Dr. Robbins Says….

I see many patients with the following scenario; they go to a new neurologist/headache doc, with daily headaches. The doc asks what they are on, then proceeds to tell them that whatever meds they are on cause the headaches. The patient says “..But doctor, I have been on these for 3 months, while my headaches have been there for 18 years!!”…..Of course, rebound does occur, but it is overdiagnosed (in my opinion..but this is my blog, so I can pontificate…)…..We need to know much more about what causes rebound, which drugs, who, why, when yada yada….certainly it does occur, particularly with high-caffeine drugs, butalbital, opioids, some nsaids etc…..

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.

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.

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.

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.