Headache Help (22 page)

Ibuprofen is also more effective than acetaminophen but may not be more effective than aspirin; stomach upset is relatively common. (See Chapter 2.) Taking small amounts of caffeine may help.

4. C
AFFEINE

Taking caffeine, in coffee, soda, or pill form, can be very helpful. It may be taken individually or with a pain reliever to enhance its effectiveness. Caffeine overuse can also lead to rebound headaches. (See Chapter 2 for amounts of caffeine in foods and drinks.)

5. C
AFFEINE
-A
SPIRIN
C
OMBINATIONS

By combining the effects of caffeine with the pain relief of aspirin, these OTC products, such as Excedrin Extra-Strength, Excedrin Migraine, or Anacin, can be very effective, and have been a mainstay of OTC headache medication for years. (See Chapter 2.)

6. K
ETOPROFEN
(OTC
AS
O
RUDIS
KT, K
ETOPROFEN
)

This well-tolerated anti-inflammatory is available over the counter in a low (12.5-mg) dose. The usual dose is two to four tablets every four to six hours, as needed. It may cause stomach upset or pain. Prescription ketoprofen is available in 50-mg and 7 5-mg doses, or as the long-acting Oruvail (100 mg, 150 mg, 200 mg). Taking small amounts of caffeine may enhance its effect. As with all NSAIDs, bleeding from the stomach or stomach ulcers may occur (particularly with frequent use).

7. M
IDRIN

Midrin, a combination of a blood vessel constrictor, mild nonaddicting sedative, and acetaminophen, is effective, safe, and well tolerated. Fatigue and lightheadedness are fairly common. By prescription only. (See Chapter 5.)

8. N
ORGESIC
F
ORTE

Norgesic Forte, a combination of aspirin, caffeine, and a nonaddicting muscle relaxant, is one of the strongest nonaddicting abortive medications for tension (and migraine) headaches, but gastrointestinal upset and fatigue are common. (See Chapter 5.)

9. V
IOXX

Vioxx is a new anti-inflammatory that does not cause the stomach pain, ulcers, or bleeding that the other NSAIDs commonly do. Vioxx is available in 12.5-, 25-, and 50-mg tablets for acute pain; 50 mg may be used in a day, but for daily use, 25 mg is the maximum. While their safety has not completely been established, these newer NSAIDs are an exciting addition to the arsenal of headache medications.

SECOND-LINE MEDICATIONS FOR ABORTING TENSION HEADACHES

If the first-line abortives don’t work, your doctor may suggest stronger therapy with a more powerful pain reliever. These medications, which are potentially addicting, include the butalbital compounds (first-line migraine abortives), the narcotics (second-line migraine abortives), or the benzodiazepines (also second-line migraine abortives). If you take them once a week or less, these medications don’t pose a problem. If you need them almost daily, they can be habit-forming and you should try preventive medication.

In rare circumstances—when first-line abortives, relaxation therapy, and preventive medications fail or cause too many side effects, and you and your doctor are confident that you would never use the medication to get high or lift you out of the dumps—your doctor may suggest using limited amounts of these habit-forming medications on a daily basis. We discuss all of these medications in more detail in Chapter 5, and we present them here in slightly different order for tension headaches.

(See Chapter 5 as well for a discussion of addiction versus dependency. The difference between the two is important to understand.)

QUICK REFERENCE GUIDE: SECOND-LINE MEDICATIONS FOR RELIEVING TENSION HEADACHES

1. B
   UTALBITAL COMPOUNDS
   (F
   IORINAL
   , E
   SGIC
   , E
   SGIC
   P
   LUS
   , F
   IORICET, AND
   P
   HRENILIN
   )
       Effective but habit-forming. Sedation or euphoria is common.
   
2. N
   ARCOTICS
   (C
   ODEINE
   , H
   YDROCODONE
   , And P
   ROPOXYPHENE
   [D
   ARVON
   , D
   ARVOCET
   ])
       A last resort, needs to be limited per month; sedation, nausea, euphoria, constipation, dizziness, and itching fairly common.
   
3. U
   LTRAM
       Mild painkiller, but sometimes effective. Nausea and fatigue are fairly common.
   
4. S
   EDATIVES
   (B
   ENZODIAZEPINES:
   D
   IAZEPAM
   [V
   ALIUM
   ], C
   LONAZEPAM
   [K
   LONOPIN
   ], C
   HLORDIAZEPOXIDE
   [L
   IBRIUM
   ])
       Sedation is common, must be monitored, a last resort; potentially habit-forming.
   
5. T
   RIPTANS
   (I
   MITREX
   , A
   MERGE
   , Z
   OMIG
   , M
   AXALT
   , R
   ELPAX
   )
       Though usually less useful for tension headaches, sometimes helpful for severe tension headaches. Many people find that their tension headaches do respond to low doses of a triptan.
   

1. B
UTALBITAL COMPOUNDS
(F
IORINAL
, E
SGIC
, E
SGIC
P
LUS
, F
IORICET
, P
HRENILIN
)

These are effective but habit-forming medications that should be used no more than once or twice a day. Sedation or euphoria are common. The generic form may not work as well as the brand name. Strict daily and monthly limits need to be set. (See Chapter 5.)

