Dear Dr. Roach: I’m writing in regard to your recent column about a 56-year-old person, recommending he or she wait till 60 for the shingles shot. In 2010 I was 56 and was told by my insurance company that they would not cover the shot till I was 60. Unfortunately, that year I suffered a shingles attack that started on the back of my head and moved into my left eye. I spent an extremely painful and stressful year, not being able to see well and going through medical treatments. My cornea was permanently damaged, and each time I have tried to stop the eyedrops I am taking, the blurriness returns. So, I have told all my friends and family to get the shingles shot as soon as possible. I hate to see anyone go through what I did!
G.J.
I thank G.J. for writing. To be clear, I do recommend the shingles shot beginning at age 50. The column was about a person nervous to get the shot during the coronavirus pandemic. I said it was OK to wait because the risk of serious complications of shingles at age 50 is low.
However, as G.J. points out, the risk of complications from shingles, even at a younger age, is not zero. I do recommend the vaccine starting at age 50, but the older a person is, the greater the risk of shingles complications, and thus the more benefit they are likely to get from the vaccine.
Dear Dr. Roach: After six weeks of severe headaches, which were originally thought to be migraines, I was diagnosed with thunderclap headaches. These headaches suddenly stopped, and I have not had another for over two years. The doctor gave me a prescription for Maxalt to be taken as soon as I feel a headache coming on. It can be repeated twice within 30 minutes of each dose. Would you please explain this condition?
P.M.
A thunderclap headache is, as its name suggests, a very severe headache that begins suddenly and reaches full intensity within one minute. This is a medical/surgical emergency, as one of the most common causes of TCH is a subarachnoid hemorrhage, usually caused by rupture of an aneurysm. This possibility must be evaluated immediately (call 911!) with imaging studies and a lumbar puncture, also called a “spinal tap.” People will usually describe it as “the worst headache of my life,” and treatment is aimed at repairing the aneurysm as quickly as possible.
There are other causes of thunderclap headache, which can be considered after exclusion of subarachnoid hemorrhage. The course of your condition — that is, multiple episodes over several weeks — suggests you have a condition called reversible cerebral vasoconstriction syndrome. In this condition, some of the arteries in the brain constrict and stay constricted for a prolonged time. It is not known why this happens. It is most common in women in their 40s. There are several predisposing conditions and medications, including preexisting migraine, although people with migraines know immediately that a TCH is NOT a typical migraine. Triptans, such as rizatriptan (Maxalt) is one of the medicines that can trigger reversible cerebral vasoconstriction syndrome, and many authorities recommend against using them. Double-check with a neurologist about this treatment. Otherwise, there are no specific treatments for RCVS. Ninety percent to 95% of people will have a course like yours, with no permanent damage and no recurrence.
Dear Dr. Roach: Years ago, you discussed tramadol as a cough suppressant. I have had a chronic cough for years, and my family doctor at the time told me to take tramadol. I have been taking it for about 10 years. My new family doctor doesn’t want to give it to me. What can I do?
Anon.
Tramadol is an opiate medication that can be dangerous if misused. Physicians need to be cautious about prescribing it. Like essentially any medication, it can be abused: taken too much of or sold, for example. It should not be used in people at high risk of opiate drug abuse.
However, you have a 10-year safety record with the medication. I hear frequently from people who have had years or decades of chronic cough with extensive evaluations that failed to make a diagnosis or find an effective treatment. For this small number of people, I think that low dose tramadol is safe and effective. I think it’s unfortunate you can’t get the medication from your new doctor. I suggest you consult a pulmonary specialist, who might find alternate treatment or decide the benefits of tramadol outweigh the risks.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu
