Hair Loss

Thinning-   
Thinning hair or change in hair texture sometimes occurs. This may begin after the first few months of interferon therapy. It does not generally represent complete loss of hair, rather some people notice an increased amount of hair in the shower drain or loss while combing or brushing. Hair returns to normal after the course of interferon is discontinued. However, whatever part of hair loss in men is attributable to male pattern baldness is gone for good.

Some people experience hair loss as a side effect of interferon, but it doesn’t always happen. It may range from a slight to moderate amount of hair loss, but I have never seen anyone become completely bald from the doseages given for hepatitis.

See our FAQ section of our web site. This list was put together by Peppermint Patti.

The hair grows back after the treatments are over. When your hair does begin to grow back in, it may come in thicker, curlier, or straighter than it did before your interferon therapy.

Hair loss can occur on all parts of the body, not just the head.
Facial hair, arm and leg hair, underarm hair, and pubic hair may all be
affected. Hair loss usually doesn’t happen right away; more often, it begins after a few weeks. At that point, hair may fall out gradually or breaks at or near the skin, and the scalp may become tender. Any hair that is still growing may become dull and dry. To care for your scalp and hair:

Use mild shampoos.
Use soft hair brushes.
Use low heat when drying your hair.
Don’t use brush rollers to set your hair.
Don’t dye your hair or get a permanent.
Have your hair cut short. A shorter style will make your hair look thicker and fuller. It will also make hair loss easier to manage if it occurs.
---

There is a special type of shampoo and conditioner designed specifically for people undergoing chemotherapy. Many people have reported good results using it while taking interferon. The brand name is "Nioxin" and it is sold only in salons.

ALOPECIA

PATHOPHYSIOLOGY

Interferon affects the hair follicles and changes the texture of the hair, thereby making it

more sensitive to breakage. Hair loss, which has been described as a possible side effect

of treatment with interferons,1 occurs by one of two mechanisms. First, loss via a

shearing or friction effect at the scalp level (often during sleep as the hair moves across a

pillow) is caused by the weak, brittle nature of hair changes. Second, loss can occur via a

spontaneous release of the hair from the follicle, leaving the follicle empty, which is

usually seen with vigorous shampooing or brushing. Alopecia is frequently observed

when therapy is continued for longer than 3 to 4 months, and is characterized by thinning

and slight-to-mild hair loss. It appears to be the most common cutaneous reaction

associated with interferon alfa treatment.2 Alopecia may become more pronounced when

interferon is discontinued and may continue for 1 to 3 months.3 In general, alopecia

associated with interferon is reversible. In some patients, hair regrowth occurs during

treatment continuation.1

Total revealed alopecia is seen more often with high-dose interferon or long-term

interferon maintenance therapy. Thinning, often unnoticeable to others, is usually seen

during combination therapy with ribavirin or low-dose, short-course interferon. Patches

of loss occur unpredictably in some patients.

PREVENTIVE STRATEGIES

Providers should:

1. Educate patients regarding the risk of alopecia, its causes, and management. Inform

patients that hair usually regrows, although the new growth may be a different

texture; however, in rare cases, hair loss may be permanent.

2. Rule out other etiologies, including a history of alopecia areata, thyroid dysfunction,

and other medical conditions, treatment, or medications (eg, chemotherapy, radiation

therapy) that may predispose the patient to alopecia.

Patients should be instructed to:

1. Use a wide-toothed comb and/or natural bristle brush; gently comb/brush only once

or twice daily.

2. Shampoo less frequently (1–3 times/wk); use conditioner or detangler.

3. Use Nioxin™ or selenium sulfide (Selsun Blue®) shampoo, or Centrum® Complete

multivitamin with zinc and selenium.

4. Use vegetable-based henna or vegetable-based hair color (eg, Aveda™, Matrix™) if

intent on coloring hair. Avoid use of peroxide-based hair dye or permanent wave

solutions while on therapy; their use is not contraindicated, but can accelerate hair

loss and hair damage.

5. Pin a silk scarf on pillowcase or buy a satin pillowcase to avoid hair loss through

friction or shearing effect.

Side Effects Management Handbook • V. Cutaneous: Skin, Hair, Nails • p. 2

6. Avoid pressure-based hair items: caps, barrettes, ponytail clips, hair bands.

7. Avoid pulsating showerheads (eg, Waterpik™); these exert too high a PSI and

facilitate loss.

8. Avoid/limit use of gels, freezing sprays, mousse; these make hair difficult to comb

through.

