work, lie down and rest, or, like me, spend time sitting in a dark room?
You should probably begin to keep this diary for at least several weeks before
you see a doctor. This diary can help your doctor not only diagnose your
headaches, but also find patterns of severity and frequency.
You should keep your diary even after you have seen your doctor as it is
important for him or her to be able to see changes in your headaches,
especially those that have occurred because of your response to a new
therapy.
The Initial Visit
Most chronic headaches are called primary
headaches. That is, they are not caused by
some illness or ailment. It is these primary
headaches that are the subject of this book.
In your initial visit to the doctor, she or he will
probably interview you first about your
headaches and your general medical condition.
You will be asked questions about your head
pain and other symptoms. Often there will be a detailed question and answer
session that will produce enough information about your headaches that your
doctor can at least form an initial diagnosis.
Your doctor will want to either identify or exclude any underlying or
secondary cause of the pain that may require treatment.
To do this, he or she will talk to you about your health in general and about
your normal activities. When you have this discussion with your doctor, be
sure to mention relevant information such as whether you have had an head
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injury in the past, abused medicines, experienced hormonal changes, or been
exposed to harmful substances that could be the cause of your headaches.
Questions You Need to Answer
Your doctor will be looking for patterns that are characteristic of a specific
type of headache.
This interview with your doctor may make you feel as if you were playing
that childhood game of “20 Questions”, as you will be asked questions such
as:
Do you do you have a mild, aching pain that develops daily or
occasional attacks of a severe, throbbing pain?
When did your headaches start?
How often do they occur?
Where is the pain located?
How would you describe that pain?
How long your headaches typically last?
Do you experience any other symptoms along with the pain?
Are there any factors that may trigger or aggravate the pain?
What helps your headaches?
You should be prepared to answer these questions and also to talk about
your medical history, including information about any serious injury you have
suffered. He or she will want to know about previous tests – for example,
tests to screen for blood pressure or vision – and the names of all
medications or supplements you are taking. Your doctor may also ask about
your family’s medical history.
The Physical Examination
Following this, your doctor will most
likely do a physical examination.
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He or she will check your ears, nose, throat and jaw to check for signs of
symptoms of infection or illness that could be causing your headaches. She
or he may also look for any neurological signs, such as vision problems or
muscle weakness that may indicate a secondary cause of your headaches.
Other Diagnostic Tools
Following this, your doctor may use one or more diagnostic tools to help
determine what kind of chronic headaches are affecting you and how best to
treat them.
These tools may include:
Psychological examination: Your doctor may suggest an evaluation by a
mental-health professional to determine if your headaches are being
aggravated by psychological influences.
Blood tests: These can determine changes in blood chemistry that might
signal the early onset of some disorders, such as anemia, thyroid disease,
low blood sugar, or kidney and liver disease.
Electroencephalography: This test, also known the EEG, shows electrical
activity of the brain. It is used to detect some disturbances in brain function
such as irregularities in rhythm, the presence of seizure-like activity, and the
effects of metabolic substances on the nervous system.
X-rays: Simple X-rays have generally been replaced by more advanced
technology such as CAT scans. However, they can be used to detect some
conditions, including sinus infection and or excessive fluid around the brain.
Computed Axial Topography (CAT) scan: This test shows radio
graphically "slices" of brain structures and can detect conditions inside the
brain that reveal most physical causes of headaches. For example, it can
detect blood clots but not aneurysms. A CAT scan is more technologically
advanced than an X-ray. As part of this procedure, you are most likely to be
injected with a relatively harmless dye to better show the brain structures. If
your doctor recommends a CAT scan, be sure to tell her or him if you are
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allergic to shellfish. This is because shellfish contain iodine, and the dye used
in most CAT scans also contains a form of iodine.
Magnetic Resonance Imaging (MRI): This test uses magnetic fields and
radio waves instead of X-rays and is more advanced than a CAT scan. The
MRI machine is essentially a large magnet. When turned on, it forms a
magnetic field, which will orient some of the atoms in your brain in a certain
direction. A detailed picture of the brain is then created as the radio waves
changed direction in the movement of these atoms.
