DOCTORS' BLOG

Archive for June, 2009

Feverfew, Petadolex, and magnesium oxide, have all held up in double-blind studies as migraine preventatives.  Petadolex has been the most effective.

1. Petadolex: Commonly used in Europe, this herb has been successful in several well-designed blinded studies.  The usual dose is two per day.  Earlier concerns about carcinogenisis with this family of herbs have decreased with Petadolex.  It is prudent to stop it every three months or so.  Available at 1-888-301-1084.  Petdolex is a very effective preventive.  Patients occasionally experience GI upset or a bad taste.  Usually well tolerated.

2. Magnesium Oxide: It has been shown that magnesium levels are low in the brain of migraine patients.  400 or 500 mg per day is used as a preventive; mild GI side effects may limit use.  250 mg tablets are found in most pharmacies.  Only mildly effective.

3. Feverfew: Feverfew has been demonstrated to be mildly effective in some patients for prevention of migraine headache.  Feverfew can cause a mild increased tendency toward bleeding, and should be discontinued two weeks prior to surgery.  Feverfew should not be used during pregnancy and patients are occasionally allergic to it.  The problem with many herbal supplements is quality control, and certain farms consistently have better quality than others.  The parthenolide content (the active ingredient) varies widely from farm to farm.  The usual dose is two capsules each morning.  Eclectic Institute (a blue and white bottle, widely available in health food stores and Whole Foods) freeze dries their herbs, and the product is highly consistent and reliable.

4. Long Chain Fatty Acids (Omega-3 fatty acids): These may play a role in headache prevention, as well as (possibly) useful for anxiety, HTN, arthritis, high lipids, depression and heart disease.  We usually recommend fish oil or Flaxseed oil, 1000 mg., two or four per day (in studies on depression, eight per day have been utilized).  Fish oil capsules may be more effective than Flaxseed oil.  Oily, fatty fishes 9Salmon, Tuna) contain more than other fishes.  Look for the brands with the highest amounts (EPA/DHA) listed on the back.

5. Coenzyme Q-10: COQ-10 is relatively safe, and has started to be investigated as a headache preventive.  Doses for headache are not known.  COQ-10 may have some positive effects on the heart as well.  We usually recommend 150 to 300 mg daily.

Everybody feels somewhat anxious or worried at times, often increased by stressful events.  Feeling very anxious or constantly worried without stress, and on a chronic basis, may be “generalized anxiety disorder” (GAD).  With GAD, there is usually unrealistic worrying and anxiety.  Symptoms of GAD include some of the following: irritability, trouble concentrating, restlessness, constantly feeling keyed-up, loss of patience, muscle tension, a feeling of shortness of breath, increased sweating, difficulty with sleeping, trouble swallowing (or feeling as if there is a lump in the throat), and heartburn, reflux, or diarrhea.  GAD is often accompanied by irritable bowel syndrome, and by headaches.

GAD may cycle in people’s lives, and certainly is worse with stress.  There is almost always a family history of anxiety, and anxiety usually starts in childhood.  Other anxiety disorders that may occur in childhood or adolescence include: obsessive-compulsive disorder, separation anxiety, and panic disorder.

As with depression, there are a number of differences in the brain, and nervous system, in people with anxiety.  There are changes in certain neurochemicals or transmitters, and genetics has a major role to play.  It is as much a physical disorder as asthma, headaches, or diabetes.

Certainly stressful events may trigger anxiety, but most people with GAD have an inherited physical and chemical difference in their brain.

Anxiety is eminently treatable with exercise, yoga, psychotherapy, biofeedback, and medication.  The medications primarily involve use of the antidepressants and/or the “pure” antianxiety medicines, in particular the benzodiazepines.  Examples of antidepressants include the SSRI’s such as Prozac, Zoloft, etc., and the benzodiazepines include Xanax, Ativan, etc.  While it is inconvenient, and somewhat expensive, to go to a psychotherapist on an ongoing basis,  is very helpful in the long run.

Insomnia is commonly seen in migraine and chronic daily headache patients.

