Headache Help (20 page)

1. N
ONSTEROIDAL
A
NTI
-I
NFLAMMATORIES
(NSAIDs) (N
APROXEN
, I
BUPROFEN
, F
LURBIPROFEN
, K
ETOPROFEN
)

Anti-inflammatories are the backbone of preventive therapy for menstrual migraines because they have the fewest side effects and are well tolerated. When one NSAID doesn’t work, your doctor will often suggest trying another before progressing to a different class of medication.

TYPICAL DOSE
: Take three days before expected headache and continue until several days past the expected time. Timing can be tricky. For ibuprofen, from 400 mg to 2,400 mg per day, split up during day. For naproxen, 500 mg, once or twice a day. For flurbiprofen (Ansaid), 100 mg twice a day.

SIDE EFFECTS
: Stomach upset, stomach pain, heartburn. Stop the NSAID if you experience more than mild stomach problems from it.

2. E
RGOTAMINE
D
ERIVATIVES

These medications are often effective, although they do carry a risk for triggering rebound headaches.

• E
  RGOTAMINE TARTRATE
  (E
  RGOMAR
  )
  TYPICAL DOSE
  : Usually 2 mg of ergotamine per day.
  SIDE EFFECTS
  : In addition to rebound headaches, ergotamine derivatives may cause nausea or severe gastrointestinal upset, as well as nervousness and leg cramps.
  
• E
  RGONOVINE
  (E
  RGOTRATE
  )
  This medication is well tolerated and occasionally effective.
  TYPICAL DOSE
  : 0.2 mg, two to four times a day.
  SIDE EFFECTS
  : Same as the other ergotamines, though usually milder.
  
• D
  IHYDROERGOTAMINE
  (DHE)
  This medication is either injected or taken as a nasal spray (Migranal) that is very convenient. DHE is usually very well tolerated.
  TYPICAL DOSE
  : I mg a day.
  SIDE EFFECTS
  : Nausea, harmless throat or chest tightness, mild muscle contraction, leg cramps, a hot feeling about the head.
  

3. D
IURETICS

H
YDROCHLOROTHIAZIDE
(D
YAZIDE
, M
ODURETIC
)

Diuretics, also known as water pills, are only occasionally helpful for migraines but also help other menstrual symptoms, such as bloating. They are generally well tolerated, but even though they are used for only a short time during the month, care must be taken to avoid losing too much potassium. Diuretics should be taken only under a doctor’s care.

TYPICAL DOSE
: Half a pill or one pill taken in the morning for two to three days prior to and with the menstrual period.

SIDE EFFECTS
: Frequent urination. Occasional rashes, weakness, or dizziness.

4. H
ORMONAL
A
PPROACHES

If your menstrual migraines are very severe and debilitating, your doctor may recommend a stronger approach, such as hormonal therapy. Before trying these powerful drugs, though, be sure you are well informed of the potential risks. They often have unpleasant side effects, which you’ll have to weigh against the pain and degraded quality of life you suffer from headaches.

• Tamoxifen (Nolvadex)
  One of the more effective menstrual migraine preventives, this medication is otherwise used in breast cancer therapy and prevention. It sometimes decreases the frequency and severity of migraines and daily headaches that occur at other times of the month as well.
  TYPICAL DOSE
  : 10 mg (the range is 5 mg to 20 mg) each day for seven to fourteen days, starting one to two weeks prior to menstruation.
  SIDE EFFECTS
  : Occasional and mild nausea, hot flashes, and menstrual irregularities; infrequent rashes, vaginal bleeding, vaginal discharges, weight gain, edema, headaches, shortness of breath, loss of appetite, pain in the legs, blurred vision, and dizziness. In very large doses in animals, malignant liver tumors have been reported. Frequent Pap smears are necessary to assess any signs of early cervical cancer.
  
• E
  STROGEN
  If your migraines are severe, prolonged, and generally debilitating, they may warrant using a strong medication. Estrogen sometimes works to prevent menstrual migraines that are triggered by the estrogen decrease that occurs during the late luteal phase of the menstrual cycle. In some women, however, estrogen exacerbates headaches.
  TYPICAL DOSE
  : 0.05 mg of ethinyl estradiol (Estinyl) each day for five days before menses and continued for two days after flow. Or 1 or 2 mg of micronized estradiol (Estrace) each day with same regimen. Or an estrogen skin patch (Estraderm) changed twice weekly and used for a total of seven days.
  SIDE EFFECTS
  : Estrogen carries many potential side effects, including breakthrough bleeding, irregular or suspended periods, menstrual flow changes, endometrial hyperplasia, yeast infection (vaginal candidiasis), nausea, abdominal cramps, colitis or cholestatic jaundice, hair loss (alopecia) or abnormal hair growth (hirsutism), hives, headache, dizziness, depression, weight gain or loss, edema, decreased libido, and tenderness of the breasts. Long-term use may also increase the risk of endometrial cancer and breast cancer.
  
• C
  ONTINUOUS
  B
  IRTH
  C
  ONTROL
  P
  ILLS
  For some women with extremely severe, prolonged menstrual migraine, low-dose continuous (noncycling) birth control pills can help. Women can use birth control pills for a number of months, to relieve the devastating headaches for that period of time. This approach is relatively safe and at times is the only effective therapy. While birth control pills may help decrease headaches, when they are used on a cyclical basis (in the usual manner), menstrual migraines are often more severe. A few of the newer pills (such as Mircette) continue to deliver a tiny amount of estrogen even during the menstrual period; these may be better than the older kinds for menstrual migraine. Women who smoke cigarettes, however, should not take the birth control pill. While this link has not been conclusively proven, the birth control pill may slightly raise the risk of stroke in women with migraines.
  
