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Help with severe headache

  Dear Dr.
  My husband sufferes from severe headaches on a daily basis.  Symptoms include, slurred speech, muscle tremors, loss of coordination, short term memory loss and increasing pain in the head.  Our physician is unable to determine the cause.  The neurologist my husband saw said he was suffering from "rebound" headaches, caused by caffeine.  He promptly stopped using all caffeine, yet the headaches continued.  Meds he takes are valium 10mg, 2x per day, soma as needed to relax neck muscles and DHE45 (injection) if headache is severe.  He has been given just about every type of drug possible but nothing is helping.  He can be perfectly fine one minute and out in la la land in nothing flat.  He has had 2 ct's both of which were fine.  Is there something you could recommend, some sort of testing needed, meds etc.?  This is really affecting our quality of life and our marriage, and we are getting desperate.  Unfortunately we can not come east, (we live in southern california) and do not have any money to travel.  Is there any clinic you could recommend here?  WE sure appreciate your taking the time to answer this.  If there is anything else you need to know please advise me.  Thank you very much.
Dear Cheryl:
I am sorry to hear that your husband has such bad headaches and that it has taken awhile to answer you.  First, it is very difficult to make a diagnosis without a good neurological exam.  So, I will try the best I can.  First, some history.  When did the headaches start, were they migraines, usual headaches relieved by over-the-counter medications that have just gotten worse, any previous trauma, or family history of migraines?.  What is the medical history of your husband, is he in good health, any chronic illness, hospitalizations, surgeries.  Any family history of chronic illness such as collagen vascular disorders, cancers, seizures, autoimmune disorders, early strokes, early MI's, DVT's, early abortions in the females in his family?  What medications is your husband taking? Where in his head are the headaches located, how intense are the pains, will sound or light change the intensity of the headache.  What does he do to make the headache better?  (anything helps?)  What makes his headache worse?  Does  he know when the headaches are coming on?  Do the symptoms(other than the headache) that your husband have ever completely resolve?  When did the symptoms beside the headache start, were they always present with his headaches or are these a new phenomena?  Judging from what has already been diagnosed, it would seem that your husband has what is called a transformed migraine headache, that occurs daily and also gives him neurological signs and symptoms.  A normal CT scan of the brain would rule out a mass, subarachnoid hemorrhage (most likely but not 100% but you would know by now), obstructive hydrocephalus, and intercranial infections.  If there are not ocular findings then likely carotid dissection, closed angle glaucoma, and pseudotumor cerebri. Laboratory test of sedimentation rate, ANA, CBC, complement C3, C4 levels would rule out vasculitis.  The lack of eye pain, anorexia, fever, night sweats, weight loss, scalp tenderness, and jaw claudication would rule out temporal arteritis.  This leaves either a transformed migraine headache or mitochondrial disorder (rare).  If the latter, it has been found that large doses of riboflavin (400 mg/day) help.  If it is the former, what I think your neurologist is leading
towards, then coming off all medications and beginning with one medication such as doxepin or elavil is appropriate (Not used as a psychiatric medication but as a seratonin enhancer).  There is a mitochondrial disorder called MELAS that can produce some of the symptoms you describe.  However, it would be rare that your husband might have this disorder.  There is a mitochondrial expert in your area, at the University of California San Diego (Dr Richard H. Hass, MD).  If any of the blood work showed elevated lactate or ammonia then this might be further checked out by him.  It is extremely unlikely that a seizure disorder could cause symptoms like this, especially without a history of a seizure disorder.  I am sure that this has been thought of and worked up.  I wish you luck and hope the headaches get better.  Keep us informed.
CCF Neuro[P] MD, RPS    

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