Headache Help (23 page)

To compare these medications, see the table “The Antidepressants: Comparing Side Effects” and the more complete descriptions with typical dosages in Chapter 6. Here’s a quick review of their main differences.

• A
  MITRIPTYLINE
  (E
  LAVIL
  )
  Effective for migraines and daily headaches, amitriptyline is inexpensive and can relieve insomnia. Unfortunately, a lot of people can’t tolerate its side effects. Very low doses (io mg at night) may be enough to help.
  SIDE EFFECTS
  : Sedation, dizziness, a dry mouth, weight gain, and constipation.
  
• F
  LUOXETINE
  (P
  ROZAC
  ), S
  ERTRALINE
  (Z
  OLOFT
  ),
  OR
  P
  AROXETINE
  (P
  AXIL
  )
  All of these medications, which are very similar, pose fewer side effects than amitriptyline, but they are not always as effective for headaches and are more expensive. They are good choices for people who suffer from the blues, a chronic, low-level depression, or for those over fifty, who need a medication with milder side effects. These are generally very safe medications; for headaches, low doses are used. (For more details on these medications, see Chapter 6.)
  SIDE EFFECTS
  : Nausea, anxiety, insomnia, and occasional fatigue. Lack of weight gain (usually) and lack of sedation are major advantages. Reduced sexual desire is common.
  
• P
  ROTRIPTYLINE
  (V
  IVACTIL
  )
  Protriptyline is often used when daily headaches are also a problem. It is nonsedating and does not cause weight gain but is not as effective as amitriptyline.
  SIDE EFFECTS
  : A dry mouth, constipation, and dizziness. Nervousness, insomnia, which can be countered by taking it in the morning, and, less often, blurred vision and stomach upset.
  
• N
  ORTRIPTYLINE
  (P
  AMELOR
  , A
  VENTYL
  )
  Although better tolerated than amitriptyline, nortriptyline is somewhat less effective. Often nortriptyline is a first-choice headache preventive for children, adolescents, and the elderly because its side effects are milder. Occasionally helpful for migraines, nortriptyline is usually more effective for chronic daily headache.
  SIDE EFFECTS
  : Similar to amitriptyline but less severe, including sedation (which decreases over time), weight gain, a dry mouth, constipation, and dizziness.
  
• D
  OXEPIN
  (S
  LNEQUAN
  )
  Very similar to amitriptyline, doxepin is more effective than nortriptyline but has stronger side effects.
  SIDE EFFECTS
  : Sedation, a dry mouth, weight gain, and constipation.
  
• D
  ESIPRAMINE
  (N
  ORPRAMIN
  )
  Unlike amitriptyline, fluoxetine, protriptyline, and doxepin, desipramine is not generally useful for migraines but often helps chronic daily headaches. It’s very well tolerated but generally not as effective as the other antidepressants. It is sometimes a first choice, however, for people over fifty who might be more sensitive to the antidepressants’ side effects.
  SIDE EFFECTS
  : Sleep disturbances if taken at night; other side effects are similar to amitriptyline but much milder.
  
• T
  RIMIPRAMINE
  (S
  URMONTIL
  )
  This is a good choice when amitriptyline no longer works (but did), if its side effects were too severe, or if you want a sedative effect. It is well tolerated compared to the other antidepressants, but is sedating. Like desipramine, trimipramine is also used much more commonly for preventing daily headaches than for preventing migraines.
  SIDE EFFECTS
  : Similar to amitriptyline, including constipation, sedation, a dry mouth, fatigue, and weight gain.
  
• M
  ISCELLANEOUS
  A
  NTIDEPRESSANTS
  (W
  ELLBUTRIN
  , R
  EMERON
  , E
  FFEXOR
  , S
  ERZONE
  )
  See the section in Chapter 6 for information on these antidepressants.
  

3. N
ONSTEROIDAL
A
NTI
-I
NFLAMMATORIES
(NSAIDs)

Commonly used to abort a headache, the NSAIDs are not as effective for preventing headaches as the antidepressants, but they do not have the antidepressants’ side effects of sedation, a dry mouth, fatigue, and constipation. They do, however, often cause gastrointestinal upset (which you should report to your doctor) and potential damage to the liver and kidneys. Nevertheless, if you are under forty and suffer from arthritis, musculoskeletal problems (painful knees, back, shoulder), menstrual migraines, or the sedating effects of the antidepressants, these medications may be useful. If you are older than forty, these medications are less appropriate for daily use. The newer NSAIDs that irritate the stomach less (Vioxx, Celebrex) may be useful; their safety and effectiveness, however, have not yet been definitively established. We do not know if they will help prevent headaches; Vioxx, however, may be effective for treating a headache in progress.

Each NSAID has slightly different properties, so if one doesn’t work or isn’t well tolerated, your doctor may suggest trying another. If you are under age forty, it’s probably worthwhile to keep searching for the right one rather than opting for a second-line medication. If you use an NSAID every day, your doctor should monitor you periodically with blood tests to be sure the medication is not causing any liver or kidney damage.

The dosing of these medications varies widely since it is important to maintain the minimum effective amount. General guidelines, however, are indicated in the list of drugs which follows. NSAIDs should always be taken with food. The NSAIDs used commonly to prevent chronic daily headache are also used to prevent migraine headaches and are discussed in more detail in Chapter 6.

• N
  APROXEN
  (N
  APRELAN
  , A
  LEVE
  , N
  APROSYN
  , A
  NAPROX
  ):
  500 or 5 50 mg once or twice a day.
  
• F
  LURBIPROFEN
  (A
  NSAID
  ):
  100 to 300 mg per day.
  
• K
  ETOPROFEN
  (O
  RUDIS
  , O
  RUVAIL
  ):
  75 to 150 mg per day.
  

