Headache Help (32 page)

4. B
ETA-BLOCKERS

5. V
ALPROATE
(D
EPAKOTE
)

Very effective for migraine and tension headaches.

If these first-line drugs prove ineffective or inappropriate, your doctor may suggest one of the following second-line choices:

1. C
OMBINING TWO OF THE FIRST- OR SECOND-LINE MEDICATIONS

2. F
EVERFEW

This herb is relatively safe and has been proven to help prevent migraine headaches. It is usually well tolerated. (See Chapter 14.)

3. G
ABAPENTIN
(N
EURONTIN
)

Related to Depakote, well tolerated, and generally safe. Tiredness is relatively common.

The third-line choices for preventing migraines in teens are:

P
HENELZINE
(N
ARDIL
)

An MAO inhibitor.

I
NTRAVENOUS
DHE

Please refer to previous chapters for details on all these medications.

CASE STUDIES

Here are some fairly typical cases among children and adolescents with migraines or tension headaches.

M
EREDITH

I
NITIAL
V
ISIT
: Meredith is a nine-year-old with a history of migraines, twice a month, ever since she was six. The migraines last five hours, with a severe but short bout of nausea. Undersleeping and chocolate are the only consistent triggers for Meredith’s migraines. She also gets tension headaches, which occur three or four times a week and tend to worsen with stress. They usually occur toward the end of the school day and decrease in the summer.

Meredith’s doctor teaches her basic deep-breathing-relaxation techniques, as age nine is a good time to try these methods. Meredith learns how to apply reusable ice packs to her head. Tylenol has been effective for her tension headaches, and she takes three or four chewable Tylenol tablets a week. Caffeine, in Coke or Pepsi, also helps. Meredith learns all of the usual migraine avoidance techniques, such as eating a diet that avoids trigger foods and wearing dark sunglasses on bright days.

W
EEK
2:
Meredith’s mother reports that the deep-breathing-relaxation techniques are helping to relieve the tension headaches, but Meredith is still getting migraines. The doctor writes a prescription for liquid ibuprofen (Children’s Advil), as Meredith has a difficult time swallowing tablets.

W
EEK
4:
The ibuprofen helps relieve the migraine pain somewhat but increases her nausea. Meredith receives a prescription for liquid promethazine (Phenergan) for the nausea.

W
EEK
16:
The ibuprofen is no longer effective, but the liquid Phenergan helps relieve the nausea. Meredith’s doctor prescribes Midrin for the migraine pain and shows Meredith and her mother how to pull apart the capsule and put the powder in juice or applesauce.

W
EEK
19:
The Phenergan and Midrin are sedating Meredith but are helping to reduce the pain by about 80 percent. Meredith wishes to try a medication that won’t make her so sleepy. The Midrin is discontinued, and Meredith tries liquid Naprosyn, an anti-inflammatory similar to ibuprofen, instead.

W
EEK
22:
The Naprosyn helps the pain about 60 percent and does not sedate Meredith. Although it increases her nausea, the Phenergan is controlling it. The plan is now for Meredith to use the Phenergan-Naprosyn combination if she’s in school with pain, but if she’s at home with a migraine, she’ll use Phenergan with Midrin, which is more effective but puts her to sleep. Such a choice is not unusual for headache patients. They learn to use different medications in different situations.

T
HE
F
UTURE:
If Meredith needs a change of medication, her doctor may prescribe a pure migraine medication, such as Migranal Nasal Spray. Butalbital medications, such as Fiorinal, Fioricet, Esgic, or Phrenilin, may also be helpful for Meredith at some point. Sedatives, such as diazepam (Valium), or narcotics, such as codeine, occasionally are useful in children of Meredith’s age but are not generally used until other alternatives have been exhausted. Triptans, such as Imitrex, have occasionally been used for children at ages nine and ten.

M
ICHAEL

I
NITIAL
V
ISIT
:
Michael, an eleven-year-old boy, has had monthly migraines since he was eight. Six months ago, he started to get moderately severe daily headaches. The migraines are also moderate to severe, last eight hours, and usually stop when he falls asleep. Michael vomits early in the migraine and then feels better. He becomes carsick easily, which is common among children with migraines. There is a strong family history of migraines, as both his mother and father have had migraines in the past. Michael does well in school and is a hard-driving perfectionist.

Acetaminophen or ibuprofen is only slightly effective for Michael’s migraines. Caffeinated soft drinks do help to some degree. For the monthly migraine, Michael’s doctor prescribes Midrin. Michael empties the contents of the large capsule into applesauce. He puts ice packs on his head as well.

The chronic daily headaches are more of a burden to Michael than the migraines. They last most of the day, every day. Occasionally, we find that children with headaches are “over programmed” and under too much stress. While the headaches are worse with stress, they are also present when Michael is relaxed and on vacation. He and the doctor practice deep-breathing and relaxation techniques. After some discussion with Michael’s parents, they decide to decrease his activities so that he does not have a planned activity day after day.

W
EEK
2:
The Midrin helps Michael’s migraine, as do the ice packs, but makes him sedated and lightheaded. His doctor prescribes Migranal Nasal Spray instead of Midrin to help relieve any migraine. His daily headaches remain as bad as ever, and the doctor prescribes naproxen as a preventive medication, 220 mg per day.

W
EEK
4:
Michael’s mother calls to say that the naproxen is working well to prevent the daily headaches, but that Michael had a migraine yesterday and the Migranal made him very sick. The doctor calls in a prescription to the pharmacy for Fioricet (acetaminophen, caffeine, and the mild sedative butalbital) to replace the Migranal.

