Q. I have very frequent migraines. When they strike, they are continual for weeks. The only thing that helps me get on with my life is Imitrex®. I believe my headaches occur mostly from stress and atmospheric changes. However, they almost always come on during the early morning hours and wake me out of sleep.

I have been to several doctors and they have no problem giving me prescriptions for the Imitrex. My insurance company, on the other hand, believes you can’t have more than nine migraines a month (that is how many pills they allow before you pay all on your own). I will take three pills a day when my migraines are in full force. I have been reading about the possibility of people with severe migraines being more susceptible to certain kinds of stroke. If this is true, what can I or should I do to reduce that risk and reduce the migraines? I am 50 years old, in good health, do not smoke, and am not over weight. I have been diagnosed with fibromyalgia. I try to exercise as much as possible, but I’m sure it is not enough; I’m just too tired and it sometimes makes my headaches worse. I have also read about preventive medicines, but I’m concerned about the side effects. I am beginning to feel that I will always be plagued by migraines. I can manage a few but not ones that last for weeks on end.

A. Your letter raises several interesting questions:

  1. What causes migraines? You mention that there seems to be a connection between stress and weather changes and your headaches. These are actually two of the most commonly identified migraine triggers. It is actually neither stress nor weather changes themselves that cause your migraines, but how they interact with your nervous system, i.e., the nervous system of a migraine-prone individual. Your nervous system has a certain “threshold” for migraine. In your case the exposure of your nervous system to stress or weather changes is enough to push you across your migraine threshold and the attack begins.
  2. Why do my migraines come on at night? Great question! Nobody knows for sure why this occurs, but the majority of migraine attacks occur in the early morning hours.
  3. Why are my migraines so hard to turn off? You mention taking three Imitrex tablets in one day when your migraines are in “full force.” In most cases, headache doctors stick with the FDA recommendation of limiting Imitrex (and other triptan medications) to two doses a day. It sounds like your headaches are returning later in the day. We know that migraine-specific medications like Imitrex work best if they are taken early in the attack, when the pain is still mild. Many people who have migraine present on awakening find they are treating when the attack is already fairly well developed. That makes it harder to turn the headache off, and may make it more likely that it returns later the same day. Some patients find that the injection form of Imitrex works better to stop an attack that is barreling along. Some patients have found that they can reduce the need to treat later in the day if they take a nonsteroidal anti-inflammatory medication, such as naproxen sodium, along with Imitrex. Another idea that may work for some patients is to take an antinausea prescription medication,such as metoclopramide, with the Imitrex to try to reduce the chance of the headache returning. None of these ideas work for every patient and all of them should be approved by your healthcare provider to be sure they’re right for you.
  4. Why do I need so much Imitrex every month? You mention that when your migraine attacks occur they are “continual for weeks.” You also mention needing to use multiple doses of Imitrex in a day when the attacks are in “full force.” Without knowing the details of how you treat it is hard to be sure, but those features raise the possibility of rebound headaches, now called medication-overuse headaches. Simply put, medication-overuse headaches occur when medications that should be part of the solution become part of the problem. Remember the headache threshold? Just as certain things push your nervous system across the migraine threshold, overuse of the very medications that can stop a migraine (like Imitrex) can, over time, actually lower the headache threshold, allowing headaches to break through more easily. While this seems to be the opposite of what should occur, it happens to many migraine sufferers.Although medication-overuse headache can occur with the use of any of the triptans, it is more commonly seen with other headache medications such as over-the-counter (OTC) combination medications containing aspirin, acetaminophen, and caffeine, as well as prescription medications containing butalbital or narcotics (e.g., hydrocodone, oxycodone, and others). In general, headache doctors feel that patients who are using any headache attack medication more than two days a week on average are at a higher risk for developing medication-overuse headache. This means two treatment days a week of any migraine attack treatment medicine, prescription or OTC.
  5. Do I need a preventive medication? Well, maybe. You really need a prevention plan. All migraine sufferers should consider themselves as needing a plan for prevention. Not everyone needs a preventive medication; there are many approaches that can be used to raise the headache threshold without using medications. These include things that you have likely heard before—regular meals, good hydration, limiting caffeine, and exercise. Patients with fibromyalgia often find that starting an exercise program not only aggravates the fibromyalgia pain, but also seems to cause headaches. A carefully crafted exercise program, sometimes developed with the help of a fibromyalgia specialist or treatment program, can often be a big help.
    Patients like you who need to treat headaches frequently often benefit from preventive medication. An effective preventive medication can provide two important benefits—it can reduce the number of attacks a patient experiences and, for many patients, an effective preventive medication makes the headaches that do breakthrough more responsive to the medicine they use to treat the attack, often reducing the amount of attack medication used.
  6. Are preventive medications safe? All of the preventive medications for migraine, just like all medications in general, have potential side effects. However, the majority of patients who use migraine preventive medications do not have side effects that prevent them from being used. A good approach is to talk to your healthcare provider about the options for migraine prevention and make a selection based on your other medical conditions, your current medication list, and your previous experiences with medication side effects. Preventive medications can be very effective and are probably underused. Most patients with medication-overuse headache would likely benefit from a treatment plan that includes the use of a preventive medication.
  7. Am I at risk for a stroke? There is a small increased risk for stroke in patients with migraine. While this increased risk is very small, you should address your personal stroke risk factors with your healthcare provider. Other factors important in determining your risk for stroke or heart attack include age, gender, tobacco use, blood pressure, cholesterol, diabetes, and family history. These features are important to evaluate in order to make the best decisions for treating not only your migraines, but your health in general.

