Ever notice that your kids and teens with headache/migraine also have some other symptoms? Like sweaty hands and feet? Tremor? Lightheadedness and dizziness? Dilated pupils? Palpitations? Constipation or diarrhea? Gastric upset? Cold extremities? Tingling or numbness in the hands or feet? Fatigue? What’s up with that?
Well, a wide variety of these findings are very common in people with headaches. They represent mild dysfunction in the autonomic nervous system (ANS), also called mild dysautonomia. The ANS controls those body functions that we consciously have control over, such as breathing, BP regulation, digestion, temperature regulation, sweating, or nervous system over stimulation.
Common causes for dysfunction in the ANS are diabetes, peripheral or central nervous system disorders (congenital syndromes or those associated with aging) or certain medications. A number of conditions are common forms of dysautonomia: postural orthostatic tachycardia syndrome (POTS), inappropriate sinus tachycardia (IST), vasovagal syncope, orthostatic hypotension, orthostatic hypertension, autonomic instability. Dysfunction within the ANS runs along a spectrum, with my headache patients at the benign end and patients with Riley-Day syndrome at the severe end of this spectrum.
There are many symptoms associated with dysautonomia and each person has their own particular symptoms. Sometimes the symptoms are merely bothersome and puzzling. But sometimes the symptoms are significant and greatly affect the person’s life, can even cause disability. The impact of dysautonomia often depends on the severity of the symptoms as well as the ability of your patient to tolerate them and their resiliency.
The most common symptoms my teenage patients complain about are sweaty hands and feet, lightheadedness/orthostatic hypotension/syncope, and fatigue. And headaches are also a symptom of dysautonomia (chicken or egg?). It is a great source of reassurance to many patients when we talk about the variety of symptoms they might experience, basically as a result of instability or over stimulation of their nervous system, from headache, stress and/or anxiety. There can be quite a bit of worry about these symptoms, that it could be a serious, undiagnosed illness. It can be a light-bulb moment.
I usually describe it as their autonomic nervous system is being overly stimulated and excited. So one way to decrease the symptoms is to decrease stimulation to the ANS. This can be done by doing things that trigger the relaxation response, such as yoga, meditation, mindfulness activities, even petting their beloved dog, cat or horse. The effects are not immediate, and improvement is generally noticed over time. So it’s not a quick fix. But over time, the ANS dysfunction can be improved in this way. I wrote about the variety of ways to turn on the relaxation response in a previous post (see Archives for February 2018, Stress and migraine).
There are also many practical ways to deal with the symptoms and difficulties associated with mild dysautonomia:
- Ensuring good hydration, using electrolyte-rich fluids and salty snacks strategically, can help with the orthostatic hypotension. This can be very helpful for athletes. (I think this advice should be standard for most teenage girls, since the most prevalent age for syncope is 15 years.) I do have a few patients with real POTS diagnoses, who need medications and are followed by cardiology, but mostly my patients just have a tendency for lightheadedness which can be managed by hydration, electrolytes, and getting up slowly with support (perhaps ‘POTS-lite’).
- Hydration is also important for dealing with constipation, in addition to added dietary fiber and medications if needed.
- Monitoring their diet for offending foods, eating small frequent meals, helps with gastric distress and GERD.
- Activity pacing can assist in increasing exercise tolerance; physical therapy may be needed when kids are really deconditioned. There are medications that can be used, but working on vascular tone with exercise is a better first step.
- I have not found much that can help with the sweaty hands and feet, though sometimes a dermatologist can offer topical treatment. Aside: Beware of anticholinergic wipes though, which can cause a temporary fixed and dilated pupil. I recently had an optometrist call me about my patient, who had this finding and was wondering if she needed to have a brain scan. She had no other symptoms, had not used scopolamine or other likely medication (most common reason for the finding). She came in that day and did finally remember that she had been given a brand-new medication used for excessive sweating. We determined the culprit for her symptom was QBREXZA (glycopyrronium),a medicated cloth indicated for the topical treatment of primary axillary hyperhidrosis (excessive underarm sweating). It is very new to the market, in December 2018. She most likely applied the wipe and touched near her eye.
- They can experience small fiber neuralgia, a painful tingling, numbness or sensitivity anywhere in the body, often hands and feet. The symptoms can be just bothersome or can develop into complex regional pain syndrome (CRPS), a potentially disabling condition. Strategies to manage these symptoms do include exercise, PT, and desensitization, along with possible medications such as gabapentin.
Headache patients usually have a mild version of these autonomic symptoms, but are often concerned that they are signs of a serious issue. Your knowledge about these benign, idiopathic symptoms and your reassurance can go a long way in preventing unnecessary and unwarranted medical diagnostics and procedures.
HeadFirst PNP 