TREATMENT STRATEGIES

Symptomatic patients should be advised to:

1. Cut hair length to decrease hair weight and rate of loss (for progressive thinning in

longer, heavier hair).

2. Purchase scarves, wigs, turbans, or caps when total revealed alopecia is anticipated.

3. Complete any hair transplant procedures prior to therapy or continue them after

completion of treatment to avoid delayed healing and risk of infection (for patients

with pre-existing male pattern baldness).

Providers should, as needed:

1. Provide a prescription for scalp prosthesis or cranial prosthesis (wig) due to

treatment-induced alopecia to facilitate insurance/Medicare reimbursement.

2. Refer patients for psychosocial support, such as support groups, and recommend

consultation with a cosmetologist or dermatologist (if appropriate) for changed body

image issues.

3. Note that drug therapy (minoxidil [Rogaine®]) for hair loss is not efficacious for

interferon-related hair loss.

REFERENCES

1. Tosti A, Misciali C, Bardazzi F, Fanti PA, Varotti C. Telogen effluvium due to recombinant

interferon a-2b. Dermatology. 1992;184:124-125.

2. Stafford-Fox V, Guindon KM. Cutaneous reactions associated with alpha interferon therapy.

Clin J Oncol Nurs. 2000;4:164-168.

3. Vial T, Descotes J. Clinical toxicity of the interferons. Drug Safety. 1994;10:115-150.

Side Effects Management Handbook • V. Cutaneous: Skin, Hair, Nails • p. 3

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Here is some great advice from our message boards:

8805.2

Olive OIL...Olive OIL and more Olive OIL...

My stint in 97-98 was interesting when it came to my hair...I had my girlfriend cut it 2 inches all the way around...the fella i had been seeing ..had a cow..haaaaaaaa...(keyword had)  i actually got 2 lime size bald spots..course I was doing mono interferon at the time and it was stronger (in my opinion) than the current treatment protocol...

Every 3-4 days I would coat my head with olive oil and just let it stay in hair and on scalp for a couple days...mind you i didn't have to go out in public when i did i would put a bandana on my head.  It soothed the scalp tremendously. At that time I could not afford nioxin so i used a gentle baby shampoo...

In March of 98 ..2 months post treatment...hair started growing back on head beautifully full and the color was the nicest it had been in years...(brownish black) with some grey ...hahaaaaaa

2000...did ol combo mombo...Friends of mine gave me Nioxin ..I loved it.  Still used the Olive Oil.

I have colored my hair off and on the last 3 years...I notice that it gets coarser.

I have my hair cut short now and I love it.

Hair on tx-whew! It thinned like crazy and got very dry and broke.
I used nioxin shampoo and I think it helped. For the breakage, I got Pantene ProV conditioner and I would really coat hair and scalp and sleep with a plastic bag. Wash it out in the morning. that really helped stop the breakage. Here I am 10 months post treatment and my hair is coming back, finally. Makes me look like a million different layers. That's all the tricks that I could come up with.

I had really fine thinning hair before I started treatment and now in week 26 my hair is really thin along the part in particular. I have continued to color my hair every 8 weeks but I only use Aveda color and a lot of Aveda products as well. As you know Aveda is as close to natural as you can get. I bought a lot of Nioxin products but I really do not like how Nioxin makes my hair feel.( like straw and sort of fly away.) I have started not to blow dry anymore( i lose too much hair brushing or combing) but my thin hair just kinda hangs lackluster on my head.

I have an awesome hairdresser - she was one of the first people I told about the hep. I asked her if I needed it, would she take me shopping for a wig (the answer, of course, was yes) but said she had other clients who had done really well on Nioxin and started me on the shampoo, conditioner and that nasty smelling folicle stuff (that I don't use because I can't stand the smell of myself)prior to starting tx. I have frosted hair which she touches up every 8 weeks (this may help it look a little thicker). I have straight, short, fine hair and when she cuts it, she works around the receding hair line by leaving the back of my bangs longer to cover it but only on the forehead "v's" (if that makes sense). It's kind of fun to watch her cut a section one length in the front and longer in the back. I also sleep on a satin pillow case so the hair slides during the night. So far, no one has made a comment to me about my hair (maybe I just have nice friends and coworkers lol

I have been using Aveda for about a year. I really like the Rosemary mint shampoo and the really light Rosemary mint conditioner. (it's not too heavy for my fine hair). I rotate that with the Color conserve shampoo and conditioners. It took me awhile to get used to the smell of some of the Aveda products but now I love the earthy smell. I usually don't have to use a conditioner when I use the color conserve shampoo but have the color conserve leave in when I am going to out in the sun.I use thehair detoxifier if I have been in the pool to get rid of the chlorine and I use the Phomollient styling foam and brillant hair spray. I use a lot of Aveda skin care and bath products as well.

