Headache Help (19 page)

5. D
AILY
T
RIPTANS
(I
MITREX
, A
MERGE
, M
AXALT
, Z
OMIG
, R
ELPAX
)

For some people with chronic daily headaches and frequent migraines, the only medication that is useful is a low dose of a triptan on a daily basis. Because these medications are relatively new, long-term side effects are still unknown. Because they are expensive and may produce long-term side effects, these medications are an absolute last resort. For some people with severe chronic daily headache and migraine, however, a daily triptan is the only effective measure.

CASE STUDIES

Here are examples of how this preventive information might be applied in a real situation.

C
ARLY

I
NITIAL VISIT
:
Carly, a twenty-two-year-old student, gets about one migraine every week. Her migraines started at age fourteen but have increased in the past year. Carly has asthma, but otherwise is healthy.

She tends to get more migraines around her menstrual period and with stress or weather changes. Red wine also gives her a migraine. Carly gets some relief from Excedrin or Fiorinal, but the headaches are severe, with nausea accompanying most of them. Carly’s mother also get migraines.

With four severe migraines a month, Carly is on the borderline between needing daily preventive medication and treating the headaches once they begin. She is placed on naproxen, a nonsteroidal anti-inflammatory, once a day as a preventive medica tion. The NSAIDs have an advantage because they do not cause drowsiness or weight gain; however, they can irritate the stomach, liver, or kidneys. Carly is also given Imitrex Nasal Spray.

W
EEK
6:
The migraines are down to two per month and the Imitrex works well, stopping the headache within one hour.

W
EEK
12:
By this time, both medications seem to be losing their effectiveness, so Carly’s doctor changes her daily preventive from naproxen to verapamil (Isoptin, Calan, Verelan), which does not affect Carly’s asthma (a beta-blocker, such as Inderal, would affect the asthma). The sumatriptan is changed to Maxalt, to relieve a migraine when it occurs. The doctor also gives her Compazine capsules for nausea.

W
EEK
16:
The verapamil is ineffective. Carly is getting at least four migraines a month. The Maxalt is partially effective, although it makes her feel somewhat tired; the Compazine helps decrease her nausea. Carly’s doctor takes her off the verapamil as a preventive medication and gives her amitriptyline, an antidepressant that is widely used to prevent headaches. Depakote would also be considered.

W
EEK
20:
Carly sleeps Well with the amitriptyline because of its sedative effect, but the doses are kept low and she does not have a problem with daytime drowsiness. The headaches are down to one per month. Although the Maxalt is somewhat effective to relieve a migraine when it occurs, Carly also begins taking Fiorinal, either alone or with the Maxalt, to enhance pain relief.

T
HE
F
UTURE
:
As her condition and sensitivity to side effects shift, Carly’s medication may change. Her doctor may take her off preventives altogether, or switch her to another preventive, perhaps Depakote or a different NSAID or antidepressant. There are also other abortives that may be more effective, such as Zomig, Amerge, Imitrex tablets or injections, Migranal (DHE) Nasal Spray, or the older ergotamines.

S
ALLY

I
NITIAL
V
ISIT
:
Sally, a forty-year-old social worker, gets two migraines a week (more during her menstrual period) and is somewhat anxious and depressed. She has had headaches for many years, but they’ve gotten worse during the past year; she also suffers from asthma. Stress, weather, cigarette smoke, and missing a meal tend to trigger her migraines. When over-the-counter medications stopped relieving her pain, her general practitioner prescribed Midrin and Fiorinal, which helped a little. Because of the frequency of migraines and coexisting anxiety and depression, she had also been given the antidepressant amitriptyline as a daily preventive to take at night. She comes to her initial visit frustrated because she has gained weight and becomes excessively tired from the amitriptyline.

Sally is switched to Zoloft, with instructions to slowly increase the dose until she is taking 50 mg per day. She is also given Imitrex Nasal Spray and tablets; she will use the nasal spray for a fastonset headache with nausea, and the tablets (if she can keep them down) for slow-onset headaches. Sally also keeps her Fiorinal as a backup for the pain. (Having two or three abortive medications or more is quite common, so patients can choose between different medications in different situations during their migraines.)

