Migraines and diving

[lulubelle]

Please, dive medicine folks, weigh in here. I am wondering what the range of opinion is here.

I have migraines, 2-3 a month. Most of the time I will wake up very early with them, and if they come at other times of the day, it usually starts as a tension headache and progresses with plenty of warning which make treating them easier. The pain is followed by nausea and vomiting some of the time. I use triptans.

So I saw a proper dive medicine doctor today. I was surprised that the migraines were his major point of focus, that he would have me stop diving entirely if I was willing to, in lieu of that, he recommended severe limitations. I understand the fact that DCI and migraines could look similar, but I have a hard time believing that I wouldn't know the difference as my migraines are never sudden in their onset and that L orbital pain is unmistakable.

I was glad to learn of the risk of triptans because there is a suitable work around for that and I'm glad I know about that.

I occasionally have headaches post dive which resolve quickly but have never had a migraine while diving.

So then I read the material on the DAN website and read that migraines are of little consequence to divers.

So what to think? I believe that this doc knows a lot more than I do, but I am unsure what to do given the discrepancy in opinion.

 

[Bubbletrubble]

You are viewing migraine headache as a completely separate medical condition from DCI...with migraine masking DCI symptomatology. It's possible that the two may actually be related. There is some research on the coincidence of migraines and PFO. 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.

There is likely a vascular component to migraines. In fact, it has been hypothesized that migraine with aura occurs due to hypoperfusion of the brain. A possible pathogenetic mechanism involves the introduction of air microemboli into the cerebrovasculature. For non-medical people who might stumble upon this thread, bubbles in the blood might be causing your migraines.

I suspect that your infrequent post-dive headaches are caused by CO2 retention.

 

[lulubelle]

You are viewing migraine headache as a completely separate medical condition from DCI...with migraine masking DCI symptomatology. It's possible that the two may actually be related. There is some research on the coincidence of migraines and PFO. 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.

There is likely a vascular component to migraines. In fact, it has been hypothesized that migraine with aura occurs due to hypoperfusion of the brain. A possible pathogenetic mechanism involves the introduction of air microemboli into the cerebrovasculature. For non-medical people who might stumble upon this thread, bubbles in the blood might be causing your migraines.

I suspect that your infrequent post-dive headaches are caused by CO2 retention.

I think his point was that due to the symptoms present, one could not differentiate a migraine from DCI. So I might have a 50K flight off of a boat for migraine treatment unneccessarily, or worse, untreated DCI which I thought was a migraine. What he was saying was that the two could not be differentiated. So just what do I DO with his opinion?

I suspect I don't have a PFO as my heart was thoroughly studied last year for unrelated reasons. But interesting thought. I don't have auras if that matters to the little rats.

Re the post dive "regular" headaches...I yoga breathe down under and am relaxed, so how might I be getting too much CO2? Anything I can do about that?

 

[Bubbletrubble]

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. Perhaps the reason for you getting the cardiac work-up didn't warrant formal PFO testing.

Hmmm. I'm not sure how auras might figure into the cerebrovascular cause underlying the migraine. Perhaps the aura indicates hypoperfusion in the visual cortex (occipital region).

If you breathe too slowly or inefficiently for a given metabolic demand, you will retain CO2. Some divers suffer from CO2 retention because they aren't fully exhaling. This can be associated with shallow breathing, using your lungs to control your buoyancy too much, or simply feeling uncomfortable underwater. These don't seem to apply to you.
Other divers get CO2 retention hits when they overexert themselves underwater. One thing that I'm sure you can do is decrease your activity level underwater. You could choose sites that don't feature a strong current (is this possible off the coast of NC?) or employ techniques to "hide" from the current during the dive.

You mentioned that your post-dive headaches happen only occasionally. I wonder if you have a tendency to get such headaches when you are doing deeper dives and are working harder at depth. Perhaps you should keep track of your underwater activity level, dive profile, and the headaches you experience post-dive. Maybe you might see some sort of correlation.