I am using a product call therapy -G I got from my hairdresser. She has told me that nioxin will only make my hair frizzier if that's a word????? It has really helped.

Headaches

Headache is a common side effect of interferon therapy. It is often worse within the first month of therapy, then improves. Increasing fluids may help reduce headaches. Many patients may take an over the counter analgesic such as Motrin or Aleve. The more long acting the medication the better. For patients taking ribavirin, headache may be a symptom of anemia. Ribavirin causes anemia in almost everyone who takes it, but some people are affected more than others. Attending regular follow up appointments is important for monitoring lab work that will detect if anemia is occurring. If anemia occurs, the dose of ribavirin may be reduced or even discontinued in severe cases.
 

MIGRAINE/HEADACHE

PATHOPHYSIOLOGY

Migraines arise from a triggering event that sets off a chain of vascular, muscular, or

neurotransmitter responses.1 The brain chemical serotonin and the trigeminal nerve

pathway (site of the nerve responsible for sensation in the face, mouth, and nasal cavity)

are the major factors in severe headache (HA). The cerebral cortex responds to emotion

or stress (two of the triggers of migraine) by releasing norepinephrine from the adrenal

medulla. This causes a release of serotonin from platelets that increases free serotonin

concentrations in the plasma. An increased serotonin level causes arterial

vasoconstriction (an ischemic event), which may be responsible for the aura experienced

by migraineurs.1 In migraines, serotonin levels rise before onset and decrease during the

HA phase. In chronic tension HAs, serotonin levels remain at a constant low. With

reduced serotonin levels, an impulse travels along the trigeminal nerve to blood vessels in

the meninges. This causes vasodilation in the meninges, which become dilated, inflamed,

and swollen; the result is HA or migraine. A vasodilatory effect similar to sepsis is

caused by the cytokine interferon that can also produce HA.

Interferon alfa causes disturbances in serotonin levels that are most often associated with

HA in patients treated for HCV infection. Patients treated with ribavirin have also

experienced HAs.2

STAGES AND CAUSES OF HA, MIGRAINE HA, AND CLUSTER HA

Common HAs may be caused by stress, tension, anxiety, allergies, constipation, caffeine,

eyestrain, hunger, sinus pressure, or muscle tension. However, migraine HA may be

caused by a multitude of other triggers.3 These triggers can include environmental or

physiologic factors, sensory stimuli, impending onset of menstruation, foods, and certain

drugs, especially those with a vasodilating effect.1

Migraine HAs have five distinct phases: prodrome, aura, HA, resolution, and postdrome.

The prodrome may begin 24 hours before onset of the actual HA. The aura, which begins

about an hour before the HA and lasts 20 to 30 minutes, may cause visual disturbances

(flashing lights, moving zigzag lines, and blind spots), or sensory sensations. The HA

itself usually starts as a dull pain, then develops into a pulsating, painful sensation—often

on only one side of the head, but 40% of patients experience it on both sides, mainly in

the temples. It may be felt on any area of the face, head, or neck. Vomiting, nausea,

photophobia, and/or phonophobia may accompany the pain. The resolution phase, with

cessation of pain and restoration of body homeostasis, usually lasts several hours,

frequently during sleep or rest. The last stage is the postdrome, accompanied by a feeling

of being drained, tired, and fatigued. Muscles ache, appetite is diminished, and emotions

are volatile.1 Cluster HAs are more severe, and are characterized by their recurring

nature. They are accompanied by throbbing, severe pain on one side of the head, tearing

Side Effects Management Handbook • VII. Flulike Syndrome • p. 12

eyes, and nasal congestion. They sometimes occur up to three times per day and may last

a few minutes or several hours.3

PREVENTIVE STRATEGIES1,3

Patients should be instructed to:

1. Establish regular mealtimes, sleep patterns, relaxation, and exercise routines.

2. Eliminate unproductive worry/stress.

3. Avoid caffeine—for withdrawal HA, slowly decrease use.

4. Avoid wide fluctuations in blood glucose by eating smaller, regular meals with

snacks.

