Author: noorali

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Migraine Headaches

Dear Dr. B: I was wondering if you could write your next column on the topic of migraine headaches. What causes them? How can you deal with them?

Migraine is a severe headache. It is often associated with severe pain on one or both sides of the head, nausea, vomiting and visual disturbance. It is the most common type of vascular headache.

Migraine headache affects 28 million Americans, 75 percent of whom are women. The first attack occurs between the ages of five and 35 years. It is rare to have first attack after the age of 40. The frequency of attacks varies a lot. But the frequency becomes less as the person gets older.

There are many types of migraine headaches. The two most common types are – the classic migraine and the common migraine.

The classic migraine is preceded by an aura – a person may see flashing lights, zigzag lines, or temporarily lose vision. There may be speech difficulty, weakness of an arm or leg, tingling of the face or hands, and confusion.

Common migraine is more common in general population. There is no preceding aura. There may be vague symptoms of mood changes and fatigue. There may be nausea, vomiting, diarrhea and increased urination.

What causes migraine headaches?

There is no known precise cause of migraine headaches. The theory is individuals have blood vessels that overreact to various triggers. This results in chemical changes in the blood and in the caliber of the blood vessels in the brain. First the blood vessels narrow and then after a while they rapidly widen and severe headache develops.

Stress and certain foods (like chocolates and cheese) can trigger an attack. Some people are affected by fatigue, glaring or flickering lights, and changes in the weather and at the time of menstruation. This list is by no means complete.

Although many sufferers have a family history of migraine, the exact hereditary nature of this condition is still unknown.


Do I need any tests?

Most of the time migraine headache can be diagnosed by your physician from your symptoms. A physical examination shows no detectable abnormalities during an acute migraine attack. Rarely CT scan or MRI of the brain is done to rule out serious causes like a brain tumor.


What is the treatment?

The object of the treatment will be:

-Drugs to reduce the duration of acute attacks
-Drugs to help treat symptoms
-Drugs to prevent future attacks

There are several drugs in each category. It will be futile to name them here. The best thing is to discuss with your family doctor. He will find an appropriate medication which suits your needs.


Can it be prevented?

You need to identify the factors which trigger your migraine. Keep a diary for few weeks to identify the triggers and then avoid them. Eat regularly and follow a regular sleep pattern. If life is stressful then learn to do some relaxation exercises. Laughter and meditation may help.

You can also visit Migraine Association of Canada’s website: www.migraine.ca (under construction but has some links) or contact them by e-mail: support@migraine.ca.


Thought for the week:

“What good is perfect eyesight when you are inwardly blind?” – From Images and Reflections by Dennis van Westerborg, a local artist and writer.

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Canada’s Healthcare System

Canadians say that proper funding and management of our health care system should be our number one priority. And elections in Canada are won or lost on what the politicians say about our health care system.

According to the Health Canada website, the Canada Health Act contains nine requirements that the provinces and territories must meet in order to qualify for the full federal cash contributions. Out of these nine criteria, five are program criteria about which we hear a lot. These five criteria require that our health care:
-should be publicly administered on a non-profit basis
-should be comprehensive and must insure all insured health services
-should be universal, all insured residents of a province or territory must be entitled to the insured health services
-should be portable, residents moving from one province or territory to another must continue to be covered for insured health care services
-should be accessible, so that the residents have reasonable access to insured services

How much does it cost to run this huge enterprise?

Total health expenditures in 2000-2001 amounted to $3,174 per capita. Currently, I believe, it costs $120 billion a year to run this big enterprise.

For $120 billion a year we should have a perfect system. But we don’t. It is one of the best in the world but it is not perfect. Is it ever going to be perfect? Definitely not. Nothing is perfect.

So, what ails our health care system? Why it cannot be perfect?

Waiting times are too long – but what does it mean? Nobody has defined this issue yet! Drugs are too expensive – but is there a reasonable plan to curtail the cost? Emergency departments are too crowded. So, how can we fix this? Do we need more ER doctors or nurses or more ER departments? Nobody has figured it out yet.

There is shortage of doctors and nurses and other health care providers but no plans to immediately provide a remedy. There are 4000 international medical graduates who are looking for work. They are allowed to come into this country but there are no plans to absorb them into our system. We cannot use their skills and education. They serve this country by delivering pizzas and driving taxis – not to mention doing other non-medical jobs.

There are inadequate Home Care services. There is shortage of medical equipment. There is shortage of acute and long term care beds.

When Paul Martin became Prime Minister, he promised to fix the health care system for a generation. He called the First Ministers conference and offered them some money – $41.3 billion in new federal funding over 10 years.

Is this going to fix the problems for a generation?

Of course not. Nothing is ever fixed permanently. You have to keep working at it. Our health care system is like a big jigsaw puzzle – you have to have all the pieces in place for the system to work properly. Unfortunately, some pieces are bigger than others so all the pieces will never be in place at the same time.

What do the Canadians think? They are torn between reality and perception. “They say the system is crumbling but are largely happy with their experiences when they use it,” says an editorial in the Medical Post.

Finally, the health care system will never be a perfect system as long as the provinces and the federal government play politics with it.

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Vioxx Withdrawal

Vioxx is off the shelves and off the medicine cabinets. In five years, Vioxx took a dive from being a super drug for arthritis and acute pain to the dust bin.

It was a made in Canada drug. Last year, 3.4 million prescriptions were filled by Canadians, and 84 million people swallowed the pill around the world. Worldwide sales of Vioxx in 2003 were $2.5 billion.

