Headache Help (17 page)

If one beta-blocker doesn’t help, your doctor is likely to recommend another because the mechanism of action of the various beta-blockers works differently.

• P
  ROPRANOLOL
  (I
  NDERAL
  )
  Inderal is by far the most widely studied and most frequently prescribed beta-blocker. It prevents blood vessel dilation and helps stabilize blood flow through a serotonin mechanism. Inderal is often prescribed with amitriptyline for optimal results.
      Inderal is usually not recommended if you have asthma or congestive heart failure, and should be used with caution if you have Raynaud’s syndrome, a circulatory disorder.
  TYPICAL DOSE
  : 60 mg to start, usually maintained between 60 mg and 160 mg per day. Must taper off to discontinue (except when used in a low dose by a young person, under age thirty, for a short time). Usually, it is taken once a day, in long-acting capsule form.
  SIDE EFFECTS
  : Because propranolol easily enters the central nervous system, side effects such as fatigue are relatively common. Diarrhea, gas, and stomach upset are also fairly common; insomnia, depression, lightheadedness, and difficulty concentrating are less common. Other possible side effects include lethargy, weight gain, less tolerance to exercising, wheezing, and shortness of breath.
  
• M
  ETOPROLOL
  (L
  OPRESSOR
  )
  This medication occasionally works when propranolol does not. If you get chronic daily headaches as well as migraines, metoprolol may be a good choice.
  TYPICAL DOSE: 25
  mg to start, twice a day. This may be increased to 50 mg, twice a day. Increasing the dose gradually minimizes side effects.
  SIDE EFFECTS
  : Same as propranolol but with fewer respiratory problems.
  
• N
  ADOLOL
  (C
  ORGARD
  )
  Nadolol is as effective as propranolol and may work when propranolol does not.
  TYPICAL DOSE: 20
  mg, increased to 40 through 120 mg, per day, with most people maintaining at 80 mg and lower. The scored tablets make dosage adjustments easy.
  SIDE EFFECTS
  : Similar to propranolol with less fatigue.
  
• A
  TENOLOL
  (T
  ENORMIN
  )
  Because this medication doesn’t affect the lungs as much as the other beta-blockers do, this medication causes fewer breathing problems. If you have any tendency toward asthma, however, you should use atenolol only with extreme caution.
  TYPICAL DOSE: 50
  mg, once a day. This may be increased to 100 mg per day, if necessary.
  SIDE EFFECTS
  : Possibly less sedation and less fatigue than with propranolol.
  
• T
  IMOLOL
  (B
  LOCADREN
  )
  Timolol is also sometimes effective when the other beta-blockers have failed.
  TYPICAL DOSE
  : To minimize side effects, this medication is usually started with 5 mg taken twice a day, then up to 2.0 or 30 mg twice a day if necessary.
  SIDE EFFECTS
  : Same as propranolol, but possibly with less sedation.
  

4. N
ONSTEROIDAL
, A
NTI
-I
NFLAMMATORIES
(NSAIDs)

The NSAIDs can be very effective for preventing migraines, but their use is limited because they tend to cause gastrointestinal distress (stomach upset or ulcers) and potentially serious liver and kidney irritation. The new class of NSAIDs, the Cox-2 inhibitors (Celebrex, Vioxx), cause much less stomach irritation and are generally deemed safe. Vioxx particularly may be a useful medication because it is indicated for acute pain, and causes fewer rashes or allergic reactions.

But for women under age forty suffering from menstrual migraines (and menstrual cramps), and for those who are under age forty and very sensitive to the side effects of the beta-blockers and antidepressants, NSAIDs may be a good choice. They also can help with arthritis or musculoskeletal problems (painful knee, back, shoulder).

If you have found NSAIDs effective as an abortive medication (to dull the pain of a migraine in progress) and your doctor recommends switching to a daily preventive medication, a lower-dose NSAID may be right for you because you know it works and that you are tolerant of its potential side effects. Remember, however, always to take these medications with food.

• N
  APROXEN
  (N
  APRELAN
  , A
  LEVE
  , N
  APROSYN
  , A
  NAPROX
  )
  Naproxen is the most widely studied and most frequently prescribed NSAID for migraines, but it is recommended only if you are under age fifty. It can be particularly useful if you get menstrual migraines and daily headaches. Naproxen is sometimes combined with another first-line preventive medication (such as amitriptyline) to enhance effectiveness. Naprelan is an excellent, long-acting form of naproxen (available in 375 mg and 500 mg).
  TYPICAL DOSE
  : 500 to 550 mg once a day, sometimes twice a day. An over-the-counter version, Aleve, is available in a lower dosage, 22.0 mg per tablet.
  SIDE EFFECTS
  : The most common is stomach upset or pain. If you find that naproxen is very effective for your migraines but gives you an upset stomach, your doctor may recommend using an antacid. Usually, if side effects do occur, the NSAID will be discontinued.
      Other potential side effects include skin rashes, fatigue, fluid retention (swelling of hands or feet), ringing in the ear, and tension headaches. When used chronically, the liver and kidneys need to be periodically monitored with a simple blood test.
  
• F
  LURBIPROFEN
  (A
  NSAID
  )
  Well tolerated, flurbiprofen is particularly useful for menstrual headaches (see Chapter 7).
  TYPICAL DOSE
  : 100 mg twice a day.
  SIDE EFFECTS
  : Risk of kidney and liver irritation; must be monitored periodically with blood tests.
  