5. Pre- and 4 hours postinterferon injection, use acetaminophen or an NSAID.

6. Maintain adequate hydration: (consumption equal, in fluid ounces, to one half body

weight in pounds; eg, 80 fl oz for a 160-lb person). Limit caffeine to AM, then use

decaffeinated products.

7. Identify and avoid dietary triggers. People who suffer from frequent HAs may be

reacting to certain foods and food additives, especially wheat, chocolate, sugar,

coffee, tea, red wine, alcohol, vinegar and/or marinated foods, citric acid, fermented

foods (aged cheese, sour cream, yogurt), monosodium glutamate (MSG), nitrites

(contained in hot dogs, bacon, luncheon meats), sulfites (used by restaurants in salad

bars).

8. Avoid environmental triggers: fumes, odors, emotional crises, weather/elevation

changes.

9. Try eliminating foods containing tyramine and phenylalanine. To determine

sensitivity, reintroduce one food at a time and observe which ones produce HA.

Phenylalanine is found in aspartame (Equal®, NutraSweet®), MSG, and nitrites. Foods

containing tyramine include alcohol, bananas, cheese, chicken, chocolate, citrus

fruits, cold cuts, herring, onions, peanut butter, fresh-baked yeast products, sour

cream, vinegar, etc. These cause the blood pressure to rise, resulting in HA.

10. Avoid iced or very cold or hot foods or beverages; lukewarm to cool temperatures are

less likely to trigger or exacerbate a migraine. Avoid chewing gum and excess salt.

Use antiemetics for migraine-induced nausea.

11. Reduce lighting/sound volume since light and sound can be triggers; use earplugs,

sunglasses, visors, close blinds, etc.

12. Keep a log to assist in diagnosis and treatment if they experience more than

occasional HA for at least 1 to 2 months. Note the time of each HA and describe

the pain (throbbing or dull), its severity, location, duration, as well as what

relieves/exacerbates the HA.

Providers should:

1. Perform pretreatment assessment of HA/migraine. Candidates for prophylaxis include

patients who have predictable attacks, at least three or more attacks per month, or

failure of symptomatic therapy. Weaning off HA medications should be attempted

after 6 months.

2. Assess date of last eye examination. Also rule out sinusitis; dental causes

(eg, temporomandibular joint, bruxism); anemia; hypoglycemia; vertebral

misalignment; medications; toxic doses of vitamin A; vitamin B deficiency;

Side Effects Management Handbook • VII. Flulike Syndrome • p. 13

diseases of the ears, nose, and throat; menstrual cycle; or hypertension as

etiologies.

3. Administer prophylactic therapy, if warranted (see table).

PREVENTIVE AGENTS FOR MIGRAINE HA1

NSAIDs

Acetaminophen (Tylenol®) 650 mg BID

Aspirin (ASA) Standard dose

Ibuprofen (Motrin®, Advil®) 300–600 mg TID

Flurbiprofen (Ansaid®) 200–300 mg/d in divided doses

Naproxen (Naprosyn®) 500 mg BID

BETA BLOCKERS

Propranolol (Inderal®) 10–20 mg BID initially; gradually increase to 80–240 mg/d

Timolol (Blocadren®) 10–15 mg BID

CALCIUM CHANNEL BLOCKERS

Diltiazem (Cardizem®, Tiazac®) 90–180 mg/d in divided doses

Nifedipine (Adalat®, Procardia®) 20–30 mg TID

Verapamil (Calan®, Covera-HS™, 80 mg TID or QID

Isoptin®, Verelan®)

ANTIDEPRESSANTS

Amitriptyline (Elavil®) 25–50 mg QHS, start 10 mg/d, titrate up ~10 mg @1–2 weeks,

up to 200 mg/d

Desipramine (Norpramin®) 50–200 mg; start 10 mg/d, titrate up ~10 mg @1–2 weeks

Doxepin (Sinequan®) 10–200 mg

Fluoxetine (Prozac®) 10–20 mg/d

Imipramine (Tofranil®) 50–200 mg; start 10 mg/d, titrate up ~10 mg @1–2 weeks

Nortriptyline (Pamelor®, Aventyl®) 10–150 mg

ANTICONVULSANT

Valproate (Depakote®, Depakene®) 250 mg BID or TID; average dose is ~1200 mg/d

Side Effects Management Handbook • VII. Flulike Syndrome • p. 14

TREATMENT STRATEGIES3

Patients should be instructed to:

1. Practice deep-breathing exercises to increase oxygen.

2. Apply cold compresses (damp, chilled cloth or gel pack) to painful location to

constrict blood vessels and ease muscle spasms, or use a heating pad or hot water

bottle to relax tense neck or shoulder muscles.

