Headache & Migraine Q & A

WebMD Live Events Transcript

In recognition of National Headache Awareness Week 2004, WebMD Live held this question and answer session with Merle Diamond, MD, associate director of the Diamond Headache Clinic. From tension headache to migraines, we looked at pain prevention and treatment tips you need to clear your head.

The opinions expressed herein are the guests' 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.

MEMBER QUESTION:
What is the current treatment for the outbreak of cluster headaches, both during flare-ups and as prevention? Currently I've not found anything that prevents, and the only medication that works during outbreaks is Stadol; however, I'm afraid of addiction.

DIAMOND:
If this is a patient with episodic cluster headaches, then the best fast treatment is usually a shot of steroid or a prednisone taper.

Normally we start at 40 milligrams and drop the dose by 5 milligrams every five days. Other medications that can be used preventatively include Topomax, Depakote, Verapamil, Methergine, Sinequan, and lithium. Some people have found even melatonin can be helpful.

To treat acute attacks, the best therapy is oxygen by mask at 15 liters for 10 minutes. Other acute treatments include Imitrex, subcutaneiously, DHE 45, lidocaine drops, and Toradol injections.

Stadol nasal spray is addictive, but if used only during attack time can probably be managed.

MEMBER QUESTION:
I have what my doctor calls silent migraines or chronic daily headaches. I have them every day and they vary in intensity, instead of getting terrible pain I get dizzy about three to four times a week. I get all the pain in the back of my neck at the base of the skull. I have had all the tests done to rule out inner ear disorders by three different ENTs. I have also had MRI, four CT scans, and blood work done. Everything was normal. I have tried a lot of preventatives such as Verapamil, Inderal, Nortriptyline. I am now taking Diazepam 2 milligrams twice daily and 30 milligrams of Elavil at bedtime. Sorry, but I wanted you to know some history.

I was wondering if you suggest I see some special type of doctor I haven't seen or if there are any medications I should ask the doctor about? Right now I am seeing a neurologist.

DIAMOND:
I think chronic daily headache and dizziness, either lightheadedness or the spinning sensation we call vertigo, can live together in the same patient. Usually a neurologist or headache specialist can deal with both. If the dizziness is truly vertigo or a spinning sensation then sometimes seeing someone who specializes in vertigo, or a physical therapist who helps with balance retraining, can be useful. A headache specialist can sometimes add some extra information to a chronic problem, and perhaps more tools for treatment.

Headache specialists can be found by looking at the National Headache Foundation web site, or you could call our clinic at 1-800-HEADACHE, but if we're not convenient perhaps a referral can be made in your area.

"There are actually only three drugs approved by the FDA for the prevention of migraines, which is pretty sad."

MEMBER QUESTION:
Unlike most people (from what I can tell), I wake up with my migraines. I have a prescription for Imitrex, but it doesn't seem overly effective. Is this because I'm not able to take the med as the migraine starts?

DIAMOND:
That's an excellent question. We clearly know that patients can treat their migraines more effectively if they can get their medication on board within 20 to 30 minutes. Our triptan medications, like Imitrex, clearly work much more effectively when given early. Unfortunately, 40%of our patients wake up with their migraines.

There are two approaches to this:

The first is the way you might use your Imitrex. If you're on tablets and you wake up with frequent migraines then injection will speed relief, as it will work more quickly.

The second approach involves recognizing symptoms we call prodrome. About 60% of migraine patients have symptoms that precede their migraine attacks from three to six hours, and are generally reproducible, or they can predict them because they've had had a history of migraines for so long. These symptoms include:

  • Carbohydrate craving
  • Yawning Neck pain
  • Light sensitivity
  • Nausea
  • Irritability

Tracking this could be done with a headache diary, and if you recognize a prodrome, treating before you went to bed that night might be helpful.

MEMBER QUESTION:
What are the most prescribed medications for migraines?

DIAMOND:
When we talk about medicines we prescribe for migraine we actually split it into three categories:

  • Acute medicine, or medicines we use to stop a specific migraine attack
  • Preventative drugs, or medications we give if people have frequent or difficult-to-treat migraines
  • Analgesic or rescue medicine, something to get rid of the pain if we haven't caught it in time

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.

MEMBER QUESTION:
I get headaches in the back of my neck at least three to four times weekly. I notice I wake up with these headaches. I have been taking Fioricet for years, and have had migraines for about 20 years. Do you think a chiropractor would be of any help?

DIAMOND:
Headaches and migraine can be treated in many different ways by health care providers. An experienced chiropractor can sometimes be useful to help treat migraines. Anyone who suffers from migraine knows they have their own ideas about what treatment they're comfortable with. I have patients who see chiropractors very successfully. Always talk to people about their credentials and ask people for their experiences.

"The most important thing you can do is find a treating health care provider who is willing to stay the battle while you continue to search for an appropriate therapy that can help to normalize your life."

MEMBER QUESTION:
I was wondering if there is any way to stop or prevent the buildup of a tolerance to abortive medications. I'm very careful not to use my abortives more than twice a week. However, lately I notice that it takes at least two doses before I gain any relief from the migraine. Any suggestions?

