Headache Help (27 page)

SIDE EFFECTS
: Nervousness, moodiness, and sleep problems; when used for brief periods, side effects are usually minimal.

Sometimes fluid retention, fatigue, gastrointestinal upset, and stomach pain.

2. V
ERAPAMIL
(C
ALAN
, I
SOPTIN
, V
ERELAN
, C
OVERA-HS
)

Verapamil is a well-tolerated calcium blocker with minimal side effects, though it may aggravate or cause chronic daily headaches. It is effective for episodic and chronic clusters, but needs to be taken for at least several days and sometimes several weeks to become fully effective.

TYPICAL DOSE
: 240 mg slow-release or long-acting pill once or twice a day. At the start of a headache, verapamil is often prescribed with cortisone and then still taken after cortisone is discontinued.

SIDE EFFECTS
: Constipation, allergic reactions (rashes), dizziness, insomnia, anxiety, and occasionally fatigue.

3. L
ITHIUM

Lithium is usually well tolerated when taken in low doses. It can be very helpful for chronic clusters and, to a lesser degree, episodic clusters. It is commonly combined with verapamil or cortisone.

TYPICAL DOSE
: 300 to 900 mg a day, occasionally higher.

SIDE EFFECTS
: Drowsiness, mood swings, nausea, vomiting, thirst, tremor, diarrhea. Low doses and good monitoring usually prevent serious problems that can occur otherwise.

SECOND-LINE MEDICATIONS FOR PREVENTING CLUSTER HEADACHES

When first-line medications do not reliably prevent cluster headaches, a physician may progress to one of these medications, which we describe in more detail earlier in the book.

1. M
ETHYSERGIDE
(S
ANSERT
)

Somewhat effective for episodic clusters but not usually for chronic clusters, Sansert can be useful but has many potential side effects, such as nausea, leg cramps, and dizziness. It is not, however, generally recommended for people with active peptic ulcers, peripheral vascular disease, cardiac valve problems, coronary artery disease, high blood pressure, kidney or liver problems, or for those who are pregnant or over forty-five. (See Chapter 6 for a full discussion.)

2. V
ALPROATE
(D
EPAKOTE
)

A seizure medication that is often used for cluster, migraine, and tension headaches, valproate is sometimes very useful but it may cause lethargy, gastrointestinal upset, mood swings, weight gain, and hair loss.

It is fairly well tolerated, but nausea, gastritis (stomach pain or burning), sedation, emotional upset (depression or mood swings), hair loss, rashes, and dose-related tremors may occur. If taken for months, weight gain is common but is usually limited. Liver functions and blood counts need to be monitored closely in the first several months, but for episodic clusters, the entire duration of use is only one or two months, and one blood test is usually adequate. (See Chapter 6 for a full discussion.)

3. E
RGOTAMINES
(C
AFERGOT
, B
EULERGAL
-S, E
RGOMAR
, E
RGONOVINE
)

While headache doctors do not usually prescribe daily ergotamines (blood vessel constrictors), because of the risk of long-term effects and rebound headaches (common in migraine patients), the risk is much smaller in cluster sufferers who typically use the medication for a briefer period, only four to eight weeks, and stop after an episode is over.

Great caution must be taken by people who are older than around age forty. Ergotamines are not usually recommended for anyone with high blood pressure, heart disease, or vascular disease in the legs.

TYPICAL DOSE
: Most effective when taken within several hours of the expected cluster attack. If a headache typically occurs at eleven
P.M.
, then optimal timing of the drug is nine or ten
P.M.
The usual dose is 1 or 2 mg (up to 4 mg) per day.

• C
  AFERGOT
  pills or suppositories may be used as the source of ergotamine, but the 100 mg of caffeine increases side effects.
  
• B
  ELLERGAL
  -S
  is comprised of ergotamine, phenobarbital (a sedative), and belladonna. The sedating effect of phenobarbital is occasionally helpful for the cluster patient, but the relatively low dose of ergotamine (0.6 mg) is usually insufficient to prevent an attack.
       
  SIDE EFFECTS
  : Nausea and nervousness, fatigue, muscle aches, tingling, numbing in the hands or feet, chest pain. (See Chapter 5 for more details.)
  

4. E
RGONOVINE
(E
RGOTRATE
)

A well-tolerated medication, ergonovine is generally not as effective as methysergide but it poses fewer side effects.

TYPICAL DOSE
: 0.2 mg, two to four times a day.

SIDE EFFECTS
: Mild gastrointestinal upset, anxiety.

5. D
AILY
T
RIPTANS

Occasionally, the long-acting daily triptan, Amerge, may be effective (taken once or twice per day) in preventing episodic cluster headache. Occasionally, sumatriptan (Imitrex) is used in this way. Triptans are not approved for this use, and the long-term safety of daily use has not been firmly established. If you are using tablets of Imitrex, then you might try injections as needed for an acute cluster headache. If your doctor has recommended that you take one or two tablets per day of Imitrex preventively, Imitrex Nasal Spray may be used on an “as-needed” basis.

Generally, daily triptans are only occasionally successful in preventing cluster headaches. However, if most of the first-line and second-line approaches have not been successful, you might need to try some last-resort efforts. To use a triptan preventively, time the triptan for one hour or so prior to the expected onset of a cluster headache. Since most people experience more of the clusters at night, try to time the triptan in the evening before you would usually experience the pain. So far, side effects haven’t been a problem with this approach, because it is usually used for relatively short periods of time.

