision, get a truly nightmarish headache, then feel nauseous and throw up! On average I'd say I got 1-5 a year for many years. I managed them with Migranal. Triptans didn't help. Migranal was an expensive pain to get, and is a poster child for our crazy pharmaceutical situation, but I digress. I had a concussion a few years ago after which I could hardly go two weeks without getting at least one scotoma. In contrast to before, sometimes it would be just the aura without headache. For insurance reasons I moved over to Nurtec which wasn't bad, and a lot less unpleasant a taste. But 30+ incidents a year was crippling. My neurologist was convinced my troubles were due to a PFO (patent foramen ovale): in the womb, we obviously do not breathe. A hole between the left and right sides of the heart allows blood to flow through from the mother. At birth a flap is supposed to cover this hole, but in many people it doesn't close all the way and there's a residual "shunt" which allows the "dirty" blood to flow straight through without going through the lungs (which also filter out junk, like microclots for example). When you strain, such as when bearing down/lifting something heavy/Valsalva maneuver, it really pushes this stuff through. Indeed I seemed to notice migraines came more frequently when I was better about exercising. I had some other sporadic things over the years. My neurologist said "the brain is a big network. Throw a bunch of crap in there, and you get nonlinear outcomes." He was convinced the PFO was to blame for all of this. I was referred to an interventional cardiologist, whose research had concluded, basically: "not all migraines are resolved by closing the PFO. But, if blood thinners make the migraines go away, in those cases closure does make them go away." Bayes at work. I was put on blood thinners and indeed they virtually stopped. (Sure enough, one of the two I did have in the year I was on Plavix--again, down from 20-30--was when I was doing the Valsava to pop my ears while a flight was landing). After a year I did have the PFO closed. I am still on low-dose Aspirin (baby/EC). The neurologist had prescribed it years earlier when he first tested me for the PFO, but I resisted having to take medication daily. My original cardiologist who examined me further for the PFO said it was tiny and thought it was clinically insignificant, and didn't think I needed the aspirin. I've had the PFO closed for a year. I had one migraine during the procedure itself (not unexpected), and one more after about six months when I went off the aspirin. So I went back on the aspirin, and will presumably continue to be on it for life. There are still unanswered questions: none of this explains the concussion, does it? The theory I've pieced together is that migraine is a probabilistic phenomenon. Things can make it more or less likely, presumably by putting the brain in a more or less resilient state. Bad sleeping habits? Inconsistent timing of food (low blood sugar)? Dehydrated? This is playing with dry kindling, waiting for the spark: perhaps a microembolism crossing through the PFO, or some other vasoactive compound (I've had them from the sun reflecting off of something and catching my eye). It was around puberty time when it all began, so a lot of stuff is going on. My thought is that perhaps the concussion "permanently" lowered my threshold. My mother had always suffered from migraines. For other reasons (old with heart issues), she went on blood thinners temporarily. Then was off the blood thinners. Then she was back on blood thinners. Sure enough, after my experience we looked at her migraine log, and can you guess what pattern we found? At present, closure is only indicated after you've had a stroke (I had at least one event that adequately qualified). I'm lucky: a few years before my adventure, my coworker had a stroke (while lifting weights) with permanent consequences, after which his PFO was closed. We already know that migraineurs are frequently at higher risk of stroke. I would bet that PFO closure will become a more routine procedure in the coming decades.