Rules for Better Sleep:

1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more.  Curtailing the time in bed seems to slidify sleep; excessively long times in bed seem related to fragmented and shallow sleep.

2.Set the alarm and get up at the same time every morning, regardless of how much you slept during the night.  A regular awakening time strengthens circadian cycling and, finally, leads to regular times of sleep onset.

3. A steady daily amount of exercise probably deepns sleep.  Yoga, deep breathing/relaxtion excercises may help.

4.Hunger may disturb sleep; a light snack may help sleep.  Caffeine in the evening disturbs sleep, even in those who feel it does not.

5. Alcohol helps tense people fall asleep more easily, but the ensuing sleep is then fragmented.  The chronic use of tobacco disturbs sleep.

6. Use the bed only for sleeping; do not read, watch television or eat in bed.  If unable to sleep, get up and move to another room until you are really sleepy, then return to bed.  The goal is to associate bed with falling asleep quickly.

7. Occasional loud noises disturb sleep even in people whoa re not awakened by noises and cannot remember them in the morning.  Sound attenuated bedrooms may help those who must sleep close to noise.  White noise sound machines or ear plugs help to blunt outside noise.

8. An occasional sleeping pill may be of some benefit, but their chronic use is ineffective in most insomniacs.

9. People who feel angry and frustrated because they cannot sleep should not try harder and harder to fall asleep, but should turn on the light and do something different.

10. Keep the lights in the bedroom down low, even prior to sleeping, because bright lights will awaken your brain.  If a night light is needed, keep it in the bathroom.

Depression is a physical, medical illness with a very strong genetic basis.  Depression usually profoundly affects your feelings, moods, productivity and behavior, and can cause physical problems as well.  Depression is a relatively common illness that affects all ages, and can occur once in a lifetime, or be on a chronic basis.

The symptoms in depression vary widely.  There is usually a depressed mood, with feelings of helplessness, sadness, and hopelessness.  Decreased motivation and loss of interest in the usual pleasurable activities often occurs.  There may be sleep disturbances, either sleeping too much, not enough, difficulties falling asleep, or easy awakening during sleep.  Concentration problems are seen, with a difficult time making decisions, often along with agitation, irritability, fatigue, and feelings of worthlessness.  There may be no interest in sex, and weight can be increased or decreased due to appetite changes.  A serious side effect of depression is suicidal thoughts, or actually committing suicide.

Some people have a “major depression”, where they ahve at least 2 weeks of serious depression, while others have ongoing mild or moderate chronic depression.  Depression may be worse in certain seasons, such as Seasonal Affective Disorder-depression in winter primarily related to a lack of sunlight.  Stressful life events may trigger depression or it may cycle in and out of people’s lives regardless of stress.  Chronic medical illnesses, sickness in one’s family, financial difficulties, and hormonal changes (particularly with postpartum depression) all may trigger depression.

The two primary treatments are medication and psychotherapy.  Exercise may help.  The combination of meds plus therapy is ideal.

Approximately 10-15% of people have strong features of a personality disorder.  General characterisitcs of personality disorders include: lack of insight, poor response to psychotherapy or other therapeutic interventions, difficulty with attachment and trusting, sense of entitlement, the creation of a great deal of chaos and distress in family and friends and co-workers around the person, etc. 

Personality disorders have a wide range of severity, from mild to very severe.  They often flip between victim, rescuer, and persecutor.  Personality disorder patients often create chaos and drama and comorbid substance abuse is common.

In general, therapy only helps people with personality disorders over long periods of time (5-7 years).  The concept of “plasticity” of the brain is very important, as some people can improve naturally over time.  However, our goals and expectations are limited.  The following is a description of some of the more severe personality disorder types.  Many people do not fit neatly into any of these categories, but have features of two or three personality disorder types.

Paranoid Personality Disorder: They tend to be non-trusting, suspicious, very secretive, and see the world as dangerous and themselves as constantly being mistreated.  They doubt the loyalty of anybody around them, are reluctant to confide in others, and believe they are being exploited or harmed.  They become angry very easily and can become violent and dangerous, as most spree killers are examples of paranoid personality disorder.

