Headache Help (25 page)

L
OUIS

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NITIAL VISIT
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Louis, a forty-two-year-old accountant, has had daily headaches for almost two decades. They hurt in a “hatband” fashion around his head and increase in severity as the day goes on. He reports that they are worse with stress and weather changes, if he drinks red wine, or if he eats food that contains MSG. The headaches wax and wane, and occasionally Louis goes four or five days without one.

For four years, Louis used two Excedrin Extra-Strength tablets a day to control his pain. Relaxation techniques and exercise have not helped. Massage helps for one day, but then the pain returns. Louis has sought relief, but to no avail, from chiropractors, allergists, dentists, sinus doctors, and eye doctors.

He began needing more and more Excedrin, to the point of taking eight a day. His stomach began to hurt (due to the aspirin in the Excedrin), and his headaches were getting worse. All the Excedrin was evidently giving Louis rebound headaches. His doctor takes him off Excedrin and places him on an antidepres sant as preventive medication, protriptyline (Vivactil). The doctor chooses Vivactil over amitriptyline because it is not sedating and never causes weight gain; he chooses it over fluoxetine (Prozac), Paxil, or Zoloft because it is more effective. Vivactil can keep people up at night, but Louis does not have insomnia.

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EEK
8:
On Vivactil, the headaches decrease to the point where Louis has almost no pain, but he has side effects from the medication, particularly constipation, a dry mouth, and insomnia. His doctor prescribes Depakote instead. While Prozac is still a possibility, Louis and his doctor decide not to continue with an antidepressant for now because of Louis’s problems with Vivactil’s side effects.

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EEK
12:
Although Louis hasn’t called the office between visits, he now reports that the Depakote helped only a bit. On his own, he went back to taking aspirin and caffeine in the form of Anacin. Once again he crept up to taking eight a day, and once more the headaches increased because of the analgesic rebound situation. A stressful divorce further increased the headaches, and Louis began mixing ibuprofen with the aspirin and caffeine. He developed an ulcer and was hospitalized. At this point, his doctor takes him off the analgesics and gives him five injections of IV DHE, which greatly helps the headaches. The doctor prescribes nortriptyline (Pamelor), a mild antidepressant, 25 mg at night, as a preventive medication. This dose is low. As nortriptyline may cause constipation (and a dry mouth), Louis’s doctor informs him about how to minimize this problem through a proper diet and laxatives if necessary.

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20:
Louis reports that he does get a mild dry mouth from the medication, but that the preventive medication (the antidepressant with no analgesics) is quite successful in that he is now getting relatively few headaches. He estimates that the pain is 80 percent better. Because this improvement is within the range of success expected with preventive medications, Louis agrees to continue on the nortriptyline. Although weight gain with nortriptyline can be a major problem, it is not in Louis’s case.

T
HE
F
UTURE
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If the current dose of nortriptyline begins to lose its effectiveness, the doctor may increase the dose. Or he and Louis may want to consider Neurontin. Alternative antidepressants, such as Prozac, Zoloft, Paxil, Effexor, or Serzone, may also help.

J
OSEPH

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NITIAL VISIT
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Joseph is a sixty-eight-year-old executive with a history of chronic daily headache, moderate in intensity, and frequent, sharp pains in the back of his head, on the right side only, lasting up to one minute. The sharp pains are diagnosed as occipital neuralgia (to read more about this condition, see Chapter 13). Joseph has had headaches since he was twenty-six, but they have gotten worse in the past several years. Stress, certain foods, and golf exacerbate them. His mother and two of his three children have a history of headaches. Joseph has had ulcers and has high blood pressure. He reports that over-the-counter medications have ceased working for him and that he has tried several prescription acetaminophen-based analgesics, but none of them has been effective.

