Dr. Robbins Says….

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.

The cost of Botox, unfortunately, just went up.. from about $390 per 100unit vial to approx $417 a vial.

The cost of Botox does limit it’s use;  the average patient now recieves 50 to 100 units per treatment.  In the earlier days, we used lower doses.  I do think Botox has a role to play in migraine, CDH, and clusters, but the role is still being worked out.

Novartis Pharmaceuticals announced Dec. 2002 that Sansert (methysergide) is no longer going to be available in the United States.  This will create problems for those who have found that the only preventative med that is effective is Sansert.  With most discontinued meds, such as certain types of Cafergot/ergotamine, the compounding pharmacists are able to make up the med.  However, this will not be possible to do with Sansert.  We will need to search for alternatives, and there are a number of alternatives.

There have now been a number of ‘placebo-controlled’ trials of acupuncture for headache patients.  The placebo is done utilizing ’sham’ acupuncture.  Unfortunately, the majority of the trials have failed to demonstrate efficacy for acupuncture over placebo.  We utilized acupuncture in our clinic for several years, but abandoned it due to general lack of efficacy.  Despite the controlled trials, some people do receive benefit from acupuncture for headache.

The question always comes up.. how much does clenching/grinding add to people’s headaches… and the answer is quite complicated.  Some feel it often IS the problem, while others feel it is vastly overstated as a contributing factor for headaches.  I believe that in certain headache-prone individuals clenching, and more importantly grinding (bruxism) does complicate matters, and splints may help.  There is a newer splint, developed by Dr. Jim Boyd (dentist), that is an anterior splint (over the front teeth).  It is fairly comfortable, and is usually worn only at night.  The important thing is to see a very competent TMJ specialist, orthodontist, or dentist good with clenching and splints.  A lot more on this important subject later.  LR

Rebound, or withdrawal headache does exist, but has generally been overstated as a cause of chronic daily headache (CDH). Headache clinic studies, which tend to be skewed toward the more severe patients, indicate a much higher percentage of rebound than better ‘population-based’ epidemiologic studies. These larger studies indicate that only 15 to 20% of CDH patients have rebound.

Rebound is more likely from the analgesics than from the triptans, particularly the ones with more caffeine (such as Excedrin). Too many patients are told ‘You are causing your own headaches, do not take anything for them for at least one month’.  It is enormously frustrating to patients who say “maybe the Excedrin IS causing my headaches, but I had the same headache BEFORE the Excedrin!”   More on this later…

I will be discussing this important subject quite a bit in the next few months.  In addition, we will have a lot on the very important subject ‘What to do when Nothing works’.  Long-acting opioids (Kadian, methadone, oxycontin, MS Contin, Duragesic patch) sustain relief, for at least 6 months, in about 17% of patients put on them.  For those patients, they can greatly enhance quality of life and functioning.  While 17% may not seem too high, it is actually not bad considering that, in this population of headache sufferers, basically nothing else has ever helped.  L.Robbins