6. I
NDOMETHACIN
(I
NDOCIN
)

Indomethacin is an anti-inflammatory that is unique because it may be effective for certain types of headache when other similar medications are not. Indomethacin may cause stomach pain or upset, but it is usually relatively well tolerated. It is very useful in the variation of cluster headache called chronic paroxysmal hemicrania (see Chapter 13). Unlike some of the preventive medications, it is apparent within days whether Indomethacin will be effective.

TYPICAL DOSE
: From 75 mg to 225 mg per day, taken with food.

7. S
TEROID
B
LOCKADE OF THE
O
CCIPITAL
N
ERVE
(C
ORTISONE
)

When other drugs cannot control a headache, sufferers can use this therapy at the peak of the series. By placing cortisone (such as Depo-Medrol or betamethasone) in the region of the greater occipital nerve, a cluster can be relieved somewhat for up to weeks at a time. These medications are well tolerated, with few side effects.

TYPICAL DOSE
: 60 to 80 mg of Depo-Medrol per injection. An injection may be repeated once, if necessary, but two injections per cluster series is generally the maximum.

SIDE EFFECTS
: Infection, discoloration, or dimpling of skin, though rare, may occur. Stomach pain, anxiety, or insomnia may also occur.

For a full discussion on treating occipital neuralgia, see Chapter 13.

THIRD-LINE MEDICATIONS FOR PREVENTING EPISODIC CLUSTER HEADACHES

If none of these strategies works for you, your doctor may recommend either intravenous DHE, administered repetitively, or a cocaine solution to be used nasally during the day to prevent the clusters.

1. I
NTRAVENOUS
D
IHYDROERGOTAMINE
(IV DHE)

Intravenous DHE can quickly cut down on the number of cluster headaches you get and can control clusters while you wait for a preventive medication (such as verapamil or lithium) to take effect. Its pain-relieving effects may last for weeks.

(See Chapter 6 for a full discussion of IV DHE.)

2. C
OCAINE
S
OLUTION
(A
LAST-RESORT, END-OF-THE-LINE THERAPY
)

If your episodic cluster series lasts several months and all other preventive measures have failed, cocaine may help you. It is particularly useful during a peak season of chronic clusters. The treatment involves using a 10 percent solution during the day to reduce the number and severity of the clusters. This dose rarely produces any euphoric or cognitive effects.

Addiction risk may be a problem (and its use generally would not be recommended if you have any addiction history), but the low concentration, high cost, and difficulty in obtaining the solution makes cocaine a last-resort therapy.

TYPICAL DOSE
: One or two drops in each nostril one to four times a day. If the clusters are severe and out of control, your doctor may suggest beginning with two drops four times a day, quickly cutting the dose down to as little as is effective. Usually limited to two grams of cocaine in two months.

SIDE EFFECTS
: Occasional nervousness or insomnia; euphoric effects of cocaine may occur but not commonly. If euphoria is experienced, the percentage of cocaine should be cut down to 4 percent or stopped completely. The patient must understand the addiction potential.

ADDITIONAL TREATMENTS FOR EPISODIC CLUSTER HEADACHES

Occasionally, other medications may help cluster headaches, including phenelzine, cyproheptadine, nifedipine, beta-blockers, antidepressants, long-acting daily opiods, or methylphenidate (Ritalin).

• P
  HENELZINE
  (N
  ARDIL
  )
  , an MAO inhibitor, is a powerful antimigraine medication that is occasionally useful for cluster headaches. (See Chapter 6 for more details.)
  
• C
  YPROHEPTADINE
  (P
  ERIACTIN
  )
  is occasionally helpful for clusters, but its effect is usually very mild. Side effects, such as fatigue and weight gain, are often problems. Best when used with other therapies for clusters.
  
• N
  IFEDIPINE
  (P
  ROCARDIA
  )
  , a well-tolerated calcium blocker, is as effective as verapamil for many cluster patients. However, if verapamil does not work, the nifedipine usually is ineffective as well. The usual dose is 60 mg per day divided into two to three doses. Its side effects are very similar to those of verapamil.
  
• B
  ETA-BLOCKERS
  are, at times, mildly effective for cluster patients, but much less effective generally than the usual cluster therapies. Propranolol (Inderal) or nadolol (Corgard) are discussed in Chapter 6.
  
• M
  ISCELLANEOUS ANTIDEPRESSANTS
  (amitriptyline, Prozac, Zoloft, Paxil) are occasionally helpful, but usually not adequate by themselves. (See Chapter 6.)
  
• L
  ONG-ACTING DAILY OPIOIDS
  (see Chapter 6) are more useful for severe chronic daily headache and migraines. If all else fails, though, they may be worthwhile for cluster headaches.
  
• M
  ETHYLPHENIDATE
  (R
  ITALIN
  )
  may occasionally be effective in stopping a cluster in progress. Low doses (10 mg) are typical; 30 mg per day should be the limit. Side effects include anxiety, insomnia, fatigue, and addiction, among others.
  

ADDITIONAL TREATMENTS FOR PREVENTING CHRONIC CLUSTER HEADACHES

To prevent chronic cluster headaches, a doctor will probably use the same treatments as for episodic clusters. When nothing else seems effective and the pain is consistently on the same side, then the doctor may suggest a surgical technique conducted at only a few medical centers.

Radiofrequency trigeminal rhizotomy
kills trigeminal nerve fibers involved in pain conduction, but sometimes the procedure must be repeated to be effective. A specialized technique, the surgery is conducted primarily at neurosurgery centers that specialize in pain treatment. A newer technique using “gamma knife radiation” is promising, and relatively noninvasive. These techniques are similar to those used for trigeminal neuralgia. Injections of botulinum toxin (Botox, et cetera) are promising for migraine and may help some cluster patients as well.