W
EEK
6:
The migraines are slightly, but not significantly, better with the Zoloft, but Sally experiences much less anxiety and depression. She is slightly fatigued from the Zoloft and has a mild problem with sweating, but she is more than willing to trade these conditions for the improvement in her anxiety and depression. The Imitrex Nasal Spray is not as effective as the tablets, and she wishes to try the injections. Sally is taught how to use the Imitrex auto-injector.

W
EEK
12:
Sally is still getting migraines about twice a week, but the Imitrex injections are very effective. However, Sally wants to try something new to reduce the number of migraines because they are significantly interfering with her life. She awakens with them at five or six
A.M.
, and they leave her sleep-deprived all day. Her doctor adds Depakote, one of the first-line preventive medications, to the Zoloft. Sally is to take a low dose of Depakote, 250 mg twice a day.

W
EEK
14:
The Depakote is causing some weight gain, but it has decreased the headaches to twice a month, down from twice a week. Sally effectively uses Imitrex injections, and occasionally she uses the Imitrex tablets and Fiorinal as well.

T
HE
F
UTURE
:
Other preventive medications that would be useful for Sally include verapamil, NSAIDs, or Neurontin. If she continues to gain weight, the Depakote may be stopped and another preventive medication instituted. Alternatively, the doctor may simply see what happens after stopping the Depakote. Headache sufferers often go into a fluid situation with the preventive medications, going off and on them, switching, and increasing or decreasing doses (depending upon effectiveness and side effects). Alternative abortives, such as other triptans (Maxalt, Amerge, Zomig, Relpax), are possibilities for Sally in the future.

7

Women, Hormones, and Migraines

F
LUCTUATING HORMONES
, especially the progestins and estrogens, seem to play an important role in influencing migraines in women. At age ten, as many boys as girls suffer from migraines. By puberty, many girls who never before had migraine problems start having them, and by the midteens, migraines become much more common and more severe among girls than boys.

Puberty and the days around ovulation and menstruation are particularly vulnerable times for women who are susceptible to migraines. A woman’s thirties and forties are commonly the worst decades, with the migraines becoming severe and prolonged. Many women experience relief during pregnancy and often after menopause. Birth control pills occasionally trigger, yet occasionally improve migraines, but for most women they don’t exert much influence on the pattern of headaches.

Researchers aren’t sure exactly why women’s hormones affect migraines. In the 1970s, researchers thought that declining estrogen levels were a major reason behind migraines, but recent research paints a more complex picture. It’s been found that the platelets and prostaglandins in the bloodstreams of women with hormonal headaches look different than those of women who are not suffering from these headaches. However, the major differences may actually occur in the brain, involving the center, called the hypothalamus, that controls the ovarian hormones. Indeed, the hypothalamus may be the ultimate source of the severe menstrual migraine. In any event, chances are that the tendency to get menstrual migraines is inherited.

MENSTRUAL MIGRAINES

Menstrual migraines can be especially miserable because they’re often more severe and harder to treat than other kinds of migraines. Typically, they occur before, during, or after a woman’s period. If you suffer from menstrual migraines, you may have headaches during ovulation and get migraines that aren’t triggered by hormones at other times of the month as well. Menstrual migraines are a major reason for lost worktime, injured relationships, and reduced quality of life.

HORMONAL INFLUENCES

Researchers suspect that the hormone mechanisms, which are controlled by the brain, are somehow different in women who get hormonal, or menstrual, headaches than in other women, though consistent patterns haven’t emerged. Some studies have found that women who get premenstrual migraines have higher levels of the hormones progestin and estrogen before their periods than women who don’t get headaches. Others suggest that a drop in estrogen levels, which occurs just before a period (and after menopause or a hysterectomy), can trigger headaches (yet in other women this drop helps their migraines). Still other menstrual migraines may be related to the fluid build-up that occurs with menstruation.

