DOCTORS' BLOG

Archive for December, 2002

A spate of recent double blinded, controlled trials for herbal therapies have, unfortunately, not turned out so well.  A large European study, of over 600 patients, concluded that Feverfew was only mildly, if at all, effective for headache.  Gingko was in the news recently, with conclusions that it was NOT helpful for memory loss.  In addition, Echinacea (used for viral colds, etc) was recently stated to not have worked better for this than placebo.  These results are discouraging, given the fact that we want these milder alternatives to truly work.

The main abortives for clusters remain:

1.  triptans (Imitrex, Maxalt, etc.),
2.  oxygen
3.  analgesics
4.  lidocaine nasal spray
5.  ergots.

Triptans do work the best, particularly Imitrex injections (many cluster sufferers get by with 2 or 3mg, which is half of a vial).  Oxygen, 100% at 7 to 10l/min, works for about 60% of pts.  Analgesics can take the edge off, but do not stop the headache.  Lidocaine is very mildly, if at all, effective, but may be helpful while awaiting something else to work.  Ergots are not used much anymore, but can be very helpful, albeit with more side effects.

Weather changes are one of the top triggers for headache;  about 40% of people with migraine feel that weather is a factor in their headaches.  It is usually when a front is coming in, the pressure drops, and people state that they can ‘feel it‘ with their head.  Many do state ‘I can predict the weather with my head‘.  Since the headaches are often in the front, this may lead to a misdiagnosis of ‘sinus headache‘.  95% of patients, in 2 recent studies, who were diagnosed as ’sinus headache’ are actually suffering from migraine.  More on this later…..

Caffeine is a ‘double-edged‘ sword.  Too much (or in some very sensitive individuals, any) will cause headaches, while some will help headaches.  Caffeine is used as an ‘adjunct’ to certain analgesics (65mg of caffeine in Excedrin, 32mg in Anacin), enhancing the effect of the nsaids.  Studies have shown that adding small amounts of caffeine to ibuprofen renders it more effective than ibuprofen alone.

I try and keep people below 150mg daily of caffeine.  Of course, sensitivity to caffeine varies widely;  some experience rebound headaches from a little, while others may consume large amounts and not suffer rebound.

The caffeine content of the various substances is listed elsewhere on this site;  a typical cup of brewed coffee has 150mg, while instant has 50 to 75mg.  Starbucks is much stronger.  tea (if it has caffeine) has about 30mg per cup, while a can of coke has 40mg.  It is very important to regulate, or consider eliminating, your caffeine consumption.

As with fibromyalgia, irritable bowel syndrome (IBS) is seen in higher percentages of headache patients than in others.  IBS may present with a myriad of symptoms, from constipation/diarrhea to acid reflux to gastritis. The key from a physician’s standpoint is to not exacerbate the IBS, but rather to utilize meds that actually help that particular person’s symptoms.

For instance, if someone has daily headaches, insomnia, and IBS with (primarily) diarrhea, a tricyclic (such as amitryptylline or doxepin) is probably the best choice of preventative.  Constipation is actually a tougher symptom to treat.  In those with IBS, med choices are more restricted because IBS sufferers tend to be sensitive to the meds (or, at least their GI system is…).

The question always arises as to who truly needs an MRI.  With routine headaches, and no neurological symptoms or signs, the usual dictum is that scans are not absolutely necessary.  However, I would never fault any physician who does a scan on all headache patients.  With newer onset headaches, new onset daily headache, neuro symptoms or signs, the ‘worst headache of my life‘,  or a major change in pattern, MRI is often recommended.  Whether you should have one (or a repeat) is a highly individualized decision between you and your doctor (I hope that you do have a doctor!).

…what do they show??…MRI scans are excellent at detecting tumors, multiple sclerosis, and similar pathology.  They do NOT make the diagnosis of migraine, but rather they rule out significant pathology.

I try and encourage people to exercise 15 or 20 minutes (at least) daily, on average. Walking, treadmill, bike, etc., even in 10 min. chunks of time, are the usual. While some people get ‘exercise-induced’ headaches, the majority may benefit from exercise. Even if headaches are not decreased, the benefits of 20 minutes of daily exercise are well-known. The trick is fitting it into your schedule and lifestyle.

Several new triptans (Imitrex-type meds) have come on the market in the past year and a half;  Axert (almotriptan) came out 1.5 years ago, and more recently Frova.  There are pluses and minuses to each.

Axert is relatively mild, with very few chest symptoms;  it is well tolerated, but does not always pack the impact (work as well) as Imitrex.  Frova is longer-lasting, with a half-life of 26 hours, which can be both good and bad.  I will explain more about Frova later.  Frova is mild, takes longer (up to 2 hours) to work, and is good for longer-developing,  slower onset, more moderate migraines.

A recent study investigated this important subject;  even if a headache med. works, nobody is happy if they gain 30lb.  Surprisingly, Prozac topped the list of weight gainers;  even more than the tricyclic nortryptylline.  Depakote did, as we know, cause weight gain, but less than Prozac.  Topomax (topiramate) was the only one to cause weight loss.  In utilizing headache meds, we are always trying to avoid side effects, and weight gain is a primary one.

Depakote ER, Extended Release tablets, are now available in 250mg tablets, as well as 500. 500mg of the ER is approx. equal to 400 of the regular Depakote, but is longer-lasting. The 250mg tabls help with flexibility in dosing.