Migraine Headache (cont.)
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 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.
Who should consider prophylactic medications to prevent migraine headaches?
Not all migraine
sufferers need prophylactic medications; individuals with mild or infrequent
headaches that respond readily to abortive medications do not need prophylactic
medications. Individuals who should consider prophylactic medications are those
who:
- Require abortive medications for migraine headaches more frequently than
twice weekly.
- Have two or more migraine headaches a month that do not respond readily to
abortive medications.
- Have migraine headaches that are interfering substantially with their
quality of life and work.
- Cannot take abortive medications because of heart disease, stroke, or
pregnancy, or cannot tolerate abortive medications because of side effects.
How effective are prophylactic
medications?
Prophylactic medications can reduce the
frequency and duration of migraine headaches but cannot be expected to eliminate
migraine headaches completely. The success rate of most prophylactic medications
is approximately 50%. Success in preventing migraine headaches is defined as
more than a 50% reduction in the frequency of headaches. Prophylactic
medications usually are begun at a low dose that is increased slowly in order to
minimize side effects. Individuals may not notice a reduction in the frequency,
severity, or duration of their headaches for 2-3 months after starting
treatment.
Next: What is the proper way to use preventive medications? »
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