Responses to questions presented by the headache specialists are not intended to be professional consultations. Final decisions as to treatment should rest with the individual’s healthcare provider.

Alternative to Vioxx®

Q. After much medical trial and error, I have been able to control my migraines with daily Prozac® and magnesium and B6. In the past, I took Vioxx at the first inkling of a migraine and it almost always seemed to stop the headache. I have continued taking the preventive medicines and was not too concerned when Vioxx was taken off the market, since I was then migraine-free. Now I am again getting migraines and my old supply of Vioxx is almost gone.

What is the closest substitute today available for Vioxx? Is there a COX-2 inhibitor on the market that might work similarly for me? Or is Vioxx still available? Since I would be taking it infrequently for the occasional migraine, I am not worried about the heart risk associated with daily taking of Vioxx.

Also, about two months ago, I switched from Prozac® to the generic version, fluoxetine. The headaches began about two months after switching to the generic. I wonder if perhaps the generic is possibly not working as well as the brand-name Prozac?

A. Vioxx (refecoxib) was removed from the marketplace voluntarily by Merck in September 2004 after a long-term use study revealed a possible increased risk of adverse cardiovascular outcomes. It is not currently available in the U.S. or worldwide. The only COX-2 inhibitor currently FDA-approved for arthritis and acute pain is Celebrex® (celecoxib). Celebrex cannot be used in patients with sulfa allergies, but may be an acceptable substitute to those who responded to Vioxx for acute migraine pain relief.

Sometimes changing from a brand-name (i.e., Prozac) to a generic antidepressant (i.e., fluoxetine) can lead to increased headaches in the beginning of the transition to the generic. This generally stabilizes over time. It is important to follow up with your healthcare provider regarding any changes in mood or pain during the initial stages of transitioning to a new form of an antidepressant.

George Nissan, DO
Diamond Headache Clinic
Chicago, IL

Worried About Serotonin Syndrome

Q. I’m concerned about a recent article in NHF Head Lines entitled “FDA Gives Warning About Combining Triptans and Antidepressants.” It said that a life-threatening condition called serotonin syndrome may occur when these drugs are combined, but it didn’t say what doses of either drug are dangerous or lethal.

I’m currently taking 20 mg of Paxil® daily, occasional doses of sumatriptan (usually 25 mg), and propranolol (20 mg three times daily).

I’m especially interested—as I’m sure a good number of your readers are—about what constitutes safe doses of an antidepressant and a triptan when taken on the same day. Also, if Paxil is taken in the morning and sumatriptan that evening or night, would that be safe?

A. The recent warning from the FDA regarding the possible occurrence of serotonin syndrome when triptans and antidepressants are used together has led to numerous inquiries from patients and the general public, since both of these medication classes are frequently prescribed in the migraine population. There is no specific data regarding occasional use of triptans to treat a migraine and the amount of antidepressant that is needed to cause serotonin syndrome. The triptans are agonists (stimulants) of the 5-HT 1B and 1D serotonin receptors, which many antidepressants affect as well. If you are clinically stable on an antidepressant, it is acceptable to use a triptan medication no more than the recommended two days a week for acute treatment of migraine, and there is no restriction on the timing of the triptan dose.

George Nissan, DO
Diamond Headache Clinic
Chicago, IL

Help for Cluster Headaches

Q. I am wondering if anything recent has come available to help people like me who suffer from cluster headaches. I think I have tried everything with no success.

A. Cluster headaches are severe, one-sided headaches that last from 15 minutes to three hours. They are associated with eye tearing, eyelid drooping, eye redness, and/or nasal congestion and drainage on the same side of the face as the pain. These headaches occur in clusters of one to three headaches a day that go on for weeks to months before resolving. The headaches often occur at night and the clusters often occur around the same time of year.

The most common abortive treatments for clusters are oxygen therapy, DHE injections or nasal spray, sumatriptan injections or nasal spray, or lidocaine nasal spray or drops. In order to break up the cluster cycle, preventive agents can be taken on a daily basis. These include verapamil, prednisone, depakote and lithium. Other treatment options that can be considered include using olanzapine as a pain reliever (which relaxes you so you can fall back to sleep) or a trial of Zomig® which has also been shown to help some cluster patients who can’t tolerate injectable agents. Occasionally, an occipital nerve block can temporarily relieve the pain to allow the preventives to keep it under control. Recent trials of melatonin at bedtime (at a dose of 9 mg) have shown some benefit. Melatonin regulates sleep, which seems to play a role in the development of cluster headaches.

Finally, surgical intervention has been used for the most intractable patients. These techniques include radiofrequency thermocoagulation therapy, glycerol trigeminal rhizotomy, trigeminal nerve root section and microvascular decompression. Even gamma knife therapy has been used to control cluster headaches. An experimental treatment called deep brain hypothalamic stimulation also holds some promise. I hope you find something on this list that you haven’t tried.

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

Need to Increase Preventive Dose Is Common

Q. I am taking 10 mg of amitriptyline, which decreased my headaches from daily to about 18 per month, but it is not working now. I have been advised to increase the dose to 20 mg. My doctor recommends that I decrease the dose when I feel better. My neurologist insists that I stay on the 20 mg dose. Does the increased dose help to raise the serotonin levels at the same time as helping to relieve the headaches? Do all antidepressants work this way—once you become better you find your body needs a higher dose?

