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Experts Answer Your Questions: National Headache Awareness Week

Preventative Therapies for Headache Treatment

Q. What percentage of the population does not respond well to preventatives? I’m 42 and have been trying preventives since I was 20 and nothing has worked. I am on topomax for the 2nd go around and I am still using Zomig 2 times a week and having to rely on Ultram on top of that every week. It seems from reading the blogs there is a bunch of us for whom the preventatives hasn’t panned out. I feel like a human guinea pig. I’ve been to neurologist #8 and she says “we have to think outside the box for you”. The last neurologist says “Western medicine has failed you”. Yes, yes and yes. But they don’t know what to do with us. I am frustrated beyond words. My migraines are barely manageable. May 21 and I have had 4 days without medicine to treat headache. I have to work. I have to have a life. I have tried everything and nothing is working.

A. I am sorry that you are not responding well to preventive therapies. At the same time, I am glad that you are continuing to seek answers to get you better. After all, the number one factor that helps in improving is positive attitude. Specifically, in clinical research roughly 50% of patients experience a 50% or more reduction in the frequency of their headaches when using conventional single migraine preventive agents. This tells us that current available treatment for migraine prevention is less than optimal, and unfortunately research progress in this area has been slow. There is a network of headache specialists in the New England area that you might consult with. Their information is on the NHF website.

Nabih Ramadan, M.D.
Diamond Headache Clinic
Chicago, IL

Midrin Taken off Market

Q. Why has Midrin and its generic forms been taken off the market? This is the one drug that controls my migraine disease and at present my doctor has no replacement for it. He just gives me a pain killer and that is not what I need. Since menopause my symptoms do not usually include the headache as a major symptom. The aura and tunnel blindness and a dull pain are the worst part of migraine for me now. When my migraines first started and through my 30’s they consisted of every symptom listed plus memory loss.

A. There are mixed reports on what has happened to Midrin. The manufacturers of Midrin reported back in November that they were still producing the product but got behind on demand. The makers of similar products (amidrine, duradrin, migraten, etc.) have stopped making their formulations and Midrin is now the only product being manufactured. There are no updated reports since then and the availability has not gotten better making people suspicious that it is no longer being made. It is however listed on the manufacturer’s website as one of its products. If your headaches/auras are occurring frequently your other treatment option would be to try to prevent them with a preventative medication. Then you would not have to suffer with your symptoms to get relief. You should discuss this with your physician.

Susan M. Rubin, M.D.
Director, Women’s Neurology Center at Glenbrook Hospital
Evanston Northwestern Healthcare
Glenview, IL

Chronic Daily Headache

Q. My daughter started having headaches when she was a teenager and now she is 25, newly married; and still suffers from daily headaches. Every couple of months she will have a migraine to the point where she needs to get to an ER or urgent care to get a couple of shots that put her out for the rest of the day. She has been to numerous neurologists and none of them have been able to relieve her from her daily headache. She is now taking daily Topamax and when she gets a bad headache turns to Relpax or Zomig.

My questions:

  1. Will she ever be free from daily headaches? I have hoped all these years that something would work, and it hasn’t so I guess I need to know and help her to accept that she will always need to be on this medication.
  2. She is trying to get pregnant, if she does, can she continue to take these medications or are there others she should check into now? The doctors she has been dealing with don’t seem too concerned, but she is and doesn’t want to harm the baby.
  3. She was going to one female in Arizona, she put her on a diet of special foods but that didn’t help and now my daughter is 5’5’’ and 100 lbs. This is also worrisome to both of us.
  4. I’ve read about in-patient facilities. Do you recommend any of those? Are the affective? Is it worth the cost/ and lost time from work etc.

A. I sympathize with your daughter’s problem since chronic daily headaches are hard to treat. However, this is the type of problem that is best dealt with one on one and not through the mail. There are a lot of factors that affect the way we treat chronic daily headaches and those would need to be addressed before recommendations could be made. I agree that ideally you would like a patient who is trying to get pregnant to be on no medication but that isn’t always realistic. If she is concerned about what she is taking she should see a genetic counselor to address this. Inpatient programs can be very helpful as well for truly intractable headaches but do involve a commitment of time and money. These are decisions your daughter needs to make and she needs to take an active role in her care if anything is going to work.

Susan M. Rubin, M.D.
Director, Women’s Neurology Center at Glenbrook Hospital
Evanston Northwestern Healthcare
Glenview, IL

Reflex Neurovascular Dystrophy causing Headache

Q. I have a 16 year old daughter who has had severe head pain at a level 8+ for 17 days… Brias history includes missing 35 days of school a year due to ‘crashes’ where she would get what we named the ‘bria’ flu that would include dizziness, head pain, severe fatigue in the limbs and body. Five years ago she developed severe foot and leg pain. We were finally sent to a children’s hospital in Washington state where she was diagnosed with Reflex Neurovascular Dystrophy, she was sent to physical and occupational therapy and slowly the pain faded away never to be seen again… but still month after month these ‘crashes’ have continued usually lasting 7-9 days.