elric 2y ago
Closing a PFO is the only procedure I know of that can cure migraine. Sadly it seems like not everyone's migraines are caused by a PFO.
hilbert42 2y ago
"I managed them with Migranal. Triptans didn't help." Similarly, I found that triptans (sumatriptan) wasn't as good or as effective as ergotamine-based formulations. Whilst sumatriptan worked it didn't suppress migraine pain as effectively as did ergotamine, nor was its effective duration anywhere near as long. A single 1mg dose of ergotamine would last 24 hours whereas 100mg (the stronger dose, 50mg being the other) of sumatriptan would last only 6 or so hours and its action not as effective. The other problem is that until recently sumatriptan† was much more expensive than ergotamine. I say 'recently' because where I am in Australia the price of ergotamine has gone up eightfold in recent months. Now, it seems the only drugs availabe are the triptans—and that's not the only problem, here triptans are only available in packs of two (or four on script for half strength tablets), which is a ridiculously small quantity—one runs out of the drug when it's most needed. (Clearly, the bastards who set the regulations don't get migraines.) On the other hand I could get 100 capsules of ergotamine on a single script. As far as I'm concerned, I'm back in the dark ages before my migraines were diagnosed. No doubt, medicos and pharmacologists who read this will say that triptans are better drugs in that they are more selective, that is their vasoconstrictive effecs are more specific and thus less harmful than ergotamine and no doubt there's some truth to that. That said, what they and drug manufacturers don't emphasize is that the triptans also have bad side effects such as serotonin syndrome which can be brought on by interactions with other drugs such as the TCAs/tricyclics, MAOIs/monoamine oxidase inhibitors just to mention a few (of the side effects). Also, they quickly become ineffective upon repeated dosing — hence the restricted quantities per script. Yes, ergotamine also has some nasty side effects but not those I've mentioned for the triptans. One of the greatest benefits of ergotamine is that it's just as effective after taking it for decades as when one first starts (I know from experience). It seems to me the benefits of the triptans have been oversold and that medicos et al actually believe the mantra. It's great for Big Pharma to have everyone believe that given that ergotamine is a readily-available natural product (from ergot fungi), and that any competent lab could refine it for medical use. It's great for Pharma to have everyone believe ergotamine is obsolete. In the meantime the switch from ergotamine to triptans has caused me nothing but trouble. ___ † Before the recent huge price hike a capsule of ergotamine was about $1 versus $8 for the half strength 50mg sumatriptan tablet (where I am in Australia sumatriptan is available OTC in packs of two for ~$16, the full strength 100mg being script only and even then only in packs of two). Now do the sums: in my case full-strength (100mg) sumatriptan only lasts 6 hours versus 24 for the 1mg ergotamine. Thus the 24-hour cost for ergotamine is [was] $1 whereas sumatriptan is 24/6 x $8 which makes it 32 times as expensive as the ergotamine! Moreover, in my case, I break open a capsule of ergotamine and take only half (0.5mg) as that's usually all I'll need. So that makes sumatriptan 64 times more expensive. Right, Big Pharma has ripped us off yet again, big-time! It's damned time governments did something about this.

elric 2y ago

Closing a PFO is the only procedure I know of that can cure migraine. Sadly it seems like not everyone's migraines are caused by a PFO.

hilbert42 2y ago

"I managed them with Migranal. Triptans didn't help." Similarly, I found that triptans (sumatriptan) wasn't as good or as effective as ergotamine-based formulations. Whilst sumatriptan worked it didn't suppress migraine pain as effectively as did ergotamine, nor was its effective duration anywhere near as long. A single 1mg dose of ergotamine would last 24 hours whereas 100mg (the stronger dose, 50mg being the other) of sumatriptan would last only 6 or so hours and its action not as effective. The other problem is that until recently sumatriptan† was much more expensive than ergotamine. I say 'recently' because where I am in Australia the price of ergotamine has gone up eightfold in recent months. Now, it seems the only drugs availabe are the triptans—and that's not the only problem, here triptans are only available in packs of two (or four on script for half strength tablets), which is a ridiculously small quantity—one runs out of the drug when it's most needed. (Clearly, the bastards who set the regulations don't get migraines.) On the other hand I could get 100 capsules of ergotamine on a single script. As far as I'm concerned, I'm back in the dark ages before my migraines were diagnosed. No doubt, medicos and pharmacologists who read this will say that triptans are better drugs in that they are more selective, that is their vasoconstrictive effecs are more specific and thus less harmful than ergotamine and no doubt there's some truth to that. That said, what they and drug manufacturers don't emphasize is that the triptans also have bad side effects such as serotonin syndrome which can be brought on by interactions with other drugs such as the TCAs/tricyclics, MAOIs/monoamine oxidase inhibitors just to mention a few (of the side effects). Also, they quickly become ineffective upon repeated dosing — hence the restricted quantities per script. Yes, ergotamine also has some nasty side effects but not those I've mentioned for the triptans. One of the greatest benefits of ergotamine is that it's just as effective after taking it for decades as when one first starts (I know from experience). It seems to me the benefits of the triptans have been oversold and that medicos et al actually believe the mantra. It's great for Big Pharma to have everyone believe that given that ergotamine is a readily-available natural product (from ergot fungi), and that any competent lab could refine it for medical use. It's great for Pharma to have everyone believe ergotamine is obsolete. In the meantime the switch from ergotamine to triptans has caused me nothing but trouble. ___ † Before the recent huge price hike a capsule of ergotamine was about $1 versus $8 for the half strength 50mg sumatriptan tablet (where I am in Australia sumatriptan is available OTC in packs of two for ~$16, the full strength 100mg being script only and even then only in packs of two). Now do the sums: in my case full-strength (100mg) sumatriptan only lasts 6 hours versus 24 for the 1mg ergotamine. Thus the 24-hour cost for ergotamine is [was] $1 whereas sumatriptan is 24/6 x $8 which makes it 32 times as expensive as the ergotamine! Moreover, in my case, I break open a capsule of ergotamine and take only half (0.5mg) as that's usually all I'll need. So that makes sumatriptan 64 times more expensive. Right, Big Pharma has ripped us off yet again, big-time! It's damned time governments did something about this.