The Clinic.

OCULAR MAGRAINES

I have been running for the last four years with a marathon best of 3:52. About a month ago while running on the treadmill at home, I experienced a "silent ocular migraine." I got off the machine for a break and when I got back on, I lost the vision in my right eye. I became very light-headed, and my right arm had a strong tingling sensation, as if I had whacked my elbow on a table. This lasted for about 30 seconds and then sight and feeling came back I felt extremely tired for about an hour. I thought I was having a stroke.

Over the next few weeks similar events occurred both during and after exercise, and sometimes, unassociated with exercise. Once it happened in the middle of the night.

I had an MRI which revealed nothing unusual. I was diagnosed as having "ocular migraines." At first I was given no treatment and was advised to continue running. Another doctor, an opthalmologist, told me to cut back on running as a possible trigger. The events were occurring more frequently (four or five times a week, sometimes as many as three times in one day).

Eventually, I was prescribed verapimil to ease vascular spasms, and so far it seems to be helpful--I've only had one episode in the last two weeks. I am wondering whether this kind of migraine is associated with running and also about the effects of verapimil on performance. I am preparing for another marathon and about to increase my training mileage. Are these migraines exercise-induced? Are there other possible triggers?

Patrick Perry

Sacramento, CA

Ocular migraines are a variant of migraine headaches. Migraines are the second most common cause of headaches after tension headaches. Migraines associated with exertion occur in 1% of the population. Most patients experience headache pain, although pure neurologic symptoms do occur. Once other conditions are excluded with tests such as an MRI, these headaches are referred to as benign exertional headaches.

One category of benign exertional headache is an acute effort migraine. This is usually associated with an intense maximal effort, as would occur toward the end of a middle distance running event. Other vascular headaches in athletes typically occur with prolonged exercise and often have neurological symptoms such as the visual disturbance you describe. Often patients have a personal or family history of migraines. These headaches once present tend to recur. Precipitating factors include certain medications, caffeine use, poor nutrition, hypoglycemia, dehydration, fatigue, inadequate warm-up, altitude, extremes of temperature, certain foods and food additives, and alcohol use. Foods that may act as triggers include chocolate, aged cheese, pickled foods, processed meats, cultured dairy products, aspartame, and MSG.

Prevention of migraines includes adherence to a strict schedule, avoiding triggers, adequate warm-up, relaxation techniques, biofeedback, and medications. Medications for effort-induced migraines are similar for common migraines. The medication you are taking is a common migraine preventative medication. Non-steroidal anti-inflammatory medications like ibuprofen before exercise often help. Also, ask your physicians about treatment once the symptoms start.

Some preventive migraine medications may affect your performance. If given in large enough doses, they may reduce your maximal exercise tolerance. Typical marathon training at the "recreational" level will not likely be affected. If you notice an effect on your exercise tolerance, consult your physician. Other alternatives are available. Good luck to you-with the right management, your running program should not be affected.

Jeffrey M. Hubbard, MD.

Clovis, CA

Since you also have symptoms involving the right upper extremity, the tingling in your arm, it might be wise to do an MRA (magnetic resonance angiography) of the brain. This is different from an MRI and can help diagnose problems in your cerebral blood vessels.

Ronald M Lawrence, MD., Ph.D.

Malibu, CA

Painful plantar fasciitis 

I am a 64 year old male and have been running for 31 years. Although I used to train every day and compete in races, for the past few years I run three days a week and alternate with strength training. I run for about an hour, at a nine- to ten-minute pace. My weight has remained stable all these years and my overall health is excellent I have never had any real problems with injury until recently.

About a month ago, I noticed some heel pain after a run. Within a few days I was unable to jog. Even walking was painful. My podiatrist diagnosed plantar fasciitis and prescribed orthotics and physical therapy. I have been told that this is a difficult problem and that it may take a long time to be up and running again. I am cross training on a stationary bike and a stair climber but my heart's not in it. I want to get back to running as soon as possible. Do you have any advice? Since I've made no changes in my routine, I don't have a clue what could have caused this injury. How can I know how to avoid it again?

