All
you see are MD's pushing Drugs:
MEMBER QUESTION:
What is the current treatment for the outbreak of cluster headaches,
both during flare-ups and as prevention? Currently I've not found
anything that prevents, and the only medication that works during
outbreaks is Stadol; however, I'm afraid of addiction.
DR. DIAMOND:
If this is a patient with episodic cluster headaches, then the
best fast treatment is usually a shot of steroid or a prednisone
taper.
Normally we start at 40 milligrams and drop the dose by 5 milligrams
every five days. Other medications that can be used preventatively
include Topomax, Depakote, Verapamil, Methergine, Sinequan, and
lithium. Some people have found even melatonin can be helpful.
To treat acute attacks, the best therapy is oxygen by mask at
15 liters for 10 minutes. Other acute treatments include Imitrex,
subcutaneiously, DHE 45, lidocaine drops, and Toradol injections.
Stadol nasal spray is addictive, but if used only during attack
time can probably be managed.
MEMBER QUESTION:
I have what my doctor calls silent migraines or chronic daily headaches.
I have them every day and they vary in intensity, instead of
getting terrible pain I get dizzy about three to four times a
week. I get all the pain in the back of my neck at the base of
the skull. I have had all the tests done to rule out inner ear
disorders by three different ENTs. I have also had MRI, four
CT scans, and blood work done. Everything was normal. I have
tried a lot of preventatives such as Verapamil, Inderal, Nortriptyline.
I am now taking Diazepam 2 milligrams twice daily and 30 milligrams
of Elavil at bedtime. Sorry, but I wanted you to know some history.
I was wondering if you suggest I see some special type of doctor
I haven't seen or if there are any medications I should ask the
doctor about? Right now I am seeing a neurologist.
DR. DIAMOND:
I think chronic daily headache and dizziness, either lightheadedness
or the spinning sensation we call vertigo, can live together
in the same patient. Usually a neurologist or headache specialist
can deal with both. If the dizziness is truly vertigo or a spinning
sensation then sometimes seeing someone who specializes in vertigo,
or a physical therapist who helps with balance retraining, can
be useful. A headache specialist can sometimes add some extra
information to a chronic problem, and perhaps more tools for
treatment.
Headache specialists can be found by looking at the National Headache
Foundation web site, or you could call our clinic at 1-800-HEADACHE,
but if we're not convenient perhaps a referral can be made in your
area.
"There are actually only three drugs approved
by the FDA for the prevention of migraines, which is pretty sad."
MEMBER QUESTION:
Unlike most people (from what I can tell), I wake up with my migraines.
I have a prescription for Imitrex, but it doesn't seem overly
effective. Is this because I'm not able to take the med as the
migraine starts?
DR. DIAMOND:
That's an excellent question. We clearly know that patients can
treat their migraines more effectively if they can get their
medication on board within 20 to 30 minutes. Our triptan medications,
like Imitrex, clearly work much more effectively when given early.
Unfortunately, 40%of our patients wake up with their migraines.
There are two approaches to this:
The first is the way you might use your Imitrex. If you're on
tablets and you wake up with frequent migraines then injection
will speed relief, as it will work more quickly.
The second approach involves recognizing symptoms we call prodrome.
About 60% of migraine patients have symptoms that precede their
migraine attacks from three to six hours, and are generally reproducible,
or they can predict them because they've had had a history of migraines
for so long. These symptoms include:
- Carbohydrate craving
- Yawning Neck pain
- Light sensitivity
- Nausea
- Irritability
- Tracking this could be done with a headache diary,
and if you recognize a prodrome, treating before you went
to bed that night might be
helpful.
MEMBER QUESTION:
What are the most prescribed medications for migraines?
DR. DIAMOND:
When we talk about medicines we prescribe for migraine we actually
split it into three categories:
- Acute medicine, or medicines we use to stop a specific migraine
attack
- Preventative drugs, or medications we give if people have
frequent or difficult-to-treat migraines
- Analgesic or rescue
medicine, something to get rid of the pain if we haven't
caught it in time
The most common acute medicine is the family called
the triptans, of which Imitrex was the first, but there are currently
seven
on the market, including Maxalt, Zomig, Relpax, Axert, Amerge
and
Frova. Other drugs that are also effective in reversing a
migraine include the ergot compound; the one we use most in this
family
is DAG 45, which comes both in a nasal spray and injection.
Another drug often put in this class, although not proven to
be effective,
is Midrin. These drugs should not be used in patients with
coronary artery disease or poorly managed hypertension. Other
reversal
drugs or acute drugs include the nonsteroidal anti-inflammatory
drugs.
The preventative drugs are really divided based upon the class
of medication they are and co-existing disorders or conditions
that the patient might have. There are actually only three drugs
approved by the FDA for the prevention of migraines, which is pretty
sad. These medications are Depakote, which is an antiseizure drug,
and two beta blockers, which are blood pressure medicines, Inderol
and Timolol.
We know from clinical experience in smaller studies that there
are other medicines that can help prevent migraine, so some of
the antiseizure drugs, such as Topomax and Neurontin, are used.
Tricyclic antidepressants, such as Elavil, work on chronic pain
and migraine as well as other types of blood pressure medicine.
So there are many choices.
The third category is the analgesics or rescue medicine, and these
are generally either nonsteroidal anti-inflammatory drugs, or medications
containing opiates or some of the atypical antipsychotic medication.
These medicines can all work on pain, but don't necessarily reverse
the process of migraine. In other words, they can get you to sleep
or get you comfortable if nothing else has worked.
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