Complex Migraine Symptoms and Their Management

The chief complaint is migraine?

Hello, Doctor.
I apologize for writing this as I have multiple symptoms.
My migraines are accompanied by tinnitus, and the pain can last for several days.
Sometimes, I experience a heavy sensation in my head that causes it to droop forward.
Occasionally, the muscles in my left neck tighten, and when I look in the mirror, my left side appears misaligned.
I have pain in my left shoulder and chest, and I can't speak too much because I feel short of breath, which makes my head feel even more dizzy and causes tightness in my neck and chest.
Even running just twenty meters causes persistent pain.
When I feel anxious, the tightness can make me feel nauseous.
I have experienced episodes of blurred vision and a drifting sensation in my left visual field, as if it is moving downward.
A doctor prescribed Clonazepam for me, 0.25 mg taken at bedtime, which helps me feel more relaxed upon waking, but the symptoms return after I eat breakfast.
I also have digestive issues with gastroesophageal reflux, which causes gas to rise to my head, triggering my symptoms.
Given this information, which specialty should I consult? My blood pressure is between 90-105 over 50-60, with a pulse of 60-80, and I have mild Mediterranean anemia and mitral valve prolapse syndrome with panic disorder.
A head MRI was normal, a stress echocardiogram was positive, and a myocardial perfusion scan showed 2% ischemia, which the doctor said is mild (as I also have related cardiac symptoms).
My thyroid tests are normal, and my carotid ultrasound is also normal.
I feel so distressed that I can't go to work.
Thank you for your help, Doctor.

Xiao Jingzi, 40~49 year old female. Ask Date: 2017/07/18

Dr. Chen Taicheng reply Family Medicine

● There are many causes of headaches, with common types including migraines and tension-type headaches.
Migraines are characterized by moderate to severe pain that can last from 4 to 72 hours, often unilateral, and may be accompanied by pulsating pain, nausea, vomiting, and exacerbation due to light, sound, or daily activities.
Some migraines may have an aura, which can present as a tingling sensation.
Tension-type headaches are usually mild to moderate and persistent, often related to stress or poor sleep, and typically present as a feeling of tightness around both sides of the head; they can sometimes also cause neck pain.
Based on your description, including visual disturbances, it seems more like a migraine.

● There are many causes of tinnitus, but the most important step is to rule out the possibility of hearing loss, such as Meniere's disease (which often presents with vertigo, hearing loss, and tinnitus) or sudden sensorineural hearing loss (which may also include tinnitus).
Most tinnitus is subjective, meaning only you can hear it, and potential causes include outer ear conditions (such as earwax blockage or otitis externa), middle ear conditions (such as tympanic membrane perforation or otitis media with effusion), inner ear conditions (such as Meniere's disease or ototoxic medications like certain antibiotics and anti-inflammatory pain relievers), and issues with the auditory nerve pathways.
● Tinnitus can occur simultaneously with headaches, most commonly associated with migraines, but it can coexist with other types of headaches as well.

● Tinnitus is an annoying symptom, but there are medications and various non-pharmacological treatments that can help improve it (though they may not necessarily cure it).
It is recommended to consult an ENT specialist to determine if there are any middle ear or systemic issues.
● A myocardial perfusion scan showing a 2% ischemia level is considered very mild and does not indicate significant cardiovascular disease.
Multiple tests have shown no issues with the brain, thyroid, or carotid arteries.
● Your issues appear to be migraines + tinnitus + panic; there are many pharmacological and non-pharmacological approaches that can help.
Please consult with both a neurologist and a psychiatrist for a combined evaluation.
Wishing you good health, Dr.
Chen Tai-Cheng from Taoyuan Hospital Family Medicine Department is concerned about you.

Reply Date: 2017/07/18

More Info

Understanding complex migraine symptoms and their management can be quite challenging, especially when multiple symptoms overlap and affect daily life. Based on the symptoms you've described, it seems you are experiencing a combination of migraine, tension-type headaches, and possibly some anxiety-related symptoms. Let's break down your situation and explore potential management strategies.

Symptoms Overview
1. Migraine Symptoms: Your migraines seem to be accompanied by tinnitus (ear ringing), prolonged pain, and a sensation of heaviness in your head. Migraines can often cause associated symptoms like neck stiffness, which you mentioned, and can lead to muscle tension in the shoulders and neck.

2. Tension and Anxiety: The tightness in your neck and shoulders, along with feelings of anxiety and nausea, suggest that stress may be exacerbating your headaches. Anxiety can lead to muscle tension, which in turn can trigger or worsen headache symptoms.

3. Visual Disturbances: The visual symptoms you described, such as blurred vision and changes in your visual field, can be associated with migraines, particularly migraine with aura. These symptoms can be alarming and may require further evaluation.

4. Gastroesophageal Reflux Disease (GERD): Your mention of digestive issues and acid reflux could also be contributing to your headache symptoms. GERD can lead to discomfort that may trigger headaches or exacerbate existing ones.

5. Cardiovascular Symptoms: Your blood pressure readings and heart-related symptoms, including mitral valve prolapse and panic attacks, could also play a role in your overall condition. Stress and anxiety can lead to increased heart rate and blood pressure fluctuations, which may contribute to headache symptoms.

Recommended Specialists
Given the complexity of your symptoms, it would be beneficial to consult with a few specialists:
1. Neurologist: A neurologist specializes in headaches and migraines. They can help determine if your symptoms are indeed migraines or if another type of headache disorder is present. They may also explore preventive treatments or medications that could help reduce the frequency and severity of your migraines.

2. Psychiatrist or Psychologist: Since anxiety and panic symptoms are present, a mental health professional can assist in managing anxiety, which might help alleviate some of your physical symptoms. Cognitive-behavioral therapy (CBT) or other therapeutic approaches can be beneficial.

3. Gastroenterologist: Given your digestive issues, consulting a gastroenterologist can help manage GERD and any related symptoms. Proper management of reflux may reduce the frequency of headaches triggered by digestive discomfort.

4. Physical Therapist: A physical therapist can help with neck and shoulder tension through targeted exercises and techniques to relieve muscle tightness, which may also help reduce headache frequency.

Management Strategies
1. Medication: You mentioned taking Clonazepam (克癲平), which can help with anxiety and muscle relaxation. However, it’s essential to discuss with your doctor whether this medication is appropriate for your situation, especially if it leads to side effects or if you find it ineffective.

2. Lifestyle Modifications: Regular exercise, a balanced diet, and adequate hydration can help manage migraine triggers. Stress management techniques, such as mindfulness, yoga, or meditation, can also be beneficial.

3. Headache Diary: Keeping a headache diary can help identify triggers and patterns in your migraines. Note when headaches occur, their severity, duration, and any associated symptoms. This information can be valuable for your healthcare providers.

4. Avoiding Triggers: Identify and avoid known triggers, such as certain foods, stress, lack of sleep, or dehydration. Managing your environment to reduce stressors can also be helpful.

5. Regular Follow-ups: Regular consultations with your healthcare providers will help monitor your symptoms and adjust treatment plans as necessary.

Conclusion
Your symptoms are complex and multifaceted, requiring a comprehensive approach to management. By consulting with the appropriate specialists and implementing lifestyle changes, you can work towards reducing the impact of migraines and associated symptoms on your daily life. Remember, it’s essential to communicate openly with your healthcare providers about all your symptoms and concerns to develop an effective treatment plan tailored to your needs.

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