Headaches and Migraine: Easing the Pain -- Seymour Diamond, MD
WebMD Live Events Transcript
In recognition of National Headache Awareness Week 2003, we asked for pain prevention and treatment tips from neurologist Seymour Diamond, MD, director of the Diamond Headache Clinic.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Diamond: In most instances there is a way to differentiate between migraine and tension and other type headaches. Migraine is sometimes characterized by calling it a sick headache. It is a one-sided headache that has either loss of appetite, nausea, or vomiting accompanying it, as well as having the head pain and the neurological signs, which may accompany many of the attacks.
The person having migraine commonly also has photophobia, which is a light sensitivity. The common tension headache is usually generalized; that is, all over the head. It is not as severe as migraine.
Sometimes migraine is characterized as a throbbing headache, as opposed to a dull or constant ache of a tension headache.
Member: How do you feel about the use of roxicodone for headaches?
Diamond: Roxicodone is [a brand version of the generic oxycodone]. For an individual headache for pain relief I have no objection to its use, but for a person who's having daily headaches or almost daily headaches, it is not my choice for therapy. The medicine can be habituating, and I think it would be wiser to seek the cause for the headache rather than treating it specifically with pain relieving drugs.
If the headaches are due to migraine, there are specific migraine drugs known as the triptans that can actually reverse a migraine attack. So it would be much wiser to use a drug such as the triptans rather than a pain-relieving drug.
Member: I can't take migraine drugs due to other drugs I take that may cause serotonin syndrome.
Diamond: We have such a wide choice of medicines that I'm sure we could find compatible medicines besides the Roxicodone for a person to take without getting serotonin syndrome. The serotonin syndrome is caused when a person is taking two incompatible medicines, usually antidepressants, and the person develops high fever, neurological symptoms, and can even go into coma. It is very, very rare, and in my 45 years doing headache work, I've only seen it happen three or four times.
Member: Is Imitrex the best medicine for menstrual-cycle triggered migraine?
Diamond: About 70% of migraine sufferers are women, and of this 70%, 70% have menstrually related headaches, that is, headaches occurring immediately before, during, or immediately after their periods. Imitrex can be used successfully to treat menstrually related headaches, but there are also many other choices. There are approximately seven different triptans on the market, and they each have individual pros and cons about their use.
There are other medicines that we can use to also help menstrual migraine. I think I discuss them in my book very thoroughly, but we can use the nonsteroidal anti-inflammatory drugs, the steroids and the ergotamines, and sometimes we use added hormone therapy during the woman's period time to help. It would be an individual therapy according to a detailed history of the woman's problem.
Member: My doctor is trying to get me off Fiorinal 3. I like the effectiveness of this medication. I have tried Imitrex and Maxalt. Imitrex was horrible. I liked Maxalt, but it's expensive. What else is there?
Diamond: Fiorinal 3 is a medicine that contains, besides aspirin, a drug known as butabital, which is a barbiturate. If taken on a daily basis it can be highly addicting. If you are having intermittent headaches, I see nothing wrong with taking the Fiorinal and codeine, although the triptan drugs might be more effective. Certainly, if you are having daily headaches, the Fiorinal and codeine would not be a desired medicine to take.
Member: What is your choice of therapy for daily headaches that elude the detection of the source?
Diamond: If a person has a daily headache or almost a daily headache, one should always first rule out any organic disorder. Most often, it is very rare to have any organic causes to a daily headache, but one must rule out such conditions as a brain tumor, an infection, or an immune disorder.
Once these things are ruled out, most daily headaches can be treated effectively by the use of the tricyclic antidepressant medicines. Although most daily headache patients do not have a depression or they may have one, the medicine is used because it is the most effective way to eliminate daily headaches once any organic cause has been ruled out. Some examples of the tricyclic antidepressants are amitryptiline, protryptiline, and doxepin.
Member: Why do light and noise bother me? I am unable to function.
Diamond: Noise and light bother a migrainer because the migraine attack affects the nervous system as well as the blood vessels, and the migraine attack sufferer has an added sensitivity of their nervous system to stimuli, such as light, sound, and touch. In fact, during most severe migraine attacks, the person suffering the attack will wish to go to a dark, quiet room and lie down.
Member: Your thoughts on topamax as a preventive medication?
Diamond: We, at the Diamond Headache Clinic, have used topamax anecdotally because it has been mentioned in the literature that it is effective in some migraine patients. We are now conducting part of a multi-clinic double blind study on its effectiveness. In our clinic, we do use it on a number of patients effectively as a preventative for migraine.
Member: Dr. Diamond, what can you tell me about "basilar artery migraines"? After 10 full years of experiencing constant dizziness and imbalance, and the last few years from migraine headaches, a neurologist diagnosed me with BAM. What should I expect? I was told that BAM is very rare, and greatly increases your risk of stroke. By how much and how can I reduce my stroke risk? Furthermore, in your experience, what is the best course of treatment for BAM? I am on the second day of treatment #2 (Inderal 80 mg once a day). The first one, Verapamil 120 mg once a day, did not work. Since I have BAM, a lot of migraine medications are forbidden to me (such as the triptans).
