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Reader's Mail: Preventive Medication for Migraine

Q. I just started taking Nortriptyline.  I take 10 mg once before bed.  Is it OK to take one of these pills at a time when I start to get a headache?

A. Nortriptyline is an example of a preventive medication, which is a drug intended to decrease the frequency, severity, and duration of headache attacks.  Preventive medications should be taken every day, regardless of whether a headache is or is not occurring.  Furthermore, preventive drugs typically require at least four to six weeks to reach their full effect. In contrast, acute drugs are not for everyday use and should provide relief quickly, usually within a few hours.

Richard Wenzel, Pharm.D.
Diamond Inpatient Headache Unit
Chicago, IL

Hormonal Headaches

Q. What is the cause of hormonal headaches and what can be done to prevent and treat them.  I stay on a low carb, no sugar, low salt diet.

I have suffered with hormonal migraine headaches and other PMDD symptoms since the age of 11.  I am now 49. In 2001, we discovered that I was estrogen dominant.  Oral micronized progesterone saved my life and me from having two weeks of migraines every month.  Unfortunately, in the past six months the hormonal headaches are back worse than ever.  The duration isn’t as long as they were pre progesterone but they are just as stubborn.  Pain relief is next to impossible.  I was just given a prescription for Frova.

A. Migraines are often dramatically affected by drops in estrogen or progesterone and some get relief, and some do worse when these hormones are added.  It sounds like it has helped you.  It is important to understand, however, that the hormonal relationships are only triggers, not the cause of migraines and there are often limitations in the use of hormonal manipulations.  Often we have to put the hormonal triggers aside and simply treat hormonal migraines the same way as all others.  You might benefit from other preventive anti-migraine medications.

Frova and other triptans can improve migraines regardless of the trigger.  When headaches are very frequent, however, or very difficult to manage with the acute medications, one needs to concentrate on preventive measures.

Mark Green, M.D.
Columbia Univ. College of Physicians
New York, NY

Weather Changes and Headache

Q. Is there a correlation between changes of seasons and dramatic weather changes from day to day that trigger migraine headaches?  I get them more during these times than any other.

A.  Weather change including change in barometric pressure is a huge trigger for migraine headaches. It is commonly thought that migraine patients inherit a genetic susceptibility to their environment; therefore, it makes sense that changes of seasons and weather changes could be a trigger for migraine exacerbation.  Knowing this trigger can help with treatment, e.g. if the weather is changing, a short-term preventive strategy can be employed.  For some patients this may involve increasing the dose of their usual preventive medication; for others, they may choose to take a long-acting triptan like Frovatriptan 2.5 mg twice a day for 3-5 days.

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

Cervical Spine and Cluster Headache

Q. Over the last three years I have had cluster headache on the left back of my head close to the center. The headache begins at 3:00 a.m.; the only way to get relief is to stand up.  Typically I have light back and neck pain the night before; the stronger the neck pain is, more painful the headache.  I have had acupuncture, chiropractic sessions and physical therapy, but nothing works. What advice can you give?

A. Although your headache warning is in the neck, this does not necessarily mean that the cause of your cluster headaches is based in the cervical spine.  It is unlikely; therefore, that chiropractic treatment or physical therapy will be of benefit for the treatment or prevention of cluster headache.   Cluster headache is felt to originate in the brain.  It is suspected to be associated with the hypothalamus area of the brain, and this may account for the timing seen in the occurrence of attacks.  It is not clear why your cluster attack is improved by standing up; other cluster headache sufferers have reported relief with exercise, but this is presumed to be due to increased oxygen intake.  High-flow oxygen is sometimes prescribed for the treatment of cluster attacks. If your attacks are frequent, you may wish to pursue the possibility of preventive medications.

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

Acute Migraine Headache

Q. I have suffered from migraines for over thirteen years; but in the last five years they have increased in intensity and frequency with new symptoms.  I have been to a headache specialist who put me on different migraine medications, had an MRI done which was negative. My only concern is that the specialist I went to just brushed it off as another typical migraine and his only solution to the problem is to put me on an Imitrex, Maxalt and Naproxen, Trixmet and Tramadol treatments; along with supplements, Feverfew, B12 and Butterbur. The migraine medication only takes the edge off but does not completely abort the migraine which lasts up to two days. The doctor later added Amitriptyline to the mix. Are there any other alternatives you could suggest besides medication?

My migraine symptoms are as follows: nausea, dizzy spells, ringing in the ears, strange smells before the headache which continues into the headache along with light sensitivity, slurring of speech which can sometimes effect my speech pattern for a few months, tingling in my arm or sometimes numbness, loss of time/blackouts, extreme exhaustion i.e. where I can’t stay awake and must sleep, eye pressure/eye twitches, headache pain is always on right side, an intense, sharp-edged, pulsating, throbbing ache that last for up to two days. I get these migraines two to three times a month.

A.  With challenging headache-associated symptoms as you experience, a comprehensive evaluation and diagnostic testing is important and it appears that this has been done.  There are wide varieties of choices for treating migraine both as the attacks occur and preventively.  The triptans, which you have been given, are the drugs of first choice for treating acute migraines.  Other choices may include dihydroergotamine or one of the more sedative type medications such as chlorpromazine or olanzapine.  Though not as specific as the triptans and dihydroergotamine, they work well for many.  Biofeedback using both the muscle relaxation as well as the hand-warming techniques can be used as an acute treatment for migraine may have preventive effects when practiced regularly.

Most of the preventive medications you have taken have been in the form of “natural therapies”.  While these may benefit some, only butterbur root (Petasites H.) has been shown to have efficacy and tolerability like the best of the preventive prescription drugs.  In Europe, the regulation of natural therapies is consistent with the standards required there for prescription medications. I suggest that the Petadolux brand of butterbur root, which is manufactured in Europe, be used.  Like all preventive medications, the dose needs to be sufficient (75mg twice a day) and used for up to three months before declaring it ineffective.  The only preventive prescription drug that you mention is Amitriptyline.  While this is among the top tier of preventive medications, an adequate dose (up to 75mg daily at bedtime) and sufficient duration of use is needed.  Other top-tier medications that may prove effective include the beta-blockers, propranolol, metoprolol and timolol; the antiseizure medications divalproex sodium and topiramate make up the remainder of the top-tier preventive treatments based on clinical research.  Many other therapies exist but have less chance of being successful than the prescription medications mentioned along with butterbur root and biofeedback.  Certainly, by the time you have been through the treatments listed above, you need to be under the care of well-trained headache specialist to maximize the options available.  The headache specialist should hold either a Certificate of Added Qualification from the National Board for Certification in Headache Management or Board Certification in Headache Medicine from the United Council of Neurologic Specialists.

Fred Freitag, D.O.
Diamond Headache Clinic
Chicago, IL

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