Gerald D. Jocobs

Negaunee, MI

In my experience, plantar fasciitis is one of the most common, painful foot problems people can encounter. It is seen among all kinds of patients, but is really frustrating when it strikes a runner. Your diagnosis is probably accurate, but other possibilities should be ruled out. These include a stress fracture of the calcaneus, inflamed bursitis of the heel, nerve entrapment syndrome, or partial or complete tear of the plantar fascia, among other possibilities.

If you were to see ten different doctors you may end up with ten totally different treatment plans. There is no right or wrong in the order or methods of treating this problem. Orthotics and physical therapy are two of the hallmarks of treatment for plantar fasciitis. Additional treatments that are commonly used for plantar fasciitis include injection therapy, night splints, supportive strapping and taping techniques, oral anti-inflammatories and, in advanced cases, immobilization, non-weight bearing and the possibility of surgery (which is a last resort when all treatments fail). Conservative treatments are usually successful; however, the length of discomfort can vary from a simple one to two week injury to chronic long-term repetitive history of pain for years.

It is not unusual for a runner with a long, injury-free history to have a problem like yours "suddenly" develop. Running is a repetitive stress activity. You can compare this to typing on a computer keyboard. Years may pass without a problem. Then, without warning, pain develops and carpal tunnel syndrome is diagnosed. Another possibility is that a sudden, small tear could result from trauma. Bruising of the heel bone due to the rocks you might encounter with trail running is another possibility.

Although age is not a major factor, and you are in excellent health, there may be some small correlation between your age and this new problem. The heel area on the bottom of the foot is a unique architectural system. It is filled with many layers and compartments of fat padding devised to protect the heel from excess shock. During the course of life, especially in runners, over a long period of time, there may be some atrophy or loss of the internal shock absorbing system. In general, aging decreases the threshold beyond which stress causes injury.

In addition to the advice and treatment you are receiving from your doctor and physical therapist, here are some tips. First, do not go barefoot or in stocking feet. Protect the heel at all times in your running shoes. Possibly consider a heel lift under the orthotic or in the shoe to elevate the heel higher. This can take even more pressure off the heel bone and plantar fascia.

Massage the foot. A good technique is to roll the foot over a tennis ball to help stimulate circulation. Use cold therapy and stretching exercises frequently. Make sure your running shoes have excellent heel cushioning and are replaced regularly. And don't forget the entire kinetic chain. Plantar fasciitis may be associated with joint problems and muscle tightness throughout the lower limb and hip. In particular, focus on stretching the calf and Achilles tendon up to three times per day. Hopefully you will soon return to pain-free running.

Douglas F. Tumen D.P.M.

Kingston, NY

You need to cut back in your workout mileage--preferably stop running until all pain is gone. Then focus on plantar fascia stretching and strengthening. Only when you can run with no pain, increase running gradually. You may also want to use a night splint to hold the foot in a dorsal-flexed position while sleeping.

Marvin Bloom, M.D.

Burlingame, CA.

Avoid steroid injections, which are sometimes recommended, as they may lead to tearing of the plantar fascia. Orthotics should not end mid arch, but should be full-length for runners. Runners who by nature usually spend a higher percentage of time on the forefoot, will do better with an orthotic that extends for the whole foot.

Lewis G. Maharam, M.D.

New York, NY

ARE YOU BOTHERED BY AN INJURY? DO YOU HAVE A TRAINING OR DIET QUESTION?

Ask The Clinic, in care of The American Running Association, 4405 East west Highway Suite 405, Bethesda, MD 20514, FAX [phone] Write a letter including as much relevant information as possible about you (age, weight, etc.) and your injury (type and location of pain), training schedule (typical weekly workouts, pace, surface), athletic and medical history, sole wear, recent changes in training, etc. Type or print your letters. Hand-written FAXed letters cannot be accepted All letters, even e-mail, much includes your name, address and phone number. Responses usually take three to four weeks, but can take as long as five.