Headache Help (28 page)

CASE STUDIES

As we have discussed, medication for clusters is used only during the cluster cycle and not in between. Abortive medication offers some relief once the clusters begin, and preventive medication helps avoid potentially disabling and excruciating pain. Here are several typical cluster headache cases.

R
ICHARD

I
NITIAL VISIT
: Richard, a forty-year-old lawyer, has a five-year history of suffering from five weeks of cluster headaches each fall. The cluster period begins slowly, increasing over one week and reaching a peak in which Richard has two or three severe cluster attacks each day. They occur between ten
P.M.
and three
A.M.
and last forty to ninety minutes. The pain is always on the right side, with the eye tearing and right nostril congested.

He is now one week into his fall cluster series. The headaches are increasing in intensity, and he is miserable with the pain. Richard’s doctor prescribes abortive medication to ease an attack in progress as well as a preventive regimen.

Richard and his doctor discuss using oxygen as an abortive, but Richard prefers to try Cafergot tablets first. He has no risk factors for ergotamines and is reluctant to self-inject DHE or sumatrip tan. He will take one Cafergot at the beginning of the cluster and apply ice to the painful area.

For preventive therapy, the doctor prescribes 20 mg of prednisone (cortisone or corticosteroid) in the morning and 20 mg with dinner, or 40 mg per day for four days, to be reduced gradually over the next two weeks. By tapering this medication quickly, Richard avoids the risk of serious side effects and he can reserve the medication for use later in the cluster period, if necessary. If Richard were taking medium to high cortisone doses for three weeks, it would not be safe to use even more cortisone, so he keeps his use to a minimum.

Along with the cortisone, the doctor prescribes 240 mg of the calcium blocker verapamil, hoping that by the time the prednisone is tapered and discontinued, the verapamil will have become effective.

D
AY
6:
Richard reports that he had five very good days, but as the prednisone is decreased, the headaches become more severe. Cafergot does not help; last night he had ninety minutes of extreme pain. Richard now agrees to give oxygen a try and rents a tank. The doctor gives him a plastic spray bottle of topical lidocaine, 4 percent, to use as needed on the side of the pain. He is to lie supine, turn his head toward the side of the pain, extend it back, and spray two or three times into the nostril as needed. While lidocaine is only somewhat effective for cluster headaches, side effects are minimal. Even just 25 percent relief makes the lidocaine worthwhile. In addition, Richard is given Imitrex Nasal Spray to use as needed (applied on the opposite side of the pain).

Richard is to continue decreasing the prednisone, with a now doubled dose of verapamil (480 mg per day) to maintain the preventive therapy.

D
AY
10:
Now in the third week of what is expected to be a five-week cycle, Richard reports that the oxygen helps, but lidocaine does not. The clusters are less severe but continue to occur twice a night. The Imitrex Nasal Spray is only mildly effective. The verapamil may be having some effect. He is down to 20 mg per day of prednisone, and he and his doctor decide to taper off the prednisone over the next six days. If the headaches get dra matically worse, he can increase it again. Richard agrees to use Imitrex injections as needed.

D
AY
14:
Richard had complete relief for four days, and then the headaches returned but were not nearly as severe.

D
AY
20:
The headaches are gone, and after one week Richard tapers off the verapamil over six days. If the headaches return during those six days, he will increase the verapamil again, to 480 mg per day, and may reinstitute the prednisone.

T
HE
F
UTURE
:
The next time Richard’s cluster period begins, he will use oxygen and Imitrex injections as abortives. He will begin taking verapamil and about two weeks’ worth of prednisone. Lithium and Depakote are other possible preventives.

S
HELDON

I
NITIAL
V
ISIT
:
Sheldon is a fifty-five-year-old insurance salesman who has been getting episodic cluster headaches once or twice a year ever since he was twenty-six. They usually occur for six or eight weeks, in the spring and fall, with two to four headaches per twenty-four hours. The headaches are always around Sheldon’s left eye, with tearing, running of the left nostril, and tenderness in the back of his head. The pain typically begins at ten or eleven
P.M.
and often awakens him from sleep. The headache lasts two hours and is sharp and extremely debilitating. Sheldon feels completely incapacitated during the headache cycle. His dad had migraines. Sheldon smokes cigarettes. Alcohol and MSG trigger increased headaches during the cluster cycle, but outside of the cycle, Sheldon never experiences a cluster headache.

Cortisone medication (Decadron, Medrol, prednisone) was effective for a number of years as a preventive used during the cluster period, but it no longer helps. Methysergide (Sansert) did not help, and verapamil (Isoptin, Calan) helped until last year, but is no longer effective. Other than smoking, Sheldon has no cardiac (heart) risk factors.

One week into the cluster series, Sheldon is placed on lithium, 600 mg (two pills), as a preventive medication to be taken at dinnertime because his headaches occur primarily at night. His doctor teaches him how to self-inject sumatriptan (Imitrex), which helps the vast majority of cluster sufferers. Imitrex is expensive, but it often stops the cluster pain within minutes. Sheldon also receives a small tank of oxygen, to breathe eight liters per minute, as needed, by mask. Sheldon is instructed to quit smoking gradually, as this often will cut down on the clusters.

W
EEK
3:
Sheldon reports that the clusters have decreased with the lithium, down to one every other night. The Imitrex does stop the clusters within ten minutes, but the oxygen helps only a little. Sheldon does not want to use Imitrex for every headache, so the doctor prescribes the butalbital compound Fiorinal as a pain reliever. While the analgesics, such as Fiorinal, are not ideal for treating clusters, they are useful at times. The pain pills do take at least twenty to thirty minutes to become effective.