DIAMOND:
People who commonly become adjusted or who become tolerant of their acute medicine will recognize that a medication will work for several months and then slowly you have to take more and more or you become resistant to it entirely. Usually patients in this situation will do better with a good preventative agent. Preventative agents will reduce the severity of migraines and will likely stop this cycle of what we in the medical community call tachyphalyxis.

MEMBER QUESTION:
I am about to lose my mind with this. I have chronic daily migraines without rebound, hemipelegic migraines, occipital neuralgia, and if they are real bad, I can't see out of my left eye. I am constantly nauseated or throwing up. I throw up at least once a day. I can be heard all over the house. I have been fired from all my jobs since graduating college. I haven't been able to work for two years now and am applying for SSDI. I also have fibromyalgia and CFS. I have had the headaches for 16 years and I have always been a complicated case. Each of my neuros has thrown up their hands and say they have exhausted all means, and then I get a letter telling me they won't treat me anymore. In fact I am expecting one from my current neuro this week. They all agree I need a pain clinic.

I have taken all the preventatives, abortives, and rescue meds. The best I have been was when seeing a doctor that had me on Wellbutrin, Celexa, Topomax, Xanax, Stadol NS, and Demerol pills. Every time something new comes out they try it on me. I get temporary relief with the pain meds, but when it wears off I am right back where I started. It is not rebound as I have been taken off all pain meds by two different doctors for about six weeks each.

DIAMOND:
Your story is one very typical of the types of patients we see in a headache clinic. I can say that six weeks off analgesic is not a long-enough period of time with someone as long a history of chronic daily headache as you to say that piece in your brain would have healed.

It is common for physicians, when patients are struggling, to say I can't help. It is also unusual for someone to say they can't care for you any more, unless something else has gone on in the relationship. The most important thing you can do is find a treating health care provider who is willing to stay the battle while you continue to search for an appropriate therapy that can help to normalize your life.

MEMBER QUESTION:
I want to know where I can find that. I have been to all the doctors around here.

DIAMOND:
I would refer you to the National Headache Foundation, www.headaches.org

MEMBER QUESTION:
My chiropractor told me that headaches are caused by certain vertebras and if you want them to go away for good then a chiropractor has to adjust those vertebras that are out of line. Is this true or not?

DIAMOND:
Not.

MEMBER QUESTION:
I started with migraines when I turned 45. It was scary. The headache does not bother me as much as the aura. It starts with numbness on one side of my body and then the zigzag lines with distorted vision. Most of the time the headache starts when the scintillating scotoma disappears, but sometimes the headache will emerge with the aura. Is the aura dangerous in any way and is it unusual not to have a real bad headache with it? I have had worse tension headaches, but it is different. The next day when I cough, my head is sore in one spot. I do have a history in the family of migraines. Does it need to be treated? Is there any way to spot the aura in midstream?

DIAMOND:
You have something we call acephalgic migraine. Because it started later in life (please don't shoot the messenger) we would normally recommend a thorough workup to rule out any organic problem, such as mild stroke or tumors, etc. Usually this workup will be normal.

Many patients who had migraine at a younger age will simply be left with aura once they hit their 50s and 60s. It is unusual to have started later in life with no history of migraine and I am curious if your "tension- type" headache might have some migraine flavor to it.

If you are a woman and you are on hormones, or hormone-replacement therapy, or oral contraceptive, it is important for you to call your health care provider and for you to let them know what's going on. New onset of aura that is associated with hormone therapy can sometimes predict a potential stroke, and I would normally recommend my patients stop the hormone.

Auras can be treated with preventative medicines we use for migraine, and your doctor can prescribe that for you if you are having frequent symptoms.

"New onset of aura that is associated with hormone therapy can sometimes predict a potential stroke, and I would normally recommend my patients stop the hormone."

MEMBER QUESTION:
How real is the risk of stroke for a migraine sufferer who is 36, on the pill, and has a mitral valve prolapse? The pill is the only thing that keeps my endometriosis at bay.

DIAMOND:
That's a great question. Historically, we used to tell our patients to avoid oral contraceptive because the oral high-dose estrogen compound made patients worse about 70% of the time. Patients with migraine, and especially patients with migraine with aura, are at a slightly increased risk of stroke than the general population. When you add an oral contraceptive to that mix it raises the risk just a little bit more. So it's really a risk/benefit ratio.

Is the endometriosis severe and is there any other option of treating it? When I discuss hormone treatment with my patients, I screen them for hypertension, smoking, and a family history of pulmonary emboli or early strokes. Individually, patients and their health care providers can decide the benefits of using this medication. I am absolutely opposed to the use of the pill in a migraine patient who smokes.

MODERATOR:
Dr. Diamond, we are almost out of time. Do you have any final words for us?

DIAMOND:
If you're having bad headaches please make sure you visit your doctor and get help. The National Headache Foundation is an excellent source and can help you with information about headaches and also give you information about people who can treat your headaches in your area. Thanks for your time.

MODERATOR:
We are out of time. Thanks to Merle Diamond, MD, for sharing her expertise with us.

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