Headache Help (12 page)

1. E
RGOTAMINES

These medications are often effective because they constrict blood vessels that have become abnormally dilated. But they often cause many side effects, including nausea and anxiety. If these medications are overused, the resulting rebound headaches can be severe. People over forty should use ergotamine with caution because this drug increases the risk of heart attack.

• C
  AFERGOT
  P
  ILLS
  These are among the most commonly used ergotamines because they may be taken orally and are thus more convenient than their suppository counterparts; they are, however, the least effective of this group. They must not be used more than one day in four to avoid the risk of rebound headaches.
  TYPICAL DOSE
  : One or two pills when pain begins, repeating every half hour or hour; no more than five a day or ten a week. When used two days in a row, rebound headaches may result.
  SIDE EFFECTS
  : Nausea with occasional vomiting is common. Nervousness, difficulty sleeping, and dizziness may occur. Less common are numbness, tingling, or muscle pain in the fingers or toes.
  
• C
  AFERGOT
  S
  UPPOSITORIES
  Though less convenient than pills, these suppositories, which contain caffeine and ergotamine, are much more effective. They’re usually not a good choice, however, if you tend to get diarrhea with your migraine.
  TYPICAL DOSE
  : Starting with one-third to half a suppository, the dose may be adjusted up or down depending on the patient’s response. No more than two per day, one in four days, or four per week is recommended.
  SIDE EFFECTS
  : Same as for the Cafergot pills but with less nausea.
  
• Cafergot PB S
  UPPOSITORIES
  More effective with fewer side effects than suppositories without pentobarbital but not as widely available. A generic preparation is available, and certain pharmacists can prepare these suppositories themselves. Cafergot PB Suppositories contain caffeine, ergotamine, and pentobarbital, which can cause sedation but helps reduce nausea.
  TYPICAL DOSE
  : Same as for the Cafergot Suppositories without pentobarbital.
  SIDE EFFECTS
  : Same as for the Cafergot Suppositories without pentobarbital but significantly milder. Sedation, however, is more common with this preparation.
  
• E
  RGOMAR
  This is a pure ergotamine (z mg) with no caffeine. Limit the dose to two in a day, one day out of four only. This drug produces less anxiety than Cafergot.
  

2. K
ETOROLAC
(T
ORADOL
)

Ketorolac is a moderately effective anti-inflammatory. It’s a good choice when you want to reduce risk of sedation or addiction or if you can’t take medication orally because you tend to vomit with your migraines. Like many other medications, this drug is more effective when injected than when swallowed in pill form. The injections are available in convenient, prefilled syringes, but the needle is large. Individual vials are now available.

TYPICAL DOSE
: When injected, 60 mg is a typical dose, which may be repeated in an hour if needed. No more than 120 mg per day, only once a week.

SIDE EFFECTS
: Stomach upset or pain, occasional sedation. Possible liver or kidney problems; people with any liver or kidney impairments should not take ketorolac; older people should use it very cautiously.

3. C
ORTICOSTEROIDS

Cortisone (either pill or injection) is one of the most effective medications for severe, prolonged migraines and menstrual migraines, but it can only be taken in small doses and for brief periods of time. Long-term use of cortisone can cause serious side effects, such as weight gain, adrenal gland suppression, and predisposition to fractures and liver failure.

Dexamethasone (Decadron) and prednisone are oral medications; Depo-Medrol is administered by injection.

TYPICAL DOSE
: One tablet or a half, usually 20 mg prednisone or 4 mg Decadron, taken with food, and repeated every four to six hours as needed. No more than three tablets per month. None of the corticosteroids should be taken with NSAIDs, or gastrointestinal bleeding can occur.

When migraines are triggered by flying, a half or whole Decadron or prednisone pill should be taken a half hour before flight time. For altitude migraines, take one pill a half hour to an hour before your plane arrives in a high-altitude city or before you reach a high summit. Take another pill four hours later. The dose can be repeated for two days.

For severe, prolonged migraines, Depo-Medrol injections (40 to 80 mg) may help, but limit to once per two months at most.

SIDE EFFECTS
: Possibly nausea, insomnia, stomach upset, nervousness, and facial flushing. Occasional weight gain or water retention. More rarely, fatigue or agitation.

4. N
ARCOTICS AND
S
EDATIVES

When triptans, DHE, ergotamine, ketorolac, or one of the corticosteroids doesn’t help or causes too many side effects, a strong narcotic, usually given with an antinausea medication, may be the answer. Doctors may be somewhat more reluctant to use these medications because of their potential for nausea as well as for abuse that can lead to addiction. Typically, these medications can calm you and induce sleep. They are useful only for one to three days and shouldn’t be used every day unless every other method for controlling daily headaches has failed. (See the section on addiction versus dependence earlier in this chapter.)

• M
ILD
N
ARCOTICS

The milder narcotics, or opioids, can be taken by mouth.

—A
CETAMINOPHEN WITH
C
ODEINE
(T
YLENOL
3,
WITH
30
MG
C
ODEINE, AND
T
YLENOL
4,
WITH
60
MG CODEINE
)
has no aspirin and therefore induces less nausea.