W
EEK
8:
Sheldon reports that the lithium was helpful for four weeks but then ceased being effective. The dose is increased to three pills per day.

W
EEK
9:
The increased dose of lithium still does not help. The doctor prescribes Depakote, which is occasionally useful for clusters. Because Sheldon is fifty-five, Depakote is safer for him than daily ergotamines. If the Depakote is not effective, however, Sheldon’s doctor might consider trying indomethacin (Indocin).

W
EEK
10:
The Depakote is not effective. Sheldon decides that because the headache cycle is due to end soon, he will simply use abortive medications—Imitrex injections, oxygen, and Fiorinal—and not pursue preventive measures.

T
HE
F
UTURE
:
When the next cycle begins, Indocin will be a very reasonable preventive alternative for Sheldon. The other medications have either stopped working or never worked for him. He will continue to take Fiorinal and Imitrex as abortives.

Imitrex Nasal Spray is a reasonable (but less effective) alternative to the injection. A steroid blockade of the occipital nerve (see the section earlier in this chapter) would also be a reasonable therapy.

11

Headaches in Children and Adolescents

W
ITNESSING
your child endure the pain of headaches can be particularly difficult. For one thing, it is always hard to see your children in pain. In the case of headaches, you may feel guilty that something you did, such as arguing with them or with a spouse, may have contributed to their distress. Or you may get headaches yourself and worry that your child may develop a similar pattern. You may also feel helpless, not quite sure how you can aid your child in pain.

When your child has frequent headaches, it can be hard on the entire family. He or she may miss a lot of school, siblings may complain over the attention paid to the sick child, or the child may relish all the extra attention and then exaggerate the head pain to keep getting more. Adolescents who get severe, frequent headaches often become depressed, and that can affect the whole family, too.

Although headaches are difficult illnesses, especially in children, you can rest assured: many nondrug strategies can help prevent headaches in children, and when medication is needed to relieve pain and restore the quality of life, there is a safe and effective arsenal from which to draw.

WHO GETS HEADACHES?

Unfortunately, many children get headaches. Head pain accounts for more than a million lost days of school every year. Even two-year-olds can get migraines, although they often are misdiagnosed as flu symptoms. Age six is a more typical time for migraines to start, especially among boys. By age seven, some 40 percent of children will have had a headache; most are minor tension (muscle contraction) headaches. By age ten, 4 percent have had a migraine. After age twelve, many boys outgrow childhood migraines, while girls start getting more of them as their hormones change. All told, about one in ten children and adolescents may suffer from migraines.

SYMPTOMS IN CHILDREN

If your family has a history of migraines and your child gets severe headaches, there is a good chance that they are inherited and that they’re migraines. Other clues leading to migraines are headaches associated with nausea, visual auras, or typical migraine triggers, such as particular foods or stress. The stress that triggers migraines may not always be “bad stress” but may be “good stress,” such as the excitement of a birthday party or a special trip. Undersleeping also results in a headache.

Migraines in children may follow a different pattern from the one they do in adults. For one, they tend to be shorter and often begin with no warning, such as flashing lights or an aura. Also, children often suffer from abdominal pain and diarrhea as well as the typical adult symptoms, such as nausea and sensitivity to light. The nausea often is severe in children and comes on early in the migraine. And although adult migraines are usually concentrated on one side of the head, children often experience pain on both sides.

Tension headaches in children, on the other hand, tend to resemble tension headaches in adults. If the headaches are severe and recurring, they are likely to be migraines and are treated as such because distinguishing between a severe tension headache and a mild migraine is very difficult, if not impossible.

If your child is getting severe or regular headaches, it is important to consult a doctor to rule out any physiological problems. About one in twenty children with headache is not suffering from a tension or migraine headache, but from a neurological illness, hormonal dysfunctions, eye problems, meningitis, infection, or other potentially serious medical condition, even a viral infection from a bite from a pet mouse. Assuming that’s not the case, the next step is to try to relieve the pain with nondrug strategies and over-the-counter medications, and, if possible, to identify and avoid headache triggers.

NONDRUG STRATEGIES TO PREVENT HEADACHES IN CHILDREN

Before we discuss how to avoid tension headaches and migraines—the two most common types of headaches in children—consider that some headaches in children are caused by eyestrain (too much TV or time before a computer monitor, a need for prescriptive eyeglasses) or an injury to the head. These factors may be involved when your child complains of headaches.

HEADACHE HELP TIP

If your child is getting frequent headaches, the first thing to do is to make sure that he or she doesn’t need glasses or a stronger prescription. Also, consider too much TV or too much time in front of the computer screen as a possible cause.

I
DENTIFYING AND AVOIDING TRIGGERS
can be very effective in warding off migraines in children. These factors include certain foods, too little sleep, smoke and other fumes, weather changes, fatigue, stress, bright lights, hunger, heavy exercise, travel, and so on. We explore these triggers in detail in Chapter 6. In addition to the foods listed there, high-sugar and high-salt foods are also potential triggers in children. Restricting what your child eats can be difficult, especially if you need to eliminate favorite foods. Try to enlist your child’s cooperation and experiment. He or she can either stop eating all the possible trigger foods at once, or a few at a time (the most common or likely suspects), adding them back one by one. Put together a chart and a calendar with your child; the more active your child is in maintaining these tools, the more cooperation will result.

R
ELAXATION AND BIOFEEDBACK
techniques can be very effective with children as young as seven or eight who can learn the simple breathing and imaging techniques to deal with stress that could be triggering headaches. Children nine and older can learn the more complex adult techniques described in Chapter 2. Because children are sensitive to stress, consider whether your child’s routine is too hectic. Medication in children should be minimal, so it is extremely important to explore these techniques fully. They can be very effective yet are tragically underused.