Joseph’s doctor instructs him in the nonmedication aspects of headaches, but relaxation techniques are generally ineffective for his age range. The doctor prescribes propranolol (Inderal), a high blood pressure medication, as a preventive. Because of Joseph’s advanced age, the doctor keeps the dose low to minimize side effects. Although an antidepressant may be more effective, Joseph’s doctor chooses propranolol to lessen his medication over the long term and because it should stabilize his blood pressure as well.

For an abortive medication, Joseph receives a prescription for butalbital with acetaminophen (Phrenilin) and instructions to take no more than two per day. Any more could lead to rebound headaches. To alleviate the sharp pains in the back of his head, Joseph gets an injection of bupivacaine (Marcaine) in that area. This procedure is easy and safe and takes just minutes in the doctor’s office yet it can provide weeks or even months of relief.

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EEK
4:
Joseph reports that his headaches are about 20 per cent better on the Inderal. His blood pressure is under control. The novocaine injection provided three weeks of relief for the pains in the back of the head, but they have started to return. The doctor increases the Inderal dose.

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EEK
6:
Joseph calls to say the increased dose does not help and leaves him tired. The doctor reduces the Inderal dose. To supplement Joseph’s preventive medication, the doctor prescribes nortriptyline (10 mg of Pamelor, quickly raised to 25 mg), a mild antidepressant, to take at night because it helps sleeping. The Phrenilin is continued as an abortive, to be taken when needed.

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EEK
12:
Joseph calls to say his headaches are 70 percent better, but he is very tired and constipated. These side effects are from the Pamelor, so the doctor lowers the dose back to 10 mg. Joseph also reports that the Phrenilin no longer relieves the headache once it starts, so he and his doctor agree that he should discontinue the medication and stick to daily preventives. Because of his ulcer problems, Joseph can’t use aspirin or anti-inflammatories as abortives, and many of the other choices are too strong and cause too many side effects. The aspirin-NSAID medications are prescribed infrequently for older people because of the increased risk of side effects with advancing age. Joseph and his doctor discuss the possibility of a very small amount of daily narcotic analgesic, such as hydrocodone, but they consider it a last resort. For now, Joseph will use the daily preventives and not chase after the pain every four hours.

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16:
Joseph reports that his headaches are about 40 percent better than they were before his first visit. The low 10-mg dose of Pamelor helps somewhat and does not make him tired. He remains on the Inderal for the blood pressure and headaches.

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HE
F
UTURE
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Other considerations, if needed, may be one of the SSRI (selective serotonin reuptake inhibitor) antidepressants, such as Prozac, Zoloft, or Paxil, all of which are used for headaches. These medications have been very useful because they generally do not cause sedation, weight gain, or constipation. However, they do have some side effects, such as anxiety, nausea, decreased libido or sexual performance, and insomnia. In addition, other blood pressure medications may help Joseph, such as different beta-blockers (Corgard, Lopressor, Tenormin) or calcium blockers (Isoptin, Calan). Depakote or Neurontin are also good possibilities. If possible, daily painkillers will be avoided. Zanaflex, a muscle relaxant, is also a possibility.

10

Understanding and Treating Cluster Headaches

C
LUSTER HEADACHES
, though uncommon, are one of the most painful experiences known to humankind. Approximately one out of 250 men, and one out of 800 women, will live with this misery. If you are one of the unfortunate few who get them, you may suffer terribly, as they can be excruciating and debilitating. The pain may last anywhere from fifteen minutes to three hours, occasionally longer. Usually, the pain sears through or around one eye, or locates itself in the temple. These headaches are called cluster headaches because they occur in waves, a series of headaches lasting several weeks to several months, once or twice a year, most commonly in the spring and fall. Occasionally, the intervals between attacks are much longer.

WHAT ARE CLUSTER HEADACHES?

