Headache Help (24 page)

4. C
ALCIUM
B
LOCKERS
(V
ERAPAMIL
)

These medications help prevent blood vessel constriction, which may occur early in a headache, and also influence serotonin. They are occasionally effective but often cause constipation and allergic reactions. Verapamil (Calan, Isoptin, Verelan) is the most effective calcium blocker. (See Chapter 6 for a full discussion.)

If the first- and second-line therapies don’t help, there are a few more possible avenues to take.

5. F
EVERFEW

Feverfew is a relatively safe herb that may help prevent migraine and daily headaches. There are a number of preparations available. (See Chapters 6 and 14 for details.)

THIRD-LINE MEDICATIONS FOR PREVENTING TENSION HEADACHES

QUICK REFERENCE GUIDE: THIRD-LINE MEDICATIONS FOR PREVENTING TENSION HEADACHES

1. C
   OMBINING
   T
   WO
   P
   REVENTIVES
         Increases risk of side effects but could enhance effectiveness.
   
2. MAO I
   NHIBITORS
   (P
   HENELZINE
   [N
   ARDIL
   ])
         Powerful and sometimes the only thing that works, but strict dietary restrictions are necessary, and weight gain and insomnia are common.
   
3. I
   NTRAVENOUS
   DHE
         Sometimes useful, but requires doctor visits.
   
4. T
   RANQUILIZERS
   (K
   LONOPIN
   , l
   IBRIUM
   , V
   ALIUM
   , P
   HENOBARBITAL
   )
         Occasionally does the trick better than anything else, but can be habit-forming.
   
5. A
   MPHETAMINES
   (R
   ITALIN
   , D
   EXEDRINE
   )
         A last resort; chemical dependency, insomnia, and anxiety are potential problems.
   
6. D
   AILY
   L
   ONG
   -A
   CTING
   N
   ARCOTICS
   (D
   OLOPHINE
   , O
   XYCONTIN
   , K
   ADIAN
   , MS C
   ONTIN
   )
         Provides excellent relief but sedation and constipation are common. May be habit-forming.
   

1. T
AKING
T
WO
P
REVENTIVE
M
EDICATIONS

If you are extremely frustrated with moderate or severe headaches and want quick results, or if you suddenly get severe headaches (usually a combination of daily tension headaches and migraines) that you can’t deal with, your doctor may suggest pushing the preventive strategy ahead at a faster pace by suggesting that you try two preventive medications. Sometimes when one preventive medication doesn’t work, two will. The various preventive medications possess different mechanisms of action.

Common combinations include a tricyclic antidepressant with an NSAID or a beta-blocker; an NSAID with a beta-blocker or a calcium blocker; amitriptyline with propranolol; sometimes valproate (Depakote) with an antidepressant, beta-blocker, or calcium blocker. One or two preventive medications may also be prescribed at the same time as repetitive IV DHE (description follows).

Although the risk of side effects increases with two medications, this treatment is justified if your headaches severely compromise your quality of life.

2. M
AO
I
NHIBITORS
(P
HENELZINE
)

Phenelzine (Nardil) is a powerful medication for migraines and daily headaches (and for depression and anxiety). Sometimes it is the only thing that works. Its use is limited, however, because of strict dietary restrictions (see “Third-Line Medications for Preventing Migraines” in Chapter 6). Some people also object to the common side effects of weight gain and insomnia.

3. R
EPETITIVE
I
NTRAVENOUS
(IV) DHE

Although IV DHE is most effective for migraines, it is sometimes useful for daily headaches as well. If you are dependent on analgesics, your doctor may prescribe DHE to help you withdraw from them. It’s a safe medication but expensive. (See Chapter 6 for a full discussion.)

4. T
RANQUILIZERS

Although only occasionally effective for daily headaches, a tranquilizer is just the right medication for some people. These drugs can, however, be habit-forming so doctors will usually minimize doses and carefully monitor you if you go on one of them.

• C
  LONAZEPAM
  (K
  LONOPIN
  )
  Useful for insomnia and anxiety.
  
• C
  HLORDIAZEPOXIDE
  (L
  IBRIUM
  )
  Relatively mild and well tolerated.
  
• D
  IAZEPAM
  (V
  ALIUM
  )
  Can be useful but habit-forming.
  
• P
  HENOBARBITAL
  May help with anxiety as well as preventing headaches.
  

5. A
MPHETAMINES

These are last-resort medications that are somewhat effective and generally well tolerated, but they can lead to chemical dependency. Insomnia and anxiety are also potential problems. Typical amphetamines used for preventing tension headaches are methylphenidate (Ritalin) or dextroamphetamine (Dexedrine). See Chapter 6 for details.

