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Home > Headache Education > NHF HeadLines Excerpts > Reader's Mail Archive > Reader's Mail Archive #162 - May/June 2008
Issue #162 - May/June 2008
Flying Triggers Migraines
Q. When I fly, I usually end up with a migraine. This is not a good way to start a fun, relaxing trip. Is there any way to prevent migraine while flying?
A. Migraine headaches triggered by flight may be related to the relative pressurization that occurs in commercial jet aircrafts. At standard flight altitudes, the condition in the passenger compartment is equivalent to being at between nearly 5000 feet of altitude (similar to Denver) and nearly 8000 feet. At 8000feet, the relative oxygen concentration in the blood is about 93% of normal. This may contribute to developing altitude sickness or at least a migraine.
The drug acetazolamide, which is a mild diuretic and used to treat altitude sickness, may help prevent migraine induced by flying. I recommend that it be taken at a dose of 250 mg twice a day starting the day before flying. Transient numbness or tingling sensations are common. Another side effect is that it can make carbonated beverages taste odd.
Frederick Freitag, DO
Diamond Headache Clinic
Chicago, IL
Does Generic Verapamil Work as Well as Brand Name for Cluster?
Q. I first experienced cluster headaches 30 years ago. They quickly became chronic, occurring twice daily with no period of relief. I was fortunate to find a doctor who had come across a study that indicated that verapamil could block cluster headaches. I started on Calan® (brand name verapamil) 80mg twice a day and within a week had complete relief from the headaches.
Since then, I have tried four times to switch. Once I tried Calan SR (sustained release). Twice I tried to switch to generic verapamil. Once, I cut the dose in half. Each time the cluster headaches returned within two days of changing medications.
Due to the huge price increase for Calan, I would love to be able to use one of the generic verapamil medications, but I’m afraid to try given the previous poor results. Is there any history of different versions of verapamil having varying effectiveness on cluster headaches? I also wonder whether I gave the generic verapamil a fair trial, time wise. Should I have tried it for longer?
A. Generic verapamil 80 mg should work as well as Calan 80 mg, but, like all generics, there are sometimes subtle, clinically-significant differences for idiosyncratic or pharmacokinetic reasons. The longer acting forms of verapamil, such as Calan SR, are sometimes not as effective as the shorter acting forms for cluster headache. My recommendation is to again consider short-acting 80-mg verapamil twice daily. If it’s not effective, consider taking it three times daily or trying the 120-mg dose twice daily.
Stephen Landy, MD
Wesley Headache Clinic
Memphis, TN
Hoping for a Guaranteed Way to Relieve Head Pain
Q. I’ve had chronic daily headaches for over four years. I just cannot get relief. I have tension headaches that typically start at the same time each day. Recently, I’ve been having more and more nausea and visual problems. I fear I may have rebound headache from using ibuprofen nearly daily for so long.
I would like to know if there is an invasive, but guaranteed method for eliminating head pain so I can have my life back. I’m doing a trial with an implant in my forehead, but I haven’t gotten the results I was hoping for. I am now hoping my doctor will allow me to try again with an occipital area implant.
A. If indeed you have tension headaches, I doubt that stimulation of a specific nerve will give you any lasting relief. Tension-type headaches are usually generalized all over the head, not localized to the area supplied by a specific nerve.
There is no guaranteed procedure that will eliminate head pain. Countless different procedures have been tried for many years and none has yet proven successful. Most chronic headaches are due to biochemical dysfunction in the brain; stimulating a nerve or destroying a nerve in the scalp isn’t going to affect the abnormality going on in the brain cells.
The use of daily pain pills, such as ibuprofen, and especially those containing caffeine can be a cause of daily headache. You need to be on a preventive type of medication. The best choice for chronic tension-type headache is one of the antidepressants, such as amitriptyline. Seeking help in identifying and reducing stresses in your life may help reduce your headaches as well.
Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH
Vitamins Have Side Effects, Too
Q. I read on your Web site that some vitamins can cause headaches. I have been off vitamins now for three weeks and feel much better. If I wanted to take a multivitamin supplement without niacin or excessive amounts of vitamin A, what do you recommend?