Antisocial Personality Disorder: These people generally have no regard for the rights of others; they are exploitative, they see themselves as superior, and are very opportunistic.  They are deceitful, steal from people around them, and often have trouble with the law.  They frequently engage in fraudulent activities, make very good ’scam artists’, and generally have no remorse.

Bordlerline Personality Disorder: They have instability of mood, poor self image, and pervasive abandonment fears.  There is an identity disturbance and major boundary issues.  Borderlines usually demonstrate suicidal behavior, very quick shifts from depression to anxiety to irritability, and paranoia under stress.  They tend to split, which is, they see people as wonderful or as terrible, with nothing in between.  suicide becomes more likely as patients get into their high 20’s and 30’s.

Narcissistic Personality Disorder: This is less common, and the people see themselves as being above others, they are grandiose, have a lack of empathy, and have a true sense of entitlement.  They may be very vain and require constant attention.

Many patients do not have all of the characterisitics of one particular personality disorder, but it is a spectrum with several characteristics of a number of personality disorders.  Treatment consists of maintaining limits and boundaries on the person, encouraging long-term weekly therapy, and medications (mood stabilizers/antidepressants) to reduce the anxiety and depression aspects of personality disorder.

4.7% of adults have ADD; it tends to be underdiagnosed, and is one of the more untreated conditions in the country.  ADHD includes the “H” for hyperactivity, but most people lose the hyperactive, fidgety portion by age twenty.  ADD is the most genetic of all psychiatric conditions and we usually screen family members for ADD. 

To have ADD as an adult, you must have had the condition as a child or adolescent.  If you did not,the attention problem as an adult is not ADD, but is a combination of stress, insomnia, medication, or other factors.  Adults with true ADD remember that they had difficulty handing in homework, troubles with boring projects or reading assignments, poor attention span, and working twice as much to achieve half the amount.  The features of ADD include: trouble starting and finishing projects (especially more boring assignments), careless mistakes, irritability, impulsivity, easily distracted, tendency to misplace things, poor attention span, and difficulty remembering appointments.

The cost of untreated ADD is enormous, with a major increase in substance abuse, auto accidents, jail time, and broken or unfulfilled lives.  While many people do learn to compensate for their attentional problem and achieve much in their lives, ADD still takes a great toll on the quality of life, and patients usually do better when treated.

ADD often has other comorbid psychological conditions such as anxiety and depression.  The attention problem interferes with life’s functioning, and leads to more anxiety, stress, and depression in people’s lives. 

The ASRS, Adult Self Report Scale, is commonly used as a screening test for ADD in adults.  The primary and most successful mode of treatment for ADD has been medication.  The “first-line” medications are the amphetamines (Adderall, Adderall XR, Vyvanse) and methyphenidates (Ritalin, Ritalin LA, Focalin, Focalin XR, Concerta).  Side effects of these meds include, among others, anxiety, faster heart rate, and insomnia.  However, these medications do, at times, help headaches and fatigue.

If Adderall or Ritalin-type medications are ineffective, or can’t be used, the second-line drugs include Strattera, bupropion (Wellbutrin), nortriptyline, despiramine or other antidepressants.  As usual, the idea with medication treatment is to find an effective dose, but try and minimize medication.

The comorbidity of migraine with anxiety and depression is well established, both in clinically based studies and in epidemiologic samples from community populations.  The physiologic overlap between migraine and depression is considerable, and antidepressants or mood stabilizers often help both conditions.  In the vast majority of migraine patients who suffer from depression, anxiety is a complicating factor.  The anxiety disorder often precedes the age of onset of migraine, with depression following afterward.  It is likely that shared environmental and genetic factors link migraine and depression.

Several studies have shown that incidences of bipolar I and bipolar II were found to be increased in migraineurs.  Recent studies have confirmed that at least 7% of headache patients fit into the bipolar spectrum and 40 to 50% of bipolar patients have migraines.