Both CAT scans and MRIs are considered controversial in diagnosing
headaches as they actually diagnose so few. In fact, most people who
undergo these tests have normal results. For this reason many insurance
companies do not reimburse the cost of either of these procedures.
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6. Coping with Migraines
If you suffer from migraines, there is bad news and good news.
The bad news is that there is no cure for migraines. Despite what you may
have seen on TV or heard on some radio infomercial, migraines just cannot
be cured.
There is no miracle cure, no pill, potion, vitamin or supplement that can stop
your migraine headaches for all time.
The good news is that in some cases you can head them off with
preventative treatments or, at least, modify their severity (abortive
treatments).
Choosing a Treatment
No one but your doctor should choose your method of treatment or the drugs
used to treat your migraines.
However, there are some guidelines that can help you understand how your
doctor may treat your headaches.
If your migraine is mild with little disability, your doctor will probably suggest
analgesics. In this case, a caffeine-containing analgesic such as Excedrin may
work best.
For severe or disabling migraines, your doctor may add an anti-nausea
medication such as Compazine, as well as DHE or triptans.
If you get poor relief or usually need to repeat your dosage for the same
headache, your doctor may consider a different acute medication.
Finally, if you usually need to use acute medication for more than two days a
week, your doctor may add a preventive therapy.
The first form of preventative treatment is to cut out foods that can trigger
headaches such as those covered in Chapter 4 that contain tyramines,
nitrites or monosodium glutamate.
There are two other types of preventative treatments; medications and
supplements. You will find supplements treated in Chapter 13.
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If you are suffering two or more migraine headaches per month, or if your
migraines are so severe that they are impacting your quality of life or ability
to function, then a good solution for you might be preventive therapy or a
preventive drug.
While all of these therapies or drugs are called preventive, you should not
become frustrated if your doctor prescribes medication that does not
immediately stop your migraines from occurring.
Your doctor may need to try several different preventive drugs before finding
the right one. The good news is that these preventive drugs have significant
potential for reducing the frequency, duration and intensity of acute migraine
attacks, and can significantly decrease the disability associated with your
chronic migraine.
Also, keep in mind that there is no drug that will prevent migraines for all
sufferers.
I have been monitoring a migraine headache group for the past several
months. Here are just a few of the comments I saw posted having to do with
migraines and drugs.
These comments are comments from individual people
and should not be considered as any sort of medical advice
“I know it seem hard to handle right now but hang in there.
The Topamax dose that is supposed to work the best is 50mg
in the AM and in the PM. The side effects go away do not
worry, the migraines go away also. The Topamax did not work
well for me until the doctor put it at the dose for the
migraine prevention level.”
“Phenergan with my medication". Now with some people
Phenergan is addictive but it has never been with me...go
figure.
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This was a miracle for me. This changed things completely.
“It is Sinus Buster, and I got the headache formula that
includes feverfew which I have chewed the leaves of before
with little success, and also taken the tablets of, with
less success. The spray has capsaicin pepper in it. My eyes
did water. It was recommended in the article to hold the
spray in the opposite hand as the nostril so you don't shoot
it on the middle which would be especially sensitive. Let me
tell you I just got it today and I was about to take my
Fioricet, and took two sprays of this in my nose. DANG it
made my eyes water. But here I sit headache free 10-20
minutes later. So, I am kind of holding my breath, hoping it
lasts.”
“I was also at that time on the max amount of Topamax, they
had upped it from 50 mg a day to 200 mg a day to help with
the nerve pain, 1800 mg of neurontin and I also take 50 mg
of Elavil, which I have been on for 2 years as a daily for
my migraines. I do still get some break through migraines,
but not nearly as frequent.”
“Instead, the doctors gave me Benadryl and Phenagran. This
really helped. After being home and having another one,
hubby went to the store and bought Benadryl. I had to take
this a few times, but it got rid of my migraine without
going to the doctor.”
“When I took Topamax it made me feel like I was on speed, I
was only on it for 2 weeks but I felt like it was two weeks
of hell because if my sleep is affected, I suffer big time.”
