The East Bay Headache Support Group met on March 9, 1999 to hear Bruce Paterson, M. D., speak on headaches and allergic disease. The meeting was held in the Monterey Room at John Muir Medical Center with 17 people in attendance. Dr. Paterson is a specialist in the treatment of allergy and asthma in his private practice in Walnut Creek, and is an Associate Clinical Professor at Stanford University Medical School.

Dr. Paterson began by stating that migraines affect an estimated 23.6 million people in the United States. Headaches can be put into two broad categories: Primary headaches are those where there is no identified cause, such as migraine and tension-type headaches. Secondary headaches are those where we can identify a cause of the head pain, such as a tumor, aneurysm, infection, or reaction to a medication.

The purpose of the immune system is to protect the body against foreign agents, like bacteria and viruses. This causes problems when a patient requires an organ transplant, though, as the body’s immune system tries to destroy the invader and then drugs must be taken to counteract the action of the immune system.

A healthy immune systems allows the body to develop antibodies to protect against subsequent exposure to a foreign agent. For instance, when we get a disease like measles or mumps, antibodies are developed so we are protected against the next time we are exposed. Colds are different, though, as there are many different cold viruses. We only get a particular cold virus once, for which we develop an antibody, but the next time we are exposed to a cold virus, it will be a different one, for which we have no immunity.

Dr. Paterson stated that if someone has never taken a particular antibiotic then they’re not allergic to it. The immune system works by memory.

Now we have a vaccine for measles, mumps, and some other diseases. The vaccine is the primary exposure to the disease, for which the body develops antibodies.

Currently there is no test to determine the level of suppression of the immune system, except when it is profound as in AIDS, or HIV, etc. Interestingly, the body’s immune system goes up when stressed.

Lupus is an auto-immune disease where the immune system mis-recognizes the cells in its own body.

Allergic disease is determined by genes. What is inherited is the tendency to be allergic to something (but not necessarily the allergen that the parent is allergic to). Only about 20% of the population is affected by allergic disease. It is believed to have developed from man’s need to protect himself from worms and parasites.

Irritant allergies are those caused by something being distributed by the air, such as pollen.  As only 20% of any given group will have allergies, if something is in the air and it bothers everybody, it is something noxious (like smoke or fumes) and not an allergen. Allergy is a well-defined medical reaction:

• Specific allergic antibody.

• Triggers a characteristic sequence of events.

• Symptoms limited to certain organ systems (that contain cells that release histamine).

• Role of histamine.

People are allergic to protein. When a person is allergic to animal dander it is actually the protein in the cat’s saliva that is causing the allergic reaction.

Dr. Paterson drew a picture of a mast cell with IgE antibodies sitting on it. He said that an allergen causes the release of histamine from the mast cell after a specific exposure. The blood vessels dilate (swell), fluids leak out of blood vessels (runny nose, or "allergic salute"), and itching starts.

Some examples of allergic diseases are:

• Hayfever (seasonal allergic rhinitis). Actually ragweed is what triggers hayfever, not hay. It was called hayfever because old time farmers discovered they had the symptoms.

• Allergic asthma.

• Hives.

• Anaphylaxis (beesting reaction). If a person is previously exposed to a bee sting and develops an allergy to the protein in the venom, he needs immediate treatment on subsequent exposure. Swelling can occur on the vocal chords, or the lungs can swell up, or there may be a drop in blood pressure (when arteries are swollen?).

Dr. Paterson stated that the stuff we’re allergic to is too small to be seen by the human eye. If you can see the pollen, that’s probably not the substance that is causing your allergic reaction.

An audience member asked if you can have bumps without itching, and Dr. Paterson answered that in most cases, hives will itch and leak.

Allergic organs are those exposed to the environment, such as the skin, eyes, nose, throat, lungs (asthma), and GI tract (food).

Types of reactions to food or medications:

• Allergic: A true allergic reaction to food is rare. It occurs within thirty minutes, and can cause anaphylaxis. A food allergy is not subtle, and a person can be tested for it.

• Adverse: such as lactose intolerance.

• Pharmacological: Reaction to substances, such as tyramine and phenylethylamine.

• Idiosyncratic: Reaction occurs unique to the individual and is not explainable by above.

We can test for allergic reactions only. Avoidance of the offending agent is the only treatment of all.