3. For sinus congestion HA, try self-massage to open up the sinuses and ease tension by

leaning head forward slightly to encourage sinus drainage. Try application of hot

compresses to the sinuses or steam inhalation.

4. Exercise to reduce or eliminate HA/migraine.

Providers should:

1. Rule out anemia.

2. For female patients who are experiencing new onset of HA on newly prescribed oral

contraceptives, try switching to a low-estrogen formulation. Oral contraceptives can

also cause migraines. Some women with migraines may benefit from using topical

progesterone cream (Crinone®).

3. Consider organic causes of HA or poor vertebral alignment (which reduces blood

flow to the brain). Determine if flat feet or high heels create vertebral misalignment.

Chiropractic adjustment may help.

4. Recommend nonpharmacologic options.3

a. Music therapy: Water/wind sounds, soothing melodies, light jazz, etc.

b. Aromatherapy (lavender oil): inhale or apply to temple, sinus area, below nose.

c. Relaxation exercises/deep breathing especially useful for tension HA; additional

oxygen may prevent HA.

d. Ice, cold compresses.

e. Accupuncture/accupressure.

5. Administer pharmacologic therapy (see table).

6. Dose-modify peginterferon as needed for HA resistant to other measures.

Side Effects Management Handbook • VII. Flulike Syndrome • p. 15

SYMPTOMATIC TREATMENT FOR MIGRAINE HA1

SIMPLE ANALGESICS

Acetaminophen (Tylenol®) 650 mg at onset; repeat Q4H PRN as directed

Ibuprofen (Advil®, Motrin®) Per manufacturer’s directions; do not exceed. If ineffective,

or acetaminophen/ASA/ prescription medication

caffeine (Excedrin® Migraine)

ASA Per manufacturer’s directions

ASA-acetaminophen with butalbital 1–2 tablets Q4–6H, maximum: 4

(Phrenilyn®, Sedapap®)

NSAIDs

(Note: Narcotic analgesics will be needed for a small percentage of interferon patients.)

Ibuprofen (Advil®, Motrin®) 300–600 mg TID

Naproxen (Naprosyn®) 750 mg initially, 250 mg thereafter; maximum: 1375 mg/d

Naproxen sodium (Anaprox®) 550–750 mg initially; may repeat after 1–2 h

Flurbiprofen (Ansaid®) 200–300 mg/d in divided doses

TRIPTAN PREPARATIONS*

Sumatriptan (Imitrex®) 6 mg SC at onset; repeat in 1 h PRN to maximum of 12 mg/24 h

6-mg auto-injector

Sumatriptan nasal spray 5, 10, or 20 mg intranasally; repeat in 2 h PRN to maximum

of 40 mg/24 h

Sumatriptan tablets (25 and 50 mg) 25 mg at onset or up to 100 mg in single dose; repeat

in 2 h PRN to maximum of 300 mg/24 h

Naratriptan (Amerge®) tablets 1–2.5 mg; repeat once after 4 h PRN to maximum of 5 mg/24 h

1 and 2.5 mg

Rizatriptan (Maxalt®) Reditabs 5 or 10 mg at onset; may repeat once after 2 h PRN

5 and 10 mg, or orally disintegrating to maximum of 30 mg/24 h (10-mg dose has greater effect)

tablets 5 and 10 mg (Maxalt-MLT®)

Zolmitriptan (Zomig®) tablets 2.5–5 mg at onset; may repeat once after 2 h PRN

2.5 and 5 mg to maximum of 10 mg/24 h

OTHER4

Various antihistamines

Prostaglandin inhibitor

*Triptans (serotonin agonists) are contraindicated in patients with ischemic heart disease, angina pectoris, arrhythmias, previous MI, and/or

uncontrolled hypertension. Use with caution with hypercholesterolemia, obesity, diabetes, smokers, or family history of vascular disease.

Side Effects Management Handbook • VII. Flulike Syndrome • p. 16

REFERENCES

1. Elhaj BR, Dopheide J, Gill MA. Migraine headaches. Pharmacy Times. 2000;59-75.

2. Khakoo S, Glue P, Grellier L, et al. Ribavirin and interferon alfa-2b in chronic hepatitis C:

assessment of possible pharmacokinetic and pharmacodynamic interactions. Br J Clin

Pharmacol. 1998;46:563-570.

