Headache Help (14 page)

W
EEK
1:
Daniel calls to say that the Imitrex helped relieve his headache, but only approximately 50 percent. The Compazine did stop the nausea, but it made him feel nervous and agitated. The doctor then prescribes Imitrex injections and teaches Daniel how to use these. The doctor also changes Daniel’s nausea medication to Phenergan, which generally does not cause the nervousness associated with Compazine. However, Phenergan can cause excessive tiredness.

W
EEK
5:
Daniel calls to say the Imitrex injections relieve the headache by about 90 percent, but he has tightness in the muscles of his jaw and neck and wishes to try something else. The Esgic has not helped. The doctor prescribes Maxalt MLT tablets for Daniel to put on his tongue during a migraine.

W
EEK
8:
Daniel comes in to the doctor’s office and reports that Maxalt MLT is moderately effective, cutting his pain by about half, but says that he would prefer going back to the Imitrex Nasal Spray. The Phenergan is useful for the severe nausea. Daniel and the doctor decide to use Imitrex Nasal Spray for most of the headaches, but injections for extremely severe migraines with severe nausea. The doctor explains that it’s common to have two, three, or even more abortive medications on hand. This gives patients options to choose from for particular headaches at particular times.

T
HE
F
UTURE
:
If Daniel later reports that he is losing control of his headaches, other possibilities include ergotamines (particularly suppositories), DHE injections or Migranal Nasal Spray, Toradol injections (Toradol is the only anti-inflammatory available as an injection), or as an absolute last resort, a strong painkiller such as Stadol Nasal Spray.

D
OROTHY

I
NITIAL VISIT
:
Dorothy is a thirty-nine-year-old lawyer who gets severe migraines about twice a month; they last for two days each. She gets no relief from various over-the-counter medications and relaxation-biofeedback methods. With previous physicians, she tried naproxen (Anaprox) and Norgesic Forte, neither of which were particularly helpful. The migraines are triggered occasionally by weather changes or stress, but 80 percent of the time the headaches do not have any identifiable trigger (as is the case for most people). Visits to a chiropractor, massage therapist, and acupuncturist have failed to provide any relief. Dorothy is very reluctant to use a daily preventive medication. She simply wishes to treat the headaches once they occur with an abortive medication.

Dorothy’s doctor first instructs her on basic nonmedication techniques such as lying down in a dark room and applying ice packs to her head. He prescribes Midrin and Fiorinal and tells Dorothy to try them separately and together.

W
EEK
3:
Dorothy reports that the Midrin and Fiorinal help about 25 percent, but leave her fatigued and washed out. Dorothy’s doctor prescribes Zomig as an abortive.

W
EEK
6:
Dorothy calls to say that the Zomig does help but makes her very nauseated. The doctor switches the medication to Imitrex Nasal Spray. He also discusses the possibility of Imitrex injections, but Dorothy wishes to wait on this approach.

The doctor also prescribes dexamethasone (Decadron), a cortisone preparation that helps shorten severe prolonged migraines. In some patients, cortisone may be the only effective abortive medication. Dorothy finds that the Imitrex Nasal Spray helps about 50 percent but leaves a slightly bad taste in her mouth. She is willing to accept this because of the headache relief. The dexamethasone irritates her stomach but shortens the headache to one day only.

W
EEK
24:
Dorothy says that the Imitrex Nasal Spray is no longer effective, and the headaches have become extremely severe in intensity. The doctor prescribes Stadol Nasal Spray, which does relieve some of the pain but leaves Dorothy unable to function. She does not like how she feels when she takes it. The dexamethasone continues to provide some relief and shorten the length of the headache. Dorothy’s doctor now prescribes Imitrex injections and teaches Dorothy how to use them.

W
EEK
26:
Dorothy calls to say that the Imitrex was helpful but made her chest feel heavy. This side effect was mild and only lasted fifteen minutes, and Dorothy does not have risk factors for heart attack. Dorothy has lost her medical insurance and says she’d like to try an inexpensive medication now. The doctor prescribes ergotamine with caffeine in tablet form.

W
EEK
29:
The ergotamine tablets provide relief, but Dorothy is extremely anxious and nauseated from them. The doctor now replaces the tablets with ergotamine and caffeine PB suppositories (one-third suppository to be used every four to six hours as needed) because these generally produce much less nausea and are more effective than the tablets. The PB portion offsets the anxiety that can occur with ergotamine and caffeine.

