Daughter born with headaches
DEAR DR. ROACH: My older daughter has had headaches most of her life. When she was young, she thought it was normal.
Severe migraines started around 1995. Many doctors later, they came up with diagnosis of a Chiari malformation. She was on oxycodone, but now she is off addictive painkillers. She suffers for several days when there is a change in the weather. When she gets the headaches, she usually stays in her bedroom and wears sunglasses when she has to take the dogs out. The last one, a few days ago, lasted about three days.
What options does she have to relieve these debilitating headaches?
ANSWER: Chiari malformations are congenital (she was born with it) abnormalities of the base of the brain, including the brainstem and cerebellum. They are more prevalent than previously believed, and with more people getting MRI scans, it is thought to be present in 0.1 per cent to 0.5 per cent of people. There are three classic types of Chiari malformations, but the most likely in your daughter’s case is Chiari malformation Type I, as the other two are rarer and are diagnosed at an early age. CM-1 normally is diagnosed in adolescence or young adulthood.
The symptoms of CM-1 are variable. Some people have no symptoms, but neck pain, headache and damage to various nerves are common.
It sounds to me as though her headaches remain a significant burden on her quality of life. I cannot say whether the Chiari malformation is causing the headaches. Worsening of headache with coughing or sneezing tends to support the CM as the cause. A neurosurgeon with experience in treating Chiari malformations would be worth consulting, and repeat imaging may be necessary, as the condition can worsen or, rarely, improve over time.
If surgery isn’t appropriate, I would recommend a pain-management specialist to help with the headaches. Given her history, opiate drugs are a bad choice. There are many different kinds of options.
I found much information about the disease and support groups at asap.org.
DEAR DR. ROACH: I have blisters on my body that are filled with yellow fluid. I have been to a skin doctor and even got bloodwork done. The doctor recommended that I take prednisone. I was hoping you could recommend a different medication. The doctor’s report said I have bullous pemphigoid.
ANSWER: Bullous pemphigoid is an autoimmune disease, where the body is attacked by its own immune system. It occurs most commonly in older adults. Symptoms often start with an itchy rash that may be indistinguishable from either eczema or hives. Most people will then develop large (1-3 centimetres), tense blisters. These can be severely itchy.
Without treatment, the disease slowly progresses over years, greatly affecting quality of life and even can be life-threatening if the disease attacks the mouth and throat.
However, prednisone is a rapidly effective and inexpensive drug, commonly used as a first-line treatment for people with severe or extensive disease. Some experts use high-potency steroid creams; however, these can be very expensive and hard to use over large areas of the body.
I want to gently remind readers that my primary goal is to educate people about both common and rare diseases. I don’t act as a physician to readers: I can’t, in absence of a thorough history, physical exam and review of the laboratory data.
DEAR DR. ROACH: I seem to have an opposite problem of many of your readers: My blood seems to be too thin. A needle prick takes 20 minutes to coagulate. I have not had any serious bleeding. I have been taking a baby aspirin (81 mg) three times per week. I am a healthy, somewhat athletic male, 64, a vegetarian with BMI of 28. I take only vitamins. I have normal blood pressure and no diabetes, and my cholesterol level is good. Should I stop taking the aspirin? I understand that it also prevents inflammation, so there is a benefit other than blood-thinning.
ANSWER: Aspirin is prescribed to people with cholesterol plaques, as its ability to prevent the blood from clotting has been clearly shown to reduce heart attack risk in people with known blockages in the arteries.
Aspirin works by decreasing the function of platelets, the specialized blood cells that start forming clots. For decades, people at higher risk for heart disease have been recommended aspirin to prevent a first heart attack, even if they aren’t known to have blockages. This is based on several studies that showed a benefit. However, more recent studies have not shown that benefit, and physicians are divided now about who should receive aspirin. The downside is that it can cause serious bleeding, especially in the stomach and intestines.
Aspirin has at least one other major benefit, which is to reduce the risk of colon (and to a lesser extent other) cancers. People with high risk of colon cancer due to polyps or family history may also be recommended to take aspirin for this benefit.
The decision to take aspirin requires an individualized assessment of risk. The U.S. Preventive Services Task Force recommends aspirin for men age 40-60 if their 10-year risk of heart disease is 10 per cent or higher (you can estimate yours at cvriskcalculator.com/).
Twenty minutes is a very long time to bleed, even on aspirin (and your dose is very low). I would be concerned about a separate bleeding problem, such as von Willebrand's disease.
Readers may email questions to ToYourGoodHealth@med.cornell.edu.