A. You are raising an important issue—vitamins, like every drug, have potential side effects. One should never assume that just because an agent is ”natural,” it is entirely safe. High doses of vitamin A and niacin, in particular, can be associated with headache. Sometimes, agents that are used to manufacture the vitamin tablet, like some of the sweetening agents and dyes, can cause headaches in susceptible individuals. You can discuss this with your pharmacist, who can suggest another product, but you should also consider whether you need to take multi-vitamins at all.
Mark Green, MD
Columbia-Presbyterian
Headache Center
New York, NY
Migraine Just Keeps Coming Back
Q. have taken Imitrex® since it first came out with successful results about 90% of the time. I began with the injections and now use the 50-mg tablets when I get a migraine, which is about once every seven to ten days. However, for the last five years my headaches have been returning within about 24 hours about 80% of the time that I take Imitrex. They then come back a third time in about 60% of attacks and a fourth time in about 25%. Has any long-term research indicated this to be a problem with Imitrex and the other triptans? Is there something that can be done to prevent it?
A. There is usually no problem redosing Imitrex on a daily basis for three to four days if the drug is effective and well tolerated, but you should consider combining Imitrex (sumatriptan) with a nonsteroidal anti-inflammatory (NSAID) medication such as Aleve® or Advil®. This potentially could decrease your migraine recurrence. In the near future, GlaxoSmithKline may have a combination tablet with both sumatriptan and an NSAID. You should also consider a higher dose of Imitrex at the onset of your migraine headache (as early intervention) or a longer-acting triptan drug such as Amerge® or Frova®. If all this fails, migraine preventive treatment is worth considering as it may decrease the frequency, intensity and duration of your migraines.
Stephen Landy, MD
Wesley Headache Clinic
Memphis, TN
Head Pain Is Gone, but Aura Lingers On
Q. I was first diagnosed with migraine in 1980. The attacks were typical and for the last 10 years I had only a handful of them. Recently, however, there has been a change. I am experiencing frequent aura but the severe pain is mostly gone. I only feel a slight heaviness in my head. Is it something that I should be worried about?
A. It is common for the headache part of migraine to improve or disappear with aging even if the aura symptoms do not. Actually, it is common for the elderly to have auras without headache, often for the first time, and be shocked when they are diagnosed as having migraine.
Mark Green, MD
Columbia-Presbyterian
Headache Center
New York, NY
Chronic or Cyclic Migraine?
Q. 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
Reader's Mail Archive
Issue #162 - May/June 2008
Flying Triggers Migraines
Q. When I fly, I usually end up with a migraine. This is not a good way to start a fun, relaxing trip. Is there any way to prevent migraine while flying?
A. Migraine headaches triggered by flight may be related to the relative pressurization that occurs in commercial jet aircrafts. At standard flight altitudes, the condition in the passenger compartment is equivalent to being at between nearly 5000 feet of altitude (similar to Denver) and nearly 8000 feet. At 8000feet, the relative oxygen concentration in the blood is about 93% of normal. This may contribute to developing altitude sickness or at least a migraine.
The drug acetazolamide, which is a mild diuretic and used to treat altitude sickness, may help prevent migraine induced by flying. I recommend that it be taken at a dose of 250 mg twice a day starting the day before flying. Transient numbness or tingling sensations are common. Another side effect is that it can make carbonated beverages taste odd.
Frederick Freitag, DO
Diamond Headache Clinic
Chicago, IL
Does Generic Verapamil Work as Well as Brand Name for Cluster?
Q. I first experienced cluster headaches 30 years ago. They quickly became chronic, occurring twice daily with no period of relief. I was fortunate to find a doctor who had come across a study that indicated that verapamil could block cluster headaches. I started on Calan® (brand name verapamil) 80mg twice a day and within a week had complete relief from the headaches.
Since then, I have tried four times to switch. Once I tried Calan SR (sustained release). Twice I tried to switch to generic verapamil. Once, I cut the dose in half. Each time the cluster headaches returned within two days of changing medications.
Due to the huge price increase for Calan, I would love to be able to use one of the generic verapamil medications, but I’m afraid to try given the previous poor results. Is there any history of different versions of verapamil having varying effectiveness on cluster headaches? I also wonder whether I gave the generic verapamil a fair trial, time wise. Should I have tried it for longer?
A. Generic verapamil 80 mg should work as well as Calan 80 mg, but, like all generics, there are sometimes subtle, clinically-significant differences for idiosyncratic or pharmacokinetic reasons. The longer acting forms of verapamil, such as Calan SR, are sometimes not as effective as the shorter acting forms for cluster headache. My recommendation is to again consider short-acting 80-mg verapamil twice daily. If it’s not effective, consider taking it three times daily or trying the 120-mg dose twice daily.