W
EEK
32:
The suppositories are somewhat effective, but the nausea remains a problem. Dorothy wishes to go back to the Imitrex injections. The Decadron has remained effective at diminishing the length of time of the headache. Dorothy continues on Imitrex injections and Decadron as needed.

T
HE
F
UTURE
:
If Dorothy needs to try another abortive medication, other painkillers such as hydrocodone, Fiorinal with codeine, or meperidine are possibilities; she may also use another form of triptan such as Maxalt MLT. Because she only gets two migraines a month, she does not necessarily need preventive medication, although some patients with two severe, prolonged migraines per month find preventives worthwhile. Using preventives is a possibility for Dorothy. Other possibilities would include Migranal Nasal Spray, which is DHE, or DHE injections that she could administer at home. Toradol injections, which are the only anti-inflammatories available as an injection, would be another possible remedy.

6

Preventing Migraines

I
T’S ONE THING
to have mastered the techniques for bailing yourself out of a migraine if one starts, but an important long-term goal is learning how to prevent your migraines
before
they start. One way to achieve this goal is to identify which triggers most affect you. Another is to take a preventive medication if you get migraines frequently.

To use this chapter most efficiently, track your migraines with the Headache Calendar in Chapter 2. Every time a headache comes on, try to identify which factor on the list might have played a role in triggering it. Highlight a handful of potential triggers and do all you can to eliminate them from your life. See if the headaches improve. Reintroduce the potential triggers one at a time. Later in this chapter, we will discuss preventive medications to use when the nondrug strategies don’t work well enough.

RECOGNIZING COMMON TRIGGERS

Many factors have been identified as possible migraine triggers, but most people are sensitive to only a few. Unfortunately, however, what triggers a headache today won’t necessarily be what brings one on next week. Also, the different elements to which you are sensitive can gang up and give you a terrible headache even when they might not have affected you individually. A sudden weather change compounded by job stress, for example, may be enough to take you over the edge. Not everyone can isolate the primary headache culprits, but others, through experience, do notice specific patterns. The more observant you are in identifying your patterns, the better off you’ll be. Be mindful of these potential triggers:

COMMON MIGRAINE TRIGGERS

• Overwhelming “daily hassles”
  
• Stress, worry, depression, anxiety, and anger
  
• Some foods
  
• Weather and seasonal changes, such as high humidity or high heat
  
• Smoke, perfume, gasoline, paint, organic solvents, and other strong odors
  
• Hunger
  
• Fatigue or lack of sleep
  
• Hormonal factors, such as menstruation, birth control pills, pregnancy, menopause, estrogens
  
• Oversleeping and excessive sleep
  
• Exertion, exercise, or sex
  
• Bright lights, such as glaring artificial lights or bright sunlight
  
• Head trauma
  
• Altitude
  
• Motion, experienced during long car rides or amusement park rides, for example
  

“D
AILY
H
ASSLES
,” S
TRESS
, W
ORRY
, D
EPRESSION
, A
NXIETY, AND
A
NGER

“Bad stress” or negative emotions aren’t the only contributors to headaches. Too many daily problems, particularly after a bad day or a poor night’s sleep, can exacerbate them as well. Although emotions do not
cause
migraines, which are an inherited, physical illness, certain emotions can
trigger
migraines. Any problem—trouble at work, illness in the family, financial woes, bickering with a loved one—that causes stress may bring on a headache. That’s not to say that the headache is psychological; rather, the stress causes complex biochemical changes in the body that can disrupt your equilibrium, and cause your neck, shoulders, and head muscles to tighten up, thereby triggering your susceptible headache mechanism.

For some people, stress itself triggers a migraine. In others, however, the letdown period that occurs after a stressful event or period precipitates a headache. Monday-to-Friday workers, for example, often suffer from weekend headaches. Migraine-free through the workweek, they may suffer from a letdown headache as soon as the weekend begins and the stressful week is over. Weekend headaches, as we’ve discussed, may also be due to caffeine withdrawal.

Depression may trigger migraines, but again, it does not cause them. As you may have experienced, suffering from severe, recurring head pain can be depressing. Recent studies have suggested that if you get migraines, you may also be at greater risk for depression and anxiety, probably because all these conditions are related to the neurotransmitter serotonin. As a result, if you do get depressed or emotionally stressed, chances are your headaches will continue until these problems are resolved.

