Ask the Expert: Chronic or Cyclic Migraine

Chronic or Cyclic Migraine?
I have been diagnosed with chronic migraine headaches. My previous “episode” resolved five months ago. I am in the middle of another episode, which started a week ago. I consulted my primary care provider and then my neurologist and have tried numerous things—a Toradol® injection, Stadol®, Phenergan®, Neurontin® and Fiorinal® with codeine and steroids. I am very foggy from these drugs and feeling very frustrated. I cannot stay drugged nor can I function with the mind-blinding pain.

A. You don’t describe your headache, but you stated that the previous “episode” resolved a number of months previously. If you were free of headache for an extended period of time, then you don’t have chronic migraine. I would think you might have cluster headache, but if it is indeed migraine, then it would fit best in the category of cyclic migraine. This type of migraine headache occurs daily or almost daily for several weeks and then eases off for a few weeks or months.

Lithium carbonate is reported to help this type of headache. Steroids will usually help any type of migraine, but you stated that a course of steroids did not help. Dihydroergotamine (DHE-45) can be used as a nasal spray or injection for a few days and will often control migraine. Likewise, using one of the triptan drugs for a few days may bring relief, but they should not be taken for more than a few consecutive days to avoid getting rebound (medication overuse) headache. The Neurontin you were given is often helpful in controlling migraine but may take several weeks to be effective. Two other antiepileptic drugs, divalproex sodium (Depakote®) and topiramate (Topamax®), are usually more effective in migraine than the gabapentin (Neurontin).

Fiorinal with codeine and Stadol may help the pain, but do not stop the migraine process and, as you note, can be quite sedating. If used daily, they can also cause one to develop rebound headaches.

Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH

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