Stephen Landy, MD
Wesley Headache Clinic
Memphis, TN
Hoping for a Guaranteed Way to Relieve Head Pain
Q. I’ve had chronic daily headaches for over four years. I just cannot get relief. I have tension headaches that typically start at the same time each day. Recently, I’ve been having more and more nausea and visual problems. I fear I may have rebound headache from using ibuprofen nearly daily for so long.
I would like to know if there is an invasive, but guaranteed method for eliminating head pain so I can have my life back. I’m doing a trial with an implant in my forehead, but I haven’t gotten the results I was hoping for. I am now hoping my doctor will allow me to try again with an occipital area implant.
A. If indeed you have tension headaches, I doubt that stimulation of a specific nerve will give you any lasting relief. Tension-type headaches are usually generalized all over the head, not localized to the area supplied by a specific nerve.
There is no guaranteed procedure that will eliminate head pain. Countless different procedures have been tried for many years and none has yet proven successful. Most chronic headaches are due to biochemical dysfunction in the brain; stimulating a nerve or destroying a nerve in the scalp isn’t going to affect the abnormality going on in the brain cells.
The use of daily pain pills, such as ibuprofen, and especially those containing caffeine can be a cause of daily headache. You need to be on a preventive type of medication. The best choice for chronic tension-type headache is one of the antidepressants, such as amitriptyline. Seeking help in identifying and reducing stresses in your life may help reduce your headaches as well.
Robert Kunkel, MD
Cleveland Clinic Foundation
Cleveland, OH
Vitamins Have Side Effects, Too
Q. I read on your Web site that some vitamins can cause headaches. I have been off vitamins now for three weeks and feel much better. If I wanted to take a multivitamin supplement without niacin or excessive amounts of vitamin A, what do you recommend?
A. You are raising an important issue—vitamins, like every drug, have potential side effects. One should never assume that just because an agent is ”natural,” it is entirely safe. High doses of vitamin A and niacin, in particular, can be associated with headache. Sometimes, agents that are used to manufacture the vitamin tablet, like some of the sweetening agents and dyes, can cause headaches in susceptible individuals. You can discuss this with your pharmacist, who can suggest another product, but you should also consider whether you need to take multi-vitamins at all.
Mark Green, MD
Columbia-Presbyterian
Headache Center
New York, NY
Migraine Just Keeps Coming Back
Q. have taken Imitrex® since it first came out with successful results about 90% of the time. I began with the injections and now use the 50-mg tablets when I get a migraine, which is about once every seven to ten days. However, for the last five years my headaches have been returning within about 24 hours about 80% of the time that I take Imitrex. They then come back a third time in about 60% of attacks and a fourth time in about 25%. Has any long-term research indicated this to be a problem with Imitrex and the other triptans? Is there something that can be done to prevent it?
A. There is usually no problem redosing Imitrex on a daily basis for three to four days if the drug is effective and well tolerated, but you should consider combining Imitrex (sumatriptan) with a nonsteroidal anti-inflammatory (NSAID) medication such as Aleve® or Advil®. This potentially could decrease your migraine recurrence. In the near future, GlaxoSmithKline may have a combination tablet with both sumatriptan and an NSAID. You should also consider a higher dose of Imitrex at the onset of your migraine headache (as early intervention) or a longer-acting triptan drug such as Amerge® or Frova®. If all this fails, migraine preventive treatment is worth considering as it may decrease the frequency, intensity and duration of your migraines.
Stephen Landy, MD
Wesley Headache Clinic
Memphis, TN
Head Pain Is Gone, but Aura Lingers On
Q. I was first diagnosed with migraine in 1980. The attacks were typical and for the last 10 years I had only a handful of them. Recently, however, there has been a change. I am experiencing frequent aura but the severe pain is mostly gone. I only feel a slight heaviness in my head. Is it something that I should be worried about?
A. It is common for the headache part of migraine to improve or disappear with aging even if the aura symptoms do not. Actually, it is common for the elderly to have auras without headache, often for the first time, and be shocked when they are diagnosed as having migraine.
Mark Green, MD
Columbia-Presbyterian
Headache Center
New York, NY
Chronic or Cyclic Migraine?
Q. 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