Issue #158 - September/October 2007
Responses to questions presented by the headache specialists are not intended to be professional consultations. Final decisions as to treatment should rest with the individual’s healthcare provider.
Concerned about Long-Term Use of Preventive Medication
Q. My neurologist prescribed Corgard® (nadolol) for the prevention of migraines. As a rule, it has been working for years. Weeks go by during which I do not have headaches, while I used to have headaches every day.
I’m concerned, however, that with long-term use this medication may be unhealthy for my heart or other organs. What would be an alternative drug that would work as well? I have tried topiramate, but it did not work.
A. Corgard has been on the market as a blood pressure medication for some twenty years or more. It is in the class of medications called beta blockers. Corgard has a long record of safety and has good, though not the best, evidence as being an effective medication for migraine.
The most effective beta blockers for migraine are propranolol and timolol. Atenolol and metoprolol have very similar levels of proven effectiveness in migraine and have also been around for several decades. There are small differences in the likelihood of side effects between the compounds.
Your concerns bring to mind a personal situation with the use of propranolol for migraine before the pivotal trials for this medication were done in the early 1970s. Patients were put through ongoing testing to assure that the medication would be safe for a healthy heart—it is!
Frederick Freitag, DO
Diamond Headache Clinic
Chicago, IL
Relationship Between the Neck and Headache
Q. I have been suffering from migraines since I was a teenager. More recently, they were coming daily and I suspected rebound headaches. However, I couldn’t go a day without medication, so I couldn’t break the cycle. I was also lying on an ice pack every day.
Then one day, I happened upon the Web site of an ear, nose and throat doctor. He said that anyone who has headaches should do cervical shower exercises. This involved standing in the shower with hot water running on the back of your neck and turning your head to look over your shoulder, holding it for three minutes, and then looking over the other shoulder. This exercise reduces the lactic acid in the muscles and calms them down. For the first time in months, I went two days without a headache. Apparently, the muscles in my neck were in an uproar from the constant headaches.
A. The relationship between the neck and migraine is a complex, but important one. A significant number of people with migraine have neck pain that either accompanies or presages the headache. This is because of the interaction between the main nerve in the brain that carries pain messages (the trigeminal nerve) and the nerves near the spinal cord in the neck. Many patients, like you, do find that neck exercises, physical therapy or flexibility programs (such as yoga or Tai Chi) help to relieve their headaches as well as neck pain.
Often, without realizing it, during a migraine attack or in anticipation of a migraine, we involuntarily tense the muscles of our scalp and neck, exacerbating or triggering the pain. Exercises to learn to relax those muscles, stretch and strengthen them, may give you a boost in managing your own migraine. Your comment about ice underscores the variability of methods patients with migraine use to treat their pain at home. For some, heat seems to soothe the pain more than ice; for others, it’s the opposite. Some of my patients alternate heat and ice on their forehead or scalp, ten minutes of each, to achieve the best relief.
Tucker Tarvez, MD
University of Kentucky Headache Clinic
Lexington, KY
Antihistamine Knocked Out Migraine…and Husband
Q. I am looking for information regarding the use of Atarax® in the treatment of migraines. My husband has suffered from migraines for about 14 years. Nothing he has ever used has worked until he took Atarax during a hives episode. It knocked out his migraine. Unfortunately, it knocks him out, too. I am wondering if this particular drug is ever used in the treatment of migraines.
A. I’m not surprised that Atarax “knocks out” your husband as well as the migraine. Atarax (hydroxyzine) is an antihistamine, primarily used to treat anxiety, relieve itching and as a mild sedative. Although antihistamines as a class are indeed used for some individuals with migraine, and one, Periactin® (cyproheptadine), is especially useful in children, they are not considered first-line therapy for migraine. Periactin has an effect on serotonin, an important chemical in the brain in patients with migraine, as well as on histamine.
I suspect that one of the reasons Atarax works for your husband is its sedative effect. Sleep, by itself, can ameliorate migraine in some patients, especially children, but in many adults as well. Antihistamines are often used for emergency room treatment of severe migraine, along with either narcotics or nonsteroidal anti-inflammatory drugs in a “migraine cocktail,” in part because of the effect of antihistamines on the anxiety that can accompany intense headache pain.
Tucker Tarvez, MD
University of Kentucky Headache Clinic
Lexington, KY
Evidence of a Link between Irritable Bowel Syndrome and Migraine
Q. I suffer from irritable bowel syndrome (IBS) and other gastric disorders. I also get frequent headaches, which seem to follow directly after or concurrent with bowel problems. I cannot find any articles on this linkage and my doctor says he has never heard of such a thing. I know at least one other person who experiences this. Can you recommend any reading sources? Also, I never had headaches until after menopause (11 years ago). Is this common?
A. There is clear evidence demonstrating an association between IBS and migraine, as well as fibromyalgia, mood disorders and overactive bladder. These are all manifestations of a sensitive central nervous system chemistry and a sensitive pain modulation system in the brain. We often call this the “migraine syndrome.”
For the non-medical reader, I recommend two books in particular: The Second Brain by Michael Gershon and Migraine by Oliver Sacks. Another book you might look for is Migraine Free by Roger Cady, MD.