A most effective way to resolve troubling emotions is with psychotherapy, which can teach you how to deal better with problems and to use relaxation methods to help mitigate the potentially damaging effects of stress. By helping you learn how to resolve conflicts with other people, modify perfectionist behavior, and deal with anger and other repressed emotions, you may actually find that your migraines diminish in intensity and frequency.

So don’t be offended if your doctor suggests psychotherapy; such a recommendation does not imply that the pain is all in your head, but is intended to suggest the potential vast benefits of psychotherapy and stress management. Too few people put in the time, effort, and money necessary to try just a few sessions with a psychotherapist to learn specific coping and relaxation skills, which can be a powerful ally in their fight against headaches. (These strategies and techniques are discussed in detail in Chap ter 2.) Learning to accept your headache situation and accept that there is no cure (though there
is
effective treatment) helps ease anxiety about headaches, which in turn can be therapeutic. You are not causing your headaches, nor should you be blamed for them.

S
OME
F
OODS

More than 25 percent of migraine sufferers can identify foods that trigger an attack. Note that if a specific food provokes a headache in you, this reaction is probably not an allergic one, contrary to the views of many people, but rather a sensitivity to specific chemicals in these foods: amines (in aged cheese, pickled herring, and bananas); phenylethylamine (in chocolate); monosodium glutamate, or MSG (in Chinese food); and nitrites (in luncheon meats, bacon, and hot dogs). The chemical may trigger a migraine because of its effect on the brain or blood vessels, which is very different from an allergic reaction.

Although food-triggered headaches often start soon after eating, several hours may go by before onset. Also, you may be sensitive to the offending food only sometimes. Women, for example, may be particularly sensitive around their menstrual periods. And remember, triggers are “additive”; one food may not cause a headache, but two offending foods may.

Study the food list that follows, and if you have a hunch about certain foods to avoid, omit them from your diet for at least several weeks. If you have no idea where to start, avoid them all or choose a few. Gradually add back one food at a time, noting which ones may be headache culprits. Don’t become frustrated or disappointed if you watch the foods carefully but still get headaches. Food is but one of many influencing factors and, compared to stress and biochemical imbalances, a relatively minor one.

COMMON MIGRAINE FOOD TRIGGERS

• Alcohol (less than the amount consumed to cause a hangover), most commonly red wine, as well as brandy, whiskey, champagne, white wine, beer, and other drinks
  
• Chocolate and chocolate milk, cocoa
  
• Cheese, ripened, such as Cheddar, blue, brick, Colby, Roquefort, Brie, Gruyere, mozzarella, Parmesan, Boursault, and Romano; and processed, though American cheese, along with cottage cheese and cream cheese, is much less likely to trigger a headache than the aged cheeses
  
• Citrus fruit, including grapefruit and orange
  
• Pineapple
  
• Caffeine in coffee, soda, cocoa, and other drinks. (Usually caffeine helps headaches; too much caffeine, though, can cause increased, rebound headaches. Heavy caffeine users need to reduce their intake gradually. Some migraine sufferers are extremely sensitive to small amounts of caffeine. See Chapter 2 for amounts of caffeine in common foods and drinks.)
  
• Monosodium glutamate (MSG) may also be labeled “autolyzed yeast extract,” “hydrolyzed vegetable protein,” or “natural flavoring.” Possible sources of MSG include Chinese restaurant food; broth or stock; canned or instant soup; whey protein; soy extract; malt extract; caseinate; barley extract; textured soy protein; chicken, pork, or beef flavoring; processed meat; smoke flavor; spices and seasonings, including seasoned salt; carrageenan; meat tenderizer; TV dinners; instant gravy; and some potato chips and dry-roasted nuts.
  
• Hot dog, pepperoni, bologna, salami, sausage, canned or aged meat, cured meat (bacon, ham), or marinated meat
  
• Fresh, hot homemade yeast bread (once cool it is OK)
  
• Buttermilk
  
• Yeast extract
  
• Acidophilus milk
  
• Pizza, freshly baked and still hot (less likely to trigger headache if cooled and reheated)
  
• Aspartame, such as NutraSweet, a popular artificial sweetener