3. Balch JF, Balch PA. Prescription for Nutritional Healing. 2nd ed. Garden City, NY: Avery

Publishing Group; 1997:299-303.

4. Haeuber D. The flu-like syndrome. In: Rieger PT, ed. Biotherapy: A Comprehensive

Overview. Boston, Mass: Jones and Bartlet; 1995:243-258.

What Is a Migraine?

Approximately 26 million Americans — 70 percent of them women — suffer from migraine, a type of headache that's often severe. Although any head pain can be miserable, migraines are in a class by themselves. These painful headaches may be preceded by a warning sign (aura) such as flashes of light, dizziness, or numbness and are often accompanied by severe nausea and vomiting and extreme sensitivity to light and sound. Migraine pain can be excruciating and may incapacitate you for hours or even days.

Fortunately, though, migraine pain management has improved dramatically in the last decade. If you've seen a doctor in the past and had no success, it's time to make another appointment. Although there's still no cure, there are medications that can help reduce the frequency of migraines and stop the pain once it's started. The right medicines combined with self-help remedies and changes in lifestyle may make a tremendous difference for you.

Signs and Symptoms

A migraine usually begins with an intense, gripping pain on one side of your head that may gradually spread. Migraines typically last from 4 hours to 72 hours, but the frequency with which they occur can vary from person to person. You may have headaches several times a month or just once or twice a year.

Not all migraines have the same patterns. Although there are several kinds of migraines, the most common are classic migraine — which is a migraine with aura — and common migraine, which has no aura.

If you're among the 10 percent of adults who have migraines with aura, you'll likely have warning signs about 20 minutes before the headache begins. These may include:

Sparkling flashes of light
Dazzling zigzag lines in your field of vision
Slowly spreading blind spots in your vision
Weakness, numbness or tingling in your face, hand or leg
Difficulty seeing or speaking

Although a migraine without aura has no classic warning signs, you may have one or more symptoms of premonition several hours before your headache actually strikes, including:

Feelings of elation or intense energy
Cravings for sweets
Thirst
Drowsiness
Irritability or depression

Migraine symptoms in children

Migraines typically begin in childhood, adolescence or early adulthood and often become less frequent and intense as you grow older. Although it's normal to think of adults as having migraines, children as young as age 2 can also have these headaches. In fact, it's estimated that between 2.5 percent and 22 percent of children experience intense headache pain. In addition to physical suffering, severe headaches often mean missed school days and trips to the emergency room, as well as lost work time for anxious parents.

Children's migraines are often accompanied by nausea, vomiting, increased sensitivity to light, diarrhea , increased urination, sweating and thirst. Visual auras aren't as common in children as in adults. If your child does have auras, he or she may also have premonition symptoms, such as:

Yawning
Sleepiness or listlessness
A craving for migraine trigger foods such as chocolate, hot dogs, sugary snacks, yogurt and bananas

Older children may have all of the signs and symptoms of migraine — nausea, vomiting, increased sensitivity to light and sound — but no head pain. These "abdominal migraines" can be especially difficult to diagnose.

The good news is that the same medications that are effective for adults also work for children. Your child doesn't have to suffer the pain and disruption of migraines. If your child has headaches, be sure to talk to your pediatrician. He or she may want to refer your child to a pediatric neurologist.
Causes

Although much about headaches still isn't understood, some researchers think migraines may be caused by functional changes in the trigeminal nerve system, a major pain pathway in your brain, and by imbalances in the brain chemical serotonin, which regulates pain messages going through this pathway.

During a headache, serotonin levels drop. Researchers believe this causes the trigeminal nerve to release substances called neuropeptides, which travel to your brain's outer covering. There they cause blood vessels to become dilated and inflamed. The result is severe headache pain.

Other studies using brain scans have shown that the volume and amount of blood reaching the brain drops during migraine attacks. This has led some experts to speculate that migraines occur when blood drains from the blood vessels in the center of your brain to outer blood vessels. Because levels of magnesium, a mineral involved in nerve cell function, also drop right before or during migraines, it's possible that low amounts of magnesium may cause nerves in the brain to misfire.

Whatever the exact mechanism of headaches, they don't just occur on their own — Something has to trigger them. Triggers can be almost anything, ranging from allergies and stress to sun glare and changes in barometric pressure.

For the nearly 65 percent of women who have migraines immediately before, during or right after their periods, that something may be changes in estrogen levels. Although the exact relationship between hormones and headaches isn't clear, hormonal fluctuations, especially during menstruation and pregnancy, seem to trigger headaches in many women with migraines.