The following NSAIDs are less commonly used for preventing tension headaches but are sometimes helpful.

—I
BUPROFEN
(M
OTRIN
, A
DVIL
):
Available over the counter; 400 to 1,600 mg per day. (See Chapter 2 for a full discussion.) Ibuprofen is short-acting, rendering it less than ideal as a preventive.

—D
ICLOFENAC SODIUM
(V
OLTAREN
):
Possibly more effective than ibuprofen, 75 to 150 mg per day.

—L
ODINE
:
A very effective anti-inflammatory, 300 to 600 mg a day.

—R
ELAFEN
:
Easier on the stomach, it may be taken once or twice a day, 500 to 1,500 mg.

—A
SPIRIN
:
Very inexpensive and available over the counter, two to six pills per day, 650 to 1,950 mg, enteric-coated usually recommended. (See Chapter 2 for a full discussion.)

—C
OX
-2 I
NHIBITORS
:
These newer NSAIDs may cause less stomach irritation than the older kinds. Though approved by the FDA as safe, their safety and effectiveness have not yet been definitively established. Vioxx is indicated for arthritis and acute pain and may be better at treating a headache in progress than at preventing daily headaches.

If neither the antidepressants nor the nonsteroidal anti-inflammatories work to prevent your daily headaches or if you cannot tolerate their side effects, your doctor may suggest one of these second-line preventive medications.

SECOND-LINE MEDICATIONS FOR PREVENTING TENSION HEADACHES

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

1. N
   EURONTIN
       A newer medication that’s effective and doesn’t cause stomach upset, though sedation or dizziness may occur.
   
2. B
   ETA
   -B
   LOCKERS
   (I
   NDERAL
   , C
   ORGARD
   )
       Occasionally useful, but cause fatigue, depression, and weight gain, and may interfere with ability to exercise.
   
3. M
   USCLE
   R
   ELAXANTS
   (Z
   ANAFLEX
   , S
   KELAXIN
   , F
   LEXERIL
   , N
   ORFLEX
   , R
   OBAXIN
   )
       Only mildly effective but well tolerated. Often combined with other medications.
   
4. C
   ALCIUM
   B
   LOCKERS
   (C
   ALAN
   , I
   SOPTIN
   , V
   ERELAN
   )
       Occasionally effective, but often cause constipation and allergic reactions.
   
5. F
   EVERFEW
       This herb can be quite effective. (See Chapter 14.)
   

1. N
EURONTIN
(
GABAPENTIN
)

A newer seizure medication (similar to Depakote), Neurontin is becoming increasingly popular for headache prevention. Neurontin is well tolerated and does not irritate the stomach or liver. However, sedation or dizziness may occur. (See Chapter 6 for a full discussion.)

2. B
ETA
-B
LOCKERS

Beta-blockers, which help prevent blood vessel dilation and may influence serotonin, are occasionally useful for tension headaches. They may, however, cause fatigue, depression, and weight gain and may interfere with your ability to exercise. The beta-blockers propranolol (Inderal) and nadolol (Corgard) are often combined with a tricyclic antidepressant or an anti-inflammatory. (See Chapter 6 for a full discussion.)

3. M
USCLE
R
ELAXANTS

These are well-tolerated medications but usually only mildly effective. Fatigue is common and limits their usefulness, although caffeine may help counter it. Some of these medications are habit-forming, but they may be used if you have an ulcer, unlike many of the other medications. They are sometimes prescribed with an NSAID to increase pain relief, and with caffeine to counter fatigue.

• T
  IZANIDINE
  (Z
  ANAFLEX
  )
  Approved for muscle spasticity, Zanaflex has recently been used to prevent tension or chronic daily headache. Fatigue may be a concern, although it decreases over time.
  TYPICAL DOSE:
  Start with one quarter or half (the tabs are double-scored) of a 4-mg tablet, at night, and increase by a quarter or half tablet in three to four days. Initially, doctors suggest using Zanaflex at night, but after four to six days, a morning dose may be added. Zanaflex may be slowly pushed up to as much as three or four in a day, in split (divided) doses.
  SIDE EFFECTS:
  Fatigue and drowsiness are common but decrease over time; a dry mouth is also common. Dizziness may occur.
  
• M
  ETAXALONE
  (S
  KELAXIN
  )
  Skelaxin has been a very reliable, safe, mild muscle relaxant; drowsiness is minimal.
  TYPICAL DOSE:
  One or two, two to three times per day.
  SIDE EFFECTS:
  While fatigue may occur, it tends to be minimal. Stomach upset, nausea, or dizziness may occur.
  
• C
  YCLOBENZAPRINE
  (F
  LEXERIL
  )
  This muscle relaxant is one of the most effective for relieving tension headaches, but it may cause severe fatigue.
  TYPICAL DOSE:
  Starting with 5 mg taken at night, increasing up to 10 mg twice a day if well tolerated.
  SIDE EFFECTS:
  Drowsiness, dizziness, lightheadedness. Less common are confusion, a dry mouth, rapid heartbeat, and low blood pressure.
  
• O
  RPHENADRINE
  (N
  ORFLEX
  )
  Sometimes effective, this medication is also nonaddicting.
  TYPICAL DOSE:
  100 mg once or twice a day.
  SIDE EFFECTS:
  Sedation, lightheadedness.
  
• M
  ETHOCARBAMOL
  (R
  OBAXIN
  )
  The generic version of this medication is inexpensive, effective, and well tolerated.
  TYPICAL DOSE:
  Starting with 250 mg at night, the dose is slowly increased to 500 or 750 mg one to three times a day.
  SIDE EFFECTS:
  Fatigue, lightheadedness, and dizziness.