Headache Help (18 page)

Methysergide is most often prescribed for people forty-five and younger because its constricting effect on blood vessels can present a problem in older people. It is also not a good choice if you have coronary artery disease, previous blood clots (thrombophlebitis), peptic ulcers, kidney or liver problems, or any vascular disorders. If you have high blood pressure, your doctor should closely monitor you on this medication.

TYPICAL DOSE
: 2 mg to start, working up to an average dose of 2 mg twice a day, taken with food. Taking a one-month rest from the medication after six months is often recommended, though controversial, to try to prevent fibrosis. A substitute medication can be prescribed during that time.

SIDE EFFECTS
: Nausea, hot feelings in the head, and leg cramps are common. Occasional severe gastrointestinal upset. “Feeling weird” is not unusual, although most people do not have significant side effects with methysergide.

3. N
EURONTIN (GABAPENTIN)

Neurontin is very promising as an antipain and antiheadache medication. Like Depakote, it is also prescribed for seizures. Neurontin is one of the few medications that does not irritate the liver; it’s proven to be very safe with few serious consequences, thus rendering it very useful for treating headache. It is one of the few newer preventive medications to come along, as most of the recent breakthroughs have been in abortive or “as-needed” medications, such as Imitrex, Zomig, Maxalt, Amerge, and Migranal. However, sedation, fatigue, and dizziness are relatively common.

TYPICAL DOSE
: 300 mg once or twice per day to start, increasing as needed to as much as 2,400 mg per day. The average dose ranges from 900 mg to 2,000 mg per day. Neurontin is available in 100-mg, 300-mg, 400-mg, 600-mg, and 800-mg capsules, and is moderately expensive.

SIDE EFFECTS
: Sedation or dizziness may occur. “Cognitive” side effects, such as difficulty thinking through problems, spaciness, mild confusion, and fatigue, can also occur, but most people tolerate Neurontin very well. Weight gain occasionally occurs.

4. N
ATURAL
H
ERBS
/S
UPPLEMENTS FOR
P
REVENTING
M
IGRAINES
(F
EVERFEW
, M
AGNESIUM OXIDE
, V
ITAMIN
B
₂
;
SEE ALSO
C
HAPTER
14)

• F
  EVERFEW
  Feverfew is an herb with the active ingredient parthenolide. As with other herbs, different farms will produce feverfew with widely different concentrations of parthenolide. This quality control remains a problem with herbs. The usual dose has been two or three capsules in the morning each day. Occasionally, feverfew is also used as an abortive to stop a headache in progress. Feverfew may also be ingested as a liquid (concentrated drops). In Europe, feverfew is often ingested by chewing the leaves that people grow in their backyards. Side effects tend to be mouth sores, or in rare circumstances, bleeding problems. Feverfew should not be used during pregnancy or if pregnancy may be a possibility.
  
• M
  AGNESIUM
  O
  XIDE
  Magnesium oxide is readily available in pharmacies in doses from 250 mg to 400 mg. The usual dose is 250 mg to 500 mg once per day as a preventive. It has been demonstrated that magnesium levels are low in the brains of migraine sufferers. Gastrointestinal (stomach) side effects may limit its use. Do not take with calcium, as the magnesium will not be absorbed. Magnesium oxide may be useful for menstrual migraine. Long-term effects of magnesium supplements, if any, are not known.
  
• Vitamin B
  ₂
  (riboflavin)
  Riboflavin, also known as Vitamin B
  ₂
  , has been used as a daily preventive for migraine in the large dose of 400 mg per day. In at least two studies, riboflavin was found to be somewhat effective. However, long-term side effects of large doses of vitamin B
  ₂
  are not known.
  

THIRD-LINE MEDICATIONS FOR PREVENTING MIGRAINES

These third-line approaches to preventing migraines are usually the treatment of last resort. Doctors won’t prescribe them until you have tried other options that have potentially fewer problems. Although all these treatments are used with caution, your doctor will take even greater precautions if you are over fifty.

QUICK REFERENCE GUIDE: THIRD-LINE MEDICATIONS FOR PREVENTING MIGRAINES

1. MAO I
   NHIBITORS
       Powerful antidepressants that can prevent migraines, but insomnia and weight gain are common.
   
2. L
   ONG
   -A
   CTING
   O
   PIOIDS
   (M
   ETHADONE
   , O
   XYCONTIN
   , K
   ADIAN
   )
       Effective for severe, refractive, chronic daily headaches and migraines. Sedation and constipation are common. Oxycontin and Kadian are particularly well tolerated.
   
3. S
   TIMULANTS
   /A
   MPHETAMINES
   (R
   ITALIN, PHENTERMINE, DEXTROAMPHETAMINE
   , M
   ETHAMPHETAMINE
   )
       Sometimes useful as a last resort.
   
4. I
   NTRAVENOUS
   D
   IHYDROERGOTAMINE
   (DHE)
       Very safe and effective but requires going to see the doctor for office injections.
   
5. D
   AILY
   T
   RIPTANS
   (I
   MITREX
   , A
   MERGE
   , M
   AXALT
   , Z
   OMIG
   , R
   ELPAX
   )
       Expensive, and the possibility of long-term side effects make these a last resort.
   

1. MAO (M
ONOAMINE
O
XIDASE
) I
NHIBITORS

These medications are helpful if you get severe migraines (or chronic daily headaches) and other medications haven’t worked. They also can be very helpful to counter depression, anxiety, and panic attacks. These are powerful medications with very serious possible side effects.

