Dr. Keith Roach

DEAR DR. ROACH: I read your recent column about migraines and strokes. About 40 years ago, I began having occasional visual-interference episodes with zigzags, blurry central vision, and more that lasted for about 30 minutes. My doctor described them as ocular migraines.

When I read about migraines, the first possible cause that was listed were preservatives, so I started reading labels. My episodes occurred only after eating food with added nitrites and sulfates. It was very consisten, so I now read labels and avoid them. And thanks to the fact that more foods are now being made without them, at 85, I have not had an episode in many years. It has made me a more careful and healthy eater.

Would I still be more likely to have a stroke? Is this a common cause of these auras, or do causes vary in people? I would hope that others would find a sure cause and solution like I did. — D.W.

ANSWER: Food additives, especially nitrites but also sulfites and sulfates, are known triggers of migraines in people who are susceptible. Finding and eliminating the triggers for migraines can be helpful, but not everyone is able to identify their triggers.

Red wine (which contains trace amounts of sulfites, even if more aren’t added) is one of the most common food triggers, but caffeine (and caffeine withdrawal) are another common cause. Poor sleep, excess stress, and hormonal changes (especially in menstruating women) are also commonly reported.

Some perceived triggers may actually be an early part of a headache. Chocolate cravings can be part of the prodrome of a headache, so people may think that chocolate caused the headache when, in fact, the headache was already on its way.

Headache with aura can be confused with a stroke. My column in January tried to point out that positive findings like zigzag lines make a migraine with aura very likely, while transient ischemic attacks and strokes are exceedingly unlikely.

However, there is an increased risk of stroke in people who have migraines with aura. This is particularly the case in younger women. I suspect but cannot prove that having fewer migraines after removing the triggers, as you have, probably does mitigate the small, increased stroke risk.

Still, it is important for all people with migraines to do what they can to reduce their stroke risk through a healthy lifestyle. Elevated blood pressure and cholesterol might be worth treating, even if they are fairly mild. Diabetes should be as well-controlled as possible. Finally, with strong evidence showing that the shingles vaccine reduces stroke risk, I’d recommend that you make sure you have had the two-dose shingles vaccine.

DEAR DR. ROACH: I’m a 75-year- old female who is hoping to keep her hair from falling out. I currently use minoxidil, but I’m not seeing any improvement. What else would you suggest? — G.E.

ANSWER: Most women in their 70s lose some of their hair. The most typical pattern is a general thinning that is somewhat worse on the crown. I do recommend seeing a doctor about this to be sure of the diagnosis. There are other patterns of hair loss, some of which are related to thyroid disease and — less frequently — to serious systemic diseases.

If the diagnosis is confirmed as female pattern hair loss, then in addition to minoxidil (which can be used either topically or as a low-dose oral pill), spironolactone (or another antiandrogen) would be the other first-line treatment. Some physicians use prostate medicines like dutasteride, and ketoconazole shampoo can also be helpful. These drugs are usually used in combination with each other.

Finally, laser or low-level light therapy, microneedling, and platelet-rich plasma have some benefit, although these are much more expensive options. A dermatologist is the expert in diseases of the hair and scalp.

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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.