Certain foods appear to trigger headaches in some people. Common offenders include alcohol, especially beer and red wine; aged cheeses; chocolate; fermented, pickled or marinated foods; monosodium glutamate (a key ingredient in some Asian foods, certain seasonings, and many canned and processed foods); aspartame and caffeine.

Other common migraine triggers include:

Stress and fatigue
Changes in weather, season, altitude level or time zone
Changes in sleep patterns, including too much or too little sleep
Bright lights
Unusual odors
Certain medications, including cimetidine (Tagamet), fenfluramine (Pondimin), nifedipine (Procardia) and theopylline (TheoDur, Theo-24)

Low blood sugar, changes in mealtimes, skipped meals or fasting
Intense physical exertion, including sexual activity
Tobacco, including secondhand smoke

Risk Factors

If both your parents have migraines, there's a 75 percent chance you will too. If just one parent has migraines, you have a 50 percent chance of being affected. You also have a relatively higher risk of migraines if you're young and female. In fact, women are three times more likely to have migraines than men are. Headaches tend to affect boys and girls equally during childhood but increase in girls after puberty.

If you're a woman with migraines, you may find that your headaches are worse during menstruation or the first few months of pregnancy. And you may not be able to tolerate birth control pills or hormone replacement therapy (HRT).

Hearing Problems

J Laryngol Otol 1998 Oct;112(10):962-3

"Sudden hearing loss in a patient hepatitis C virus (HCV) positive
on therapy with alpha-interferon: a possible autoimmune-microvascular
pathogenesis"

Cadoni G, Marinelli L, Santis AD, Romito A, Manna R, Ottaviani F
  Institute of Otolaryngology, Catholic University of the Sacred Heart,
  Rome, Italy.

Alpha interferon (alpha-IFN) is used for the treatment of various
systemic disorders. Side-effects of alpha-IFN therapy can
involve numerous organ systems, but sudden hearing loss has
only once been recorded. We report a case of sudden hearing
loss occurring in a patient with chronic hepatitis C treated with
alpha-IFN and recovered five days after the discontinuation of
this agent. This is the first record of anti-endothelial cell antibodies
detection in a patient with sudden hearing loss. The finding of
anti-endothelial cell antibodies suggests an association between
sudden hearing loss and microvascular damage during interferon
therapy.

HERBS AND VITAMINS

HUMAN FACTORS RELATED TO HERB SAFETY

1. There is a widespread misconception that anything natural is safe.

2. Specific health conditions can make the individual susceptible to herbal poisoning

(HIV, chemotherapy, pregnancy, lactation, poor nutrition status, gender, age).

3. Self-assessment and self-medication are potentially dangerous for persons who do not

understand human anatomy and medical conditions.

4. Wildcrafting (gathering herbs in the wild) may result in problems due to incorrect

plant identification or contamination.

5. Toxicity may occur due to lack of understanding of appropriate use or dosage, or

from long-term use.

6. Use of multiple herbs might result in interactions.

7. Persons using herbs might delay obtaining needed medical treatment.

8. Products may be poorly labeled, or patient may purchase products from an unreliable

source.

9. There may be variations in the herb/concentration due to storage conditions.

10. There are over 1400 species of herbs and most have not shown true efficacy in

clinical trials.

11. Herbal treatments have been protected since 1962 and are not regulated by the US

Food and Drug Administration (FDA). They are sold as food products.

BEFORE TAKING HERBAL SUPPLEMENTS

Patients should be instructed:

1. If ill, consult with the healthcare provider.

2. Do not use herbal therapies for serious illness, or in children.

3. Notify healthcare providers of all alternative medicines being used, and inform

providers if use is discontinued, since this may affect laboratory values.

FACTS ABOUT HERBS AND SUPPLEMENTS1-4

Alfalfa: contains a chemical that acts as an anticoagulant; has been linked to kidney

damage.

Aloe vera gel: used externally for the treatment of burns and wounds. Used in cosmetics,

allergy medications. Lethal dose is 1 g/d for several days.

B6: reduces cell growth; inhibits protein tyrosine kinase. Used for melanoma prevention

and neuropathy.

Black cohosh: some indication of relief of hot flashes and improved mood. Large doses

cause dizziness, nausea, headaches, stiffness, and trembling. Not safe for persons taking

blood pressure medication or those with CV disease.

Borage: contains toxic pyrrolizidine alkaloids.

Calamus: contains carcinogenic cis-isoasarone.