The clinical spectrum of bipolar disorders is an evolving concept.  It is the milder end of the bipolar spectrum that tends to be missed; look for those with persistently agitated, angry personalities, with frequent depressions and/or “too much energy”, with a strong bipolar or depressive family history.  They may not have a clear hypomanic or manic episode.  Soft bipolar signs include: early (teens) depression, severe depression, quick onset depression, “bipolar” reaction to certain meds (up all night, mind racing, etc.), agitated angry depression, very high anxiety and mood swings, poor response to medication, and moody personality.  Sleep disorders are commonly seen.  Cyclical depression “for no reason”, with high anxiety, is common for bipolar depression.

Recognizing bipolarity and establishing the bipolar diagnosis is essential for a client’s therapeutic implications.  Undiagnosed bipolar patients often are given a number of antidepressants, with predictable hypomanic (poor) results.  Mood stabilizers often are very helpful for the moods and headaches.  Divalproex sodium (Depakote) is effective for mania, hypomania, depression associated with bipolar disorder, and for headache prevention.  Divalproex sodium has become one of the primary migraine and chronic daily headache preventives.  Lamictal is also becoming one of the most commonly used mood stabilizers and is one of the only effective medications for bipolar depression.  Additionally, the new antiepiletics may prove to be helpful for bipolar disorders and/or migraine. 

The recognition of increased comorbidity between migraine and bipolar illness has important clinical implications.  By broadening our concept of the bipolar realm, we can improve outcome in these patients.  Recognition of the milder end of the bipolar spectrum is crucial, as the clinical stakes for missing bipolar ilness are enormous. 

Unfortunately, medications used for bipolar patients are often more effective for the manic/hypomanic symptoms, leaving the depression frequently untreated.  Bipolar patients spend the majority of their time in depression, and we need better medications.  Many patients need two to four meds (such as Lamictal, Lithium, and an antidepressant).

In the study conducted by Dr. Robbins and Joseph Maides, Jr., DO, only 46% of tested patients obtained significant long-term relief from a preventative medication.  Lack of efficacy was cited as the primary reason for medication discontinuation.

Chronic daily headache poses a significant problem, with 3 to 4% of the population suffering from this condition.  There are a variety of preventative medications available, including (but not limited to): sodium valproate, antidepressants, beta blockers, muscle relaxants, NSAIDS, gabapentin and topiramate.  Many patients cannot tolerate these medications, or efficacy is lacking.  Among those who do benefit, over time the side effects (such as weight gain or fatigue) may cause discontinuation of the medication.  Alternatively, the patient may experience declining efficacy.  Most of the new breakthrough medications have been in the abortive category (particularly the triptans).  There has been a lack of new, novel headache preventatives.

Overuse of analgesics, on a chronic basis, may cause or exacerbate daily headaches.  For these patients, withdrawal of the analgesics often will lead to an improvement in the headache.  The usual preventative medications may be ineffective for those who are overusing analgesics.

There is no doubt that chronic daily headache sufferers are difficult to successfully treat, and medication overuse is a major factor.  Initially, studies indicate a widely varying success rate for the treatment of chronic daily headache, between 47 and 97%.  However, after four years, many of the patients who were able to discontinue their analgesics relapsed into medication abuse (44% in one study, 60% in another study).  Even after one year, 30 to 35% of patients relapsed into overuse of the analgesics.  These patients usually have a poor quality of life.  One major contributing factor to the medication overuse is the failure of the preventattive medications to adequately decrease the chronic daily headache.

There is a disconnect between the results of company-sponsored short-term studies and what we observe, albeit anecdotally, regarding long-term success of dailly preventatives.  We need long-term studies, at least six to nine months, in order to adeequately evaluate daily preventatives.  In addition, we need novel, more effective daily preventatives for chronic daily headache.

Menstrual headaches are often severe, prolonged and debilitating.  The abortive therapy follows the general abortive therapy for migraine.  In addition to the usual abortives, cortisone (Prednisone, Dexamethasone) is effective for many women; they are utilized in very limited amounts.  We use 10 or 20mg Prednisone or 2 to 4mg Dexamethasone every 8 to 12 hours, 3 tabs per month only.  The severe intensity of menstrual migraines often dictates stronger abortive measures.  Triptans are particularly useful.  Many women with severe menstrual migraines require combinations of triptans, low dose cortisone, analgesics, and antiemetics. 