Diamond: Basular artery migraine, or BAM, usually occurs when the migraine occurs in the back of the head or the circulation of the brain's blood vessels in the back of the head. It is very common in young women, and dizziness, altered speech, and confusion are common symptoms. I know of no evidence that it increases the propensity to stroke any more than any other kind of migraine.
I certainly would see if the Inderal helps. If you are worried about stroke, you might want to combine it with aspirin or other anti-clotting medicine.
Member: On a scale of 1-10 how safe is triptan use for women in early their 60s?
Diamond: Probably if it is used judiciously, it is all right to use it if the person has used it previously. What I mean is if you have been taking it all along for the past four, five, or six years before you reached the age of 60 I see no contraindications. I would sort of draw the line over the age of 65 or 70 about its use. Certainly I would not want its frequent use after the age of 65.
Member: I would like to know if you ever reach an age when migraines will subside or will you always suffer? I'm now 61.
Diamond: The older you get, in most instances, the less frequent your migraines occur. There are exceptions to this. I'm sorry to say that as your blood vessels get harder your migraines will lessen.
Member: Would topomax be useful for daily migraine sufferers who are allergic to tricyclic antidepressants (imipramine)?
Diamond: Topomax might be effective in these type patients; however, there are studies in migraine and there are also studies in patients having daily migraine. Its effectiveness in daily headaches is now being tested. In some anecdotal cases it has been helpful.
Member: Are there certain foods we should avoid that can cause or aggravate a migraine?
Diamond: Yes, there is. Although some of my colleagues would argue with me, clinically I have seen red wine, aged cheeses, chocolate, nuts, pizza, and hot dogs all being triggers for migraine. The National Headache Foundation has a diet list that you can obtain from them. I think it's free of charge. We are giving their web site address -- www.headaches.org.
Member: I have been taking Effexor for three months for menopause symptoms. Could this drug cause migraines?
Diamond: I do not believe Effexor could cause migraines. In fact, I think it could be more of a help than a cause.
Member: I am doing a national research test with Wells Institute on a new drug for the prevention of migraines. I have in the past taken Inderal 120 mg twice daily with excellent results. The research test drug Aricept is either 5 mg or 10 mg once a day. What your thoughts on this new preventive medication?
Diamond: There have been some anecdotal articles about its effectiveness. Aricept is usually used for senility or Alzheimer's disease. We are now doing some studies at our clinic on its possible use in migraine. I would say we don't know the answer about its effectiveness yet.
Member: Why does Maxalt-MLT have aspartame (phenalalanine) in it if it causes migraines in so many people?
Diamond: The question whether aspartame is a trigger for migraine is debatable, and the amounts in the Maxalt is probably of such a minimal amount it would not precipitate the headache.
Moderator: How can a person determine what is the trigger for their migraines?
Diamond: The best way to determine a trigger for your migraines is to keep a calendar and mark down what foods, whether it was during your menstrual period, whether it occurred after watching a movie or television, whether there was an emotional or work event that precipitated your headache. If you keep a calendar, you will be aware of what triggers your particular headache.
Member: Has hormone replacement therapy been identified as a possible contributor to migraine?
Diamond: I have seen hormone replacement therapy as a possible trigger for migraine. The whole question of hormone replacement therapy is now up for grabs, and we are being advised against it by some authorities and there are still some affirmative thoughts about it. The fluctuation of the hormones, when given artificially, not produced by the body in the form of hormone therapy, can precipitate migraines in certain sensitive women. I usually do not prescribe it for any of my migraine patients.
Member: If I am taking a medication like Inderal and it is not keeping my headaches at bay and I still end up taking my Axert. Is that an indication that I need to have my dosage adjusted (40 mg)?
Diamond: Forty milligrams of Inderal is a very insufficient dose. A good prophylactic preventative dose of Inderal is usually 80 to 160 mg daily.
Member: I am suffering from weekly low-key migraines for over a year, as well as somewhat monthly very bad migraines. My neurologist (I have multiple sclerosis) blames that I am on Effexor, an antidepressant that raises my blood pressure. My psychiatrist (I have bipolar II disorder) blames my MS. My general practitioner blames bad posture. How likely are these causes?
Diamond: Effexor would not cause your migraine. There is very little evidence that your MS causes migraine, as well. Bad posture is probably not a cause. I would suggest you see a headache specialist to see if they can ascertain other treatments and causes for your migraine.
Member: Are allergies and migraine related?
Diamond: No. Allergies are not related to migraine. I'm not saying that a migraine may be intensified if you're in an allergy season, but basically they are not related. At the Diamond Headache Clinic we did a study on the relationship to allergy and headache and found no relationship whatsoever.
Member: What are hemiplegic migraines? One doctor told me he thought I have those, but my headaches don't seem to fit the definition I read recently on a web site.
