Migraine & Headache Q & A (cont.)

The most common acute medicine is the family called the triptans, of which Imitrex was the first, but there are currently seven on the market, including Maxalt, Zomig, Relpax, Axert, Amerge and Frova. Other drugs that are also effective in reversing a migraine include the ergot compound; the one we use most in this family is DAG 45, which comes both in a nasal spray and injection. Another drug often put in this class, although not proven to be effective, is Midrin. These drugs should not be used in patients with coronary artery disease or poorly managed hypertension. Other reversal drugs or acute drugs include the nonsteroidal anti-inflammatory drugs.

The preventative drugs are really divided based upon the class of medication they are and co-existing disorders or conditions that the patient might have. There are actually only three drugs approved by the FDA for the prevention of migraines, which is pretty sad. These medications are Depakote, which is an antiseizure drug, and two beta blockers, which are blood pressure medicines, Inderol and Timolol.

We know from clinical experience in smaller studies that there are other medicines that can help prevent migraine, so some of the antiseizure drugs, such as Topomax and Neurontin, are used. Tricyclic antidepressants, such as Elavil, work on chronic pain and migraine as well as other types of blood pressure medicine. So there are many choices.

The third category is the analgesics or rescue medicine, and these are generally either nonsteroidal anti-inflammatory drugs, or medications containing opiates or some of the atypical antipsychotic medication. These medicines can all work on pain, but don't necessarily reverse the process of migraine. In other words, they can get you to sleep or get you comfortable if nothing else has worked.

MEMBER QUESTION:
My husband has recurring migraines and has had for a long time. I've been trying to find events that may trigger them -- he had a throbbing headache after sexual intercourse -- it came almost immediately when he had a climax. I am trying to understand the relation of migraines to blood flow in vessels.

DIAMOND:
Some migraines are associated with exertion. A sexual headache, or coital headache, is not all that unusual in a migrainer. It's called benign exertional headache, although if he's never had it before or the pattern has changed he should consult with his doctor as soon as possible. In a patient who's never had it before, we will often do an MRI and MRA to look at the blood vessel. Typically, the good news is those tests are normal.

Once we know nothing dangerous is going on we can treat these benign exertional headaches the way we treat any other headache. Sometimes we can use the drug Indocin, which is an anti-inflammatory, about half an hour before intercourse to prevent these headaches.

MEMBER QUESTION:
Is it normal to get migraines during my period? This is the only time that I get them besides when I am outside in the sun all day.

DIAMOND:
Women have three times more migraine headaches than men, and it's likely that hormonal fluctuations or changes contribute to this. Sixty percent of women with migraines can predict they will have at least some of their attacks around their menstrual cycle, so it's very common, and being able to predict these attacks can help your health care provider prescribe a treatment during these migraine episodes.

Many of our patients with migraine will have more attacks in high humidity or when they're in the sun for long periods of time. We always suggest lots of fluids and wearing a good, broad-brimmed hat to keep your head from getting so hot and to protect you from the sun. Taking breaks in the shade or cool environment can help to prevent these headaches.

"Women have three times more migraine headaches than men, and it's likely that hormonal fluctuations or changes contribute to this."

MEMBER QUESTION:
Why do I get more migraines when I am pregnant? I know I can't take my migraine medication, but what over-the-counter medication is best to take during pregnancy?

DIAMOND:
That's a great question. Many patients with migraine actually feel better when they're pregnant, but obviously not everybody. Usually patients with migraine will struggle most during the first trimester, or through the first 12 to 14 weeks of pregnancy.

The safest over-the-counter medication is Tylenol, which for many people, is not terribly effective for migraine. Prescription medications can be used, and include Tylenol with codeine, or hydrocodone, which is Vicodin, as long as they don't need to be used frequently. Many of the drugs we use in pregnancy are classified category A, B, C, D, and X. Most analgesics are category C, which are neither safe nor harmful; they have not proven to be either. Most of the drugs have been used frequently in pregnancy without significant problems for the baby.

Two of the triptans, Imitrex and Zomig, have been approved by the American Academy of Pediatrics for breastfeeding.

MEMBER QUESTION:
I am in my late 30s and have mild fibromyalgia, but no other health problems. During the past 10 years I have been getting increasingly severe headaches from the heat. I can't do outdoor activities for more than 30 minutes when the temps get above 80 degrees without getting a headache. Fioricet prevents/relieves the headaches, as does cooling down, although it can take hours for them to subside without medicine. When I haven't taken Fioricet and am unable to cool down (when hiking, canoeing) the headaches get severe enough to go to the ER, but I haven't done so because there were no hospitals nearby. Staying hydrated doesn't prevent them.

If Fioricet prevents the headaches, am I just masking the symptoms of something I should be worried about? If not, would a preventative like Depakote help, which is what my doctor has recommended. I obviously can't take Fioricet every day, so my activities are very limited in the summer.

DIAMOND:
Your physician is concerned about the Fioricet because of the risk of overuse and rebound headache. If it can be used intermittently or less than one or two times a week, it would not be a problem, but obviously in the summertime you have many more migraines than that.

A good preventative drug, such as Depakote, might protect you from having so many migraine attacks and work well to reduce your heat-related migraines. Other medications, like Indocin or a triptan might also treat some of these attacks.

MEMBER QUESTION:
I guess I'm just not sure what is going on. I am guaranteed to get a headache if I go out in the heat and am concerned the headache is a symptom of something else

DIAMOND:
If the headaches are new or different and you you've never had any type of imaging, like an MRI, having a thorough workup at least one time is important. Other testing would depend on the rest of your medical history. It is important to make sure that those two tests are normal.

MEMBER QUESTION:
I have dull headaches that can last up to two weeks after my cycle is over and sometimes longer. I usually get the migraine on the Tuesday of my cycle week. I take Fiorinal and Topomax, 75 milligrams a day. Things are not improving. Any suggestions?

DIAMOND:
For patients like you with prolonged menstrual headaches, prevention is the key. I assume you are taking Topomax throughout the month. If you are only taking it around your cycle it might not be as effective. On the other hand, if you are taking it every day, and at 75 milligrams it is not effective, the dosage could be increased to 100 to 125 milligrams a day. If at that point you still have not noticed a decrease in frequency or severity of this two-week attack, another preventative might be useful.

Fiorinal can produce analgesic rebound and may make episodes of migraine last longer if it must be taken daily for prolonged periods of time. We prefer using a long-acting anti-inflammatory medication or a triptan to break the migraine cycle, and use the Fiorinal solely as a rescue medication sporadically or infrequently.