Although MAO inhibitors may be used with relative safety and may be the only medications that will help prevent your migraines and daily headaches, it is essential that you avoid certain foods and medications while taking an MAO inhibitor because they could significantly increase the risk of a high blood pressure crisis. These include:

• Sumatriptan (Imitrex) or other triptans (Amerge, Maxalt, Zomig, Relpax)
  
• Meperidine (Demerol)
  
• Over-the-counter decongestants (Check with the doctor if you want to take any OTC medication.)
  
• Excessive caffeine (more than two cups of coffee or cola drinks), chocolate
  
• Red wine, sherry, ale, and beer
  
• Tenderized meats, liver, fermented meats (pepperoni, summer sausage, salami, bologna)
  
• Caviar, dried or salted fish, herring
  
• Aged cheeses
  
• Yogurt, sour cream
  
• Bananas, overripe figs, avocado, raisins
  
• Yeast extracts, soy sauce
  
• Fava beans
  

Occasionally, an MAO inhibitor is used in conjunction with certain other antidepressants, beta-blockers, and calcium blockers; if you take such a combination, your doctor will need to monitor you closely.

• P
  HENELZINE
  (N
  ARDIL
  )
  This is the most effective and frequently used MAO inhibitor, but liver function and blood pressure need to be monitored with its use.
  TYPICAL DOSE
  : 15 mg to start, taken at night, and sometimes increased over one to three weeks to an average dose of 45 mg if needed. If ineffective even at 60 mg, then another medication should be tried instead. Take at night to avoid interactions with certain foods. If phenelzine causes insomnia, try taking it in the early morning.
  SIDE EFFECTS
  : Insomnia and weight gain. Less common side effects include a dry mouth, constipation, rapid heartbeat, agitation or other mood changes, swelling of the hands or feet.
  

2. L
ONG
-A
CTING
O
PIOIDS
(M
ETHADONE
, O
XYCONTIN, MS
C
ONTIN
, K
ADIAN
)

For a tiny select group of severe headache sufferers with refractive chronic daily headaches and migraines, long-acting opioids can be useful. The short-acting ones, such as hydrocodone or codeine, tend to cause addiction and rebound headaches when used daily. If daily opioids are necessary, the longer-acting ones, which are effective for eight to sixteen hours, do not cause rebound headaches and may be used once or twice per day on a regular (but not on an “as-needed”) basis. Doses need to be kept low with all of these medications. Oxycontin and Kadian are particularly well tolerated.

Another advantage of these opioids is that they do not cause the weight gain and other side effects that many other preventive medications do. However, these are an absolute last resort to be used when basically nothing else works. They may cause sedation, depression, and constipation. Although less than 5 percent of patients with pain or severe headaches who use narcotics ever become addicted, it’s still a small risk but one that’s definitely worth taking if other options don’t work. Most people do become dependent on these medications, but not addicted, and that is a crucial difference (see the section in Chapter 5 on addiction versus dependence).

• M
  ETHADONE
  Methadone is inexpensive and used in low doses, 5 mg to 20 mg per day. It is crucial to begin with very low doses. If methadone is overused in the beginning, it is extremely dangerous.
  
• O
  XYCONTIN
  Oxycontin is a long-acting form of oxycodone that is well tolerated and available in multiple doses. Again, doses must be kept low, 40 mg per day or less.
  
• K
  ADIAN OR MS
  C
  ONTIN
  These are longer-acting forms of morphine. They are also useful because they are very long lasting (particularly Kadian). The usual dose of Kadian is 20 mg once or twice a day.
  

3. S
TIMULANTS
(R
ITALIN
, P
HENTERMINE
, D
EXTROAMPHETAMINE
)

Stimulants are occasionally useful as last-resort therapy. Occasionally these are used as an adjunct to long-acting opioids or other medications. Addiction, however, is always a concern with these medications. While some patients may respond well to stimulants as a last resort, they are only used when absolutely no other measures have been helpful.

4. I
NTRAVENOUS
D
IHYDROERGOTAMINE
(IV DHE)

This treatment is very safe and extremely effective for preventing and relieving frequent or severe migraines, daily headaches, or cluster headaches, but its use requires going to a doctor’s office or hospital to receive intravenous injections. Typically, IV DHE will give you good relief for at least one or two months, occasionally for as long as eight months.

Your doctor may also recommend this treatment if you have become dependent on narcotic painkillers, such as codeine, or analgesic overuse, and, as a result, you suffer from rebound headaches. This medication can help you withdraw from your dependence.

If you have high blood pressure, your doctor will treat you cautiously with the medication. If you have heart disease or peripheral vascular disease, your doctor probably won’t use it at all.

TYPICAL DOSE
:
When administered, at the doctor’s office
, the doctor will ask you to take an antinausea medication at home, preferably Reglan because it is mild, and a few Turns. At the office, you will get an injection, probably a shot twice a day for one to three days, or a total of two to six doses.

When administered at the hospital
, the injection can be given three times in one day, or up to nine doses in three days. The accompanying antinausea medication can be stronger, so you can take larger doses, which, in turn, will be more sedating. Typically, you’ll need a two- or three-day stay in the hospital, so the staff can monitor and care for you.

SIDE EFFECTS
: Nausea, hot feeling in the head, a temporary tightness in the throat or chest, leg and muscle cramps, and a tem porary rise in blood pressure. Occasional diarrhea or brief muscle tension headache afterward. The side effects, if present, usually last less than one hour. To combat nausea, which is common, an antinausea medication is usually taken before the DHE.