What does my MRI scan report indicate?

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Posted on Mon, 8 Jun 2015 in Brain and Spine
Question: Hi, I have a MRI report. it says this: SUPRATENTORIAL STRUCTURES: There are bifrontal and left parietal scattered periventricular and subcortical white matter signal hypertensities on T2 and FLAIR weighted imaging which are nonspecific. The differential diagnosis includes migraine headache, a demyelinating process such as multiple sclerosis, vasulitis, small vessels ischemic disease, and infection such as Lyme disease. I am taking this MIGRAINE medication: Generic for BUTALBITAL/APAP/CA TAB every four hours. Yet the pain does not go away. I have a headache in more than one month. I have like 10 percent brain pain too.
doctor
Answered by Dr. Dariush Saghafi 1 hour later
Brief Answer:
Medication Overuse Headache Likely to Ensue

Detailed Answer:
Good afternoon. My name is Dr. Saghafi and I am an Adult Neurologist and Headache Specialist and would like to comment on some things about your case.

First of all, you must keep in mind that when an MRI is read by a radiologist they're usually working without much clinical information to go on. In other words, most orders from doctors will simply ask for the scan to be done without specifying what anyone is really looking for or any of the important symptoms or features of the patient's presentation. Only on rare occasions will a request to a radiologist contain enough detail or make specific mention of where in the brain the clinician was thinking there might be a problem. Therefore, when the radiologist has to make the read they simply are going call every thing that appears to be abnormal to them without regard to what the PROBABILITY is that the patient could actually HAVE any of those diagnoses.

So, in your case when the radiologist makes the call that the scan shows a picture which could be consistent with LYME DISEASE.....that's not to say that you have that diagnosis or even a good chance of that diagnosis because if you haven't been out in tick infested woods or sleeping with deer much in the past few months then, you almost would be a walking legend if you could come up with LYME DISEASE out of nowhere. BUT, the radiologist has to include that possibility in his conclusion simply because to him the picture looks like it fits.

If all you presented with to the doctor who ordered the study was severe headaches and nothing else (no numbness or tingling anywhere, no muscle weakness, no trips, no falls, etc.) then, the likelihood that you are suffering from multiple sclerosis is extremely small and the T2/FLAIR spots that are mentioned are more likely what we refer to as UBO's (Unidentified Bright Objects) which are most frequently seen in patients who suffer with migraine headaches.

Also, if you are a heavy smoker, have very high cholesterol levels, or are a severely out of control diabetic then, you could also have the picture on the MRI that you see reported. But the fact that you are only 29 years old and so young, even having all those risk factors would probably still not even cause the brain lesions to appear as those usually don't come about at least the mid to later 30's. So again, I think the cause of the lesions is more likely than not the migraine headaches.

As far as the choice of medication is concerned for your headaches; I do not use this drug in my patients at all. It is a narcotic and by taking it 4x/day you are a huge setup for something called MEDICATION OVERUSE HEADACHES which can occur in susceptible individuals who take more than 10-15 doses of a drug PER MONTH. In your case, do the math....at 4x/day you are already at risk for MOH within 3-4 days of starting the drug. And then, stopping the medication could cause withdrawal symptoms not to mention the risk of becoming pharmacologically dependent upon the medication which will lead to rapid tolerance of its effects on your headaches requiring that you take more powerful drugs.

In my clinic we approach headache management from a totally different perspective than most general practice or even neurological practices might and require that headache diaries be kept so as to document and track symptoms as well as the effectiveness of medications/interventions that are used as acute abortives vs. medications used as preventatives making adjustments as needed in conjunction with lifestyle changes.

Therefore, in my experience the use of narcotics, semisynthetic narcotics, or any abortive medication which has to be used more than TWICE WEEKLY constitutes a patient who should be reviewed for both the types of headaches they may have as well as alternative regimens that could be offered.

My advice therefore, is to seek out a neurologist who is a headache specialist and not only that but one is interested in IDENTIFYING THE EXACT type of headaches you may have as well as someone who is willing to do some foot work to find the best regimen for you without automatically just giving you medications which are not destined to work very well in the long run due to the risk of MOH or which have other undesirable qualities such as addiction, withdrawal side effects, etc.

Of course, you could always drop in to the XXXXXXX Ohio area and I'd be happy to see you as well and you could both get your headaches seen and treated as well as start to see why XXXXXXX Ohio is fast becoming a favorite tourist attraction as well as Mecca for Cultural, Sporting, and Musical Events. After all, we have the XXXXXXX Browns, the XXXXXXX Indians, and the awesome XXXXXXX Cavaliers. LOL.

I hope this answer satisfactorily addresses your interesting question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback.

Also, if there are no other questions or comments, can I ask that you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

Please direct more comments and questions to me in the future at:

bit.ly/drdariushsaghafi and I would be honored to answer you very quickly and continue this interesting discussion.

Please keep me informed as to the outcome of your situation.
All the best.

