Many of my patients come to my office with long lists of physicians, and 10-20 medications that they have tried and have failed to stop their headaches. For many of my patients, their headaches are disabling, they cannot complete their jobs or fulfill their family obligations due to severe headaches.
WHAT CAUSES YOUR HEADACHES?
Much of the research on migraine is still controversial, but all the different researchers agree on the following points:
- Migraine usually improves with age, and less serotonin receptors are found as the patient ages, however, headache worsens in 47% of postmenopausal females.
- headache may flare up in the climacteric, thought to be secondary to fluctuating levels of estrogen
- ERT 2can exacerbate migraine or relieve it.
- Kudrow1 reports a 58% improvement in headache control with reduced dose, continuous ERT that avoids the estrogen withdrawal issue
- since more than 30% of women have been exposed to ERT in menopause, the increased
- stroke risk must be weighed quite seriously; Also, many women have increased headaches when placed on ERT.
- Neri3 investigated 556 postmenopausal women at a clinic and found that 2/3 of women with physiological menopause improved in their migraines, but 2/3 of those who had a surgical menopause had a worsening of their pre-menopausal migraine.
- Greenblatt found that for women who required estrogen for their cardiac status or menopausal symptomology, but developed severe migraines, that their headache could be reduced by adding testosterone and switching from oral to parenteral form (Estraderm) which provides a physiological ratio of estradiol to estrone, and a steady-state concentration.
1.Kudrow L. The relationship of headache frequency to hormone use in migraine. Headache 1975;15:36-40.
2.Christophe Tzourio; British Medical Journal, vol 310, April 1995. and Silberstein S. AASH Proceedings, November, 1997, p. 96
3.Neri I, Granella F, Nappi R, Manzoni GC, Facchinetti F, Genazzani AR. Characteristics of headache at menopause: a clinico-epidemiologic study. Maturitas 1993; 17:31-37
Before I write a script for any medication, I encourage my patients to try non drug treatments, such as:
Acupuncture - found to be most helpful for patients who have frequent adverse reactions to medications, or who cannot take most headache medications due to interactions with their present medications.
Biofeedback Training - indicated for pregnant females or other patients who cannot tolerate adverse effects of medications, or patients who are reaching their maximum dosage on traditional medications
Relaxation techniques including yoga training - same indications as for Biofeedback
Physical therapy - indicated for severe tension headache
Massage therapy - especially effective for tension headache, post-traumatic headache
Occipital nerve blocks - especially indicated for tension and post-traumatic headache
We all agree that many triggers will cause migraine, and that one cranial nerve, the trigeminal nerve is central to the initiation of the migraine.We know that the following precipitants trigger migraine, however, no researcher can give you the details of the precise steps between these well-known triggers and the appearance of the headache patient in the ER with a refractory migraine.
- if HORMONE changes, weather, skipping meals trigger the headache ==> likely migraine headache
- if ALCOHOL triggers the headache ==> consider cluster if it occurs within a few minutes of taking alcohol
- when STRESS is worst ==> headache is usually tension, but when stress is immediately resolved, migraine headache is more common
- changes in SLEEP patterns can trigger both tension and migraine type, but true sleep disruption due to a severe headache may be due to ==> tumor, bleed
- if EXERTION, or if headache occurs abruptly after a change in position, bending ,cough, sneeze triggers their headache ==> they are benign in the majority, but your physician must check for secondary headaches, specifically tumors or systemic causes. Systemic causes that must be ruled out for a headache patient are:
- Anemia
- Carbon monoxide poisoning
- Hyperthyroid/ Hypothyroid
- High blood pressure
- COPD, asthma
- Acute or chronic liver or kidney disease
- Renal dialysis
- Low blood sugar
- Bleeding disorders
- Heart disease
- Infectious diseases: especially CNS Lyme: for more information on Lyme, see below
- Glaucoma headache
- Vasculitis
- Within the brain: Tumors, hemorrhage, stroke, fistula
- by International Headache Society definition of menstrual migraines, 90% of the headaches have to occur within 48 hours prior to menses
- 60% of female migrainers have changes in their usual headache pattern at menses, but have headaches at other times of the month. This is termed menstrual exacerbation, but not true menstrual migraines.