Dr. Paterson then talked about headache foods. There are no mast cells in the brain. If an individual experiences a headache after eating a certain food it is not an allergic reaction.

Many foods contain tyramine (including wine), and other foods contain phenylethylamine (chocolate).

Following is a list of foods that are known to trigger headaches in some people, although Dr. Paterson said this list is not as extensive as the list published in the March 1999 newsletter of the East Bay Headache Support Group:

• alcohol, especially wine and beer

• citrus

• chocolate

• dairy products

• beans

Dr. Paterson presented a slide depicting dural blood vessels in three states: basal, vasodilation, and normalized.

He said that if an antihistamine is taken and the patient shows no improvement, then the patient’s symptoms are not caused by an allergy.

Food additives that are known to trigger headaches (it is not the sodium that is the problem in these additives):

• Sodium chloride

• Sodium nitrite

• MSG

• Aspartame (artificial sweetener

Medicines associated with headache:

• Nitroglycerine

• Oral contraceptives

• Hormone replacement

• Reserpine (old blood pressure medicine)

• Caffeine (too much can cause a headache, or caffeine withdrawal can trigger a headache)

All of the above cause the blood vessels to dilate.

Potential triggers of migraine headaches:

• Hormones

• Chronobiologic challenges (daily, weekly, monthly rhythm). The body puts out cortisol secretion in the morning and the evening.

• Carbon monoxide

• Environmental changes

• Sensory stimuli

• Food and beverages

• Drugs

• Emotional stress

If one takes his/her medication very regularly, they seem to have fewer headaches.

Where is the connection between allergy and headache? Dr. Paterson that that the main connection is through the sinuses, which are empty bony spaces in the head.

Sinusitis:

• Is common (especially in adults).

• Acute and chronic: With acute sinusitis there may be a fever. It is easier to treat because the bugs are less established. Chronic sinusitis can last four to eight weeks sometimes, and it may require long courses of antibiotics. The patient also needs to use a decongestant and topical nose sprays.

When secretions can’t move out of the sinuses, then they have the opportunity to get infected.

Per Dr. Paterson, the course of action for a case of sinusitis would be:

• Prescribe an antibiotic for two weeks.

• If some improvement, then he’ll prescribe another two weeks of antibiotic.

• If not better, then a different antibiotic is tried.

• If not better after two antibiotics, then a CAT Scan is taken. It may be amenable to surgical intervention.

Dr. Paterson said the most important medication to use is an antihistamine. Use an antihistamine for itchy eyes, sneezing, runny nose symptoms. The original antihistamines on the market caused drowsiness in the patient, but now there are Claritin and Allegra which don’t cause drowsiness.

A decongestant only decongests the sufferer, whereas an antihistamine does all the rest to relieve the symptoms.

Cortisone is a steroid, but it is not related to the male sex hormone.

Topical, locally acting medications are safe for pregnant women to use.

Other therapy:

• Allergy shots—to be used only for clearly defined allergies. Provides desensitization. The patient is given increasing doses of the thing they are allergic to, such as pollen.  This seems to only work as an injection—if pollen is put into the nose to try to desensitize the patient, it doesn’t work.

Unusual causes of headache:

• Hypervitaminosis A: too much Vitamin A

• TMJ: Temporomandibular Joint Disease

• Dental Infections (maxillary sinuses)

• Vasculitis

Dryness of the nose causes headache, which happens all the time in California with our dry climate. One purpose of the nose is to humidify and filter the air before it gets to the lungs. Treatment for a dry nose is saltwater nasal sprays.

Q. Are vaporizers helpful?

A. It doesn’t necessarily help, but it can’t hurt. Note, though, that mold and house dust mites need 50% humidity to grow, so for a person with an allergy to mold or mites, it can be detrimental.

Q. What about air purifiers?

A. All homes leak air. The air purifier can’t possibly filter all of the air in your house— there are too many leaks. Dr. Paterson doesn’t think this really helps, because making one’s home environment pure doesn’t help the person to live a normal life elsewhere (when he’s away from home). "Allergy is a quality of life disease."

Q. Is it possible to have a mild allergic reaction to a food?

A. No, there are no mild food reactions. A food allergy is potentially life-threatening. If it’s a mild food reaction, it’s called an "adverse reaction," not an allergy.

