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Reader's Mail: New Headache May Be Related to Caffeine

Q: I have been having a mild-to-moderate throbbing pain above my ear that comes and goes. My eye bothers me, too. Two ibuprofens seem to lessen the throbbing. I do drink a lot of coffee with caffeine and am not sure if that’s a factor. I am only worried because I have never had headaches before. How can I be sure I don’t have a tumor or bleeding in the brain?

A: Your description of the pain is not alarming. However, given the fact that you have never had headaches before, I would advise you to see your healthcare professional and have an MRI of the brain to rule out any organic cause of your headache.

That said, it is very possible that the headache is a result of caffeine overuse, which can cause rebound headache. You should reduce your intake to a maximum of one serving a day.

George Urban, M.D.
Diamond Headache Clinic
Chicago, IL

Can a Six-Year-Old Have Migraine Headaches?

Q: My six-year-old granddaughter is having headaches about once a month and I am worried. The headaches progress in this order: She says she is tired, then her head hurts on the right side above her eyebrow. She turns very pale and vomits. She sleeps anywhere from an hour to all night, then awakens feeling fine. Does this sound like a migraine and is it common for six year old?

A: Migraine can start at any age and what you describe sounds very much like it. The tiredness would be a “prodrome,” a warning sign that she is starting a headache. Migraine is most often on one side of the head, and often around the eye, temple and forehead. (Sometimes people think they don’t have migraine because their entire head hurts but migraine can be on both sides of the head, one side, or move from one side to another.) Most children who get migraines tend to get pale and vomiting is common. Most adults who had migraine as a child report that as they got older they no longer vomited with every attack.

Please be sure and have your granddaughter seen by a healthcare professional. It is quite likely that some treatment can be found to help relieve her headaches without her having to vomit and go to bed for several hours.

James W. Banks, M.D.
Ryan Headache Center
St. Louis, MO

Don’t Give Up Hope on Six-Month Headache

Q: My 18-year-old daughter has had a headache for six months. It never goes away no matter what she takes. Her primary doctor gave her a prescription for a limited number of Vicodin®, which dulls the pain a little, and she takes a muscle relaxant.

She had her first migraine with aura at age 20 and, until this year, only got a migraine about twice a year. I thought she got off easy compared to her oldest sister who suffered from severe migraine all through high school, and her other sister who had, but outgrew, cyclic vomiting syndrome.

My daughter has had all the tests you can imagine and is seeing a neurologist who diagnosed her with chronic daily migraine. He says the next step is for her to work up to 200 mg. of Topamax®. I’m concerned because she tried up to 50 mg. before, but experienced tingling in her hands and nausea.

My daughter’s quality of life is suffering and we are desperate for relief for her. Do you have any advice?

A: Your daughter’s situation is actually quite common among headache specialty practices, and it sounds as though she should be under the care of a provider who specializes in headache management. There are headache specialists throughout the U.S. Check the National Headache Foundation’s Physician Finder for the names of headache specialists in your area.

Three things stand out in your letter. First, that another daughter had cyclical vomiting, which is a type of migraine syndrome, supports the genetic tendencies of migraine. That she improved should be reassuring for your younger daughter. She, too, will most likely be able to get relief and back to a functional, satisfying life. Second, the tingling of the hands and feet is not uncommon with Topamax. It is not dangerous and, in fact, may well indicate that she will respond to Topamax. Usually the tingling resolves once a person stays at a particular dose level for a while.

Many people report trying and failing numerous preventive medications, but upon taking a more careful history, we often find that the dose was not adequate and/or the medication wasn’t tried for a sufficient length of time to make it an adequate trial. Sometimes it takes a combination of two or more medications to get effective control of headaches. It is always a trial and error process. There is no test that can tell a physician what specific medication will work for a particular patient. What may work for one person may not work for another or what one person may tolerate another may not, even within the same family!

Finally, there is more and more evidence linking the use of narcotic pain medications such as Vicodin (hydrocodone) and butalbital (Fioricet®, Esgic®) with worsening of headaches, actually making people refractory to more appropriate medications. I strongly discourage the use of those medications.

Don’t give up hope. Have your daughter check out the NHF website and search for a headache specialist. The website also has some excellent suggestions for biobehavioral tools that can help manage chronic headaches.

James W. Banks, M.D.
Ryan Headache Center
St. Louis, MO

Ten Years of Sinus Headaches Were Actually Migraine

Q: I started having migraines while pregnant with my third child, when I was 37. The pain is located at the left temple and over my left eye. Sometimes it feels like the side of my face is kind of numb and sometimes my teeth hurt.
At first, my doctor thought I was having sinus headaches although a sinus series x-ray showed everything normal. I took Benadryl® for sinus headaches for about 10 years. I suspected the headaches were worse around or before my menstrual cycle, but my doctor never seemed to see any association. Eventually he referred me to a neurologist who diagnosed me with migraine.
My neurologist put me on amitriptyline and then nadolol, with Amerge® being the “heavy” drug that I take when an out-of-control headache is coming on. I recently went off of amitriptyline and nadolol, as it has been three years and I didn’t feel good about taking a daily prescription for that long. I wasn’t better anyway. I still take Amerge when I need it, which is about every two weeks. It seems someone should have an answer for me. Eighteen years is a long time.

