Case studies in headaches-2 & 3

Case 2

A 72-year-old woman develops headaches in the past month. They are located all over her head, and she describes aching of her shoulders, neck, and head. It has become painful to brush her hair, and she notes tenderness over her temples.She feels “just awful” and even has some weight loss and a low-grade fever. She notes that when she chews her jaw aches.

When someone over 50 years of age develops a new headache that is associated with tenderness of the scalp or temples, it needs emergent attention. This could represent temporal arteritis; an inflammation of arteries,which if untreated can lead to blindness in one out of three people. Usually people with temporal arteritis feel achy and generally awful.

Often the scalp hurts even more when they are out in the cold weather. It is amazing how tender the scalp can become with this condition,and hair brushing can become quite an ordeal. Often, chewing food causes even more pain in the jaw or in the tongue. A simple blood test, an ESR (erythrocyte sedimentation rate), is performed. An abnormal ESR is highly suggestive of temporal arteritis. If temporal arteritis is suspected, a biopsy of the artery in the temple is indicated.

Case 3

A 52-year-old woman has a long history of migraine with her periods. They are difficult to treat. She is delighted that after menopause last year, they went away. Wanting estrogen replacement therapy, she is placed on Premarin. Now her migraines are back, and she does not know what to do.

After menopause, the levels of estrogen remain low and estrogen withdrawal is less likely. Frequently, when a woman who had severe menstrual migraines becomes menopausal, the whole problem resolves. Then she starts taking estrogen replacement therapy (ERT), and the headaches return. Whether it is good or bad for you to take estrogens after menopause is controversial, and we are not going to discuss all of the arguments. Is it possible to take estrogen and still benefit from a natural reduction of migraine that being postmenopausal brings? The answer is “maybe”.

You cannot predict what will happen to your migraine if you take estrogen replacement therapy. Usually something happens, however. The most common form of estrogen replacement therapy is the use of Premarin,which is a mixture of multiple forms of estrogen. It appears that estrogen patches, which release estrogen gradually, therefore preventing precipitous falls, seem least likely to worsen the problem and the most likely to help.Other estrogen preparations may also be acceptable; particularly those which also contain male sex hormones.

Look also for implantable forms, which give very even,continuous levels, to be available in the future.