In January the crash lasted 25 days…terrible head pain(8-9) with dizziness initiating the crash and ending it, fatigue of the limbs (everything feels weak she says) and nothing digesting well so bouts of nausea… February was ‘okay’ no head pain but now she is on the 17th day of the same thing as in January. The head pain looks a tiny bit more like a migraine than ever before because of sensitivity to light and sound. There has never been a pain killer that has done anything for Brias leg or head pain. My question, does RND ever manifest itself in head pain?

A. Your daughter’s head pain may be a manifestation of migraine but with the constellation of symptoms she has, a careful neurological work-up is essential. NHF has a directory of doctors in the Washington State Area. I recommend you pick a neurologist from that list who would have an interest in migraine but be able to more completely evaluate your daughter’s full array of symptoms to make a diagnosis and treatment plan.

Susan Hutchinson, M.D.
Director
Orange County Migraine & Headache Center
Irvine, CA

Cervicogenic Headache

Q. I have extraordinary severe headaches, they usually start in my neck and then into my head. I’ve been told I have osteoarthritis. This supposedly is the cause of my headaches. There is no way I could tell you how many injections I’ve had in my neck plus two surgeries one on my C-6 and C-7. My headaches are still so severe I can’t stand it. My doctor gives me Tramadol-HCL 50 mg. These don’t begin to help me. I really don’t know what to do, they just keep on injecting my neck which may help for a week, but then it’s hurting again, and like I said they will not give me any pain medication other than what I already have.

I just really don’t know what to do. My headaches make me unpleasant to be around and sometimes it’s hard to do my work around the house. I am disabled because of severe depression with suicidal tendencies. So if there is anything you can do to help me, let me know.

A. For osteoarthritis, the use of daily NSAID medication if often helpful; also, a physical therapy evaluation and cervical traction (as taught by a physical therapist) may be of some benefit in reducing both neck pain and the part of the headache that is cervicogenic (neck origin). However, the greater issue for you would appear to be your severe depression with suicidal tendencies; until that is helped; your headaches and pain are likely to continue. Careful medical attention including psychiatry care is highly recommended. It is possible that your headaches will improve if your depression gets better.

Susan Hutchinson, M.D.
Director
Orange County Migraine & Headache Center
Irvine, CA

Headache Disorders

Q. Migraine disease has neurological and genetic characteristics that other headache disorders don’t have. In fact, a migraine attack doesn’t necessarily include a headache as a symptom and include other symptoms like nausea, phonophobia, and photophobia that the other disorders lack. Why is migraine disease grouped or listed with other headache disorders?

A. Conventionally, we divide headache disorders into those that have a clear cause, which are called secondary headaches, such as headache after head trauma, meningitis or bursting brain aneurysm, and the so-called primary headaches where a clear cause cannot be established. Examples of primary headaches include migraine, cluster headache, and tension-type headache. Tension-type headache is the most common of the primary headache in general, but migraine is the most common primary headache that health providers evaluate.

Nabih Ramadan, M.D.
Diamond Headache Clinic
Chicago, IL

Arachnoid Cyst and Migraine

Q. Twenty-four years ago I fell over one story and suffered some damage to my septum. In September of 2006, I took a tumble and hit the back of my head on a hardwood floor which dazed me for a minute. In December, I started noticing that I began having a few more headaches than normal. I started slowly having balancing problems and having pain in my right ear. I also began having memory problems and couldn’t come up with simple words like ‘catalog.’ Through this, I had been having headaches at an increasing amount. The carsickness was intolerable. I could barely drive myself to work because of the nausea, which is very unusual. As I walked down the hallway at my school, I would veer to the left or stumble like I was on a boat and a wave hit it. I went to the Dr. to take care of the ‘ear infection.’ After an MRI, they found a 12 sq. cm arachnoid cyst in the upper left paramedian part of my brain.

I was told that I have migraines, but none of the drugs I’ve been put on have helped. The headaches are everyday, all day long. They are sharp and splitting in one spot (the same place always) and radiating/dull periodically. I can’t sleep at night. I have had strange flashes of memories at unrelated times. I have been told that there is no way that this cyst could be causing problems for me, but I just can’t shake the feeling that there is something more going on than simple migraines. My neurologist has told me that he doesn’t understand what is going on and is going to refer me to a clinic. Does anyone have any ideas? Please? I’m 29 and I just can’t see going to teach each day with an axe sticking in my forehead and stumbling around.

A. It is a difficult to know for sure what could be causing your headaches and imbalance without actually examining you and seeing your test results. Your daily headaches could be due to transformed migraines which are a transition from episodic to daily headaches sometimes due to inappropriate or inadequate treatment of the headaches when they were episodic. Other possibilities would include hemicrania continua or new onset persistent headaches which are often difficult to treat with standard migraine medications. Sleep deprivation can make all of these symptoms worse. While the symptoms could be due to raised intracranial pressure from your arachnoid cyst this unlikely especially based how you describe the lesion and this would more likely cause seizures which shouldn’t be daily/continuous. I would encourage you to follow the recommendation of your neurologist to see a headache specialist at a headache clinic or medical center. After a thorough examination they can make further suggestions for evaluation and management.