- only 14% of migrainers have exclusively menstrual migraines, with no history of migraine the remainder of the month
Many physicians and patients have asked me why migraines are generated both from low estrogen prior to the menses and from higher, well-controlled estrogen from oral contraceptives or from ERT. The answer lies in Sommerville’s research 1who completed the landmark study
confirming that menstrual migraine is due to a sudden drop in estrogen, not to excessively high or low baseline levels.
Silberstein2 and Cupini3 went on to refine this theory, they found that:
- migraines with aura are more likely to begin with high sustained sex hormone levels such as in pregnancy, and oral contraceptives use
- migraine without aura acts differently, for it is more likely to be triggered by decline in sex hormone levels such as at postpartum or immediately prior to menses
.
However, I am not convinced that this is the entire explanation of hormonally precipitated migraines. More research is being done to ferret out the place of progesterone and testosterone.
1 Sommerville BW. The role of estradiol withdrawal in the etiology of menstrual migraine. Neurology 1972; 22:355-365. and Estrogen-withdrawal migaine. Neurology 1975;25:239-244
2 S. Silberstein. AASH Proceedings, Nov, 1997, p. 82
3 Cupini LM. Sex-hormone related events in migrainous females. Cephalgia. 1996;15:140-4
TREATMENT of MENSTRUAL MIGRAINES
Most important, the patient has to use non-pharmaceutical treatments such as avoiding food triggers, sleep changes, use good sleep hygiene or regularity, immediately prior to menses, if possible, avoid stresses in the week before menses.
Of course, as expected, these benign tools are sometimes not sufficient, and the physician must resort to medications. Almost any class of prophylactic headache medications that the patient presently takes ( such as beta-blockers, calcium-channel blockers, anti-depressants, anti-convulsants, ergotamines, serotonin antagonists used for prophylaxis ) can be increased short-term, approximately 4 days prior to menses and continued for 2-4 days through the menses as needed. Off-label research has shown: Imitrex 25 TID, as per L. Newman and R. Lipton’s small study, Naprosyn 375 mg TID, Midrin one tab QHS, for 4 days prior to menses, then discontinued.
If these medicines do not alleviate the headaches:
Discuss with your physician the benefits and risks of short-term hormonal treatment such as: low-dose estraderm transdermal patch, only for 4 days prior to menses, if there are no contraindications to hormonal therapy.
- in order to lessen the fluctuations of estrogen, oral contraceptives are sometimes recommended, but there is a lot of controversy in the medical community about the wisdom of this choice:
- In study of women placed on oral contraceptives for treatment of their headaches, Ryan 1 found. 33% increased frequency of headache, 33% decreased their frequency, and 33% remained the same.
- However, if aura develops or worsening of the headache occurs, oral contraceptives must be discontinued as there is a significantly increased stroke risk for women on oral contraceptives, which significantly increase blood pressure, lipidemia, coagulability.
1 Ryan, R. A controlled study of the effect of oral contraceptives on migraine. Headache 1978;17:250-1
Patients who have recently had a motor vehicle accident, a fall during work, sports, or in the home often present with a post-traumatic headache. It was previously thought that post-traumatic headaches were almost entirely psychological and tied to the patient’s wish for insurance compensation. However, this has not been supported by evidence.
- Is this a bid for compensation? These are some of the many research studies that have concluded that post-traumatic headache is a true disease, and is not merely an attempt to obtain money from insurance companies.
- RC Packard1 studied patients seen 23 months after the compensation award had been won: only 32% returned to full-time work, 20/50 were not working, and headache was still present in 42/50 patients at 23 months after settlement
Also, see Rimel's study2 documenting the increase in headaches after the acute hospitalization.
Symptoms of post-traumatic/ post-concussive syndrome: headache (80%); psychiatric (50%) (depression, easy fatiguability, diminished libido, personality change), cognitive problems (poor concentration, difficulty with memory), dizziness, which is usually movement associated (50%) , some will have true vertigo. Tinnitus, hearing loss is not uncommon, blurred vision, diplopia seen with brainstem contusion or concussion, diminished taste and smell with shearing of the olfactory nerve fibers are also seen in post-traumatic syndrome.
