Q: LAST year I was diagnosed with a hernia near my navel. My GP referred me to a consultant who didn't want to operate as I have a gap from my navel up to my chest, caused by exercising too early after having children. I was advised to contact my GP if I heard gurgling noises. Is the gap dangerous?
CR
A: A hernia occurs when an organ pushes through the muscle that contains it - in your case, something within your abdomen is coming through a gap in the abdominal wall.
It sounds as though the gap is between the rectus abdominis muscles on either side of the abdomen. A gap can open due to stretching in pregnancy, and also if you're overweight. This is known as divarication of the recti.
The small lump you say you found last year is a result of abdominal contents - probably a loop of intestine or part of the omentum, a fatty membrane - pushing through the space.
This kind of hernia is usually painless, and the bulge often flattens when the abdominal wall muscles relax - if you're lying down, for example. However, in some cases the lump will not flatten - this is known as an incarcerated hernia, and seems to be what you are describing.
Occasionally, these hernias can twist, cutting off their own blood supply. If a loop of bowel is trapped, it will block the intestine, resulting in acute pain and noisy bowel sounds. This requires quick surgical attention, which is why you must be aware of gurgling noises.
I think it's likely that you do need this hernia repaired, given that it sounds as if it's incarcerated. Do speak to your GP about whether a further referral for surgery is advisable.
Q: I'm 78 and can't remember a day when I haven't had a headache. I have been prescribed numerous medications and had a brain scan, which was fine. My GP decided I have migraine.
RD
A: Chronic migraine - defined as having moderate to severe migraines on at least 15 days a month - is debilitating.
The condition often appears in people who have had the occasional migraine earlier in life.
Infrequent migraines can become a chronic problem owing to factors including genetics, a history of head injury, significant stress (such as that from divorce or unemployment), and being female (because of menstrual hormone changes).
Many sufferers also experience nausea, disturbed sleep and an aversion to lights, sounds or smells.
You say in your longer letter that your doctor has tried common preventative medications such as painkillers, antidepressants and anti-inflammatories which, frustratingly, have not worked.
Treatment usually focuses on prevention - not least because taking painkillers for 10 to 15 days a month or more may trigger medication overuse headache. You will have trialled different drugs for two to three months each.
There are many first-line medications, such as the beta blocker propranolol - thought to help by stabilising blood vessels in the brain so they are less likely to over-dilate - and topiramate, an anticonvulsant which may reduce the activity of nerve cells in the brain related to migraine. There is also the antidepressant amitriptyline, which boosts levels of the pain-regulating brain chemical serotonin.
I suggest speaking to your GP about seeing a neurologist specialising in migraine. They will be able to arrange for you to try second-line treatments.
These include botulinum toxin injections and anti-CGRP injections, which block chemicals responsible for pain signals, as well as other antidepressants.
The neurologist may also suggest cognitive behavioural therapy to help manage your response to migraine and hopefully reduce its impact.
And it's worth considering over-the-counter supplements such as riboflavin (vitamin B2) and coenzyme Q10. These have both been shown to reduce the frequency and severity of migraine headaches.
IN MY VIEW... IN-PERSON GP VISITS SAVE LIVES
THE migration away from face-to-face consultations, coupled with too few GPs, can be risky, especially for older and vulnerable patients.
I'm thinking of those such as my mother, a frail 92-year-old with type 2 diabetes. She should be undergoing regular blood tests and examinations to check for peripheral neuropathy, a type of nerve damage, and other diabetes complications.
But for a recent blood test she was told to go to a hospital nine miles from her home, without a companion, because of Covid. How is she meant to navigate the vast building unaided, while using a walking frame? Circumstances were similar for her eye check. Many in her position simply wouldn't go.
A new study has shown that 11 per cent of those with type 2 diabetes also experienced depression, and this in turn more than doubled their risk of damage to the heart, brain, kidneys and nervous system.
It is therefore vital that GPs see patients to evaluate them for depressive illness as part of regular care - but this is even more unlikely to happen now that we are evolving away from face-to-face GP care.
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