A. Most patients who do well on amitriptyline need more than the 10 mg dose. I often have patients on 30-50 mg about an hour before bedtime. This does increase serotonin levels. I push the dose up slowly so as to not go past the effective dose, but I find that 10-20 mg is a bit small. I keep many of my patients on it for 6-12 months or more before trying to taper them off slowly.

It is true that any medicine can lose its effectiveness for headache. We call this tachyphylaxis. If that happens, I might first try raising the dose or switching to another medication. If someone is doing well on a medication that raises serotonin levels, I do not immediately lower the dose.

Alan Rapoport, MD
David Geffen School
of Medicine at UCLA
Los Angeles, CA

Aura Continued After Pain Ended

Q. I have suffered from migraine with aura for about five years now. I have been prescribed Maxalt® and it works brilliantly. However, each time I get a migraine, my disturbed vision (similar to what I experience before the headache starts) lasts longer and longer. My last migraine was three weeks ago and I still have problematic vision with blurry areas and patches. Is this safe and can anything be done to reduce these after effects? I have also been prescribed propranolol for this but it doesn’t seem to work.

A. When a patient has lasting visual complaints after an aura, I usually do an MRI scan of the brain and send them for a neuro-ophthalmological evaluation. If the scan is normal, which it often is, then I know I am dealing with migraine aura.Maxalt is an excellent triptan and works to stop migraine pain quickly, but it is not usually helpful with the aura. If the auras are frequent or bothersome, I try certain preventive medications, like verapamil, but not usually beta blockers like propranolol. Sometimes, I just use large doses of magnesium and vitamin B2 (riboflavin)—400 mg per day of each.

You should also ask your healthcare provider to tell you about the association of patent foramen ovale (PFO) with migraine with aura. PFO is a small hole in the heart that some migraine with aura patients have. Repairing the hole helps reduce migraine in some people, though the procedure carries certain risks. There are ongoing studies about this situation and you may want to take part in one of them.

Alan Rapoport, MD
David Geffen School
of Medicine at UCLA
Los Angeles, CA

Treatment for Occipital Neuralgia

Q. I’d like to know what new studies are being done on occipital neuralgia and which medications people take for the condition. Can what a person eats or drinks have an effect on the pain?

A. Occipital neuralgia is characterized by an aching, pressing, stabbing or throbbing pain usually in the back of the neck and head. It is a common type of posttraumatic headache, but can be seen without injury as well. The headache may be due to entrapment of the greater occipital nerve.

Treatment often includes injection with a local anesthetic and a long-acting steroid. The results can sometimes be dramatic, with relief experienced immediately after the injection. In severe cases, a procedure called radiofrequency ablation can be done. Preventive medications for occipital neuralgia include drugs like gabapentin and topiramate; the choice of which preventive medication to take is best made by your healthcare provider. What a person eats or drinks would generally not have an effect on the pain.

Susan Hutchinson, MD
Headache Center
Women’s Medical Group of Irvine
Irvine, CA

Doctor Recommended BOTOX®

Q. I had a head injury two years ago and have had major headache and vomiting every day since then. My doctor is suggesting that they inject BOTOX in my forehead and in the back of my head. Is he suggesting a good thing or not and what about the long term? He said it would have to be done every two months and that it is painful.

A. The use of botulinum toxin type A (BOTOX) for the treatment of chronic daily headache and migraine is still being investigated and is not an FDA-approved treatment for headache as of yet. It has shown some benefit in clinical trials, especially in those related to daily headache pain relief, but there is also a high placebo rate associated with many of the studies.

The effects of BOTOX can last for up to three months. It is generally a well tolerated procedure. The most common side effect is pain at the injection sites after the procedure. You should discuss this with your neurologist/headache specialist prior to the procedure. BOTOX is a good option for a patient who has failed several preventive medications in the past and whose headache is frontal and neck-related.

George Nissan, DO
Diamond Headache Clinic
Chicago, IL

Medicating Headache While Pregnant

Q. I was diagnosed with chronic tension and TMJ headaches. They got so bad that I had a headache for one month straight. I could hardly do anything and it put a strain on my relationship with my husband. I was on trazadone and clonzepam for anxiety. Now I’m pregnant and cannot take either of my medications. I have had a headache for three days now and have tried everything I can think of. My doctor does not want me on any medications if I can help it, but I’m afraid the headaches will get as bad as they used to be. What medication would be OK for me to take without having to worry about hurting the baby?

A. Most of the medications used for the prevention of migraine and tension-type headaches are classified by the FDA as Class C for pregnancy. This means that there is not any evidence for or against the use of these medications during pregnancy. Sometimes, tricyclic antidepressants such as amitriptyline or blood-pressure lowering medications such as propranolol can be used as a daily preventive medication during pregnancy. The SSRI antidepressant class, including sertraline and fluoxetine can be considered during pregnancy, although headache prevention data regarding these drugs is limited.

As far as acute treatment of migraine during pregnancy, triptans can be considered in certain instances. There is a sumatriptan pregnancy registry in Europe (and in the U.S. as well) that has been ongoing for several years. Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen can be used in the first and second trimesters of pregnancy only, since there is a risk of bleeding in the third trimester.

It is important to discuss treatment options with both an OB/GYN and a headache specialist before taking any medications during pregnancy.

George Nissan, DO
Diamond Headache Clinic
Chicago, IL