So You Think You Have Tried Everything, Do You? Then Think Again. Part I

(This will part I of  4 part series. I will try to post a new part each week)

I recently heard a patient say that she was thinking about giving up on finding a solution for her headaches.  It wasn’t as if her headaches were a minor problem either.  Her headaches were ruining her life. But she felt like she had “tried everything” and nothing had worked.  Not only did she tell me this during our first appointment, but it was almost the first thing out of her mouth.  She had actually come close to canceling her first appointment because she felt so helpless.  However, as I reviewed her story, she had really only tried about 5% of the things that could potentially help her.  So I thought this would be a good time to review all the possible treatments for headache disorders.  It goes far beyond a little chiropractic manipulation, Topamax® and Imitrex®.

Before I start this review, I want to make it clear that I come at this from an evidence-based perspective, and believe that I cannot make claims that are not consistent with the available research.  I will also add that this list should not be taken as a “cookbook” for how to treat headaches.  It takes a lot of skill and knowledge to know how to help a patient navigate through the abundant treatment options and personalize a treatment regimen specifically for them. Dr. Moren and I have a combined 40 years of experience in headache medicine.  We have taken care of thirty thousand patients during this time, the vast majority doing very well.  We go to every major headache meeting and read the headache research journals on a monthly basis to keep up on all the latest information. This gives us the skill set and compassion to make these ideas work in reality.

As I build this list, I will organize it by tiers I – IV, each tier more advanced than the previous one.  What is meant by “abortive” are things that actually turn off the headaches. What is meant by “symptomatic” are things that treat the symptoms but don’t turn off the headaches.  What is meant by “preventative” are things intended to prevent the headaches from even starting.  I will also further divide these tiers into the categories of non-pharmacological (meaning without drugs) and pharmacological (meaning including the use of drugs).

 

Abortive/Symptomatic Non-pharmacological Treatment / Tier I

Behavioral

 

Of course patients should always try behavioral treatments first and continue using them along with all other abortive / symptomatic treatments. These include behaviors such as getting yourself into a dark room where it is quiet.  Some people respond to ice packs or cool wash cloths to the head and some to heat.  You should try to relax, and if you have been trained in biofeedback (see above) it is a good time to use those skills.

 

Some people respond to listening to peaceful music and others to relaxation tapes but many prefer silence.

 

I will mention here, under behavioral, that some people respond to taking caffeine in moderation to help stop a headache.  But sleep can be an effective treatment too and you should avoid the caffeine if there is a chance you can sleep off a headache.

 

I’ve had patients tell me that getting a massage during a bad headache is helpful, but that isn’t always practical.  Others have reported chiropractic manipulation helps.

 

Symptomatic / Abortive Pharmacological Treatment / Tier I

OTC (over the counter) When you start with medications, at the tier I level, use what the safest, cheapest thing that is effective. That usually means over-the-counter medications.
Ibuprofen /Naprosyn Pros: Cheap, easy to find and relatively safe.  At this point in time, we do not believe that anti-inflammatory medications (also called NSAIDs) cause medication overuse headache, a condition where headaches are worsened by medications.

 

Cons: Rarely works alone, although can be taken with other medications (mentioned below). Even though these are OTC, they are not completely safe as they can irritate the GI tract and rarely effect the kidneys.

 

Acetaminophen (plain) or combination with aspirin and caffeine (for example Excedrin Migraine®) Pros: These (especially the combination medications) tend to be more effective than the anti-inflammatory medications mentioned above. They are also cheap and easy to find.

 

Cons: Unlike the NSAIDs, these medications can cause medication overuse headache if used more than 2-3 days per week for long periods of time.  If acetaminophen is taken at too high of a dose, it can also cause injury to the liver.

Medications – Prescription

I will give a brief commentary about the use of prescription medications for the acute treatment of migraine.  Far too often patients are placed on pain killers, either butalbital or narcotics, as the first step.  There are only a handful of rare situations where this is a good idea.  One example is the situation where someone has serious contraindications to all the good headache-specific medications (triptans or ergots, such as Imitrex® or Migranal®) and their headaches are not very frequent,  but are severe.  At the Tier I level, when you need a prescription medication, you should always start with something that can actually treat the headache and not simply cover it up.