 

[lulubelle]

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. Perhaps the reason for you getting the cardiac work-up didn't warrant formal PFO testing.

Hmmm. I'm not sure how auras might figure into the cerebrovascular cause underlying the migraine. Perhaps the aura indicates hypoperfusion in the visual cortex (occipital region).

If you breathe too slowly or inefficiently for a given metabolic demand, you will retain CO2. Some divers suffer from CO2 retention because they aren't fully exhaling. This can be associated with shallow breathing, using your lungs to control your buoyancy too much, or simply feeling uncomfortable underwater. These don't seem to apply to you.
Other divers get CO2 retention hits when they overexert themselves underwater. One thing that I'm sure you can do is decrease your activity level underwater. You could choose sites that don't feature a strong current (is this possible off the coast of NC?) or employ techniques to "hide" from the current during the dive.

You mentioned that your post-dive headaches happen only occasionally. I wonder if you have a tendency to get such headaches when you are doing deeper dives and are working harder at depth. Perhaps you should keep track of your underwater activity level, dive profile, and the headaches you experience post-dive. Maybe you might see some sort of correlation.

Or DCI masquerading as a migraine.

I had multiple echos, but not a transesophageal echo or transcranial doppler. Perhaps it wouldn't be a bad idea to rule out PFO.

No current free sites here, but good idea about keeping track of whether the post dive headaches occur on the deeper dives. I think you may be on to something there.

Thanks!

 

[Saturation]

Migraine is not a disease that disqualifies one from diving. Its especially helpful that you can discern the migraine h/a from a post dive h/a, migraine has a characteristic pattern and prodrome.

DCS presenting as a headache alone is uncommon; if it did represent DCS it will eventually progress to DCS if left untreated so thus, it would also be associated with more typical symptoms and signs, helping the diagnosis.

It is not definitive, but most migraine sufferers I know, get their h/a improve with diving and hyperbaric 02 Rx, not trigger it. Some get addicted to it to prevent h/a from happening, but again, that's anecdotal.

http://www.ncbi.nlm.nih.gov/pubmed/18646121

Please, dive medicine folks, weigh in here. I am wondering what the range of opinion is here.

I have migraines, 2-3 a month. Most of the time I will wake up very early with them, and if they come at other times of the day, it usually starts as a tension headache and progresses with plenty of warning which make treating them easier. The pain is followed by nausea and vomiting some of the time. I use triptans.

So I saw a proper dive medicine doctor today. I was surprised that the migraines were his major point of focus, that he would have me stop diving entirely if I was willing to, in lieu of that, he recommended severe limitations. I understand the fact that DCI and migraines could look similar, but I have a hard time believing that I wouldn't know the difference as my migraines are never sudden in their onset and that L orbital pain is unmistakable.

I was glad to learn of the risk of triptans because there is a suitable work around for that and I'm glad I know about that.

I occasionally have headaches post dive which resolve quickly but have never had a migraine while diving.

So then I read the material on the DAN website and read that migraines are of little consequence to divers.

So what to think? I believe that this doc knows a lot more than I do, but I am unsure what to do given the discrepancy in opinion.

 

[cdolphin]

Migraine is not a disease that disqualifies one from diving. Its especially helpful that you can discern the migraine h/a from a post dive h/a, migraine has a characteristic pattern and prodrome.

DCS presenting as a headache alone is uncommon; if it did represent DCS it will eventually progress to DCS if left untreated so thus, it would also be associated with more typical symptoms and signs, helping the diagnosis.

It is not definitive, but most migraine sufferers I know, get their h/a improve with diving and hyperbaric 02 Rx, not trigger it. Some get addicted to it to prevent h/a from happening, but again, that's anecdotal.

Normobaric and hyperbaric oxygen therapy for migra... [Cochrane Database Syst Rev. 2008] - PubMed result

Saturation,

The OP mentioned triptans are counter-indicated if diving. I take Maxalt for occuring migraines which is, I presume, a triptan. I didn't see anything on the DAN site regarding this drug being counter-indicated. Could someone elaborate? lulubelle, what have you found that confirms this?

