Managing Your Headaches 2nd Edition
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The symptoms worsen when she is active and are preceded by a flashing zigzag line that migrates from the center of her visual field to the lateral periphery. The headaches are not associated with her menstrual cycle and have not changed in character or frequency since she began using an OC.
She does not smoke. Skip to main content. Clinical Review. How to choose a contraceptive for a patient who has headaches. OBG Manag. Author and Disclosure Information Kristina M. CASE 1: Patient reports a history of migraine A year-old nulliparous woman has severe dysmenorrhea that has been unresponsive to treatment with nonsteroidal anti-inflammatory drugs NSAIDs.
Is an OC appropriate for this patient? Progestin-only options exist that will provide her with excellent contraceptive efficacy and help relieve her dysmenorrhea: the etonogestrel subdermal implant Implanon depot medroxyprogesterone acetate DMPA injection Depo-Provera the levonorgestrel-releasing intrauterine system LNG-IUS; Mirena.
Progestin methods are safe The use of progestin-only methods has been promoted in headache sufferers, especially those who have a specific diagnosis of migraine, because progestins do not add to the elevated risk of stroke that accompanies migraine with aura. Menu Menu Presented by Register or Login.
Medicine Neurology. Free Preview. Buy eBook. Buy Softcover. FAQ Policy. About this book Frequent headaches seriously affect the lives of millions of sufferers. Show all. However, our goals and expectations are limited. The concept of plasticity of the brain is very important, as some people do improve naturally over time. One study of borderline personality disorder in adolescents indicated that, by age 30, one third of the subjects no longer had borderline personality disorder. Many people do not fit neatly into any of these categories, but have features of two or three personality disorder types.
Failure to identify those with personality disorders leads to increased risk for the provider and the patient. The small percentage of patients with moderate-to-severe personality disorders in a typical practice are the ones who create the majority of the drama, as well as legal and regulatory problems for the treating physicians.
Central sensitization syndromes, including chronic migraine, irritable bowel syndrome IBS , fibromyalgia, and chronic pelvic pain, can occur together with migraine, which complicates treatment. A common site for medical comorbidities in headache patients is the gastrointestinal GI tract, with IBS being the most common comorbid GI disorder. IBS frequently is encountered in migraine patients, and very often practitioners try to use medications that help the GI symptoms as well as the headache.
It is much easier to help patients who primarily have diarrhea because some of our medicines, such as the older tricyclic antidepressants tricyclics , slow the gut transit time. Constipation, on the other hand, is tougher to ameliorate. Many people with fibromyalgia also have chronic daily headaches and insomnia. These groups overlap, not only with pain but with psychological comorbidities as well. Fibromyalgia patients share the allodynia commonly felt by headache patients. A number of medicines are used for both headache and fibromyalgia, such as tricyclics and muscle relaxants.
Some other common medical comorbidities are hypertension, insomnia, and fatigue.
If you ask large groups of headache or migraine patients what their biggest problem is other than headache pain, it tends to be excessive daytime sleepiness. It is challenging because there are no algorithms for headache patients since everyone is different. For example, suppose a year-old woman who is 25 pounds overweight presents with chronic headache and complaints of excessive fatigue. Amitriptyline or valproate would make her more tired and lead to weight gain.
Some medications, such as protriptyline Vivactil, others and ARBs do not exacerbate fatigue, and, occasionally, small doses of stimulants can be effective. Modafinil Provigil, others or armodafanil Nuvigil may offset the fatigue but do not help headaches. These are expensive medications, but they can improve quality of life for many headache patients.
The fatigue that headache patients frequently encounter is, in part, related to the insomnia they experience. Clinicians should encourage patients to follow sleep rules and should prescribe behavioral treatments. Sedating tricyclic antidepressants and certain muscle relaxants, such as tizanidine Zanaflex, others or cyclobenzaprine Amrix, others , may help both conditions.
More effective insomnia medications are needed. In patients with hypertension, treatment with many of the antihypertensives can reduce migraine pain in addition to lowering blood pressure. Most beta-blockers will help, as will the calcium channel blockers. It does take a village to treat a severe pain patient. Psychotherapy often is important and I strongly recommend it as part of treatment. However, whether it is because of money or time, most people will not see a therapist.
Evaluation and Management of Life-Threatening Headaches in the Emergency Department
Cognitive-behavioral therapy is the usual approach, but with personality disorders one must take more of a dialectical tack. It is important to identify the best therapists in your area because the skill levels of psychotherapists vary widely Table 1.
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However, there is no good algorithm that applies to headache treatment to determine how many headaches a month are too many. We might use preventive medicine in a patient with as few as 2 headaches a month if they are severe and prolonged and are not relieved by drugs.
In contrast, we may choose not to use preventive medicine for another patient who has 5 headaches a month but can take an acetaminophen-caffeine or a triptan and obtain relief, because all medications have possible side effects. For abortive therapy, there are many choices among the triptans.
All of the triptans are effective, but they each have different clinical characteristics. The generic tablets include sumatriptan Imitrex, others , rizatriptan Maxalt, others , naratriptan Amerge, others , and zolmitriptan Zomig, others. Sumatriptan, rizatriptan, zolmitriptan, and eletriptan Relpax have slightly better efficacy than naratriptan and frovatriptan Frova. Naratriptan and frovatriptan have a slower onset and are longer acting than the other triptans.