Preventive Treatment: The timing of preventive therapy is difficult for most women; either their menstrual periods are irregular, or the headaches occur at different times.  However, in some women the following may be helpful:

1. NSAIDS (Naproxen, etc.):Effective for many women and usually well tolerated.  There are started one day prior to the expected onset of the headache.  Many NSAIDS have been utilized, including naproxen, ibuprofen, flurbiprofen, meclofenamate sodium, etc.  GI upset is common.

2. Triptans: Frova is a long-acting, smooth, well-tolerated triptan.  Its utility in menstural migraine has been established.  One method of dosing it is 2.5mg once or twice a day for three to five days around the time that the menstrual migraine would occur.  While not as well studied, the other triptans may also be helpful as menstrual migraine preventives.  They are started the day prior to headache onset.

3. Hormonal approaches: Estrogen has been used, but is questionably effective.  Occasionally, the birth control pill, even on a cyclic basis, will reduce headaches.  If used continuously (no break), it may provide some relief.  The birth control pill, however, can also increase migraines.  As with other preventives, hormonal approaches often are disappointing, or they may initially provide relief, with declining efficacy over months.  The most commonly utilized hormonal approach is the continuous b.c.p., with a menstrual period every four months.

1. Legitimize the headache problem as a physical illness.  When we mention that it is a medical condition, primarily inherited, and that there is too little serotonin in the brain in people with headaches, patients respond exceedingly well to this.  Once we have established this, the patients are much more amenable to addressing anxiety, depression, etc. with therapy or other means.

2. In choosing preventives, look at comorbidities, particularly: anxiety, depression, insomnia, gastritis, GERD, IBS, constipation, hypertension, asthma, and sensitivities or allergies to other drugs.  These often determine which way to proceed with medication.

3. It helps to view chronic headaches as a continuum or spectrum.  The “in between” headaches may not fall neatly into the current tension or migraine categories.  Additionally, patients need to accept with chronic daily headaches that it is not a black and white situation.  If a headache is reduced from severe to moderate, then the situation is improved and we should not feel inclined to change all the medication.

4. Preventives do not work for everyone; only 50% (at most) of patients achieve long-term relief with daily preventitive medications.  To see the possible full beneficial effects of preventitives, however, the medication must be used consistently for a minimum of four weeks.

5. It can “take a village to help a person with severe pain”.  Get other “villagers” involved , such as psychotherapy, massage, physical therapy, pain specialists or acupuncture.  We cannot promise patients that their headaches will improve with psychotherapy alone, but coping with headaches and the stresses that headaches produce is often improved with therapy.  Biofeedback is underutilized, and should be offered more often.

6. Learn about and recognize personality disorders.  Additionally, watch for soft bipolar signs in headache patients who have anxiety and depression.  Bipolar disorder tends to be underdiagnosed, and is seen in as many as 6% to 8% of migraineurs, primarily in the mild and soft forms (Bipolar II or III).

7. Heed red flags in your patients on opioids; while pervasive behaviors help to determine addiction, even one red flag early in treatment should be seriously considered.  In using opioids, you must be willing to say NO and set LIMITS.

8. Acceptance of the chronic illness (headache) is a helpful state of mind for patients to achieve and helps to ease anxiety.  When patients feel they can actively help their headaches (“self-efficacy”) by medication or biofeedback or other means, it improves their sense of well-being and enhances positive outcomes.

9. Pain is what the patient says it is, and it’s as bad as what the patient says it is.  Be aware of cultural and ethnic differences in the perception and experience of pain.  Additionally, the “level of pain” is not an accurate predictor of disability in chronic pain patients.  Accurate predictors are active coping, such as therapy, exercise, working, socializing, etc.

10. When we place patients on antidepressants, we need to make it clear that we are trying to directly help their headache by increasing serotonin, and also state that we certainly hope this medication helps with anxiety, depression, etc.  Additionally, for depression to improve, it is important to control pain and, likewise, to help pain, we must treat depression.