Both estrogen and the progestin progesterone are known to influence serotonin receptors, and low levels of estrogen can significantly impact the hypothalamus (the gland that controls the hormonal secretion functions) and its control mechanisms. The truth is, researchers do not yet understand the mechanisms behind hormones and headaches.

T
REATING
M
ENSTRUAL
M
IGRAINES

Mild to moderate
menstrual headaches that last only a day or so can often be relieved with one of the over-the-counter medications or anti-inflammatories discussed in Chapter 2, such as Excedrin, Aleve, ibuprofen, or a prescription NSAID.

Severe, prolonged
menstrual migraines, which are not uncommon, can be relieved with injections and then prevented by following several approaches, as summarized below.

R
ELIEVING MENSTRUAL MIGRAINES
:
In general, your doctor will probably use the same strategies to relieve a menstrual migraine as a general migraine. When the migraines are severe, the cortisone medications, especially Decadron or prednisone, in limited amounts, are among the most effective treatments. The triptans (Imitrex, Amerge, Maxalt, Zomig, Relpax) are extremely important in combating menstrual migraines. Many women need to resort to Imitrex injections, which are probably the most effective “as-needed” medication. If these strategies fail, a strong narcotic taken with a strong antinausea medication, such as Compazine, can help. Because menstrual migraines can be severe, many women must resort to these powerful treatments. Refer to Chapter 5 for detailed discussions of these medications.

P
REVENTING MENSTRUAL MIGRAINES
:
As with general migraines, your menstrual migraines may be triggered by typical migraine foods, as outlined in Chapter 6. However, you may be sensitive to these foods only the week or so before your periods. To prevent menstrual migraines, experiment with abstaining from alcohol (especially red wine), chocolate, aged cheese, and other common migraine-trigger foods; eating regularly and including plenty of complex carbohydrates (pasta, rice, beans, whole grains) to maintain steady levels of blood sugar; exercising; and using relaxation techniques to minimize stress. Also, experiment with caffeine—in some women, caffeine helps; in others, it is a trigger.

If your menstrual migraines are predictable, moderately severe, and not responsive to nonmedication strategies, your doctor may suggest trying preventive medication beginning on the day before the expected onset of the migraine and continuing until two to three days past the time you normally get migraines. Details on medications doctors typically use for preventing menstrual migraines follow.
Note: Many of the medications mentioned in this chapter have been discussed in detail in previous chapters. Please check the index to locate more detailed information.

MEDICATIONS FOR PREVENTING MENSTRUAL MIGRAINES

QUICK REFERENCE GUIDE: MEDICATIONS FOR PREVENTING MENSTRUAL MIGRAINES

1. NSAID
   S
   (N
   APROXEN
   , I
   BUPROFEN
   , F
   LURBIPROFEN
   , M
   ECLOFENAMATE
   S
   ODIUM
   )
       The backbone of menstrual migraine therapy: effective, well tolerated. Start three days prior to the expected onset. Gastrointestinal upset is common. Doctors do not yet know if the newer NSAIDs, which are easier on the stomach, such as Vioxx, will be effective for menstrual migraine.
   
2. E
   RGOTAMINE
   D
   ERIVATIVES
   (
   ERGOTAMINE TARTRATE
   [E
   RGOMAR
   ], E
   RGONOVINE
   [E
   RGOTRATE
   ], DHE)
       Start one to three days prior to onset. These drugs can be effective but often cause gastrointestinal upset and nausea, and can trigger rebound headaches.
   
3. D
   IURETICS
   (D
   YAZIDE,
   H
   YDROCHLOROTHIAZIDE,
   M
   ODURETIC
   )
       Water pills that are occasionally useful.
   
4. H
   ORMONAL
   A
   PPROACHES
   (T
   AMOXIFEN
   [N
   OLVADEX
   ],
   ESTROGEN, CONTINUOUS BIRTH CONTROL PILLS
   )
       These have potential risks and side effects such as nausea, bleeding, weight gain, and edema.
   
5. T
   RIPTANS
   (A
   MERGE
   , I
   MITREX
   , M
   AXALT
   , Z
   OMIG
   , R
   ELPAX
   )
       For some women, these are the most effective abortive and preventive therapy.