Stewart J. Tepper, M.D.
New England Center for Headache
Stamford, CT

Why Headaches Worsen with Fever

Q. I am a 67-year-old male who takes 100 mg of topiramate twice a day as a migraine preventive. My headache pattern is highly variable, but tends toward one to three days of migraine every 15 days, well relieved by Imitrex. That is, except for about twice a year when I have a cold or flu with its associated fever. Then I am in for six or seven days of much worse pain with little relief from Imitrex. What is the physiological reason for this and is it common?

A. Headache patterns are commonly exacerbated by acute illnesses such as a cold or flu. This is true to a greater extent in the presence of fever. One explanation for this regards alterations of chemical activities in the body that play a role in both fever and migraine. Serotonin, for example, modulates the brain’s control of body temperature and also plays a central role in the generation of migraine headache. In addition, during illness Migraineurs are exposed to more headache triggers. This can include alterations in sleep patterns, meals, and an increased stress level. These changes may additionally result in the worsening of headache patterns. However, headache associated with fever may also be a symptom of a more ominous problem such as a central nervous system infection (meningitis, encephalitis, etc.). Other symptoms and signs of such infections can include stiff neck, cognitive changes, weakness or numbness of the body, seizures, changes in speech or language, nausea/vomiting, and skin rash. Therefore, patients with new headaches or worsening headaches in the presence of fever should seek medical attention to rule out possible serious underlying conditions.

Todd Schwedt, M.D.
Mayo Clinic
Scottsdale, AZ

Treating Headaches from a Spinal Tap

Q. I have a question about a spinal headache that my wife is suffering from. She recently had an epidural and is now having headaches. She is taking Motrin®, but it has not helped. Do you have any suggestions of what she can take or do to stop these headaches?

A. Low cerebrospinal fluid pressure headaches following spinal taps or epidural anesthesia occur in approximately 10% to 30% of patients. Such headaches are considered to have an orthostatic component, meaning they are worsened by standing and improve after lying down. Headaches tend to be diffuse throughout the head, moderate to severe in intensity, and dull or throbbing in nature. Coughing, sneezing, straining, and shaking the head may also make head pain worse. In some cases, headache is accompanied by nausea and vomiting, dizziness, and ringing or fullness in the ears. Initial treatment recommendations may include bed rest, hydration, and caffeine. These simple interventions are often times effective in relieving pain. The majority of these headaches resolve within 2 to 14 days with an average duration of 4 to 8 days. However, if initial treatments are ineffective and the headache persists, placement of an epidural blood patch may be indicated. During this procedure, 10 to 20 milliliters of the patient’s own blood are injected into the epidural space around the spinal cord. In most patients, this provides headache relief either by plugging the hole through site (massage, muscle relaxers, antidepressants, and pain killers.) She is now getting shots of cortisone and Novocaine® directly into the base of her head.

Q. The first group of shots took two days to work and removed the pain completely. The next time it only lasted two weeks. I don’t know if it is the person administering the shots or the drugs not doing their job and becoming less effective. I love this woman and it is very hard to see her miss work and be in pain from one treatment to another.

A. The term occipital neuralgia is in some ways a misnomer because the pain is not necessarily from the occipital nerve and does not usually have a neuralgic (electrical, shooting) quality. Greater occipital neuralgia can cause an aching, pressure, stabbing, or throbbing pain in a nuchal-occipital (neck and back of the head) and/or parietal (top), temporal, frontal, periorbital (around the eye), or retro-orbital (behind the eye) distribution. Occasionally, a true neuralgia may be present with spasms of shooting pain. The headache may last for minutes to hours to days and can be unilateral or bilateral. The headache may be due to an entrapment or pinching of the greater occipital nerve in the trapezius or semispinalis capitis muscle in the back of the head, or it can come from trigger points (hyperirritable points) in these or other muscles. However, pain can also come from the C2-3 facet joint (a small joint between the vertebrae in the upper posterior portion of the neck). Other upper-cervical spine and back of the brain pathology may produce a similar headache. A head injury can also injure the C2-3 facet joint and cause a third type of occipital headache. Greater occipital neuralgia can be treated with nonsteroidal anti-inflammatory medications (such as Aleve®), muscle relaxants, antiseizure medications (such as gabapentin), antidepressant medications, physical therapy, and nerve blocks. Experimental treatments include implantation of peripheral nerve stimulation systems, partial dor which spinal fluid is leaking or by increasing the pressure.

