Dear Lisa,
I am a 19 year old nursing student and I need your help! Since I was about 5, I have suffered from some form of migraines. They have gotten worse as I have gotten older. I have worked with my pediatrician and two neurologists and over about 10 years, we diagnosed me with pseudotumor and dura-sinus thrombosis (b/c a blood clot was found in one of the veins in my brain). I have been put on an uncountable number of meds, and most didn't seem to help, or I had horrible reactions too. Currently I am taking a diuretic twice a day (500mg) and using the medicine called "Amerge" for when I do get a headache. I was doing really well for the past two or so years and then in this last six months I seem to have fallen again. I met with my neurologist last week and had another spinal tap done to see if my pressure was still high. It was 165, which as I was told, was low and normal, thus suggesting that the Diamox was working, and/or that I no longer had a problem with pseudotumor. I should probably say as well, that the psuedotumor diagnosis is a very odd one for me b/c I am not obese or in bad shape, but rather tall, thin and I try to stay active.
Anyways, for the past six months, I have experienced a horrible pulsing sound in my ears when I sleep and I feel like my head just throbs with each pulse. It doesn’t happen every night, but often. I woke up this morning with horrible pounding in my head, and I heard the "swooshing" sound as well. I began to get horribly nauseated as it got worse. It was 4am and I have a roommate and I couldn't just get up. The other thing is that my right eye begins to hurt terribly as well when this happens. I don't have double vision, or blurriness, it just hurts, aches, and throbs. Getting up and out of bed tends to help a little. But today the headache, nausea and eye sensitivity lasted most of the day and this is not unusual. I don't have a kink in my neck, and no other part of my body feels odd. I have done food diets and kept journals and have never found anything.
Sincerely,
“Nursing Student with killer pain”
Dear “Nursing Student with killer Pain”,
WOW! The one thing that I can say is, all of your experience with your own health conditions, medical specialists, diagnostic testing, coping with pain and navigating the health care system, you sure are going to be a great Nurse. I’m sure it has been extremely difficult dealing with your pain and medical problems from such a young age and find it very admirable that you have chosen a career dedicated to helping others. Your future patients will benefit from all of your life experiences.
Asking questions also makes a good Nurse and a well informed patient. When it comes to your health, there are never too many questions, especially when the situation is not clear. The first issue I would like to address is your diagnosis of Pseudotumor cerebri. I am sure you already know that Pseudotumor cerebri is a condition that is caused by increased intracranial pressure. This increased pressure can lead to cerebral edema (swelling) or subarachnoid fluid accumulation.(1) Typically the reason for the increased pressure is unknown.
The symptoms of Pseudotumor cerebri include a headache that occurs first thing in the morning or wakes a person at night, nighttime or early morning vomiting, visual field deficits and problems with lateral deviation of the eye caused by sixth cranial nerve palsy. The conditions that are associated with Pseudotumor Cerebri include; obesity, menstrual irregularities, Addison disease, pregnancy, Hypoparathyroidism, Iron Deficiency Anemia, middle ear disease, Vitamin A excess or deficiency, Steroid therapy, Oral Contraceptive use, diseases that obstruct the cerebral spinal fluid pathways and obstruction of the major venous sinuses.(1,2)
You will find that as you become more involved with the health care field that medicine is not an exact science. When it is determined that a certain type of person has a risk factor for a disease or that a disease is associated with other findings, this does not mean that every patient needs to have a certain characteristic or condition in order to be diagnosed. All this means is that through researching past cases, common factors were found. Many times the reason for the association is not known. So the fact that you are not obese does not change your diagnosis of Pseudotumor cerebri.
You did mention that you were diagnosed with a dura sinus thrombosis. This can lead to an obstuction of the major venous sinuses which happens to be an assoociated finding in patients with Pseudotumor cerebri. Chances are this finding contributed to your Pseudotumor cerebri diagnosis more than your weight or level of fitness.
The next thing that I would like to mention is that I am not sure I understand the outcome of the visit with your Neurologist last week. You mentioned that you had a spinal tap to see if your pressure was still high and you were told that your pressure was 165 and normal, suggesting that the Diamox was working and/or that you no longer had a problem with Pseudotumor. I am not a Neurologist, but from the sources that I have, the lumbar puncture of patients with Pseudotumor cerebri demonstrates elevated opening pressure, often more than 20 cm H20. (2) Increased intra-cranial pressure (ICP) is defined as a sustained elevation in pressure above 20mm of Hg/cm of H20. (3 ) So I am not sure that I understand the results of your lumbar puncture reading. Since a reading over 20mm of Hg/cm of H20 is considered elevated, the report that your reading of 165 is normal is confusing. Perhaps the number was miscommunicated to you. I suggest investigating this further by discussing the results and the interpretation of those results with your Doctor.