• O
  OPHORECTOMY
  (
  REMOVING THE OVARIES
  )
  In very rare circumstances, some women who are over forty and suffer from prolonged, severe, refractive menstrual migraines find relief with Lupron injections to stop the menstrual cycle. When this approach works, a few women have had an oophorectomy to relieve the devastating headaches permanently. This step is controversial, and there’s no consensus whether it is ever indicated or appropriate.
  

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

For some women, triptans are the most effective abortive and preventive therapy. Ideally, the longer-acting one (Amerge) may be best; however, Imitrex effectively prevents menstrual headaches in certain women.

TYPICAL DOSE
: The usual dose is one tablet twice per day, starting about one day prior to the “usual” onset of the migraine. These usually would be continued for three to five days. The timing of a menstrual migraine is often difficult to predict, however. Amerge (2.5 mg) is very well tolerated and is particularly suited to this use. The FDA, however, has not yet indicated triptans for this use. (See Chapter 5 for a complete discussion on triptans.)

6. V
ITAMINS AND
M
INERALS
(S
EE CHAPTER
14)

Magnesium oxide (250 mg to 500 mg per day) has been helpful for some women with menstrual migraines. It is usually taken daily, or for one week prior to and with the menstrual period. Long-term side effects, if any, are not known.

Calcium may be helpful as well (750 mg to 1500 mg daily). In addition, Vitamin B
₂
(riboflavin), 400 mg per day, has been superior to a placebo for migraine prevention in several studies. Long-term side effects, if any, are not known.

HEADACHES DURING PREGNANCY

If you suffer from migraines, chances are that pregnancy, especially the second and third trimesters, will bring a welcome relief. If you do get headaches at this time, however, they are particularly hard to treat because you must avoid drugs that may potentially be harmful to the fetus. First try ice packs, relaxation therapy, and rest in a dark room. Ask your doctor about using small amounts of medication, such as acetaminophen (Tylenol). While caffeine decreases headaches, its use during pregnancy remains controversial. Limited amounts are probably fine. If you need something stronger, the doctor may try small doses of meperidine (Demerol), hydrocodone (Vicodin), or acetaminophen with codeine. Limited amounts of cortisone are also used on occasion. Take antinausea medications only if absolutely necessary, and only in small amounts. Over-the-counter preparations that may help nausea include Vitamin B
₆
and Emetrol. For more severe nausea, Reglan or Compazine are occasionally used.

If your migraines are frequent and severe, or you get daily headaches that are intolerable, your doctor may recommend preventive medications with minimal doses after the first trimester. A beta-blocker (such as propranolol, metoprolol, nadolol, or timolol) is often prescribed and discontinued three weeks before delivery to avoid harming the baby. Be sure you understand all the risks before trying any of these medications.

When beta-blockers don’t work or can’t be used, the doctor may recommend a very low dose (such as 10 or 25 mg) of amitriptyline if daily preventive medication is necessary. However, there have been isolated reports that amitriptyline may trigger abnormalities in babies’ arms or legs. Again, be sure you understand whatever risks that this or other medications pose during pregnancy. Prozac and Zoloft have been used during pregnancy, and preliminary studies indicate that they are probably safe. However, this has not been proven. You need to be completely informed about all the possible risks of any medications used during pregnancy.

HEADACHES DURING BREASTFEEDING

Like pregnant women, women who are breastfeeding should minimize taking medication. If they get headaches that require medications, they may take, as needed, acetaminophen, caffeine, and NSAIDs. If necessary, they may also take a narcotic painkiller. Because of sedation, Fioricet or Esgic are used with caution. Antihistamines are not used. Prochlorperazine (Compazine) is the antinausea drug of choice. Ergots and triptans are best avoided. Preventively, beta-blockers, calcium blockers, and Depakote can be used. Women may take steroids in limited situations for limited periods of time. Antidepressants are utilized with caution, although the SSRIs (selective serotonin reuptake inhibitors, such as Prozac, Zoloft, and Paxil) have been widely used during this period.

MIGRAINES DURING AND AFTER MENOPAUSE

Typically, migraines worsen during menopause, but then may improve afterward. Yet it is not uncommon to have a different experience: some women get worse headaches after menopause; others enjoy a complete cessation of head pain. Some women who have never had a headache problem get severe migraines for the first time during menopause. Still other women experience no change in their migraine patterns.

If possible, doctors generally minimize hormone replacement in migraine treatment. Although hormones seem to help some women, they worsen headaches more often than help them. For many women, hormones don’t affect the headaches one way or another. If you take hormones for other reasons and want to reap the benefits of these hormones, talk to your doctor about whether they seem to affect your headaches. If your headaches become severe after taking hormones, it may be necessary to stop taking them.

Which hormones you take and how you use them can influence your headaches. In general, the natural estrogens, such as Premarin, tend to aggravate headaches more than the “synthetic estrogens,” such as Estinyl and Estrace, do. The hormone patch, which delivers a smooth, controlled amount of estrogen, sometimes leads to fewer headaches. If you haven’t had a hysterectomy, progestins (progesterone, such as Provera), along with the estrogen, are usually necessary. There are tablets that contain a combination of estrogen plus progesterone. Progestins often exacerbate headaches, and doctors prefer to minimize the progesterone. After a hysterectomy, the primary use of progestins (to prevent uterine cancer) is no longer necessary. Thus, after a hysterectomy, doctors often skip the progesterone.

Ideally, estrogens that are used continuously (noncycling) are better for headaches. When the estrogen is stopped for one week, the dip in estrogen levels may increase headaches. However, by using continuous estrogen, the risk for breast or uterine cancer may be slightly increased. After a hysterectomy, women are often placed on continuous estrogen without a break.