Headache Help (21 page)

The “as-needed” and preventive medications basically remain the same during and after menopause. However, as you get older, you become at higher risk for cardiac (heart) problems, and so doctors may recommend that you abstain from using the triptans (Imitrex, Amerge, Maxalt, Zomig, Relpax). Ergotamines are rarely used after age fifty. As for preventive medication, weight gain is often a major problem during these years. Searching for preventive medication that does not exacerbate or cause weight gain is important. The preventive medications that tend to minimize weight gain include NSAIDs, calcium blockers, and select antidepressants, such as Vivactil, Prozac, Zoloft, Paxil, Celexa, Wellbutrin, and Effexor.

CASE STUDY

Here is a fairly typical case of a woman who gets menstrual migraines and how her doctor helps her manage them.

S
UZY

I
NITIAL VISIT
:
Suzy, a thirty-four-year-old social worker and mother of two children, gets severe migraines for four days each month, usually beginning one day before her menstrual period. She has regular periods, every twenty-eight days, and no other health problems. She has tried, with little or no benefit, ibuprofen, Fiorinal, Midrin, Tylenol 3, Vicodin, and Excedrin.

Because Suzy usually begins sensing the migraine just prior to the beginning of her period, she is advised to start naproxen, an NSAID, three days before her menstrual period. Naproxen is particularly effective in preventing menstrual migraines. For an abortive medication, the doctor prescribes sumatriptan (Imitrex) tablets because Suzy does not want to give herself injections at this time.

W
EEK
16:
Suzy reports that the naproxen helped for the first two months, but then lost its effectiveness. The Imitrex tablets do not help much. Suzy’s doctor prescribes flurbiprofen (Ansaid), another NSAID, as a preventive medication, Imitrex injections and a small dose of dexamethasone (Decadron) as an abortive medication.

W
EEK
24:
Suzy says the flurbiprofen was not effective and because she gets incapacitating and prolonged (four days) migraine attacks, she is prepared to try hormonal therapy to prevent them. She and her doctor discuss fully the risks and possible side effects, from nausea, hot flashes, and rashes to vaginal discharges, weight gain, and shortness of breath. Suzy receives a prescription for estrogen to take before her periods to prevent the attacks. Her abortive regimen is working in that it shortens her attacks significantly.

W
EEK
32:
The estrogen is not effective, so Suzy’s doctor pre scribes tamoxifen (Nolvadex) to take for one week before menstrual periods.

W
EEK
40:
Suzy reports that the tamoxifen is working well and that she feels in good control. When she does get a migraine, the Imitrex injections and dexamethasone usually help.

T
HE
F
UTURE
:
Other possibilities as preventive approaches include: low-dose (continuous) birth control pills, water pills (diuretics) used prior to the menstrual period, or triptans (Imitrex, Amerge, Maxalt, Zomig, Relpax) used for four or five days. As-needed ergotamines, strong narcotics, injections of Toradol (injected by Suzy at home) or Stadol Nasal Spray are additional possibilities.

8

Treating Tension Headaches in Progress

M
IGRAINES
may be the most common headaches treated by doctors, but tension headaches plague the general population much more commonly; more than three-quarters of all headaches are tension headaches. Although the name “tension headache” may seem to imply that all headaches come from stress and tension, these are
not
psychological problems. This name is actually very misleading.

WHAT IS A TENSION HEADACHE?

Tension headaches can hurt anywhere around the head, but usually they cause pain on both sides. Sufferers often describe them as band-like, aching, pressing, tightening, or dull. Some people wake up in the early morning with the headache pounding or throbbing. Although usually mild or moderate, these headaches can be severe, waxing and waning throughout the day.

Unlike migraines, these milder headaches come on with no warning or auras, but most people can go on coping with work or home responsibilities. When tension headaches are severe, however, they may be accompanied by dizziness, nausea, and sensitivity to bright lights, much like migraines. Because it is sometimes difficult to distinguish between a severe tension headache and a mild migraine, many researchers suspect that the two headaches are the same illness, with tension headaches at the milder end of the spectrum.

Tension headaches may start at any age; about 40 percent of people start getting them in childhood or in their teens. Whether they will continue for a lifetime is unpredictable. Almost 40 percent of children and adolescents with tension headaches do outgrow their headaches by age twenty. However, if a child has had daily headaches for several years and has a parent who has had migraines or daily headaches, the child is likely to have them for years as well, although they may stop for months or even years, and then recur. In adults who get migraines and tension headaches, the migraines usually decline after age fifty but the tension headache pattern often persists.

TYPES OF TENSION HEADACHES

Usually tension headaches occur periodically, and in most cases, an over-the-counter pain reliever, a nap, and a relaxation exercise will relieve them. Ice packs applied to the head may also help.

When they occur more frequently, though, they are either
episodic
, occurring at least twice a week, but not more than fifteen times a month, or
chronic
or
daily
, occurring more than fifteen days a month for at least six months, or almost every day. The lines between the two get blurry if you get spells of daily tension headaches for weeks or months, and then very few headaches for a period of time. Also, many people who get tension headaches get migraines from time to time. For some people, the daily tension headache is much more of a problem than the occasional migraine; other people don’t mind the daily headaches but are compelled to do something about their migraines. You are certainly not alone if you suffer from these frequent headaches—more than five million people in the United States get moderate or severe chronic daily headaches.