• K
  ETOPROFEN
  (O
  RUDIS
  , O
  RUVAIL
  , O
  RUDIS
  KT)
  Ketoprofen is quite helpful in preventing migraines, and sometimes tension headaches.
  TYPICAL DOSE
  : 75 mg to 150 mg per day. Now available as a very convenient once-a-day preparation called Oruvail (100, 150, and 200 mg).
  SIDE EFFECTS
  : Similar to the other NSAIDs; liver and kidney blood tests should be regularly monitored.
  
• C
  OX-2
  I
  NHIBITORS
  (C
  ELEBREX
  , V
  IOXX
  )
  These newer anti-inflammatories may prove to be useful for headaches. Safety and efficacy have not been definitively established though. Vioxx appears to be particularly useful due to fewer allergic reactions, and it’s indicated for acute pain. Vioxx is available in 12.5-mg, 25-mg, and 50-mg tablets. The usual dose would be 12.5 or 25 mg once a day.
  

5. C
ALCIUM
B
LOCKERS

Calcium blockers are generally not as effective as antidepressants, Depakote, or beta-blockers. However, they have fewer side effects and do not usually cause the weight gain or lethargy that these other preventive medications often do. If you are an athlete or would be particularly dismayed by a beta-blocker’s effect of impeding athletic performance, you may want to ask your doctor about using calcium blockers to prevent your migraines.

    The primary medication prescribed in this group is verapamil, although nifedipine (Procardia) and diltiazem (Cardizem) are occasionally helpful.

• V
  ERAPAMIL
  (I
  SOPTIN
  , C
  ALAN
  , V
  ERELAN
  )
  This is the most widely prescribed and most effective calcium blocker, but it may take up to six weeks to become effective. Also useful for cluster headaches, verapamil is often combined with amitriptyline or naproxen to maximize relief. If you have Raynaud’s syndrome, a circulatory disorder common among migraine sufferers, then verapamil may be a particularly good choice for you as it helps counteract the problems associated with Raynaud’s.
  TYPICAL DOSE
  : Convenient once-a-day tablet, 120 mg to start, increased to an average of 180 or 240 a day.
  SIDE EFFECTS
  : Relatively few other than constipation, which is very common. Occasional skin rashes, dizziness, insomnia, swelling of hands and feet, and anxiety. Fatigue is less common.
  

SECOND-LINE MEDICATIONS FOR PREVENTING MIGRAINES

QUICK REFERENCE GUIDE: SECOND-LINE MEDICATIONS FOR PREVENTING MIGRAINES

1. T
   WO FIRST-LINE MEDICATIONS ARE USED TOGETHER
   .
       Two are often more effective than one.
   
2. M
   ETHYSERGIDE
   (S
   ANSERT
   )
       Extremely effective, but nausea, leg cramps, and dizziness are common.
   
3. G
   ABAPENTIN
   (N
   EURONTIN
   )
       Often useful and produces no weight gain. Often combined with a first-line preventive medication.
   
4. N
   ATURAL
   H
   ERBS
   /S
   UPPLEMENTS
   (F
   EVERFEW
   , M
   AGNESIUM
   O
   XIDE
   , V
   ITAMIN
   B
   ₂
   )
       These supplements can sometimes be very useful.
   

1. T
WO
F
IRST
-L
INE
P
REVENTIVE
M
EDICATIONS

In some cases, using two medications can be effective when each medication used individually was not. Typically, a doctor may suggest combining two preventive medications if you:

• H
  AVE TRIED
  I
  NDIVIDUAL
  M
  EDICATIONS, BUT
  T
  HEY
  H
  AVEN’T WORKED
  .
  Usually doctors prescribe one preventive medication at a time, starting with low doses and raising them slowly if needed. Most people appreciate this approach, are prepared to wait for the medications to work, and are willing to switch medications if necessary.
  
• A
  RE EXTREMELY FRUSTRATED AND WANT FAST RESULTS
  .
  When you have moderate or severe chronic daily headaches as well as bothersome migraines, you and your doctor may decide to push ahead at a faster rate with the preventive approach. Depending on how severe your headaches are and how frustrated you are with treatments, your doctor has several ways to accelerate your treatment, among them increasing your doses more quickly than usual.
  
• A
  RE SUFFERING FROM A NEW ONSET OF SEVERE HEADACHES
  .
  If you have become very upset and frustrated with head pain because your headaches seem to be worsening or becoming more frequent, the doctor may decide to push preventive medication at a faster pace.
      Typically, the doses and potential side effects of using two medications together are the same as when they are used individually. Here are some common pairings that doctors use to prevent migraines.
  
• D
  EPAKOTE WITH ANTIDEPRESSANTS
  Depakote may be combined with antidepressants, beta-blockers, or calcium blockers. For people with bipolar illness (manic-depression), Depakote plus an antidepressant is often very effective for mood swings, anxiety, and depression. Depakote with other medications, though, may cause sedation or weight gain.
  
• A
  MITRIPTYLINE WITH PROPRANOLOL
  When amitriptyline increases heart rate, propranolol is often added to neutralize the effect. This combination is often used when both migraines and chronic daily headaches are problems.
  
• N
  SAID WITH ANOTHER FIRST-LINE MEDICATION
  Naproxen (or another NSAID) is often prescribed with amitriptyline (an antidepressant), propranolol (a beta-blocker), or verapamil (a calcium blocker) to serve as both preventive and abortive medications.
      If you are over fifty, however, an NSAID is usually a third-line choice because of the increased risk of gastrointestinal, kidney, and liver problems.
  

2. M
ETHYSERGIDE
(S
ANSERT
)

This extremely powerful preventive medication seems to help constrict swollen blood vessels and affect serotonin, but it is not commonly used because of the possible side effect of fibrosis, a “thickening” about the lungs, heart, or kidneys, which occurs in one out of seven hundred patients. With careful use and low doses, however, it can be relatively safe and effective.