Q. Is there any way an antihistamine can help someone relieve their headache?

A. Only if the headache is caused by sinus disease.

Q. How quickly would you see a result?

A. The antihistamine takes effect in hours.

One member of the audience said she took Sudafed (a decongestant) and it helped her "sinus" headache. Dr. Paterson said a common mistake is to mix up antihistamine and decongestant. There are only two decongestants: Sudafed and PPA.

Q. Can you take both an antihistamine and Imitrex (a triptan)?

A. Yes.

Q. If a person vomits ten minutes after eating a particular food, is it an allergy or an adverse reaction?

A. Dr. Paterson answered that it probably would be an adverse reaction. If hives are immediately apparent, though, then it could be an allergic reaction. Or vomiting could be a side effect of taking a medicine.

Q. What if you have an adverse reaction to an anti-inflammatory?

A. Dr. Paterson said that if you find you can’t tolerate one anti-inflammatory, then you won’t be able to take any of them, including aspirin. Adverse reactions to anti-inflammatories can mimic allergic reactions.

Q. What about Celebrex, the latest anti-flammatory drug on the market?

A. Dr. Paterson answered that he’s not very familiar with it yet and so couldn’t say anything about it.

Q. What is going on if you get more headaches during hayfever season, but test negative on a skin test?

A. Maybe it’s association of symptoms in relationship with others who have allergies. Allergy gets blamed for all kinds of stuff it doesn’t do. Is it really an allergy,or an adverse reaction? Viruses have seasons (in the wintertime), so maybe your symptoms are related to a virus.

Q. One member of the audience commented that the decongestant she takes makes her headaches worse and makes her wired, but it does help to decongest her sinuses.

A. Dr. Paterson responded that maybe she should use a cortisone-based nasal spray instead. It doesn’t have the ability to get into the brain to cause the headache.

Perhaps she is over-vigorously sniffing the decongestant. He advised when you inhale a nasal spray, be certain not to breathe when you use it—don’t sniff it back into your sinuses. He stated that a decongestant can cause headaches, but it is rare with an antihistamine.

Q. What about taking Nasalchrom for seasonal hayfever?

A. Dr. Paterson answered that it is not as good as topical nose sprays. You can start taking it daily in January and take it for six months, but note that cortisone is better.  So start an inhaled nasal spray four to six weeks before the season starts. Note it doesn’t work for the first three days, you can take it year-round, and it is safe to take daily for 25 years. Beware that Afrin is a well-known nasal spray which is not to be used longer than three days.

Q. Why would an anaphylaxis reaction start late in life?

A. Dr. Paterson stated, "Nobody is born with an allergy." Allergies don’t tend to first exhibit themselves later in life, but they can. What turns genes on and what turns genes off? The person who answers that question will most certainly become wealthy.

Q. What about outgrowing allergies?

A. Dr. Paterson gave a qualified yes to this question. He said that probably symptoms will come back.

Q. Are there other foods that can cause headaches?

A. Dr. Paterson didn’t suggest any, but he did say if you think you have a problem with wheat or some other food, do a food challenge, that is, eat only one food at a time (can be for less than a week) until you can identify the trigger.

Q. When should a person ask their primary care physician for a referral to an allergist?

A. The patient would have to have other allergic symptoms besides headaches. Ascertain whether decongestants help your condition.

Q. A member of the audience mentioned having had hives for a year. What would Dr. Paterson do to treat this condition?

A. He answered that he would give the patient lots of antihistamines. Prednisone can’t be used for a long period of time. Atirax is a favorite for taking at nighttime, plus there are antihistamines you can take in the daytime which don’t cause drowsiness. He said you can get used to the drowsiness—the dose can be gradually increased and tolerated by the patient.

Q. Is there a way to test oneself to measure when the body releases cortisol?

A. Cortisol probably kicks in at the time you get up, if you get up at the same time every day.

Q. Do you have a feeling about Vitamin B2?

A. Dr. Paterson answered, "No."

Q. What can be done for mosquito bites?

A. Dr. Paterson said there are three types of reactions to mosquito bites, which are:

• Little itchy bump

• One inch bump, and itchy

• Anaphylaxis (this is rare)

Apply topical cortisone immediately to mosquito bites.