2. N
ARCOTICS
: C
ODEINE, HYDROCODONE
(V
ICODIN
),
PROPOXYPHENE
(D
ARVON
, D
ARVOCET
)

These are last-resort medications that are generally not to be used daily and should have strict monthly limits. Your doctor will recommend them only if the milder abortives and daily preventive medications have not worked and your quality of life is significantly compromised by your tension headaches. Side effects may include, among others, sedation, nausea, euphoria, constipation, dizziness, and itching (or a rash, if you’re allergic). (See Chapter 5.)

3. T
RAMADOL
(U
LTRAM
)

This excellent milder painkiller occasionally is useful for migraine sufferers. Tramadol may cause nausea or fatigue, but is generally well tolerated. The usual dose is one or two every four to six hours as needed. While addiction has occurred with Ultram, it is less likely than with the other narcotics.

4. S
EDATIVES
: B
ENZODIAZEPINES, SUCH AS DIAZEPAM
(V
ALIUM
)
AND CLONAZEPAM
(K
LONOPIN
)
AND CHLORDIAZEPOXIDE
(L
IBRIUM
)

These are habit-forming medications that commonly cause sedation. Your doctor should give you a monthly limit and monitor your use; if you need more than the limit, your doctor should switch your medication. If possible, avoid daily use. (See Chapter 5.)

5. T
RIPTANS
(I
MITREX
, z
OMIG
, M
AXALT
, A
MERGE
, R
ELPAX
)

These are generally thought of as “pure migraine” medications. However, severe tension headaches and milder migraines may share similar mechanisms in the brain. For many people, a small dose (half of one tablet) of a triptan may stop the tension headache. (See Chapter 5.)

If these medications fail or you take them too often, and you still suffer from severe and frequent daily headaches and feel that your quality of life is seriously compromised by these headaches, your doctor will probably discuss taking preventive medication as well as abortive medication. We discuss this strategy in the next chapter.

9

Preventing Tension Headaches

I
F YOU’VE TRIED
relaxation methods, small to moderate doses of the abortive medications, or are using these medications so often that you’re running the risk of getting rebound headaches, don’t despair. If your quality of life is still significantly impaired by the frequency and severity of your headaches, preventive medication may be the next step. Many people who switch to preventive medications find that they end up taking less medication and less powerful medication for better relief.

When considering preventive medications, keep in mind the guidelines discussed in Chapter 6.

1. Realize that the goal is moderate improvement with minimal side effects.
   
2. Be willing to change medications.
   
3. Try to be tolerant of mildly annoying side effects.
   
4. Be patient. Many medications take several weeks to become fully effective.
   
5. Be well informed about each drug you try.
   

CHOOSING PREVENTIVE MEDICATION

As with other headache situations, finding the right drug to prevent your daily chronic headaches isn’t as simple as one would like. You and your doctor will have to consider many factors, such as whether you also get migraines, and your sleeping patterns and stomach sensitivity. As in other headache cases, chances are you’ll need to take a trial-and-error approach, trying several different medications before you find the right balance of good pain relief with minimal side effects. Again, keep in mind that your goal is to improve your pain by at least 50 to 90 percent with as little medicine as possible. Your doctor will strongly consider whether you have a tendency toward anxiety or depression when choosing a preventive medication.

Many of the medications discussed in this chapter are not specifically indicated for headache by the Food and Drug Administration, as explained in Chapter 1. However, they are commonly used, and many doctors and patients have found them helpful. As with our other discussions of medications, this information is meant to serve as a guide only, and you should be sure to check the package insert for complete information about side effects and contraindications.

FIRST-LINE MEDICATIONS FOR PREVENTING TENSION HEADACHES

QUICK REFERENCE GUIDE: FIRST-LINE MEDICATIONS FOR PREVENTING TENSION HEADACHES

1. D
   EPAKOTE
       Quite effective, though gastrointestinal upset, fatigue, and weight gain may occur.
   
2. A
   NTIDEPRESSANTS
       Effective, but sedation, dizziness, a dry mouth, weight gain, and constipation are common.
   
3. N
   ONSTEROIDAL
   A
   NTI
   -I
   NFLAMMATORIES
   (NSAIDS)
       Less effective than antidepressants but without their side effects; however, GI upset is common. Long-term use may lead to stomach ulcers.
   

1. V
ALPROATE
(D
EPAKOTE
)

A seizure medication, valproate, or Depakote, has become increasingly popular in headache treatment. However, it commonly causes gastrointestinal upset, fatigue, and weight gain; hair loss (alopecia) may also occur. (See Chapter 6 for a full discussion.)

2. A
NTIDEPRESSANTS

These medications are the mainstay therapy for preventing daily headaches and may help whether you are depressed or not. Choosing an antidepressant depends on your anxiety level, age, sleeping patterns, and your tendency to become constipated. Although these medications may also help with depression, they are used here because they benefit headaches, most likely through a serotonin mechanism.