Migraines and diving

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Interesting thread; I've learned something from it. Thanks Lulubelle.

However, there was still that niggling thought in the back of my mind in regard to PFOs (right to left shunt), especially since I dive SO much. So I went a couple of years ago and got myself checked out via a trans-esophageal echocardiogram and a bubble test with agitated saline with and without Valsalva maneuvers. Happily, I have no PFO and my migraines are "just" migraines--apparently not a major issue for me in as far as diving is concerned.

Lulu, this doctor seems quite convinced that you shouldn't be diving, perhaps even since he has brought up secondary reasons (the sepsis) to discourage you. Not that I'd recommend "shopping" for a doctor in order to find one who will tell you what you want to hear, but have you thought about getting another opinion so that you can make a more informed decision to continue diving as you currently do or to adapt your diving somehow to your physical constraints?

The PFO thing had occurred to me too. I may have it ruled out as I do deeper dives here in NC. It would be reassuring to know that I didn't have this working against me.

I don't think this doctor really took the time to gather the facts, not the least of which was my understanding of my migraines, their triggers, their management, the absence of concerning neurological symptoms, and the absence of any migraines while diving. The sepsis had nothing to do with diving, that was due to a medication I take, not a chance I would have lasted 4 days had I been exposed while diving. Doesn't mean it can't happen again, in the water, in an airplane, on the beach, etc. The world is dirty. This doc was not a diver, and everything he spoke to was theory.

Had he given me a valid data based rather than theoretical reason or explanation for his recommendations, I might be inclined to take them, but he did not.

I read the DAN content on migraines which said that migraines were generally of no consequence to divers in the absence of serious neurological symptoms and spoke with a physician there today. He agrees that these recommendations sound a bit extreme and recommended that I get a second opinion which I'll do.
 
I'm still confused. Were you on an immunosuppressive medication? Or did you just have a syndrome that appeared to be sepsis, but turned out to be anaphylaxis or some other side effect of a medication? If you were on immunosuppression, the disease entity underlying the need for that might trump anything else, in terms of concerns about diving.
 
FWIW, there is data to suggest that a NO-mediated mechanism underlies other types of headache as well. If you are interested, you can do a Pubmed search for the terms "nitric oxide" and "headache." You should get numerous hits.

For more info about CGRP, the Wikipedia entry is surprisingly good.

I hope that this post clarifies things a little...

Thanks for taking the time to clarify that question. It does raise another question in my own mind, though, and I hope it's an easy one to answer. I have been diagnosed with not just one, but two types of migraine--the "classic" variety and the "cluster headache" variety. (Poor me!) Several years ago a headache doctor (more properly a "pain" specialist) who was also a migraine sufferer (cluster headaches) put me on calcium blocker meds, telling me that there was some evidence that they might help prevent or diminish the strength of "classic" headaches. He said there wasn't evidence that they did anything at all for the "cluster" type. Is this all related to the CGRP-linked-to-migraine studies?
 
Try the extract of butterbur and B2. That data is actually pretty good. I got that from the head migraine guy at Duke. I won't take prescription drug prophylaxis and am not at a point where I need it.

I've never heard of that. Interesting. Thankfully since menopause my migraines are almost gone. I hope for your sake, you don't follow your aunt. I was getting 7-10 migraines a month when I started peri-menopause. (sorry men, TMI)



Well, he is right, there are yucky things being cultured in oceans and off of beaches. But I just can't stop going out in the world now, can I?

Haha, I was teasing about the drysuit and helmet! Although, your waters may almost be chilly enough.


I like the "Go Diving" recommendation. Preferably with Nitrox...
 
A relationship between the presence of PFO and increased DCI risk is certainly possible. This work may be of interest to you. I realize that the linked paper is on a mouse model. :)

Comment: Although the mouse study you linked is suggestive, well controlled studies involving humans seem to show no statistically significant relationship until PFOs of quite substantial size are involved.


1. “Circulation. 2010 Mar 30;121(12):1406-12. Epub 2010 Mar 15.