A: The majority of women who suffer from migraine will have worse headaches around menses and ovulation, evidence of a hormonal trigger. Your situation is unusual because of the onset of migraine at age 37, which is much later than usual. Migraine attacks are often more frequent during menopause, presumably because of varying hormone levels. Sometimes the headaches are better when taking a low, steady dose of estrogens, but some women will have worsening of their migraine with taking any extra estrogen. Remember, however, that the hormone cycle is just one of many possible triggers.

Taking a daily preventive medication will often reduce the frequency and severity of attacks, though apparently amitriptyline and nadolol didn’t do much in your case. If the headaches are occurring only every two weeks and you can control them with a triptan, then a daily preventive may not be indicated. Perhaps it would be worth trying a different triptan other than Amerge to see if you get more reliable relief.

Robert Kunkel, M.D., Consultant
Center for Headache and Pain Neurological Institute, Cleveland Clinic
Cleveland, OH

Indomethacin Causing Stomach Problems

Q: I have hemicrania continua, but cannot take indomethacin for it due to severe stomach problems. Is there another alternative?

A: Hemicrania continua is a very specific headache diagnosis. It is a persistent, one-sided headache that responds to indomethacin. If you were correctly diagnosed, you should respond to 50 to 150 mg. per day. If you cannot tolerate this drug because of stomach upset or heartburn, adding ulcer protective drugs such as Prilosec®, Nexium®, Protonix® or even Carafate® may help reduce or eliminate side effects. If you have a history of stomach ulcer or bleeding, however, you should not take indomethacin. Celebrex® or even aspirin may help and some antiseizure medications are occasionally effective.

George Urban, M.D.
Diamond Headache Clinic
Chicago, IL

New Daily Persistent Headache Is Tricky to Understand and Treat

Q: I’m struggling with NDPH (New Daily Persistent Headache). Do you have any advice?

A: New daily persistent headache is a puzzling thing. For those who aren’t familiar with it, I’ll give a brief description. NDPH is a daily headache that starts suddenly and is daily from the outset. Often it happens in people who have never had any sort of headache before. Patients can often name the exact time the headache started. Sometimes they will report having a cold or viral illness when things started. Other times the headaches will start during a period of stress. Still other times, it will seem like the headache truly came out of the blue.

There are a few things that can act very much like NDPH and need to be considered. Sometimes daily headaches can start after even very mild head trauma. This is generally diagnosed as post-traumatic headache, but it often acts similarly and is treated similarly to NDPH. Low cerebrospinal fluid pressure headaches, which usually are much worse when upright than lying down, are not always so clearly positional, and can look similar to NDPH. Finally, medication overuse headache can appear to start suddenly, though it should not be as sudden as NDPH. When medication overuse headache masquerades as NDPH, it is likely because the medications were used for something other than headache, such as low back pain.

NDPH is very hard to study in the laboratory, so it’s hard to get basic insight into how it works. While I am speculating, it seems reasonable to assume that some event or series of events sensitizes the trigeminovascular system (the network of nerves and blood vessels that transmit pain in the head). But it is hard to understand why such a sensitization would occur so suddenly, without warning.
Also tricky about NDPH is that there is not much consistency in which medications work. This may be because NDPH is actually more than one entity. It is reasonable to try several medications from different drug classes to maximize your chances of success. Your healthcare professional can help with this.

K.C. Brennan, M.D.
David Geffen School of Medicine, UCLA
Los Angeles, CA

Avoiding Rebound Headache with Narcotics

Q: Years ago I was trapped in a vicious rebound headache cycle from taking narcotics almost every day. I had to endure painful withdrawals to stop those drugs. Today I am better, but I will soon need back surgery. I am scared to use narcotics again. What else can I use for pain?

A: First and foremost, please speak with your surgeon prior to your surgery to communicate your expectations and fears regarding pain. This conversation can help ensure that your pain-control needs are properly met.

Your question noted a key piece of information—the fact that you were taking narcotics “virtually every day.” Furthermore, I suspect that this situation had been occurring for many months, if not years, since most rebound headache sufferers have endured their condition for prolonged periods of time. I would argue that you could use narcotics after your surgery, particularly in the days or even the first few weeks after your procedure, which is the time when you are most likely to need narcotics. After that time, the pain is typically either gone (and the narcotic stopped) or decreased enough that non-narcotics drugs are effective.

To avoid a return to the problems you experienced during your rebound headache cycle, you want to avoid using daily or almost-daily narcotics for consecutive months. If you find yourself moving towards that situation, speak with your healthcare professional. Another non-narcotic option for postoperative pain is ketorolac, which is an injectable, anti-inflammatory medication.

Richard Wenzel, PharmD
Diamond Headache Clinic
Chicago, IL

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