Three to four times more common among men than women, cluster headaches cause extreme and sudden pain without any warning or aura. Although experts assume that serotonin imbalances cause clusters, they also think that a malfunctioning of the body’s biological clock, the hypothalamus, may also be involved because of the cyclic nature of these headaches. This malfunctioning might be due to subtle structural brain differences in people who get cluster headaches. Using the latest imaging technology to peer into the brain, researchers have reported recently that the density of brain matter in people who get cluster headaches is significantly different from that of people who don’t get the headaches. This area of the brain affected is what controls the body’s biological clock, which could be why cluster headaches strike with such regularity, at certain times of day or night. Cluster headaches are probably one of the vascular headaches, as are migraines, partly caused by constricting and dilating blood vessels—probably of the carotid artery close to the eye—but surrounding nerves are also involved. Since smokers have a higher rate of cluster headaches, subtle changes in the bloodstream that may occur in smokers probably also play a role.

Usually cluster headaches start between ages twenty and forty-five. If you first got cluster headaches early in life, you may outgrow them by your fifties; people who start getting cluster headaches later in life have a greater chance of having chronic cluster headaches.

A cluster headache often begins with a sense of fullness in one ear and then progresses to a stab of pain near the eye, forehead, or cheek, sometimes even as low as the jaw. Within minutes, the pain can become excruciating. For most people, the pain remains on the same side, though occasionally it may switch to the other, either during the same cluster cycle or in the next cycle. Your eye will probably tear and your nose will run on the same side as the pain.

On average, attacks last forty-five minutes, starting at the same time of day, usually during the night. Typically, they build in intensity over days or weeks. The series of headaches most commonly consists of one or two headaches a day for three to eight weeks (sometimes for as long as five months), once or twice a year. These clusters are called “intermittent” or “episodic.” About one in ten sufferers has “chronic” cluster headaches, with less than a six-month break between cycles.

The pain may be extremely intense, “like an eye is being pulled out.” Many people writhe in agony, rock, or bang their heads against the wall. Some sufferers say that the pain is worse than it would be if a limb were cut off in an accident. In contrast to migraine sufferers, who seek a dark, quiet room and lie still, people who are suffering from cluster headaches tend to pace about.

Cluster headaches are often misdiagnosed as a sinus or allergy problem because of the runny or stuffed nose and teary eye. You can probably identify your headaches as clusters if they follow this pattern:

• Onset between ages twenty and forty-five
  
• Most common among men (three to four times more than in women)
  
• Occur same time of year, with no headache between the cluster cycles
  
• Attacks usually occur at night
  
• During a cycle, alcohol is the most common trigger
  
• Severe, excruciating pain on one side, usually around the eye
  
• Eye tearing (lacrimation) and red on the side of the pain
  
• Small pupil (miosis of the pupil)
  
• Drooping eyelid
  
• Stuffed or runny nostril on the side of the pain
  
• Sweaty face or forehead (on the side of the pain)
  

NONDRUG STRATEGIES TO TREAT CLUSTER HEADACHES

Unfortunately, very little except medication really helps cluster headaches. The pain is too severe for relaxation methods, although a few simple deep-breathing exercises can help you cope with the dread and anticipation of another cluster. People in the midst of a series are often extremely anxious, fearing a night of intense, excruciating pain.

Applying ice to the painful area may help, although some people prefer heat. A hot shower massager with moderate pressure on the scalp may also ease some pain.

Once a cluster series has started, sensitivity to alcohol is much greater and often can trigger an attack. The other typical headache foods are less important, although you should avoid especially MSG, and to some extent, aged cheeses, aged meats, and chocolate during a cluster series. Occasionally, certain triggers, such as the letdown after stress, excessive cold or heat, or bright light may bring on a cluster. By and large, however, you can’t control the time when a cluster will strike, except perhaps with medication.

TREATING CLUSTER HEADACHES WITH MEDICATION

If you get either intermittent or chronic cluster headaches, you will probably cope best if you have medication both to treat and to prevent an attack. Since the pain is very sudden, intense, and relatively brief, lasting less than an hour, the abortive medication must act quickly. Taking medication by mouth usually isn’t fast enough. An oral pain reliever is more useful if your attacks typically last more than an hour. Antinausea medication is sometimes used, not only to combat nausea but for its sedative effect as well.