Ask the Doctor: Hypertension & Cognitive Decline; Cluster Headaches; Epilepsy & Mental Decline

Q: I have read that, as a person with high blood pressure, I am at greater risk for cognitive decline, even though I am on blood pressure drugs. Doesn’t treatment reduce risk?

A: Studies suggest that, compared to people with normal blood pressure, all individuals with hypertension (high blood pressure, defined as a systolic reading higher than 140 mmHg, and a diastolic reading higher than 90 mmHg) face increased overall risk for cognitive decline, whether or not they are receiving treatment. This is why it is so important to take measures through strategies such as a healthy diet, exercise, and weight loss to control blood pressure as much as possible. Hypertension’s cognitive toll is thought to be related to the higher incidence of silent strokes or other subclinical changes that affect brain blood vessels and tissue. The risk for cognitive impairment is greatest in untreated individuals, who are less likely to monitor and control their blood pressure and thereby reduce their exposure to these cerebrovascular events. Treatment with antihypertensive med-ications does appear to offer some protection from cognitive decline. A statistical analysis of data from a large study of hypertension published in 2010 in the online journal PLOS ONE concluded that the probability of maintaining cognitive function in older adults was slightly higher if individuals received treatment for the condition than if they received placebo.

Q: My wife suffers terribly from frequent cluster headaches. Recently, I heard of a new invention that might help her find relief. Would you please tell me about it?

A: You are probably referring to a small implanted electrostimulator that has been approved for use in the European Union (but not yet in the U.S.) for the relief of cluster headaches. Cluster headaches are characterized by acute and disabling pain around and behind the eye. About 15 percent of people with cluster headaches report daily attacks. The almond-sized device, which is manufactured by the U. S. company Autonomic Technologies, Inc., is implanted through a small incision in the upper gum to a position behind the nose, where it delivers low-level electrical charges directly to a part of the autonomic nervous system often involved in severe headaches. On-demand treatment is activated by a handheld remote controller, which is held to the cheek by the patient until headache pain sub-sides. According to a preliminary study published in Cephalalgia in February 2013, the device has shown good success in providing relief for people with frequent cluster headaches, The researchers reported that 27 percent of 38 patients experienced rapid and complete relief from acute attacks, and 28 percent said the treatment reduced pain to mild levels

Q: I recently developed epilepsy and have been experiencing mild memory problems. Is it true that people with epilepsy face faster-than-normal mental decline?

A: Research published in the July 8, 2013 online issue of JAMA Neurology suggests that among people with mild memory problems, those who have epilepsy that started later in life and without clear risk factors (e.g., a brain tumor or stroke) show signs of mental decline almost seven years earlier than those who do not have epilepsy. Epilepsy in these individuals often goes unrecognized because as much as 55 percent of seizure activity is nonconvulsive, involving instead temporary periods of language difficulty, memory lapse, sensory phenomena, or feelings of déjà vu. The researchers found indications that treatment with drugs such as lamotrigine (Lamictal) and levetiracetam (Keppra) may help curb the seizures and possibly improve patients’ clinical course; however, whether or not these anti-epileptic medications can help improve cognition or slow decline has yet to be determined.

—Editor-in-Chief Maurizio Fava, MD

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