 

Triptans

 

Sumatriptan (Imitrex®)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Triptans are a class of medications specific to headaches and work by turning off the headache system within the brain.  I will mention just one example of a medicine in the Triptan class at the Tier I level, sumatriptan (Imitrex®), while there are five others I will mention at the higher tiers.

 

Pros:

In general the triptans are great medications because they go to the source of the headache and mimic the brain’s own system for shutting down a bad headache. When they work well, the headache is actually gone (not just covered up) within two hours and without side effects.  When non-headache specific pain medications are used they simply numb up the head.  However when they wear off, the headache pain comes right back.  Sumatriptan is the only medication I select at the Tier I level simply because it is the oldest, cheapest, and is often the only Tier I level  treatment approved on insurance plans.

 

Con:

Regarding the triptans in general, they do slightly constrict blood vessels, which means you should not use them if you have bad blood vessel disease.  While sumatriptan is the favorite of the insurance companies due to its low cost, it is in the middle of its class for effectiveness but probably has higher side effects (including a tight chest, neck or jaw) than some of the others. This class of medication can cause rebound if used consistently for three days a week or more, over a long period of time.

Midrin® This is not a triptan (mentioned above) but a pain medication that is specific to headaches. It contains acetaminophen plus an ingredient called

Isometheptene.  This ingredient does also constrict blood vessels but that is probably not how it works in headaches.

 

Pros:

 

This medication has been around for decades and many people swear by it.  It can be used sometimes when triptans cannot.

 

Cons:

 

Because it is so old, sometimes it is hard to find. It has left the market several times, only to come back months later.  If you take it as it is prescribed, you could take up to 1,625 MGs of acetaminophen within five hours.  That might be a little hard on the liver.  We don’t know of any liver failure with Midrin so far.

 

It too can cause rebound headaches when taken consistently for more than two days per week for long periods of time.

 

When headaches occur more than one day per week or are exceptionally severe, then the emphasis should be placed on prevention.

 

Nonpharmacological Prevention / Tier I

Trigger Avoidance Looking for and avoiding triggers is always the best starting point for the treatment of migraine.  The truth is however, many people have triggers that are not controllable. Examples of this kind of trigger are menstrual cycles, weather changes, and stress. We also are finding that there are no universal triggers that affect everyone. In fact, many people have no triggers.  It is unrealistic to believe that if you look hard enough, you will find the magic trigger that someday you will be able to avoid to make your headaches go away for good.  Book authors and TV Physicians exploit this hope and cause a lot of disappointment, just like in area of weight loss gimmicks.

 

You will likely find many people advising you about headache diets and other lists of possible triggers that go back for decades.  In fact, we used to put people on very strict migraine diets. We do not anymore as we didn’t find it effective and the science that supports them is modest at best.

 

My suggestion is that you try to stabilize your life as much as possible. Go to bed at the same time, get up at the same time, and take caffeine and alcohol in moderation.  When it comes to food, look for a clear pattern before you give up something that brings joy to your life  . . .  like chocolate.   Because gluten free diets are so vogue right now, it can be tempting to jump on the bandwagon. But I repeat, there is no significant evidence to support that these kinds of diets help in the treatment or management of migraine for most people.

 

However, there is evidence to support the fact that smoking makes headaches worse, so quitting smoking should be a no-brainer.

 

One potential trigger can be other medications you may be taking.  Virtually all medications can cause worsening headaches as a side effect, most notably are the estrogen-containing products and some of the new anti-depressants.

 

The other way that medications can cause headaches to be worsened is by causing rebound headaches, or what we now call medication overuse headache (MOH).  When someone is experiencing MOH, their normal headaches get worse, more frequent and become more difficult to treat over time as the result of taking too many of these medications over long periods of time. The highest risk for MOH are combination analgesics (pain pills that contain more than one product), which include such as prescription medications as butalbital (Fioricet®) and OTC medications such as Excedrin®.  These should not be used more than two days per week and sometimes cutting back on them is the first step towards getting better. It takes three months to get these out of your system, before you can get well. Many people need the support of a headache specialist to get off of these medications.