The query has required a total of 40 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi 1 hour later
Thank you for your answer. May I know what kind of medication can I use before I find a specialist? Thanks for your coming response.
doctor
Answered by Dr. Dariush Saghafi 14 hours later
Brief Answer:
Not really

Detailed Answer:
Thanks for the follow up question. The choosing of a BEST medication for headaches requires much more knowledge of your headache process and should be done carefully over time. In my clinic patients will keep track of their headaches for a period of no less than 2 weeks and usually at least 4 before we decide upon the best medication. It is often the case that a person may actually be suffering from a MIXED picture meaning they may have even more than 1 headache type at the same time.

This requires tracking, documentation, and then, analysis by the doctor to determine the best medications. If you are having headaches intermittently or episodically then, there are certain medications for those....if they are daily or chronic then, there is another type. If they are autonomic in nature then, another...etc. etc. This is why I suggest that at least for the headache part of your problem you may wish to seek out a headache specialist. A good one should be available in your area and should follow a sequence as I mentioned before trying to prescribe a particular agent.

On the other hand, because you have an imaging study that was read by the radiologist as having some other information that is slightly unusual for a young person such as yourself it is also necessary they look at this information and decide whether or not your headaches are as a consequence of another type of problem so they can target treatment toward the cause and not just treat the headaches and miss the big picture.....make sense?

In any case, I must say that the use of butalbital every 4 hrs. is a choice I would have to lodge disagreement with since it is not helpful to curing any type of primary headache problem and can lead to MEDICATION OVERUSE HEADACHES as I described in my other answer. You need to secure either a neurologist or headache specialist who is willing to spend a little time going over the details of your problem in order to get good answers.

Maybe if it gets warmer here on Lake Erie's shores you'd consider a trip North? HAHA! BTW, there are many types of HEADACHE DIARIES and LOGS for headaches you can find on the internet just by googling them. Some of more basic than others but at least you could get started on the documentation side of things and that way have something to take to the specialist. I'm not sure the person who is prescribing the butalbital would be interested in that approach but you could try giving them a diary of your events and see if that changes their mind on anything.

I hope this answer satisfactorily addresses your interesting question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback.

Also, if there are no other questions or comments, can I ask that you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?

Please direct more comments and questions to me in the future at:

bit.ly/drdariushsaghafi and I would be honored to answer you very quickly and continue this interesting discussion.

Please keep me informed as to the outcome of your situation.
All the best.

The query has required a total of 53 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Dariush Saghafi 7 hours later
Hi, thank you very much for your time in answering my question. I have another question that I think I found in the internet something related with my pain. Therefore, before I begin to ask you this question I have to tell you about something how the headache began. I was working in the pizza oven for around 4 days and the big headache began like one month ago at the time I was working. There were other employes who were working at the pizza oven that was over 500 F and nothing happened to them but to me was different. I looked at the history of my father and he was a heavy alcohol drinker. But I never drunk alcohol in my life. According to the internet the heating causes thiamin defieciency to be disactivated to those who have the disease passed down by the parents. And the question is: Do you think I have Wernicle Korsakoff? Thank you very much for your coming response.
doctor
Answered by Dr. Dariush Saghafi 13 hours later
Brief Answer:
Wernicke Korsakoff

Detailed Answer:
Thank you for your follow up question.

I do not think you have Wernicke Korsakoff syndrome based upon the style of your writing these questions that you have submitted. Having said that I cannot truly know whether you have any of the other features or clinical parameters which could define the disease....

If you've never drunk alcohol in your life then, it would be very very rare for you to be suffering from this disease entity....even though you worked in the pizza oven area for 4 days.....

Wernicke's itself would require that you have a condition which caused eye movement problems....actually, paralysis. I'm sure you would've told me something of that if you had it....secondly, you'd have to also have a problem called ataxia which is where you'd be walking almost like a robot....very rigidly with legs wide apart, unbalanced, and a risk probably for falling....you don't say anything about that.....and then, the 3rd thing you'd have to have would be extreme confusion....and again, the way you write your questions, I don't detect confusion or difficulty with comprehension.....

Bottom line, no I don't think you have Wernicke/Korsakoff syndrome.

If you wanted to ask the question whether or not I think it would hurt you to take thiamine supplement in case you feel you may actually be deficient in some way.....the answer to that is....NO PROBLEM.......You could purchase, if you'd like a bottle of thiamine and simply follow the directions on the bottle to take a standard daily dose. If you did that for a few months you may then, see if it makes any difference to you before deciding whether or not you should continue.

Again, with the history that you don't drink alcohol at all I can't imagine how you could be thiamine deficient to the point of having learning or severe memory problems (totally in-apparent from your writing)...

You could also get a blood test looking for thiamine deficiency. If you want also then, throw in a B12 and a folate level as well just to complete the tests then, you could get the entire complement of what is usually asked for when someone is tested who is thought to have WKS.....which I DON'T THINK you've got.

I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback.

Also, may I ask that you not forget to CLOSE THE QUERY on your end so these questions can be transacted and archived for further reference by colleagues as necessary?

Please direct more comments and questions to me in the future at:

bit.ly/drdariushsaghafi

and I would be honored to answer you very quickly and continue this interesting discussion.

Please keep me informed as to the outcome of your situation.

Be well sir....

The query has required a total of 71 minutes of physician specific time to read, research, and compile a return envoy to the patient.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Dariush Saghafi

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Practicing since :1988

Answered : 2474 Questions

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