It is common for a patient and their doctor to attribute new symptoms to a past medical condition. For example, it may be assumed that joint pain is most likely Arthritis in a patient with a history of Rheumatoid Arthritis or headaches are due to a Migraine in a patient with a history of migraines. When symptoms have a different presentation, persist, are resistant to therapy or come without an explanation it is important to step back and look at the whole picture. Sometimes you need to start from the very beginning and evaluate all possible causes of a Headache.
The evaluation should start with a routine screen and physical examination that is typically performed the first time a patient complains of recurrent or chronic headaches.
An initial screening for headaches includes; a physical examination including Vital signs and blood pressure screening, an neurologic evaluation, cardiac evaluation, routine bloodwork screening evaluating liver and kidney function and thyroid levels, imaging studies ruling out an AVM malformation, lesion or mass, an ear, nose and throat examination to rule out sinus or middle ear disease, an ophthalmologic examination and an evaluation of the cervical spine. (4) In addition, all medications and herbal remedies used should be reviewed in order to determine if any interactions or common side effects could be responsible for symptoms.
Hypertension or High Blood Pressure is a potential cause of headaches that may be overlooked. (4) Symptoms of High Blood Pressure include headaches, more frequent nosebleeds than normal and dizzy spells. Although most people with High Blood Pressure have no symptoms at all. (5) Many patients with known High Blood Pressure have told me that they feel a hot sensation in their face or head or humming by their ear when their blood pressure is out of control.
More importantly, in your case, the prescription medication, “Amerge” belongs to the 5-HT1 agonist class and can potentially cause High Blood Pressure as a side effect. (6) In healthy volunteers, dose related increases in systemic blood pressure have been observed after administration of up to 20 mg of oral naratriptan (Amerge). Significant elevation in blood pressure , including hypertensive crisis has been reported on rare occasions in patients receiving 5-HT1 agonists with and without a history of hypertension. (6)
Since you are taking this medication and presently suffering from a reoccurrence of you headaches it would be a good idea to have your blood pressure monitored to make sure that you are not having an elevation in your blood pressure. I also think that it is important to have the pulsing and ‘swooshing” sound in your ear evaluated. Your Neurologist or an Otolaryngologist (ENT specialist) can perform this evaluation. When a patient complains of humming, swooshing or buzzing in only one ear, many times an MRI is ordered in order to determine the cause of the symptoms.
If it is determined that your evaluation is normal, it is likely that you will find that the headaches that you are having are due to a Migraine or a migraine variant such as a Cluster headache. A Cluster headache is a sharp very severe headache that usually localizes in or around one eye. This type of headache often begins 60 to 90 minutes after falling asleep and is commonly associated with tearing and nasal congestion on one side.(6) The cause of Cluster headaches is unknown but alcohol is a known precipitating factor. In some cases a Headache specialist is needed in order to decipher the type of migraine that a patient is having and determine the best course of treatment to relieve the pain.(7)
I hope this information was helpful and that you find resolution to your symptoms soon.
If you are interested in reading other Pediatric Advice Stories about topics discussed:
Cluster Headaches
Chronic Headaches
Migraine Triggers
References:
(1) Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:640-641.
(2)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006.35(5):345-353.(3)Neurosurgery on the Web. Thamburaj A. Intracranial pressure. Available at: http://www.thamburaj.com/intracranial_pressure.htm. Accessed Jan 2007.
(4) Linder S. Understanding the Comprehensive Pediatric Headache Examination. 2005.34(6):442-446.
(5)The Mayo Clinic. High Blood Pressure(Hypertension). Available at: http://www.mayoclinic.com/health/highbloodpressure//DS00100/. Accessed Jan 2007.
(6) Physician’s Desk Reference. 2004. Montvale, NJ. Thomson PDR at Montvale:1425.
(7)Alper B, Passarelli B. Cluster Headache. The Clinical Advisor. 2006. August:85-86.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice About Common Health Problems
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