Lack of association between migraine headache and patent foramen ovale: results of a case-control study.

Garg P, Servoss SJ, Wu JC, Bajwa ZH, Selim MH, Dineen A, Kuntz RE, Cook EF, Mauri L.

Division of Cardiology, Brigham and Women's Hospital, Boston, Mass 02115, USA.

Comment in:

Circulation. 2010 Mar 30;121(12):1377-8.

Abstract

BACKGROUND: Clinical observations of migraine headache symptoms in patients with a patent foramen ovale (PFO), both of which conditions are highly prevalent, have raised the question of a possible pathophysiological relationship. We sought to evaluate the assumption of an association between migraine headaches and the presence of PFO by use of a large case-control study.

METHODS AND RESULTS: We conducted a case-control study to assess the prevalence of PFO in subjects with and without migraine. Case subjects were those with a history of migraine (diagnosed by neurologists at a specialty academic headache clinic). Control subjects were healthy volunteers without migraine 1:1 matched on the basis of age and sex with case subjects. Presence of PFO was determined by transthoracic echocardiogram with second harmonic imaging and transcranial Doppler ultrasonography during a standardized procedure of infused agitated saline contrast with or without Valsalva maneuver and a review of the results by experts blinded to case-control status. PFO was considered present if both studies were positive. Odds ratios were calculated with conditional logistic regression in the matched cohort (n=288). In the matched analysis, the prevalence of PFO was similar in case and control subjects (26.4% versus 25.7%; odds ratio 1.04, 95% confidence interval 0.62 to 1.74, P=0.90). There was no difference in PFO prevalence in those with migraine with aura and those without (26.8% versus 26.1%; odds ratio 1.03, 95% confidence interval 0.48 to 2.21, P=0.93).

CONCLUSIONS: We found no association between migraine headaches and the presence of PFO in this large case-control study.”

2. Can J Neurol Sci. 2009 Nov;36(6):740-4.

Contrast echocardiography and migraine in divers with patent foramen ovale.
Di Fabio R, Giugni E, Angeloni I, Vanacore N, Casali C, Pierallini A, Vadalà R, Pierelli F.

Department of Neuromotor Rehabilitation, Sapienza University of Rome Polo Pontino-ICOT, Latina, Italy. rob.dif@tiscali.it

Abstract

BACKGROUND: It has been proposed that the patent foramen ovale (PFO) may be associated with migraine, in particular migraine with aura. However, it is not clear whether paradoxical embolism triggers crises of headache. Cerebral embolization is provoked in subjects with PFO through contrast echocardiography, a safe method to diagnose the presence of foramen ovale pervium.

METHODS: Twenty-four men practicing diving, an activity characterized by increased prevalence of PFO and migraine, underwent trans-thoracic echocardiography with contrast solution, composed of saline and air mixture and checked for the occurrence of migraine in the following 24 hours.

RESULTS: A PFO (five of minimal size, i.e. visible only during Valsalva, one of small and two of medium size) was detected in 8/24 divers (33%). No one reported headache over the 24 hours after the procedure.

DISCUSSION: Our preliminary data suggest that cerebral micro-embolism, provoked by contrast echocardiography, does not systematically trigger migraine crises when a minimal-to-medium sized patent foramen ovale is present.”

3. “Chest. 2010 Feb 12. [Epub ahead of print]

Small and Moderate Size Right-to-Left Shunts Identified By Saline Contrast Echocardiography Are Normal and Unrelated To Migraine Headache.
Woods TD, Harmann L, Purath T, Ramamurthy S, Subramanian S, Jackson S, Tarima S.

dagger Wheaton-Franciscan Health Care, Racine WI.

Abstract

BACKGROUND: We suspected based on clinical experience that the prevalence of both intracardiac and pulmonary arteriovenous malformations (PAVM) are higher than previously reported in a healthy population when using modern ultrasound technology combined with a rigorous saline contrast echo (SCE) protocol. We hypothesized the prevalence of right-to-left shunts (RLS) would be so high when employing this sensitive technique, there would be no significant association of RLS with migraine headache.