—A
SPIRIN WITH
C
ODEINE
contains aspirin (which is good for migraines) and codeine, but also tends to induce nausea.

—H
YDROCODONE WITH
A
CETAMINOPHEN
(V
ICODIN
, Z
YDONE
, N
ORCO, AND
L
ORCET
)
is well tolerated for a narcotic medication. Zydone and Norco contain less acetaminophen.

—V
ICOPROFEN
contains 750 mg hydrocodone plus zoo mg ibuprofen. This is an effective combination but may lead to stomach upset. More effective than Vicodin.

  TYPICAL DOSE
: One every four to six hours, as needed.

  SIDE EFFECTS
: Nausea, sedation, addiction.

—P
ROPOXYPHENE
(D
ARVON OR
D
ARVOCET
)
is sometimes helpful for migraine sufferers when the other mild narcotics aren’t. As with many medications, each person responds differently.

  TYPICAL DOSE
: One or two pills every three or four hours, as needed. Limit to six pills per day at most.

  SIDE EFFECTS
: Nausea, sedation, addiction.

—T
RAMADOL
(U
LTRAM
)
is an excellent milder painkiller. Ultram has combined opioid and serotonin-level action; unfortunately, this drug
causes
headaches in some people while relieving headaches in others. Tramadol may cause nausea or fatigue, but is generally well tolerated. The usual dose is one or two tablets every four to six hours as needed. In rare cases, Ultram can be addictive but is less so than the other narcotics.

S
TRONG
N
ARCOTICS

Sometimes these strong medications are the only ones that will help a severe migraine. No more than three or four tablets a day or ten pills a month for any of these medications is recommended. Injections offer better pain relief than tablets and may be administered with an antinausea medication.

—B
UTORPHANOL
(S
TADOL
)
nasal spray is a strong narcotic that is slightly different from the others. It is called a “mixed agonist/antagonist,” which sets it into its own class. Stadol is convenient because it can be used if you feel nauseated. The usual dose is one spray in one nostril only, every four to six hours as needed. Side effects may be severe and include sedation, fatigue, and confusion. However, when used properly, Stadol has been a safe medication. It is habit-forming and should not be used for daily headaches except in rare circumstances.

—M
EPERIDINE
(D
EMEROL
)
injections are more effective than tablets.

  TYPICAL DOSE
: For oral meperidine, 50 to 100 mg every three to four hours, as needed; 50 to 125 mg per injection.

  SIDE EFFECTS
: Nausea and drowsiness, sometimes constipation. Can be habit-forming if used often.

—M
ETHADONE
(D
OLOPHINE
)
lasts longer than Demerol and carries less potential for nausea and addiction.

  TYPICAL DOSE
: 5 or 10 mg per injection, every three to four hours, 20 mg per day at most.

  SIDE EFFECTS
: Same as with meperidine.

—
OXYCODONE
(P
ERCOCET
, P
ERCODAN
, T
YLOX
, O
XYCONTIN
)

  TYPICAL DOSE
: One tablet (5 mg oxycodone with aspirin or acetaminophen) every three to four hours. Injections are not available. Oxycontin is the slow-release, long-acting form.

  SIDE EFFECTS
: Same as with meperidine.

—M
ORPHINE

  TYPICAL DOSE
: For tablets, 15 mg every three to four hours, or 10-to-15-mg injections.

  SIDE EFFECTS
: Same as with meperidine.

HEADACHE HELP TIP: FOR SOME PEOPLE, NARCOTICS MAY BE HELPFUL

Myths die hard. Until recently, few physicians considered narcotic medication appropriate for noncancer pain because of dangers of addiction. Recent studies have shown, however, that very few people who use opioids for pain become addicted. The American Pain Society and the American Academy of Pain Medicine both endorse opioid treatment for selected cases of chronic noncancer pain, such as severe headaches. Many doctors now understand that although some patients may need increasing doses for pain relief, that need is usually caused by intensifying pain. They also expect physical dependence with narcotic medication but distinguish that from addiction, which is a psychological craving. People who are dependent on opioids because of pain syndromes can be withdrawn gradually from the medication.

• S
EDATIVES

Sedatives are always useful for severe migraine because sleep is a powerful weapon against headache.

—B
ENZODIAZEPINES

• D
IAZEPAM
(V
ALIUM
)

A sedative and a muscle relaxant, Valium may be less effective as a generic.

TYPICAL DOSE:
5 or 10 mg every three or four hours if necessary but no more than 20 mg a day. Should not be used daily.

SIDE EFFECTS
: Sedation, disorientation, and euphoria; may increase depression if used frequently.

• C
LONAZEPAM
(K
LONOPIN
)

A somewhat stronger sedative than Valium, Klonopin is often used to induce sleep. It should not be used daily unless other means have not been helpful.

TYPICAL DOSE: 0.5
mg to 2 mg every three or four hours, as needed. No more than 4 mg a day.