Susan M. Rubin, M.D.
Director, Women’s Neurology Center at Glenbrook Hospital
Evanston Northwestern Healthcare
Glenview, IL

Migraine triggered by Fluorescent Lights

Q. I know fluorescent lights causes me to get a migraine. Do you have info on this? I am buying up bulbs now. I have had jobs in past that had these lights and it caused me to have headaches.

A. It is not unusual for patients with migraines to be sensitive to light when they have a migraine. However, it has also been noted that bright lights or flashing lights can trigger a migraine in sensitive patients. Fluorescent lights are a more common trigger because the erratic flickering of the bulbs, toxic (visible) wavelengths, or perhaps some combination of effects. With new laws requiring the transition to compact fluorescent bulbs we may see an increase in migraines in the years to come. Unfortunately there have not been any studies that I am aware of that specifically look at the impact of compact fluorescent bulbs on migraine frequency. The good news is that medications prescribed to prevent acute migraine attacks seem to work for migraines triggered by fluorescent lights. Also, regarding the known relationship between adverse visual stimuli (glare, flickering, harsh light) and migraine, recent research has shown that wearing a mild green-blue spectacle tint greatly improves fluorescent light tolerability. Hopefully this will help prevent your migraines.

Susan M. Rubin, MD
Director, Women’s Neurology Center at Glenbrook Hospital
Evanston Northwestern Healthcare
Glenview, IL

Tension-Type Headache

Q. I have had significant relief for my tension-type headaches for sixteen years, but I am now presently experiencing worsening conditions with no sign of relief. I have been under the care of ten physicians at Mayo and Cleveland clinics. I have taken Roxicet, Cipro, Paxil, Prilosec, Vioxx, Serzone, Celexa, Trileptal, Metronidzol, Depakote, Zonegran, Mirtazapine, Indomethacin, Phrenilin and several other medications. Currently I am not seeing a neurologist.

Three years ago the physician at the Cleveland Clinic took me off all medications as none of them had or were doing me any good. It was his position that until such time as the pharmaceutical industry came out with some drastically new and different drugs aimed at this area of problems that it was futile for me to continue taking what was currently available.

I have experienced a couple of seizures and am told periods of effacia in recent years. My GP currently has me taking on a daily basis 81mg of aspirin, 1000 mg of Vit B12, 75 mg of Plavix, 20 mg of Simvastatin and two 100mg Zonisamide capsules. About six months ago I experienced a worsening of my condition with a general increase in the intensity of headaches and more frequent episodes of dizziness.

I would appreciate your comments. Is there, in your opinion, something that can be done to provide significant relief for the headache pain, and perhaps the dizziness?

A. In light of the episodic dizziness and the worsening of your headache pain, the diagnosis of tension-type headache may need to be reconsidered, or additional diagnoses considered. One thing in your story that I would wonder about is whether periods of aphasia are a type of seizure, or whether they represent a type of headache symptom. Your case is very complicated and is deserving of the diagnostic skills of a headache expert.

Christina Peterson, M.D.
The Oregon Headache Clinic
Milwaukie, OR

Migraine Headaches

Q. I have been having migraines for years after I gave birth to my first baby. I recently started having seizures last year. I have been taking Firocet for years, but now my Neurologist is refusing to prescribe it for me. I now take Epridin and it isn’t helping much to give me relief. I have stayed in bed for days and nights with severe migraines, vomiting and nausea. I could not eat or drink. I have been in the emergency room a lot for IV treatments and pain medicine injections. I also take Imitrex pills and injections but they are too expensive. I am wondering if you could help me.

A. You don’t mention how often your headaches are occurring, but they sound terribly disabling to you. Disabling migraines that affect you four or more days a month are best treated with a daily preventative medication in addition to an abortive medication like Imitrex or Epidrin. Several of the preventative medications happen to be anti-epilepsy medications. You might bring this up with your neurologist and see if that would be appropriate in your situation. There are many other options in addition.

Christina Peterson, M.D.
The Oregon Headache Clinic
Milwaukie, OR

Tyramine Diet and Soy Beans

Q. Based on the Tyramine diet soy beans are allowed; however, I have read many articles on avoiding all soy products including raw soybeans due to the levels of glutamate which convert to or are close to MSG. As a practical matter; when trying to determine if there is a food trigger, should all soy products be eliminated from ones diet, even boiled, raw soybeans?”

A. I think it is too restrictive to avoid all soy products in an attempt to avoid migraine headaches. Dietary changes for a migraine patient are best done based on personal experience and not by “lists” of what to avoid. I usually recommend that migraine patients look back for 24 hours leading up to a migraine and make note of what they ate and drank. Once there is a pattern as to a certain food causing a migraine, e.g. peanuts or aged cheese, then it makes sense to begin avoiding that product. For most migraine patients, greater triggers for migraine include stress, hormonal changes and weather.

Susan Hutchinson, M.D.
Director
Orange County Migraine & Headache Center
Irvine, CA

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