METHODS: We recruited 104 healthy volunteers to undergo a SCE followed by completion of a migraine questionnaire. The SCE were meticulously graded for shunt size and location based on left heart contrast quantity and timing. The migraine headache questionnaire was graded by a neurologist blinded to SCE results.

RESULTS: 104 volunteers underwent the study protocol. We found 71% of volunteers exhibited evidence of RLS. PFO was identified in 40(38%), PAVM in 29 (28%), and 5 subjects had evidence of both (5%). Based on questionnaires, 42 (40%) of the volunteers had migraine headache (29% with aura). There was no significant association of migraine headache with PFO (OR 0.59, 95% CI 0.16-2.12, p=0.54) or PAVM (OR 0.8, 95% CI .34-1.9, p=0.67), although only 13 (13%) of volunteers had evidence of large RLS.

CONCLUSIONS: When using modern ultrasound technology combined with a rigorous SCE technique, the majority of healthy volunteers demonstrate some degree of RLS. PAVM in an otherwise healthy population is common. Small and moderate size RLS do not appear to be significantly associated with migraine headache.”

4. “Curr Pain Headache Rep. 2009 Jun;13(3):221-6.

Patent foramen ovale and migraine: association, causation, and implications of clinical trials.

Tepper SJ, Cleves C, Taylor FR.

Center for Headache and Pain, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. teppers@ccf.org

Abstract

Patent foramen ovale (PFO) appears to be associated with migraine with aura (MA), probably through cardiac shunting. PFOs may also be comorbid with cryptogenic strokes. Although multiple open-label, retrospective, and case-controlled studies have noted sometimes dramatic reductions of MA after PFO closure, the only prospective sham-controlled study of PFO closure for MA, MIST, was negative for all primary and secondary measures of migraine improvement. MIST did demonstrate an association between MA and severe PFO shunts prospectively. Difficulty with recruitment closed the MIST II and ESCAPE trials; the PREMIUM and PRIMA randomized controlled trials are ongoing at the time of this writing.”

Regards,

DocVikingo
 
Yeah, I got it all wrong: migraine symptoms masquerading as DCI. PFO detection is limited to certain methods. It's possible that your cardiologist didn't perform the tests (transcranial doppler or transesophageal echocardiogram) to reveal the presence of PFO. FWIW, PFO can't be diagnosed by cardiac stress tests, EKG, bloodwork, heart exam using stethoscope, or transthoracic echocardiogram.

Correction. The research shows that PFO most assuredly can be detected by transthoracic echocardiogram (TTE) (typically using a contrast agent and provocation procedure). However, the detection rate is much superior with transesophageal echocardiogram (TEE) and transcranial Doppler (TCD) using a contrast agent and provocation procedure, and these are the preferred procedures in the majority of circumstances.

Regards,

DocVikingo
 
What is known about Maxalt and Imitrex reveals no theoretical issues with recreational diving.

There are no reports to date, of any issues with such drugs in any type of diving.

Both drugs typically have 1/2 lives of ~ 2 hours or less. In 12 hours 98% is gone, in a day 99.99% of the drug is gone. So if a doc is completely conservative just don't dive for a day or less.

In practice, I've seen a number of real divers dive with all kinds of drugs, including Imitrex. As expected, nothing to report, so I'm not sure what this dive doc is considering.

Agreed.

Regards,

DocVikingo
 
I read the NIH paper. So how does one get hyperbaric O2 treatment outside of research settings?

Hi lulubell,

Headaches in and of themselves, migraine or otherwise, are not included in the UHMS INDICATIONS FOR HYPERBARIC OXYGEN THERAPY (Indications). In essence this means you can obtain HBOT for them by being in a reserarch protocol and or paying out of pocket. Don't anticipate any assistance from your health coverage.

Regards,

DocVikingo
 
https://www.shearwater.com/products/peregrine/

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