The most devastating are the cognitive impairments, so the post-traumatic headache patients tend to withdraw, which increases depression. Therefore, the physician has to recognize cognitive changes quickly; often decrease the workload to part-time, so that patients will not get fired. It is necessary to discuss with the patient and the family that they should expect personality changes, increased irritability, decreased ability to handle stress, and that the patient may need cognitive retraining to succeed at his work.
1.Packard RC. Posttraumatic headache: permanency and relationship to legal settlement. Headache. 1992;32:496-500
2.Rimel RW. Disability caused by minor head injury. Neurosurgery. 1981;9:221-8
- During pregnancy there is an increase of estradiol levels by 100 times.
According to Hainline1 women with pre-existing tension headache are not significantly changed by pregnancy
- 67% of women without AURA prior to pregnancy improve, but most women with migraine + aura worsen during pregnancy
- most women with migraines + aura have their first headache during pregnancy or following delivery
RX:
- For those women who do not improve or have their headache worsen, a rational plan is as follows:
1: Make use of all non-pharmaceutical approaches possible: avoid triggers, do not skip meals, keep to regular sleep patterns, biofeedback, relaxation training, nerve blocks, reduced work schedule
2. If possible, defer medications until the second and third trimester when organogenesis is complete
3. If the non-pharmaceutical treatments fail, try Tylenol PO or rectal.
4. If this fails, and the mother’s and fetus’s health begin to be jeopardized by constant vomiting, dehydration, electrolyte imbalance, then the physician must consider short-term medications
5. Avoid vasoconstrictors, as sumatriptan, ergotamines ( because of stimulation of the uterine muscle), midrin ( which potentially affects uterine circulation) are all absolutely contraindicated in pregnancy; also avoid barbituates due to their deleterious effects on the fetus with neurobehavioral and congenital malformations implicated, and ASA with its negative effect on clotting of the mother and fetus, and by affecting prostaglandin synthetase can cause premature closure of the ductus arteriosus
6. Avoid codeine, which in retrospective studies has caused fetal malformation2.
7. Tigan (Trimethobenzamide) is considered the safest of the anti-emetics for the pregnant migraine.
8. If at all possible, avoid prophylactic medications that require daily administration. If absolutely necessary, use Tricyclic antidepressants, Fluoxetine, and Beta Blockers which have had the greatest usage in pregnancy without known teratogenicity.
9. Calcium channel blockers may be safe for prophylaxis, but may theoretically have a tocolytic action on the uterine muscle, so delay or lengthen labor
10. Warn the patient to avoid herbal preparations which can harm the fetus or cause premature labor.
11. Research is divided on the safety of caffeine - a cup of strong coffee early in the headache episode may stop the headache, but a recent study has implicated caffeine in early spontaneous abortion, low birth weight3
12. If an abortive agent is absolutely needed 4; Corticosteroids are effective in aborting acute migraine attacks, and as Prednisone is a category B drug, as it is metabolized before crossing the human placenta, while dexamethasone and cortisone cross the placenta and should be avoided
1 Hainline B. Headache. Neurologic Clinics. 1994;12:443-460
2 Khan K, Chang J. Neonatal abstinence syndrome due to codeine. Arch Dis Child Fetal Neonatal Ed. 1997;76:F59-60
If a patient requires medications, these are the most common medications we use and their adverse effects to monitor for:
A = Anti-convulsants; Just as anti-convulsants have improved seizure frequency for epileptic patients we use the same medications for actively inhibiting over-excited neurons, or nerve cells, that are involved in creating the pain of headache.
Absolute contraindications: pregnancy for most, but not all anti-convulsants, as some anti-convulsants can cause defects in the fetus.
Adverse effects to watch for with anti-convulsants: dizziness, lethargy, nausea/vomiting
S= Serotonin 5HT2 receptor antagonists such as Methysergide (Sansert) or Cyproheptadine (Periactin)
- Adverse effects for Periactin: drowsiness, increased appetite, weight gain, increased growth in children due to interference with regulation of growth hormone
- Adverse effects for Methysergide: excessive scar tissue formation in the pulmonary, and cardiac areas
ACUTE TRADITIONAL HEADACHE MEDICATIONS
- NARCOTICS and partial opioid agonists like Stadol NS (Butorphanol)
- check with Stadol users that they are free from pulmonary hypertension, and cardiac risks; note that patients on diet medications previous to their headache evaluation, should be cleared by a cardiologist before initiating Stadol due to the risk for increasing pulmonary hypertension
- ANTI- EMETICS: dopaminergic antagonists such as Haldol and Thorazine, Risperidal other anti-dopaminergic agents and Olanzapine are used for prevention of headache on an experimental basis.