Diamond: There are certain individuals that have stroke-like symptoms occurring during their migraine attacks. They may have a weakness in an arm or leg and show other neurological signs while they're having their migraine attacks. These neurological and stroke changes usually disappear in a day or two. There are a group of migraine sufferers where this is a hereditary factor, and the hemiplegic migraine runs in their family. Only rarely will hemiplegic migraine progress to a permanent stroke.
Member: I have an 8-year-old sister who gets headaches very often and when she does, it appears to be very painful; she cries herself to sleep and wakes up next morning feeling OK. Is this normal for an 8-year-old? She wears glasses; she doesn't do any heavy work; no harsh studying; and no head damage. Should I be worried?
Diamond: It sounds like this young girl has migraine attacks, and certainly there are medicines available both to treat the attacks and to cut down the frequency of attacks. I would suggest she see someone knowledgeable about headaches and get treatment for them. Please read Headache and Your Child, by Firesides books. It was a work of choice by me. I always wanted to do a children's book. I really wanted to do this one.
Member: Why do migraines onset in the middle of the night?
Diamond: It's rare that migraine attacks will wake a person up from sleep. Cluster headaches will do that. Most migraine sufferers will wake up and tell you their headache started when they wake up, but it has to be a very severe migraine to actually wake you up during a sound sleep. Cluster headaches are God's way to repay men for giving migraine to women.
They are called cluster because they occur in groups or bunches. Ninety percent of sufferers are male. The sufferer will get this one-sided headache usually around the eye. It is a severe stabbing pain lasting 15 minutes to four hours, and the sufferer gets a group of them occurring two to 12 times a day for two to three months. Tearing of the eye, flushing of the face, and drooping of the eyelid all accompany the headache.
Member: How can you tell if a headache is caused by sinus problems? What can you do to treat them?
Diamond: One of the great misconceptions, and part of this misconception is caused by radio and TV ads, is that sinus disease frequently causes headache. As a cause of headache, sinus disease is a rare cause. Most often, what is attributed to sinus disease is actually migraine. For a person to have a sinus headache, they would have to have a high fever and actually puss coming out from the sinus.
Member: Are there any known medical conditions that may predispose a person for migraines?
Diamond: There are some medical conditions where there is a frequency, for example, lupus, but these are so inconsequential that they are not of any clinical importance.
Member: What is more helpful for migraines -- heat packs or cold packs?
Diamond: Usually cold is better for migraine than heat, and there have been some studies conducted that show that use of cold packs helps a little more than the heat does.
Member: Can you tell me about the new triptan, Relpax?
Diamond: We have done some work with Relpax. It is a good and efficient triptan, and we have found it effective. We have done some research with it before it was marketed, but I think that all triptans that are marketed have been proven effective.
Member: Can Imitrex or other triptans cause rebound headaches? I have been diagnosed with migraine, and the only medicines I ever take are prescriptions such as Imitrex or Frova. The headache (mild to moderate) usually goes away at first, but another will develop on the other side of my head hours later. This cycle goes on and on almost every day. What can I do?
Diamond: It would be inadvisable to take triptans on a daily basis. I do believe that you can get rebound from the triptan drugs. You should seek out a preventative medicine to try to lessen the number of attacks you are getting.
Member: My daughter began developing headaches in second grade. We saw a neurologist and went through a battery of tests including an MRI. Everything was negative. Then summer came and the headaches stopped. Every school year, two months or so into the year her headaches begin again. One every two weeks or so and by the end of the year she can have one or two a week. She is now 11 1/2 and the headaches are coming every day whether in school or not. She is very intense and a perfectionist. I think they are stress headaches. I also wonder if the ibuprofen is now not working because she has been taking them every day for six weeks or so. She has also become very emotional, up one moment and teary the next. I'm wondering if puberty can now be playing a role. This week we have begun to keep a diary for her to keep track of the headaches, rate them and whatever else is going on in her life. Should I take her back to the physician again? Can a physician tell if hormones through puberty is causing them? Not sure where to turn at this time. Any info would be greatly appreciated.
Diamond: I would certainly have your daughter see someone knowledgeable about headaches, and from your description consider therapies such as biofeedback, which is a way to treat headaches without medicine, and may help her because it certainly seems like stress is a factor in her headache problem. But certainly she should be seeing a headache expert.
Moderator: How does one find a headache expert?
Diamond: Write the National Headache Foundation or call them or get online, www.headaches.org.
Moderator: Dr. Diamond, we are almost out of time. Before we wrap up for today, do you have any final comments for us?
Diamond: If anybody is losing time from work or their family or their social events due to a headache problem, if they're in any way incapacitated by their headaches, they should seek out the proper treatment. Read about headaches, read some of the books that are out about headache and certainly get the information from the National Headache Foundation.
Moderator: Our thanks to Seymour Diamond, MD. For more information, please read his books, Conquering Your Migraine and Headache and Your Child.
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