Todd Schwedt, M.D.
Mayo Clinic
Scottsdale, AZ

Occipital Nerve Blocks Explained

Q. My doctor wants to try a nerve block in my neck to see if it will help my headaches. What can you tell me about this kind of treatment and would you recommend it? I’m female, age 53, have had headaches since my early 20s, and have been under doctors’ treatment all this time. We have tried all preventive medicines and biofeedback.

A. Your doctor is probably referring to a greater occipital nerve block given in the back of the head along the superior nuchal line (the horizontal ridge of bone just above the neck). The nerve supplies sensation from the skin of the posterior scalp. Patients with greater occipital neuralgia may benefit from an occipital nerve block with a local anesthetic with or without a orticosteroid. Occipital nerve blocks with corticosteroids can also be effective for transitional or short-term treatment to temporarily turn off cluster headaches. Occipital nerve blocks may even be an effective treatment for acute migraine headaches. The block may relieve headache by altering the painful input to the trigemino-cervical complex (an area in the upper cervical spinal cord containing nerve fibers important in migraine generation). You may wish to discuss the injection with your doctor again if you have further questions about your particular case.

Randolph W. Evans, M.D.
Park Plaza Hospital
Houston, TX

Numerous Causes for Occipital Neuralgia

Q. I am in love with a woman who has had occipital neuralgia for the last three years. She has had many of the treatments you discuss on your Web Site (massage, muscle relaxers, antidepressants, and pain killers.) She is now getting shots of cortisone and Novocaine® directly into the base of her head. The first group of shots took two days to work and removed the pain completely. The next time it only lasted two weeks. I don’t know if it is the person administering the shots or the drugs not doing their job and becoming less effective. I love this woman and it is very hard to see her miss work and be in pain from one treatment to another.

A. The term occipital neuralgia is in some ways a misnomer because the pain is not necessarily from the occipital nerve and does not usually have a neuralgic (electrical, shooting) quality. Greater occipital neuralgia can cause an aching, pressure, stabbing, or throbbing pain in a nuchal-occipital (neck and back of the head) and/or parietal (top), temporal, frontal, periorbital (around the eye), or retro-orbital (behind the eye) distribution. Occasionally, a true neuralgia may be present with spasms of shooting pain. The headache may last for minutes to hours to days and can be unilateral or bilateral. The headache may be due to an entrapment or pinching of the greater occipital nerve in the trapezius or semispinalis capitis muscle in the back of the head, or it can come from trigger points (hyperirritable points) in these or other muscles. However, pain can also come from the C2-3 facet joint (a small joint between the vertebrae in the upper posterior portion of the neck). Other upper-cervical spine and back of the brain pathology may produce a similar headache. A head injury can also injure the C2-3 facet joint and cause a third type of occipital headache. Greater occipital neuralgia can be treated with nonsteroidal anti-inflammatory medications (such as Aleve®), muscle relaxants, antiseizure medications (such as gabapentin), antidepressant medications, physical therapy, and nerve blocks. experimental treatments include implantation of peripheral nerve stimulation systems, partial dorsal entry root zone rhizotomy (cutting nerve roots), and sectioning the inferior oblique muscle and freeing up the nerve.

Randolph W. Evans, M.D.
Park Plaza Hospital
Houston, TX

Herbs for Migraine and Exertional Headaches

Q. I recently started using a tincture of feverfew, skullcap, and lavender to prevent migraine headaches. For the most part there has been a dramatic decrease in all headache activity. I am very encouraged. However, one trigger for migraine for me is physical exertion. I am a bicycler and if I ride over 30 miles of flats and hills, there is a good chance that about an hour after I finish my ride I will feel the pain associated with migraine begin. Is there anything that is available that can be added to the tincture to help me out?

A. Most headache specialists are not well-versed in homeopathy or tinctures and that question would be better asked of nutritionists and health food specialists. What I can tell you is that there are six substances that can be bought over the counter that have reasonable effectiveness in migraine. They are: vitamin B2, magnesium, coenzyme Q10, the Petadolex® brand of petasites (butterbur), melatonin, and feverfew. There is an anti-inflammatory medication that I prescribe one hour before exertional headaches begin called indomethacin. You could check if you can get a tincture of an anti-inflammatory substance added to what you are already taking. Failing that, a headache specialist could prescribe indomethacin. That doctor may want to examine you and possibly even do certain tests to be sure of your diagnosis.

Alan Rapoport, M.D.
The New England Center for Headache
Stamford, CT