- BUTALBITAL - CONTAINING MEDICATIONS: Fiorecet/Fioronol or Phrenilin [ same as Fiorecet without caffeine]
Adverse Effects: sedation, rebound headache generation due to butalbital
- MIDRIN ( = isometheptene, a vasoconstrictor, and dichloralphenazone, a sedative, and acetaminophen)
Contraindicated with: MAO inhibitor, renal and hepatic disease, glaucoma, hypertension, Coronary artery disease
- DHE 45 - contraindicated for pregnant migrainer, CAD, peripheral vascular disease,thrombophlebitis, after recent MI or CVA, uncontrolled hypertension
- ERGOTS: Ergotamine tartrate
Adverse effects: These products are derived from a fungus that grows on rye grain. Ergots stimulate alpha 2 receptors causing increased blood pressure
- diarrhea, dizziness, leg muscle spasm, peripheral vasoconstriction so is contraindicated with thrombophlebitis, has caused gangrene, heaviness in the chest and coronary vasospasm
- SUMATRIPTAN (Imitrex) - a serotonin or 5HT1 receptor agonist-same contraindications as above for ergots, also contraindicated with basilar or hemiplegic migraine, most researchers also feel contraindicated with complicated migraine, must wait 24 hours after ergotamine, and 2 weeks after an MAO inhibitor for clearance of these medications before administering Imitrex
- ZOLMITRIPTAN (Zomig) - a new 5 HT1 receptor agonist
- NARATRIPTAN - a new 5 HT1 receptor agonist.
- RIZATRIPTAN - a new 5 HT1 receptor agonist.
- STEROIDS - Decadron 10 mg load IV with 4 mg Q3hr [max = 2 days]
Adverse Effects: avascular necrosis of the femoral head, hyperglycemia, peptic ulcer disease, cataracts, osteoporosis, psychosis
You might be wondering why, as a traditionally trained neurologist, I am interested in alternative medicine. The reason is as follows:
Almost all of the medications used for prophylaxis of headaches have approximately a 60% efficacy rate. This is not a spectacular success rate in treating headaches. Because so many of my patients in my headache/chronic pain clinic have found only moderate or transiently successful relief from traditional medications, and so many of them are asking me if one of the alternative medicine treatments they have heard about is effective or safe, I have become interested in researching what is known about these treatments for chronic pain and headache. The research in alternative medicine is very scanty in US journals, but is significantly more available and of better quality in European, Australian journals
Usually, my patients are concerned about the safety, and effectiveness of many of the medications they see in the health food store, and wonder if they are just throwing away their money on sugar water tablets packed in a beautiful container, and costing quite dearly.
My aim is to give you an even-handed/ unbiased view of both sides of this argument and to make you aware of the dangers of both traditional and non-traditional medications. Also, my second goal is to make you aware of the less than perfect efficacy of traditional medicines for headaches, in which most prophylactic medications are called ‘60%- ers’ as they work for 60% of most patients, but not near 100%, and the scanty research on the effectiveness and safety of alternative medicines.
- My personal aim over the next few years is to strongly encourage traditionally trained physicians to become responsive to their patients who want to know about alternative medicines, and to become knowledgeable enough to advise their patients on which alternative medicines are worth trying out when their traditional medicines fail, and which alternative medicines are a pure waste of money.
Especially in the field of chronic pain and headache where traditional medicines have been less than spectacularly successful; many of my patients asked me the following type of questions which piqued my interest. These are the types of questions you want to make sure that your physician is qualified to answer.
- Can I use feverfew safely with the traditional medications you are giving me?
- What is the efficacy of feverfew in comparison to other analgesics?
- Since you use SSRI’s and tricyclic antidepresssants for treatment of pain, can I safely substitute St. John’s wort for your medications?
