Headache (cont.)
In this Article
What should migraine sufferers do?
Individuals with mild and infrequent migraine headaches that do not cause
disability may require only OTC analgesics. Individuals who experience several
moderate or severe migraine headaches per month or whose headaches do not
respond readily to medications should avoid triggers and consider modifications
of their life-style. Life-style modifications for migraine sufferers include:
- Go to sleep and waking up at the same time each day.
- Exercise regularly (daily if possible). Make a commitment to exercise
even when traveling or during busy periods at work. Exercise can improve the
quality of sleep and reduce the frequency and severity of migraine headaches. Build up
your exercise level gradually. Over-exertion, especially for someone who is out
of shape, can lead to migraine headaches.
- Do not skip meals, and avoiding prolonged fasting.
- Limit stress through regular exercise and relaxation techniques.
- Limit caffeine consumption to less than two caffeine-containing
beverages a day.
- Avoid bright or flashing lights and wearing sunglasses if sunlight is a
trigger.
- Identify and avoid foods that trigger headaches by keeping a
headache and food diary. Review the diary with your doctor. It is impractical to
adopt a diet that avoids all known migraine triggers, however, it is reasonable
to avoid foods that consistently trigger migraine headaches.
What are prophylactic medications for migraine headaches?
Prophylactic medications are medications taken daily to reduce the frequency
and duration of migraine headaches. They are not taken once a headache has
begun. There are several classes of prophylactic medications: beta blockers,
calcium-channel blockers, tricyclic antidepressants, antiserotonin agents and
anticonvulsants. Medications with the longest history of use are propranolol
(Inderal), a beta blocker, and amitriptyline (Elavil), an antidepressant.
When choosing a prophylactic medication for a patient the doctor must take into account the drug
side effects, drug-drug interactions, and co-existing conditions such as
diabetes, heart disease, and high blood pressure.
Beta blockers
Beta-blockers are a class of drugs that block the effects of beta-adrenergic
substances such as adrenaline (epinephrine). By blocking the effects of adrenaline, beta-blockers relieve stress on the heart by slowing the rate at
which the heart beats. Beta-blockers have been used to treat high blood
pressure, angina, certain types or tremors, stage fright, and abnormally fast
heart beats (palpitations). They also have become important drugs for improving
survival after heart attacks. Beta-blockers have been used for many years to
prevent migraine headaches.
It is not known how beta-blockers prevent migraine headaches. It may be by
decreasing prostaglandin production, though it also may be through their effect
on serotonin or a direct effect on arteries. The beta-blockers used in
preventing migraine headaches include propranolol (Inderal), atenolol
(Tenormin), metoprolol (Lopressor, Lopressor LA, Toprol XL), nadolol (Corgard),
and timolol (Blocadren).
Beta-blockers generally are well tolerated. They can aggravate breathing
difficulties in patients with asthma, chronic bronchitis, or emphysema. In
patients with who already have slow heart rates (bradycardias) and heart block
(defects in electrical conduction within the heart), beta-blockers can cause
dangerously slow heartbeats. Beta-blockers can aggravate symptoms of heart
failure. Other side effects include drowsiness, diarrhea, constipation, fatigue,
decrease in endurance, insomnia, nausea, depression, dreaming, memory loss,
impotence.
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) prevent migraine headaches by altering the
neurotransmitters, norepinephrine and serotonin, that the nerves of the brain
use to communicate with one another. The tricyclic antidepressants that have
been used in preventing migraine headaches include amitriptyline (Elavil),
nortriptyline (Pamelor, Aventyl), doxepin (Sinequan), imipramine (Tofranil), and
protriptyline.
The most commonly encountered side effects associated with TCAs are fast
heart rate, blurred vision, difficulty urinating, dry mouth, constipation,
weight gain or loss, and low blood pressure when standing.
TCAs should not be used with drugs that inhibit monoamine oxidase such as
isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and
procarbazine (Matulane), since high fever, convulsions and even death may occur.
TCAs are used with caution in patients with seizures, since they can increase
the risk of seizures. TCAs also are used with caution in patients with
enlargement of the prostate because they can make urination difficult. TCAs can
cause elevated pressure in the eyes of some patients with glaucoma. TCAs can
cause excessive sedation when used with other medications that slow the brain's
processes, such as alcohol, barbiturates, narcotics, and benzodiazepines, e.g.
lorazepam (Ativan), diazepam (Valium), temazepam (Restoril), oxazepam (Serax),
clonazepam (Klonopin), zolpidem (Ambien). Epinephrine should not be used with
amitriptyline, since the combination can cause severe high blood pressure
Antiserotonin medications
Methysergide (Sansert) prevents migraine headaches by constricting blood
vessels and reducing inflammation of the blood vessels. Methylergonovine is
related chemically to methysergide and has a similar mechanism of action. They
are not widely used because of their side effects. The most serious side effect
of methysergide is retroperitoneal fibrosis (scarring of tissue around the
ureters that carry urine from the kidneys to the bladder). Retroperitoneal
fibrosis, though rare, can block the ureters and cause backup of urine into the
kidneys. Backup of urine into the kidneys can cause back and flank (the side of the
body between the ribs and hips) pain and
ultimately can lead to kidney failure. Methysergide also has been reported to
cause scarring around the lungs that can lead to chest pain, and shortness of
breath.
Calcium channel blockers
Calcium channel blockers (CCBs) are a class of drugs that block the entry of
calcium into the muscle cells of the heart and the arteries. By blocking the
entry of calcium, CCBs reduce contraction of the heart muscle, decrease heart
rate, and lower blood pressure. CCBs are used for treating high blood pressure,
angina, and abnormal heart rhythms (e.g., atrial fibrillation). CCBs also appear
to block a chemical within nerves, called serotonin, and have been used
occasionally to prevent migraine headaches. The CCBs used in preventing migraine
headaches are diltiazem (Cardizem, Dilacor, Tiazac), verapamil (Calan, Verelan,
Isoptin), and nimodipine.
The most common side effects of CCBs are constipation, nausea, headache, rash, edema (swelling of the legs with fluid), low blood pressure, drowsiness,
and dizziness. When diltiazem or verapamil are given to individuals with heart
failure, symptoms of heart failure may worsen because these drugs reduce the
ability of the heart to pump blood. Verapamil and diltiazem may reduce the
elimination and increase the blood levels of carbamazepine (Tegretol),
simvastatin (Zocor), atorvastatin (Lipitor), and lovastatin (Mevacor). This can
lead to toxicity from these drugs.
Anticonvulsants
Anticonvulsants (antiseizure medications) also have been used to prevent
migraine headaches. Examples of anticonvulsants that have been used are valproic
acid, phenobarbital, gabapentin, and topiramate. It is not known how
anticonvulsants work to prevent migraine headaches.
Next: Who should consider prophylactic medications to prevent migraine headaches? »
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Last Editorial Review: 3/23/2007
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