W
EEK
20:
Michael comes in to the doctor’s office and reports that he has felt better for several months, but his daily headaches are back. Evidently, the naproxen has lost its effectiveness. The doctor prescribes a low dose of amitriptyline (Elavil), 10 mg, to be taken at night.

W
EEK
21:
Michael’s mother calls to say the medication seems to have no effect. The dose is raised to 25 mg. week 22: Michael’s mother calls to say that the daily headaches have eased somewhat, but she would like to try a higher dose. The amitriptyline dose is raised to 50 mg.

W
EEK
24:
Michael’s daily headaches have vastly improved, but Michael is tired, with a dry mouth. His dose is lowered to 35 mg.

W
EEK
32:
Michael comes in for a checkup, and his mother reports that the side effects of the Elavil have abated. The daily headaches are 50 to 70 percent improved.

T
HE
F
UTURE
:
The goal with children is to minimize medication yet alleviate the headaches. Because 35 mg of amitriptyline appears to be the highest dose that Michael can tolerate, if the headaches get worse, he should consider nortriptyline (Pamelor or Aventyl), a milder form of amitriptyline. While not quite as effective as amitriptyline, the nortriptyline often produces milder side effects. SSRIs (Prozac, Zoloft, Paxil) would also be considered and are usually well tolerated. A beta-blocker such as propranolol (Inderal) may help. If the headaches remain very much improved, the daily preventive medication should be discontinued periodically to assess whether it is still necessary. Many children go off and on daily preventive medication depending on the severity of their headaches. In a boy such as Michael, there is a 50 percent chance that he will outgrow the headaches by age twenty.

R
ICHARD

I
NITIAL
V
ISIT
:
Richard, a seventeen-year-old high school student, has a five-year history of migraines once a month; more recently, the headaches have increased to twice a month. He also gets very mild, frequent tension headaches, but they do not bother him. The migraines are very severe, lasting sixteen to twenty-four hours, with mild nausea. All of the over-the-counter medications have been ineffective. Richard’s mother and sister both have had headaches. Richard is usually a good student, but this semester he has started to stay home from school more frequently and his grades have fallen.

He and his doctor discuss diet, relaxation techniques, and the other nonmedication strategies. Richard has been using marijuana and alcohol at least three times a week. He agrees to stop, as the drugs may be responsible for worsening his headache situation. Because of his recent history of missing classes and doing poorly in school, his doctor suggests a consultation with a psychotherapist. Age seventeen is a difficult time for many adolescents, who may experience hidden stresses and depressions. Using headaches to avoid classes may also be a symptom of school phobia, which Richard needs to address with a therapist.

W
EEK
4:
Richard is seeing a therapist and reports that relaxation techniques have helped his milder headaches, but that the migraines persist. He receives a prescription for Midrin as an abortive medication to relieve the pain once it starts. His migraines do not occur frequently enough to justify the use of a daily preventive approach.

W
EEK
6:
Richard calls to say that the Midrin is mildly effective but makes him very drowsy. The doctor switches his prescription to Imitrex Nasal Spray.

W
EEK
8:
Richard calls to say that the Imitrex helps but he is tired from it. The doctor now prescribes Aleve, an anti-inflammatory, to be taken with Reglan, a mild antinausea medication. This is a nonaddicting, first-line medication tactic. week 20: Richard reports the medications in combination are working well.

W
EEK
32:
Richard reports that the Anaprox and Reglan are no longer effective. His doctor prescribes Migranal Nasal Spray. Migranal is safe, nonaddicting, and can actually abort a headache, not simply cover the pain. Richard calls after his next migraine to say it is effective.

W
EEK
44:
Richard phones to report that the Migranal no longer works. Richard’s doctor does not want to prescribe the butalbital medications (Fiorinal, Esgic, Phrenilin) for Richard. These drugs are mildly habit-forming, and Richard has a history of overusing alcohol and marijuana. Instead, his physician switches to another triptan, Maxalt.

W
EEK
50:
Richard reports that the Maxalt is working well, although he experiences twenty minutes of mild nausea after the tablet, as well as tingling in his arms. All of these side effects, however, go away easily and the headache dissipates within one hour. Richard remains slightly fatigued but is able to function well the rest of the day. He decides that he will take Maxalt with him as he goes away to college.

T
HE
F
UTURE
:
Other possibilities for Richard include Amerge or Zomig (other triptans), Cafergot PB suppositories, DHE injections, or, as a last resort, a butalbital compound or narcotic analgesic. Amerge may be a particularly good choice, since it is a mild, well-tolerated triptan.

12

Headaches in People Over Fifty

T
HE GOOD NEWS
is that if you have a history of migraine, cluster, or tension headaches, chances are you’ll find relief in your fifties. The bad news, though, is that many people still have problems with headaches as they get older, and some people begin getting troublesome headaches in their fifties or sixties.

If you’ve never had problem headaches before and are just starting to get them, or your headache patterns are suddenly changing, your doctor will probably want to do a complete workup. This is especially important as you get older. The doctor will need to be certain that the headaches are not being caused by a serious disorder that occurs more commonly as people age, such as a brain tumor, arteritis, heart disease, or high blood pressure. Other conditions that become more common as you age and that can affect headaches include depression, arthritis in the neck region, strokes from blockages in the arteries to the brain, hemorrhage in or around the brain, glaucoma or other eye conditions, or the interaction of various medications. Your doctor will also need to assess whether a cervical spine disorder, chronic renal disease, anemia, or a respiratory disorder are contributing to your headaches.