New Warning on Imitrex

Q. I’ve been a National Headache Foundation subscriber for many years and a sufferer for over 40 years. When Imitrex (sumatriptan) was available it was a miracle for me. I have taken Imitrex for many years, usually having my physician prescribe three packages (27 pills) for a 3 month’s supply (mail order). Now my physician has limited me to only one package (9 pills) for 3 months, stating that there have been new warnings about sumatriptan use and that patient use of it needs to be closely monitored. I have always been careful not to exceed two doses in a 24-hour period, but often my migraines come in clusters and I might need to take, 6 or more pills in one week, so the 9 pills will never last 3 months. Are there new warnings on Imitrex or do you think this is an insurance problem?

A. It is unfortunate that many migraine sufferers are limited on how many triptans pills (i.e.-Imitrex) they may receive. This may lead to increased days of disability and unnecessary anxiety. I am not sure if your physician or your prescription plan is limiting you but it is more likely your prescription plan. Many prescription plans limit relatively expensive medications. Most triptans pills are about $20 per pill. The medication package insert for Imitrex (and many triptans) states “the safety of treating an average of more than 4 headaches in a 30-day period has not been established.” This statement does not mean they are not safe if used more frequently and many headache specialists, including myself, feel comfortable prescribing them up to 2 days per week in healthy patients. However, some prescription plans use this statement to mean a maximum of 4 treatment days per month with an average of 1 ½ doses per headache, thus limiting coverage to 6 pills per month. Since Imitrex comes in packages of 9, you are allowed 9 per month. Ask your prescription plan if they have an appeals process which will allow more.

Loretta Mueller D.O.
University Headache Center
Stratford, NJ

Environmental Headache

Q. Prior to menopause my migraines were mostly hormone driven. Since going through menopause my migraines are now triggered by weather changes, bright light, loud noise, and perfume and food preservatives. I have taken all the recommended vitamins for years with little response. My neurologist put me on Topomax 100 mg in the morning and at night as well as Relpax at onset of the headache. Perfume is hard to deal with unless I become a hermit. It is everywhere even at migraine seminars. Do you have any advice besides wearing an oxygen mask? Weather changes are causing me to spend a lot of my life in bed with ice packs since the relpax doesn’t help. I go to work even though I do not feel well but I do not function well. Have you heard of taking food enzymes to help with food sensitivities? I’ve ceased eating out and have given up eating processed foods, etc.

A. There are many potential triggers for migraine, as in your case. These triggers may not be consistent, or may be additive, and often change with time. Obviously you cannot change the weather (without moving) and I agree strong perfumes are much too prevalent. Your best bet is to reduce your brain’s excitability. Standard approaches are both non-pharmacologic and pharmacologic. Regulate your sleep and meal schedule, eat a healthy diet, exercise, and avoid known dietary triggers. It may be time to change or add another daily preventive medication. Common classes include other anti-epileptics, anti-depressants, or blood pressure pills. I have not heard of food enzymes helping headaches.

Loretta Mueller D.O.
University Headache Center
Stratford, NJ

Occipital Neuralgia

Q. Can you tell me if a normal MRI of the brain on a 29 year old can rule out occipital neuralgia? Can you tell me if there are any diagnostic/laboratory tests that can be done on a patient that would rule out the diagnoses of occipital neuralgia?

A. There are no tests such as an MRI which will prove or disprove occipital neuralgia. The diagnosis is based on clinical features and may usually be confirmed pain relief after numbing and/or anti-inflammation injections around the nerve (an occipital nerve block). Typical features include stabbing or electrical shock-like pain starting in the back of the head on 1 or both sides (depending on whether 1 or both occipital nerves are involved). The pain may radiate to the front of the head or behind the eye and the scalp is sometimes tender to touch. It is usually caused by injury or irritation to the occipital nerves which come from the neck to the scalp in the back of the head.

Loretta Mueller D.O.
University Headache Center
Stratford, NJ

Disabling Migraines

Q. My wife has had disabling migraines for several years. She was released from a local hospital; they spent 7 days treating her migraines to get them under control. We have tried several different treatments to include Topamax for preventative meds and Botox for migraine control. She is a flight nurse and would like to remain on flight status, but when the pain is severe she has to be hospitalized. If we do not find someone who can treat the problem without putting her in the hospital and pushing narcotics she will be unable to retain her flight status. She was injured in the Army and had a migraine related stroke in 2003 and Chari Decompression in Jan 07. Now we are at wits end to locate someone who can give her a somewhat normal life, Any and all help you can provide would be greatly appreciated.

A. With her history of a migraine-related stroke, an Army injury and a Chiari decompression, it sounds like your wife may have more than just “migraine”. Many different headache disorders can lead to debilitating headaches and getting the correct diagnosis is the key to finding appropriate treatment. Your wife should get an evaluation from a headache specialist to review her entire history and figure out what is going on. From there, they can work together to develop a strategy to get her on the road to good control. Looking at the National Headache Foundation website should hopefully provide you with a specialist near you.