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“I started on Topamax about a 1 1/2 weeks ago. Yes, the mood
swings are great aren't they. My husband said I am getting
very bad. He wants me to stop taking them.”
“I am now on Namenda, Inderal, Tarka, Cymbalta and then my
pain meds should I need them. I take Phenergan.”
As you can see, different migraine suffers react differently to different drugs.
In many cases, it takes a combination of drugs to provide relief.
In any event, here is some information on some drugs that have been found
to be helpful in treating migraines for some people.
It is important to understand that I am not a physician nor a trained
specialist in headaches or headache relief.
The information in this chapter and throughout this book is based on
research I have done over the past several months and represents the best
information I was able to find from a variety of sources.
You should never you take any of the medications cited here
unless prescribed by your doctor after personal consultation.
N.S.A.I.Ds
The NSAIDs are platelet antagonists and prevent platelet clumping, an action
that is commonly associated with the development of migraines. They also
affect serotonin levels.
NSAIDS are most often used in preventative treatment of those who suffer
from chronic migraines. They are unique in the treatment of migraine, and
anti-inflammatory and analgesic properties make them good choices for
endive, symptomatic, and prophylactic therapy. In fact, recent studies
suggest that the regular use of aspirin or other platelet-active drugs in this
category might reduce the recurrence of migraine by approximately 40%.
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The most common complaint associated with the use of NSAIDs is
gastrointestinal problems.
Typical nonsteroidal anti-inflammatory drugs or NSAIDs such as ibuprofen
(Advil, Motrin and others) or aspirin can help relieve mild migraines.
There are also drugs in this family marketed specifically for migraine
headaches. These are typically a combination of acetaminophen, aspirin and
caffeine. One example of a combination drug sold over-the-counter is
Excedrin Migraine.
Prescription Drugs
The Food and Drug Administration have approved a
number of prescription drugs for use in preventing
migraines.
They include cardiovascular drugs, antidepressants,
anti-seizure drugs and NSAIDs.
Cardiovascular Drugs
Cardiovascular drugs, which are commonly used in
the treatment of high blood pressure and coronary
artery disease, have been shown to reduce the
frequency and severity of migraines. In fact, these
drugs are considered to be among the first-line
treatment agents.
Propranolol: This drug, better known by the brand name Inderal, is a beta
blocker and is currently considered by some to be the first choice drug in
migraine prevention.
Beta blockers do many things that may contribute to their efficiency in
migraine prevention.
This includes preventing the widening of the cranial arteries, blocking the
beta-receptors, blocking the platelets from clumping and decreasing the
ability of platelets to stick to the walls of the smallest blood vessels or
capillaries.
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Other beta blockers: If your physician does not recommend that you take
propanol, he or she may suggest another beta-blocker.
One that has received approval in migraine prevention is Timolol, which is
marketed under the brand name Blocadren.
Another beta blocker, nadolol (marketed as Corzide) has also been used
successfully in migraine prevention.
Divalproex sodium: Depakote is a brand name for divalproex sodium,
which is the drug most recently approved in migraine prevention. While it is
not clearly understood how divalproex sodium can prevent migraines, it may
be due to its ability to increase levels of the amino acid GABA, which is
believed to be involved in migraine development.
If you also suffer from seizures, mania or anxiety, it may be worth asking
your doctor about divalproex sodium.
However, it does have side-effects, including nausea, gastrointestinal
distress, sedation, pancreatitis, some blood disorders, tremor and liver
toxicity.
Methysergide: Sansert is the brand name of methysergide. It is a
synthetic drug and is closely related to ergotamine medications, which occurs
naturally. While this drug may be one of the most effective for migraine
prevention, it is normally used only for patients who suffer from frequent,
severe, disabling migraines that do not respond to less toxic agents.
Its adverse effects include vomiting, abdominal pain, nausea, drowsiness, leg
cramps, numbness, weight gain, hair loss, fluid retention, and low blood
pressure.