I also suffer from migraines, and have also had the occassional CO2 post-dive headache. There is a difference! In addition CO2 headaches respond to narcotic pain relievers, but migraines won't. (as migraine sufferers know).

 

[Bubbletrubble]

The OP mentioned triptans are counter-indicated if diving. I take Maxalt for occuring migraines which is, I presume, a triptan. I didn't see anything on the DAN site regarding this drug being counter-indicated. Could someone elaborate? lulubelle, what have you found that confirms this?

@cdolphin: I realize that this question wasn't addressed to me, but I'll butt in anyway.

Yes, the generic name for Maxalt is rizatriptan (a drug in the triptan family).

It's thought that triptans work as serotonergic (5HT-1B, -1D) receptor agonists on two structures (either directly or indirectly):

1. In cerebrovasculature (blood vessels feeding the brain) - effect = vasoconstriction
2. At sensory nerve endings - effect = pre-synaptic inhibition

The two effects are probably linked, but researchers aren't quite sure. To be honest, our understanding of the pathophysiology of migraine is still pretty cloudy. One interesting hypothesis is that 5HT-1B/D agonists pre-synaptically inhibit neurotransmitter release from trigeminal sensory neurons. Molecular middle-man pathways might involve calcitonin gene-related peptide (CGRP) and substance P. (Several papers show that nitric oxide-induced headache in humans is correlated with increased levels of CGRP, which normalize in response to administration of triptans.) This results in mitigation of vasodilation and nerve-based inflammation.

Put simply, triptans can cause blood vessels to tighten up. This change in blood flow appears to be coincident with alleviation of headache symptoms, but it might also have ramifications on off-gassing. Theoretically, it's possible that the decreased flux of blood might slow off-gassing from central nervous system tissue, leading to increased Type 2 DCS risk.

I don't believe that there is any evidence in the literature that demonstrates triptans increase DCS risk in humans or animal models. This is purely a theoretical risk.

Without knowing specifically how the triptans help headache sufferers and without really understanding DCS pathophysiology, it's difficult to gauge how dangerous (or safe) triptan use is in divers. Honestly, I'd be surprised if many physicians performing dive clearance check-ups could even connect triptans with increased DCS risk.

 

[Saturation]

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.

Saturation,

The OP mentioned triptans are counter-indicated if diving. I take Maxalt for occuring migraines which is, I presume, a triptan. I didn't see anything on the DAN site regarding this drug being counter-indicated. Could someone elaborate? lulubelle, what have you found that confirms this?

I also suffer from migraines, and have also had the occassional CO2 post-dive headache. There is a difference! In addition CO2 headaches respond to narcotic pain relievers, but migraines won't. (as migraine sufferers know).

 

[lulubelle]

Migraine is not a disease that disqualifies one from diving. Its especially helpful that you can discern the migraine h/a from a post dive h/a, migraine has a characteristic pattern and prodrome.

DCS presenting as a headache alone is uncommon; if it did represent DCS it will eventually progress to DCS if left untreated so thus, it would also be associated with more typical symptoms and signs, helping the diagnosis.

It is not definitive, but most migraine sufferers I know, get their h/a improve with diving and hyperbaric 02 Rx, not trigger it. Some get addicted to it to prevent h/a from happening, but again, that's anecdotal.

Normobaric and hyperbaric oxygen therapy for migra... [Cochrane Database Syst Rev. 2008] - PubMed result

It was interesting to have this doc say that I shouldn't dive if I have a migraine history (even though mine does not include neurological symptoms such as aura, paralysis, visual loss, etc). I then went to the DAN website and saw that migraine was considered a relative risk condition, not a contraindication, and that from what I read I should be fine. Interesting.

I read the NIH paper. So how does one get hyperbaric O2 treatment outside of research settings? Sounds a lot less pathologic than the meds that have to be used. I haven't ever been on a dive when I had a headache and certainly not a migraine, so I have no idea what the impact might be. What I DO know is that diving is very relaxing for me.