Soon after the withdrawal of Vioxx, the stock price of Merck and Co., a U.S.-based pharmaceutical giant, the world’s second-largest drug maker, fell $12.07, or 26.8 per cent, to close at an eight-year low of $33 in New York.

The company’s legal problems continue to grow as it was hit with class-action lawsuits in Canada and USA.

So, why all the fuss about Vioxx?

It is simple. It is a good drug for arthritis and acute pain but it is not good for the heart. And here is how they found out.

A study was designed to evaluate the efficacy of Vioxx 25 mg. in preventing recurrence of colon and rectal polyps in patients with a history of colon and rectal adenomas (pre-malignant polyps).

The study, involving 2,600 patients between the ages of 40 and 96, was to have lasted three years. But last week, just 18 months into the research, the company learned the risk of heart attack and stroke was double in patients taking Vioxx and halted the trial.

This information was not new to the company. Previous studies had created a suspicion that Vioxx might be bad for the heart. The question is: Why did it take so long for the company to come to grips with the situation? Is there something wrong with the regulations, the way new drugs are brought into market?

Two weeks ago, we discussed in this column, the side-effects and dangers of using non-steroidal anti-inflammatory medications (NSAIDS). The column can be read again on my website: www.nbharwani.com. These drugs are used to treat arthritis but do increase the risk of ulcers or bleeding in the stomach in the long term. Vioxx comparatively had fewer gastrointestinal complications.

The drug had become very popular. Some doctors have even prescribed Vioxx to young girls to treat menstrual cramps although it is not approved for use in children.

Why does Vioxx increase the risk of heart problems?

The answer is not clear. It probably raises the blood pressure. Now the tables have turned. At this time, I presume, the blood pressure of the CEO of Merck and Co. must be fairly high.

What happens now?

Arthritis affects millions of Canadians and they are all looking for pain relief. Nobody likes pain. Especially, if it is painful to move and walk. There are many drugs in the market for arthritis. Your physician will have to carefully evaluate your situation and advise you accordingly. Do not make any drastic or sudden changes in your medications until you have discussed the situation with your doctor.

Thought for the week:
“I joined a health club last year, spent about 400 bucks. Haven’t lost a pound yet. Apparently, you have to go there.”

E-mail from a friend.

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Skin Cancer

Dear Dr B: Recently I had surgery for skin cancer called basal cell carcinoma. Besides surgery, are there any other options for the management of this cancer?

Basal cell carcinoma (BCC) is a form of skin cancer and is the most common cancer found in humans.

BCC and squamous cell carcinoma (SCC) are also known as non-melanoma skin cancers. Melanoma is the third type of skin cancer. Approximately 30 percent of the malignant skin cancers diagnosed among Albertans each year are non-melanoma skin cancers – BCC and SCC.

Non-melanoma skin cancers account for greater than one million new cases of cancer annually in the United States and are responsible for 1200 to 1500 deaths per year. Costs of US$500,000,000 have been estimated in the management of these malignancies.

BCC usually grows slowly. It is locally invasive and does not spread to distant parts of the body – liver, lung, brain, bones etc. But melanoma can spread to other organs of the body.

The clinical outcome of BCC is difficult to predict. It may remain the same size for many years or it may grow rapidly. It can cause local destruction of tissues especially on the face.

BCC can occur at any age but the incidence increases over the age of 40. The incidence among the young people is increasing due to increased exposure to the sun.

Who are prone to skin cancer?

People who have fair skin, have tendency to freckle, have high degree of sun exposure, make excessive use of sun beds, had previous radiotherapy or phototherapy, male sex, and those who have genetic predisposition.

How is BCC treated?

“The first line treatment of BCC is often surgical excision. Many alternatives are available, including curettage, cryosurgery, laser treatment, surgical excision with predetermined margins of clinically normal tissue, excision under frozen section control, Moh’s micrographic surgery, radiotherapy, topical treatment, intralesional treatment, photodynamic therapy, immunomodulators, and chemotherapy”, says an article in the British Medical Journal.
The article says that although many treatments are used for BCC, little research is available that accurately compares these different treatment methods against each other and for different types of tumour.

If BCC is not adequately treated then two thirds of recurrent tumors appear in the first three years of treatment and 18 percent appear between five and 10 years after treatment.

According to the BMJ article the following treatments are most often used in the management of BCC:

• -excisional surgery – seems to be the most effective with low recurrence rate,
• -curettage and cautery,
• -radiotherapy,
• -cryotherapy, and more recently
• -photodynamic therapy and
• -imiquimod cream – preliminary studies suggest a short term success rate of 87-88 percent for imiquimod cream in the treatment of superficial basal cell carcinoma, although this cream has not been compared with surgery.

Surgery remains the main stay of BCC management. More research is required to compare imiquimod cream with surgery. Other methods of treatment have not shown to be superior to surgery.

Prevention of skin cancer is very important. This should start in childhood. Reduce exposure to sun, use sunscreen, use wide-brimmed hat, and have suspicious looking moles removed surgically. More than 90 percent of skin cancers occur on sun-exposed areas of the body.

If you like to worship sun, then expect to burn and eventually get cancer.


Thought for the week:

“Exercise will make you fit, but fitness and health are not synonymous. Exercise alone is not enough to make you healthy. To achieve good health, exercise is an essential part of a compressive lifestyle program ……….”

Dr. Dean Ornish’s Program for Reversing Heart Disease.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!