In addition, using methysergide long-term has been associated with the
production of fibrous tissues in the lining of the kidney and lungs, and fibrotic
thickening of the cardiac valve.
For this reason, you should not be kept on methysergide for more than four
to six months consecutively, and should be given a 4-to 6-week drug-free
interval between treatments.
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Also, if you have a history of collagen disease, fibrotic disorders, peripheral
vascular disease, coronary artery disease, severe hypertension, or
thrombophlebitis, you should probably not take methysergide.
Calcium Channel Blockers: Calcium channel blockers may also be effective
in the prevention of migraines, but it may take two to four weeks for their full
effects to be realized. It should be noted that, while these agents have been
studied extensively in both the U.S.A. and Europe for migraine prevention, no
calcium channel blocker has yet to receive approval in migraine prevention in
the U.S.A.
These drugs are used to treat hypertension for some heart patients in the
United States.
Verapamil is a calcium-entry blocker that maintains its effects and for this
reason, is useful as a migraine preventative agent. It is marketed as Calan,
Isoptin, or Verelan. The most common side effect of verapamil is
constipation, but other side effects may include flushing, light-headedness,
hypotension, rash, and nausea.
Nimotop is the brand name of Nimodipine, which has also been used
effectively to prevent migraine. Unfortunately, it has also been known to
cause more behavioral changes, sedation, and other central nervous system
effects than other calcium blockers.
Antidepressants
Tricyclic antidepressants (TCAs) do have an anti-migraine effect, but are
not usually considered to be the first choice in preventing migraines.
However, they may be useful in some patients, especially those who have
both migraine and tension type headaches.
Amitriptyline (brand name Elavil) is a well-established antidepressant used
in migraine therapy, usually along with doxepin (brand name Sinequan),
nortriptyline and imipramine.
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These antidepressants are usually more effective in sedation than
protriptyline (brand name Vivactil) or desipramine, which is commonly
known as Norpramin.
Be aware that these drugs may cause dry mouth, blurred vision, weight gain,
conservation, blurred vision, hypotension, rapid heartbeat, sexual
dysfunction, and urine retention.
This means you should not be on antidepressants if you have a narrow-angle
glaucoma, prostate problems or cardiac conduction disturbances.
SSRIs
Serotonin uptake inhibitors (SSRIs) and some of the other newer
antidepressants have a more targeted attack as they operate more
specifically than serotonin receptors and their side effects are not as
disabling. However, as with TCAs, it may be as long as two to three weeks
before you begin to feel the therapeutic effects of these drugs.
The SSRIs, such as Prozac (fluoextine), Zoloft (setraline), and Paxil
(paroxtine) have also been found to help prevent migraines.
However the side effects of these drugs can include nausea, insomnia,
weight-loss, sexual dysfunction, and agitation.
Wellbutrin (bupropion) and Desyrel (trazodone) are other antidepressants
that have shown some ability to prevent migraines.
However, bupropion, can produce insomnia, anxiety, and seizures, and
should not be used if you have a history of seizures or are prone to eating
disorders such as bulimia.
Also, trazodone can cause priapism (persistent erection of the penis with pain
and tenderness) and should be avoided if you're a male patient.
MAOI’s
Nardil (phenelzine) and Marplan (isocarboxazid) are Monoamine
oxidase inhibitors (MAOIs) that have been found to be helpful in
preventing migraines.
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Monoamine oxidase has been identified as one of the chemicals that are
instrumental in developing migraines, and these drugs prevent some of its
actions.
Adverse effects associated with MAOIs include insomnia, dizziness, blurred
vision, impotence, urinary retention, orthostatic hypotension, edema in the
feet, ankles and hands, and weight gain.
Alpha Blockers
Clonidine: This Alpha Blocker’s efficiency in migraine prevention is not as
good as that of the beta blockers. It acts on the part of the brain that
subsequently affects the blood vessels.
However, it has been found to be helpful in those patients who experience
food-related attacks. It can also be helpful to patients withdrawing from
opiates (narcotics).
The side effects of iodine which is contained in this preparation may include
drowsiness, constipation, disturbances of ejaculation, dry mouth, orthosta