If you really did not have any history of episodic, disabling headaches as a younger woman, then new headaches after age 50 are a “red flag” symptom that should prompt a thorough and careful evaluation to make sure there is no other cause. However, the fact that you have had worse headaches now for 11 years, that you haven’t had progression to more problems, and that you have IBS, all suggest that your headaches are probably part of the migraine syndrome.
James W. Banks, MD
Ryan Headache Center
St. Louis, MO
Exploding Headache Syndrome
Q. My son is a life-long headache sufferer, as am I. He is 43 years old, a rescue paramedic, in good health, a nonsmoker, of normal weight. Over the past two years, a new phenomenon has occurred. He is awakened with what seems at first like a loud explosion, so much so that it causes him to leap out of bed. The first time it occurred, he said it sounded like a gunshot close to his ear. These “explosions” occur approximately once a month and are not necessarily associated with a migraine. He’s even awakened his wife to see if she heard anything. I am constantly researching migraines and headache phenomenon, but have never heard of this and find it very alarming. Can you shed any light on this?
A. Your son has a rare headache disorder, named (surprisingly enough) “exploding head syndrome.” Dr. Pearce first described this in a paper, in 1988, that studied a series of fifty patients. Patients with this syndrome hear an explosive noise or see flashes of light at the onset of sleep or deep relaxation. Usually a migraine follows, but some people do not experience pain. Its relationship to sleep has been well documented and studied. Drs. Sachs and Svanborg did sleep studies during attacks and found no unusual brain wave patterns during the explosions. Drs. Cohen and Kaube suggest a disorder of the circadian rhythms, or the sleep-wake cycle, and group this disorder in with other hypnic, or sleep-related headaches. They also suggest that the hypothalamus is activated in this disorder. All the authors who describe this headache disorder emphasize its benign nature. Nevertheless, a specialist should investigate any dramatic change in a headache pattern.
Your son’s case certainly seems to be associated with a sleep/wake disorder. Irregular sleep patterns seen in paramedics and shift workers often can trigger both headaches and sleep disorders. Clomipramine, lithium, melatonin, nifedipine and indomethacin have been used as a preventive treatment. Reassurance that this is a benign headache disorder is often enough. Your son has a low frequency of exploding headache occurrence and special occupational needs. I would recommend either a headache or sleep specialist to determine which course of action would suit him best.
Deborah Reed, MD
American Migraine Center
Lyndhurst, OH
New Daily Persistent Headache
Q. I have been having headaches 24 hours a day, 7 days a week since the 20th of October, 2006. I am 69 years old and have never had a history of headaches. I have had an MRI, a CT scan and a spinal tap. All of the tests were normal. I was prescribed indomethacin and was told that if it didn’t work within three or four days that it wouldn’t work. It didn’t phase it! I have taken other pain killers, mostly over-the-counter types, and none even come close to helping.
I really don’t believe these headaches are migraines. Everything I have read about migraines seems different. I experience constant pressure around the temples and the back of my head. The pain level is 3 to 4 on a 10 point scale. I am able to sleep and my appetite is good, but I am getting depressed as I don’t know where to turn. Do you have any suggestions?
A. The fact that you know the exact date your headache started, and note that it has continued unabated since that date, suggests to me that you have a relatively newly-recognized headache syndrome called New Daily Persistent Headache (NDPH). I agree that your headaches are not migraine in the strictest sense. Although migraine certainly can become chronic and cause daily pain, migraines generally start periodically. NDPH, however, is a headache that begins one day and continues from that day forward. The pain of NDPH, like yours, is generally on both sides of the head and is described as a “tight” or “pressure” sensation, rather than pulsating.
The fact that your physician prescribed indomethacin suggests to me that s/he was also considering another chronic daily headache syndrome called hemicrania continua, which would be on one side of the head and would respond very well to indomethacin.
Unfortunately, NDPH is a difficult headache condition to treat and your depression regarding this lack of response is very understandable. There are some reports of response to preventive medications, such as topiramate or gabapentin, and to bilateral occipital nerve stimulation, but many patients don’t seem to gain relief from any therapies. The fact that you had a spinal tap is reassuring, as infection within the nervous system or high pressure of the spinal fluid are conditions that should be excluded when considering a diagnosis of NDPH.
Tucker Tarvez, MD
University of Kentucky Headache Clinic
Lexington, KY
Could Triptans Affect Pregnancy?
Q. My daughter is 25 years old and suffers from migraine headaches. She has been using Imitrex® for about six months with good success. I, on the other hand, have been reading about the side effects. She and her husband plan to start a family within the next year or so. She says she won’t take Imitrex while she is pregnant. My question is, will this drug affect her fertility and could past use of the drug harm an unborn child?
A. Your daughter is wise to not take Imitrex, or any other triptan or ergot, when pregnant. Imitrex (sumatriptan) is rated by the FDA as a Category C drug during pregnancy, meaning there have been no adequate scientific trials in humans to assure safety. However, birth outcomes in pregnant women who have used sumatriptan have been studied and recorded in the Sumatriptan Pregnancy Registry. The percentage of poor outcomes (birth defects or stillbirths, etc.) was no greater in these women than that expected in the general population. I am not aware of any data that show that Imitrex would affect fertility. The good news for your daughter is that most women with migraine enjoy an improvement in their headaches when pregnant, especially in the second and third trimester.
Tucker Tarvez, MD
University of Kentucky
Headache Clinic