Supplements The four supplements that have shown some promise of helping to reduce headache are riboflavin, butterbur, co enzyme Q 10, and magnesium. Anyone who claims that some other supplement is helpful, (including feverfew), is not basing their claims on research.  As with trigger avoidance, I wish I could say that there are natural supplements that will prevent your migraines.  However, the truth is that only the few mentioned above have shown benefit and that benefit is modest.  I do encourage my patients to try all four supplements before we move on the next Tier of treatment levels.
Procedures At the Tier I level there are a few procedures that I would suggest. What I mean by “procedures” are any hands-on treatments.

 

Chiropractic treatment is worth trying if you are interested.  To date, I’ve only found one study that was done using good-scientific criteria that supported the use of chiropractic treatment in headache management.  It compared chiropractic treatment to the medication amitriptyline. While the treatments were being done both groups improved. After the treatments ended and both the amitriptyline and the chiropractic treatments ceased, the chiropractic group did better for the subsequent four weeks while the amitriptyline group reverted to baseline or slightly worse.

 

I will make the blanket statement that anyone using “lasers,” magnets (except for the magnetic migraine gun, which is recently FDA approved), “activators”, or other tools is pursuing a treatment that has no basis in science or on the understanding of the human body.

 

Acupuncture may offer benefit. There have been many studies of acupuncture in migraine.  Honestly it is hard to study it fairly, because to do so, you must have a placebo group.  It is really hard to do fake acupuncture for a study. Most of the studies have shown modest benefit for both the real and fake acupuncture.  I will warn that, in my opinion, anyone who claims greater than modest success is not being honest. But I do encourage all my patients to try it if they can.  The biggest downfall of the use of acupuncture is that it is not covered by insurances because of a lack of scientific support.

If you have tried some of the above and you still have headaches one day per week or more, it is time to consider prevention medications.  Next I will mention and comment on those medications which I consider to be in the first Tier. There will be many more medications discussed when we cover the other Tiers.

 

 

 

Pharmacological Prevention Treatments / Tier I

Beta blockers

Propranolol, Nadolol, Atenolol

Pros:

Of the three listed, nadolol and propranolol are most effective. Beta blockers can be highly effective and usually have low side effects. They are generic, cheap (however nadolol recently went up in price) and can be taken once a day. After 40 years of experience with millions of people having taken them, the only thing we can say about long-term use is that people on beta blockers tend to live longer, healthier lives, have fewer heart attacks, and possibly have a lower risk of dementia. So those people who warn you that medications are evil and dangerous, etc. are simply not telling the truth when we’re talking about beta blockers.

 

Cons:

Fatigue can be the most common side effect, and usually occurs at the higher doses of the medication.  You cannot take beta blockers if you have asthma.  There was concern in the 1990s that beta blockers could worsen depression symptoms. Some mental health professionals still believe this.

 

The only negative long term study that has been done suggested that there was an increase in complications if the patient taking beta blockers, were elderly and had undergone major surgery.

Calcium channel blockers

Verapamil, Nimodipine (possibly Nifedipine)

Pros:

These have some of the lowest side effects. Verapamil is relatively cheap, but Nimodipine might be more effective.

Cons:

Verapamil probably doesn’t work for general migraine prevention as well as beta blockers.  However, it may work as well in cases such as migraine with aura and migraine that always occur on one side (a point not proven scientifically).  Nifedipine is probably worse.  Nimodipine might work the best but is very expensive.  The most common side effects are constipation and edema.  The calcium channel blocks are rarely associated with an electrical heart block.

Tricyclic antidepressants

(Amitriptyline, Nortriptyline)

Pros:

Work relatively well and are cheap.   Amitriptyline can also help insomnia.  Both may help other comorbid pain problems such as fibromyalgia. They can be taken once a day. They have been around a long time and have had millions of people take them for extended periods of time.

 

Cons:

They can have some nuisance side effects including dry mouth, modest weight gain and sedation.