- Can I safely use St. John’s wort with some of the medications that I am taking for my headaches?
- Can I use valerian safely to quicken falling asleep as physicians stress that adhering to a fruitful sleep pattern is so important to prevent headaches?
- Is magnesium efficacious and safe for prevention of migraines? Can it be given to me in an acute attack?
- Is riboflavin B2 as effective as the medications you have given me for migraine prophylaxis?
- Which one of these herbs pose a danger to me?
I have found it necessary to unearth the best references possible to answer these patients’ questions. These are the types of questions I will be addressing.
Borage - anti-inflammatory and diuretic
Adverse effects: contains toxic pyrrolizidine alkaloid metabolites causing hepatic failure; note that research was not available as to the presence or absence of these toxic metabolites in the borage oil after the extraction process
Capsaicin (Capsicum frutescens) 25 mg BID - after initial release of substance P, depletes peripheral nerves of substance P, therefore is a potent inhibitor of platelet aggregation
Clove oil - active ingredient Eugenol, induces anesthesia of the trigeminal nerve
no studies available
Feverfew (Tenacetum parthenium) - 125 mg BID, vasodilator, reduces synthesis of prostaglandins and leukotrienes, major contributors to the neurogenic inflammation that leads toward initiation of headaches1 . However, De Weerdt2 disagrees with Johnson and Hylands, as De Weerdt found that feverfew was no more effective than placebo.
Adverse effects: AVOID during pregnancy, some studies report that this is a vasodilator, problems arise when this is combined with strong traditional medications such as Calcium-channel blockers, which also vasodilate
Ginger - 600 mg QID, 1-3 gms TID in fresh root, anti-emetic, analgesic by inhibiting cyclooxygenase formation, a major enzyme in the inflammatory cascade
Adverse effects: gastrointestinal discomfort, may increase gallbladder disease
Magnesium - decreased level of Magnesium found in many patients with chronic headaches3
- can be given both as prophylaxis, Slo-mag 64 mg BID for headache prophylaxis or as MgSo4 1 gm IVP over 5 minutes in ER
Adverse effects: has been associated with possible hepatotoxicity and mortalities in Europe, although some information indicates that the mortalities and hepatotoxicity were due to contaminant with germander, not the scutellaria, itself. Nevertheless, it seems imprudent to use this until we have more information.
St. John’s Wort (Hypericum perforatum derived from chrysanthemum) - anti-inflammatory, antidepressant, serotonin enhancer, also found to be an MAO inhibitor in vitro
Adverse effects: questionable safety with other medications that are contraindicated with MAO inhibitors such as sumatriptan, DHE. Note that this research that SJW is an MAO inhibitor is in vitro only, there is no research confirming that this is an MAO inhibitor when used with humans.
Valerian - sedative/ 1-3 gms of dried herb TID, 300 mg qhs
Adverse effects:excessive drowsiness when mixed with TCA’s
1.Johnson ES, Kadam NP, Hylands DM. Efficacy of feverfew as prophylactic treatment of migraine. British Medical Journal,1985;291:569-73. Also, Murphy JJ, Heptinstall S. Randomised double-blind placebo-controlled trial of feverfew in migraine prevention.The Lancet, July 23,1988.
2.De Weerdt CJ, Bootsman PR, Hendricks H. Herbal medicines in migraine prevention: Randomized double-blind crossover trial of a feverfew preparation. Phytomedicine 3(3):225-230,1996.
3.Mauskop A, Altura B. Intravenous magnesium sulfate relieves migraine attacks in patients with low serum ionized magnesium levels: a pilot study. Clinical Science, 1995; 89:633-636.
4.Schoenen J. High-dose riboflavin as a prophylactic treatment of migraine: results of an open pilot study. Cephalalgia.1994;14:328-9.
My goal in this web page has been to show you that there are positive points and grave concerns about the adverse effects of BOTH traditional and alternative medicines for treating headaches, and that you have to be careful in discussing thoroughly with your physician the benefits and the risks of either type of medication.
FOR MORE INFORMATION on the HERBS MENTIONED
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Disclaimer - Menopause-Online is not intended as medical advice. Its intent is solely informational and educational. The information is not a substitute for talking with your health professional.