Side Effects Management Handbook • VIII. Gastrointestinal • p. 14

Cayenne: acts as counterirritant for pain relief. Used in arthritis, herpes zoster, toothache,

diabetic neuropathy, and musculoskeletal pain. Internally, acts as gastric stimulant. Avoid

contact with eyes.

Chamomile: flowers contain an oil believed to have an antispasmodic and antiinflammatory

effect on the gastrointestinal tract. Studies have indicated that it is an

effective mouthwash for minor irritation and infections of the mouth and gums. Persons

who have allergies to pollen should avoid this herb.

Chaparral: suggested use as an antioxidant, blood purifier, in cancer and acne. Induces

liver toxicity: the FDA has found links to acute hepatitis and severe liver damage.

Chondroitin complex: found in cartilage; thought to relieve pain from arthritis.

Coenzyme Q10: a body enzyme that acts in the production of adenosine triphosphate;

boosts the immune system, and relieves CHF.

Coltsfoot: contains toxic pyrrolizidine alkaloids.

Comfrey: used externally to reduce the swelling around broken bones. Internal use can

cause liver damage due to toxic pyrrolizidine alkaloids. It has been linked to cases of

obstructed blood flow from the liver.

Dandelion: considered a liver remedy because it enhances the flow of bile. The leaf is a

diuretic comparable to furosemide (Lasix®), but dandelion replenishes potassium and

other minerals that are normally depleted by diuretics.

Dogbane: contains toxic cardioglycosides.

Ephedra (ma huang): decongestant, CNS stimulant; might decrease appetite; increases

hypertension; causes dry mouth; potential adverse effects include psychosis, stroke, and

memory loss. Caffeine potentiates the effect. Ephedra has been blamed for 20 to 30

deaths.

Feverfew: may diminish frequency and severity of migraine headaches.

Folic acid and vitamin B12: downregulate oncogenes; improve appetite and sleep; aid in

methyl metabolism.

Foxglove: contains toxic cardioglycosides.

Garlic: some evidence that half a clove per day might lower cholesterol an average of

9%. It decreases clotting, and can interfere with anticoagulants, including warfarin

(Coumadin®).

Germander: contains toxic alkaloids with a potential for liver damage; acute hepatitis

has been linked to its use.

Ginger: used to aid digestion and prevent nausea due to motion sickness and surgery.

Ginkgo biloba: unsafe for those with bleeding disorder; overdose might induce

irritability, restlessness, diarrhea, and vomiting.

Ginseng: interacts with the antidepressant phenelzine (Nardil®) and interferes with some

other medications as well; has caused asthma attacks and menstrual changes.

Glucosamine: moderate effect on pain relief and improved mobility. May be as effective

as ibuprofen (Advil®, Motrin®). Some evidence to show the slowing progression of

cartilage loss in affected joints. May interact with blood-thinning medications and have

harmful effects on insulin resistance in type 2 diabetes.

Goldenseal: used as an antibacterial agent in eye drops and for diarrhea.

Guaraná: high in caffeine.

Side Effects Management Handbook • VIII. Gastrointestinal • p. 15

Herbal Ecstasy: contains large concentrations of caffeine, ephedra, and other stimulants

in amounts that can disrupt the balance of hormones and the CNS; has caused permanent

heart damage.

Jin bu huan: marketed for insomnia due to pain and stomach ulcers; reported poisoning

in children.

Kava kava: acts as antagonist to dopamine; induces relaxation/sleep, and decreases

anxiety. Anticonvulsant and muscle relaxant; potentiates other CNS depressants. Has

been associated with multiple cases of liver toxicity, including liver failure necessitating

transplant.

Licorice: increases blood pressure in those prone to hypertension, alters electrolytes, and

causes pseudoaldosteronism.

Lobelia: alkaloid similar to nicotine. In low doses it is an expectorant that works by

dilating the bronchial tubes; higher dose can cause slowed respiration, sweating, rapid

heart rate, low blood pressure, coma, and death. It is dangerous if combined with nicotine

(including the patch or gum).

Maitake: studies have shown it possesses antitumor, anti-HIV, antihypertension,

antidiabetes, anti-obesity, and antihepatitis activities through enhancement of the immune

system. Not only does it seem to improve positive benefits of conventional

chemotherapy; it also aids in the amelioration of side effects.

Melatonin: hormone. It produces relief of circadian-based sleep disorders. Used for sleep

difficulties in the elderly and those with seasonal sleep disorders.