TENSION HEADACHES: NOT PSYCHOLOGICAL BUT INHERITED

Just like migraine headaches, tension headaches are not psychological or “all in the head” but legitimate medical illnesses. Although stress and tension trigger the headaches or make them worse, they are not the true cause of the pain. In fact, the term “tension headache” is erroneous and promotes this misconception. That is why many doctors call these headaches “muscle contraction headaches” instead. As with migraines, the real root of the headache, or cause, is a genetically inherited predisposition to triggers that produce increased muscular tension and changes in blood vessels and the central nervous system. The triggers may be stress, daily hassles, anxiety, or other factors, such as missing a meal, bright lights, undersleeping, and cigarette smoke.

Researchers suspect that tension headaches, like migraines, are caused by serotonin changes in the brain. In many ways, tension headaches and migraines are related.

• Both respond to similar medications: antidepressants, calcium blockers, anti-inflammatories, and beta-blockers.
  
• Both are linked to similar biochemical changes.
  
• Both are commonly associated with neck pain and muscle spasm.
  
• Both are often linked to a family history of headaches.
  
• Both commonly involve muscle tenderness on the head and brain blood flow changes.
  
• A mild migraine is very difficult to distinguish from a severe tension headache.
  
• The vast majority of people with chronic daily headaches also get migraines.
  

TREATMENT FOR TENSION HEADACHES

When the occasional tension headache occurs, the correct way to treat it is very similar to the suggestions offered in Chapter 2.

• Use a relaxation technique.
  
• Apply ice to your head.
  
• Try to ignore the pain if it is mild.
  
• Consider taking medication.
  

As always, the goal is to take as little medication as possible. If you need medication, your doctor will probably begin by suggesting a first-line abortive. These medications can be very effective, but if overused they carry the risk of causing rebound headaches. If you take numerous pills on a daily basis—more than two or three a day—you need to use relaxation methods more regularly or consider trying preventive medication.

All these medications are discussed in detail in Chapters 2, 5, and 6. We present them here in order of preference for tension headaches, and review their most salient features.

FIRST-LINE MEDICATIONS FOR ABORTING TENSION HEADACHES

QUICK REFERENCE GUIDE: FIRST-LINE MEDICATIONS FOR RELIEVING TENSION HEADACHES

1. A
   CETAMINOPHEN
   (T
   YLENOL
   ), A
   SPIRIN
       OTC pain relief. Acetaminophen is very well tolerated but much less effective than other treatments. Aspirin often upsets stomach. Can cause rebound headaches if used too much.
   
2. N
   APROXEN
   (A
   NAPROX
   DS, A
   LEVE
   )
       OTC, effective, but gastrointestinal upset is common.
   
3. I
   BUPROFEN
   (M
   OTRIN
   , A
   DVIL
   , N
   UPRIN
   , R
   UFEN
   , H
   ALTRAN
   , I
   BUPRIN
   , M
   EDIPREN
   , M
   IDOL
   200, T
   RENDAR
   )
       OTC, effective, but gastrointestinal upset is common; however, ibuprofen is more effective for headache than acetaminophen.
   
4. C
   AFFEINE
       OTC caffeine beverages or tablets make other medications more effective and reduce drowsiness. Too much can cause rebound headaches.
   
5. C
   AFFEINE
   -A
   SPIRIN
   C
   OMBINATIONS
   (E
   XCEDRIN
   M
   IGRAINE
   , A
   NACIN
   , E
   XCEDRIN
   E
   XTRA
   -S
   TRENGTH
   )
       OTC, quite effective, but if used too often, cause rebound headaches. Excedrin has been a mainstay of headache therapy for many years.
   
6. K
   ETOPROFEN
   (O
   RUDIS
   KT, K
   ETOPROFEN
   )
       OTC NSAID; effective but often causes stomach upset.
   
7. M
   IDRIN
       Effective, safe, mild, nonaddicting sedative. Fatigue and lightheadedness are common.
   
8. N
   ORGESIC
   F
   ORTE
       Effective, quite strong, but gastrointestinal upset and fatigue are common.
   
9. V
   IOXX
       A new NSAID with much less tendency to cause stomach bleeding.
   

1. A
CETAMINOPHEN

Although less effective than aspirin or the medications that follow, acetaminophen is more easily tolerated. If you take more than 1,500 mg a day on a daily basis, rebound headaches may occur and you should consider daily preventive medication. (See Chapter 2.) Long-term daily use may lead to liver or kidney problems.

A
SPIRIN

Aspirin is more effective than acetaminophen but has a greater risk of side effects. The main problems with aspirin are stomach irritation (gastritis or ulcers) and an increased tendency to bleed. Taking aspirin every day, however, has a number of beneficial effects, including decreased risk of heart attack, stroke, colon cancer, and perhaps Alzheimer’s disease as well. (See Chapter 2.)

2. N
APROXEN
(A
LEVE
)

The OTC version of naproxen is a very effective anti-inflammatory but can commonly cause stomach upset and nausea. (See Chapter 2.) Naproxen is longer-acting than ibuprofen; taking small amounts of caffeine may increase its effect.

3. I
BUPROFEN
(M
OTRIN
, A
DVIL
, N
UPRIN
, R
UFEN
, H
ALTRAN
, I
BUPRIN
, M
EDIPREN
, M
LDOL
200, T
RENDAR
)