Susan Broner, M.D.
The Headache Institute
New York, NY

Auras without the Headache

Q. I am currently 58, in good health, take no pills. I am 5’4′ and weigh 125 and have been at this weight (give or take a few) for the last 20 years.

I have had about 15 migraine headaches since I was 14 years old, maybe 5 or 6 between the ages of 14 and 21 that included the usual tremendous migraine pain. I experience auras with all my migraines. They stopped until I was about 32. When they began again, I experienced an aura which started out tiny and enlarged until it fills my whole field of vision and then goes away, leaving a slight headache. I usually have about two during a year, and then it skips a year. During the last two, I started doing my yoga breathing and the aura goes away quicker than it used to.

Is this still considered a true “migraine” or is this something else. Do you know if any of your members have described a similar situation? The last two times I had the aura, the middle joints of my ring and middle finger of my left hand felt like someone was electrically stimulating them, like a dentist drilling without the pain. Any clues you can give me. My family doctor said that since I don’t get the migraine pain, don’t worry, but this new wrinkle of the tingling feeling has me concerned.

A. Migraine with aura only affects about 20% of all people with migraine. An aura is often visual, being seen in both eyes and often as you describe – a central area of light, often surrounded by shimmering, zigzag lines that slowly expand to cover a portion of the visual field. Some people experience other neurological symptoms with aura, such as tingling or numbness of a limb, a weak or clumsy hand, speech problems, and so on. Aura typically lasts 5 to 60 minutes, but in some cases can last longer. Aura is typically followed by a headache, although there are people who get aura without headache. The pain that follows is typical of a migraine headache, with moderate to severe pain and associated with either light and sound sensitivity or nausea or vomiting, although some people can get milder headaches.

Any time an aura changes, or is prolonged (lasting more that 60 minutes), an evaluation should be sought. With your new symptoms, which are atypical, you should see a neurologist. It’s important to be evaluated to rule out worrisome causes of the symptoms, such as seizure, tumor or other problem.

Susan Broner, M.D.
The Headache Institute
New York, NY

Hemiplegic Migraines

Q. I am a 39 year old who started with migraines with aura through the pregnancy of my first child in 1992. From then on, I have suffered all kinds of migraines, always starting with aura, sometimes stroke like; I can’t speak properly, it comes out gibberish, can’t unlock my hands or connect words in my head . In 2005, while brushing my teeth getting ready for work, suddenly I got really dizzy and then collapsed. My husband helped me down the stairs, my jaw started to ache and I went to hospital. “Do you suffer with migraine?” “Yes”, I replied “but I have had a stroke”, “no you have migraine” they replied, convinced I would die if I went home, they decided to admit me. By Wednesday they confirmed I had a stroke, further diagnosis led to PFO, then I had closure trial Biostar in November of that same year. In 2006 had weakness in right side progressed to paralysis in right side of face felt really weird had a bitter taste on tongue. I went back to the hospital for CT and MRI scans, which confirmed no further strokes, the diagnosis was migraine. In 2007 while working, I felt my heart flip, felt weird and my colleague took me home. On the way I experienced a jaw ache, jaw paralysis, arm and leg paralysis and was semi conscious. I went back to hospital, had CT and MRI scans, which were normal but revealed a small hole in the heart with a diagnosis of TIAS.

A. There is a relationship between migraine with aura, PFO and stroke which has been well documented. Patients with migraine with aura are two times more likely to have a PFO and are also more likely to have a stroke (even without a PFO). Closing the PFO can prevent secondary strokes and studies are ongoing to see if it also prevents migraine. Other holes in the heart may also play a similar role. However, the episodes you are having now sound like complicated migraines or possibly seizures. Fortunately many of the medications used for migraine are also helpful for seizures. You did not say what you were taking to prevent these episodes but based on the severity of them a preventative medication like should be started. While it would be nice to have a definitive diagnosis, treatment should be instituted while you are completing your work-up.

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

Acute Cephalgia

Q. Can you tell me the difference between migraine headache and acute cephalgia? Which one is worse, migraine headache or acute cephalgia?

A. Acute cephalgia is the technical term for headache but it does not specify a cause. Migraine is a specific kind of headache characterized by two out of four of the following characteristics: throbbing, unilateral, moderate to severe pain that is worse with movement and one out of two associated symptoms: sensitivity to light and sound or nausea and/or vomiting. Acute cephalgia can be due to migraine but could also be due to something as simple as sinusitis or as severe as a ruptured aneurysm. There are many causes of acute cephalgia which could be better or worse than a migraine. Migraine is just one cause of acute cephalgia.

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