The triptan nasal sprays, particularly zolmitriptan, are fast acting. If one triptan is ineffective, I usually will try 1 or 2 other triptans before giving up on the class. Since , more than million people have been treated with the triptans, and their safety has been well established. Side effects of tingling and pressure can occur initially with these agents. We have become more comfortable using triptans in higher risk populations.
During pregnancy, particularly after the first trimester, triptans may be safer than many of the other migraine medications. Other than the triptans, OTC products, such as ibuprofen, naproxen Naprosyn, Aleve, others , aspirin and caffeine combinations, can be effective, as can aspirin combined with metoclopramide Reglan, others.
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Prodrin, a combination of a small amount 20 mg of caffeine, acetaminophen, and a mild vasoconstrictor isometheptene mucate can be a nonaddicting option for intermediate headaches. This agent is similar to Midrin, but it contains caffeine and does not contain the sedative in Midrin, dichloralphenazone. Dihydroergotamine DHE probably is underused. The nasal spray Migranal, others often leads to severe nasal congestion and the injections D. Since , when DHE was introduced, there have been relatively few severe side effects reported.
An inhaled version of DHE is expected be available soon. DHE is primarily a venoconstrictor, so it actually safer than other ergotamines, which are arterial constrictors. Butalbital and opioids, including butorphanol nasal spray, or various forms of fentanyl oral preparations, can be used as a last resort in some patients, with some caveats. Butalbital compounds are controversial and are not used in Europe. Butalbital results in rebound headaches more than do simple analgesics.
Additionally, use of butalbital and opioids in headache patients has been found to increase the risk of transformation from episodic headache into daily headache. Butorphanol and fentanyl are highly addicting and frequently cause side effects. The opioids with quicker onset tend to be overused and have more withdrawal symptoms.
These parenteral opioids should be used very sparingly in carefully selected patients. When sedation is needed, we will occasionally use medications such as quetiapine Seroquel, others or benzodiazepines off label.
The stigma of chronic migraine - Harvard Health Blog - Harvard Health Publishing
When nothing works for refractory headaches, particularly for prolonged menstrual migraines, corticosteroids can be used in limited amounts. It is important to minimize the cortisone dose. We use 2 to 4 mg of dexamethesone or 10 to 20 mg of prednisone every 12 hours as needed. The dose packs deliver a higher dose than usually is necessary. I would usually limit these to three or four tablets a month.
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Triptans should not be used on a daily basis, except in unusual circumstances. Rebound headache always is a consideration and is a remarkably complex subject. The term medication overuse headache has been overused. Many patients are labeled as having medication overuse headache, when in fact they simply have frequent migraines. The major question with rebound headache is which drugs, and how much of these drugs, will trigger rebound. It appears that the butalbital and opioid medications, and the high caffeine drugs—such as the acetaminophen-caffeine combination product—may be more likely to cause rebound.
Transcranial magnetic stimulation TMS is a safe, non-invasive, nondrug abortive treatment. Patients may use the stimulator at home. Over the next few years, I predict that TMS will achieve a larger role as an abortive. Antiemetics are important adjuncts for those with nausea. Ondansentron Zofran, others lets people get on with their day without sedation. We also use other antiemetics, such as metoclopramide or prochlorperazine Compazine, others , which are somewhat sedating. The goal is to keep people out of the ER, and antiemetics help in this regard.
It is a major problem, is difficult to treat, and contributes to analgesic overuse. Preventive therapy is used more often in patients with chronic daily headache than in those whose migraines occur a few times a month. When it comes to preventives, each person is unique. Although comorbidities guide how we proceed, patient preferences also are important. Patients have to be willing to put up with possible side effects. The severity of the chronic headache is important.
We aim our preventive medications at the predominant, more bothersome type of headache and strive to limit the drugs prescribed as abortives. If patients are taking OTC medications and need to take more than 2 a day, we must consider daily preventive medicine. Triptans may be used, but overuse may lead to rebound. Tramadol Ultram, others is a mild opioid that may be useful if patients can limit use to mg or less per day. Any medication used abortively for chronic daily headache should be strictly limited to 2 doses.
Headache diaries or apps, such as ChronicPainTracker may help, but we also need to convey realistic goals to the patient. The rest of the patients discontinued preventives for various reasons. We desperately need more effective preventives with fewer side effects. Tricyclics remain a mainstay of headache treatment. Amitriptyline and nortriptyline can cause weight gain, dry mouth, and constipation, but we use small to medium doses for most patients. For example, I will start a patient on 5 mg of amitriptyline.
Some people remain on 10 or 20 mg of amitriptyline per day for years and do very well. Amitriptyline is metabolized into nortriptyline, which has fewer side effects. Protriptyline is one of the only tricyclics that does not cause weight gain, but it may cause anticholinergic side effects. With protriptyline, patients experience dry mouth and constipation, but there is minimal sedation and no weight gain. One benefit is that the generic tricyclics are very inexpensive. Topiramate Topamax, topiramate ER, others and sodium valproate Depakote, others are the anticonvulsants primarily used for headache prevention.
These are indicated for migraine. Headache patients often discontinue these agents due to annoying side effects, so it is crucial to keep the dosage to a minimum, starting with a low dose and tapering upward. With topiramate, memory difficulties and mental fog are common. Depression or anxiety may occur as well. As the dose is increased, tingling of the extremities can occur due to carbonic anhydrase effects.
Topiramate can enhance weight loss, but these anorexic effects wane over a number of months. With topiramate, many patients do well on 25 or 50 mg, so I will slowly increase to 50 mg and then, if needed, to mg.