6. D
AILY
L
ONG
-A
CTING
N
ARCOTIC
O
PIOIDS

The longer-acting opioids, such as methadone (Dolophine), Oxycontin, and Kadian or MS Contin have been used for chronic cancer pain. For those with constant, chronic moderate, or severe pain, these medications sometimes provide excellent relief. The advantage of longer-acting opioids is that they help for eight to twelve hours, as opposed to the shorter-acting medications (such as Tylenol with codeine, Vicodin, and Darvocet). These are actually
less
addictive than the short-acting opioids. (See Chapter 6 for details. Also see Chapter 5 for a discussion of addiction versus dependence.)

CASE STUDIES

Here are several case studies, showing how all this information on tension headaches might be applied.

P
HYLLIS

I
NITIAL VISIT
:
Phyllis is a twenty-seven-year-old woman who is home with a young child. She reports that she first began getting chronic daily headaches at sixteen, but they stopped for a few years, from age twenty-two through twenty-four. They have since returned and are now severe. Occasionally Phyllis gets a migraine, but her primary problem is the daily headache. It hurts all over her head as “an aching pressure” and is present all the time, “twenty-four hours a day.” She says that over-the-counter medications are of no use. Relaxation techniques do help, but she does not want to do the deep breathing and imaging. The headaches are not increased by any triggers that Phyllis can identify. She says, “Whether I am under no stress or great stress, the headache is there all the time, day after day, and is just the same. It hurts a lot.” Chiropractic and massage therapy helped for one or two days, but only minimally. Allergy testing, dental (TMJ) testing, and eye tests were all normal.

Phyllis’s doctor prescribes 10 mg of amitriptyline (Elavil) as a preventive medication to be taken at night.

W
EEK
6:
Phyllis cannot tolerate Elavil because she gained weight and was very tired, even on this low dose. Her doctor prescribes fluoxetine (Prozac), 20 mg each morning, as Prozac usually causes very little sedation or dryness in the mouth.

W
EEK
10:
Phyllis suffers no side effects from the Prozac, but the medication works only moderately well; she says the pain is “fifty percent” better and wants more relief. Her dose of Prozac is raised to 40 mg a day. week 13: Phyllis calls her doctor to say she’s still getting a headache every day and that the 40 mg of Prozac is making her feel tired and “spacy.” The doctor lowers the dose again to 20 mg and prescribes the anti-inflammatory naproxen (anti-inflammatories as preventive medications are prescribed much more in Phyllis’s relatively young age range than for older patients).

W
EEK
16:
Phyllis reports that she is getting no additional relief and the doctor takes her off the naproxen, which carries the risk of gastrointestinal, kidney, and liver side effects. He adds nortriptyline (Pamelor), 10 mg, at night. Phyllis gains some weight, but the headaches are 75 percent improved, and she wishes to stay on Prozac plus Pamelor.

T
HE FUTURE
:
If Phyllis is willing, she can try other preventive medications, such as other antidepressants or valproate (Depakote), but she prefers to stick with her current regimen for now. Beta-blockers, such as propranolol, are also possibilities. Gabapentin (Neurontin) is also a good possibility.

H
EATHER

I
NITIAL VISIT
:
Heather is a thirty-three-year-old stockbroker with a history of severe daily tension headache and one migraine monthly. She’s had the daily headaches since age sixteen, but they didn’t become severe until two years ago. Her job is very stressful, as is her marriage. When Heather saw a physician last year, she was taking sixteen aspirin plus over-the-counter caffeine tablets and six ibuprofen tablets a day. Her blood tests revealed that her liver was irritated and she was having severe stomach pains due to the stress and medicine.

Heather’s physician took her off the aspirin and ibuprofen and prescribed Esgic (a butalbital compound with acetaminophen and caffeine), but Heather is now consuming ten Esgic tablets a day.

She is experiencing some degree of analgesic rebound headache, in which her medication is actually creating more pain for her the next day. This is a common problem and usually occurs when someone takes more than four or five pain relievers (though can range from as little as two to as many as eight) a day.

Heather tapers off the painkillers and gets four injections of intravenous DHE, which is commonly used to help people withdraw from analgesics and to relieve the headaches for a period of time. The key with Heather is to avoid painkillers and to find an effective daily preventive medication.

The physician prescribes nortriptyline (Pamelor), a tricyclic antidepressant that is somewhat milder than amitriptyline (Elavil). They hope that the medication will prevent both the daily tension headache as well as the monthly migraine. Heather also receives a prescription for sumatriptan (Imitrex) tablets for the migraines, but the plan is simply to use preventive medications for her daily pain.

W
EEK
4:
Heather has successfully withdrawn from the analgesics with the DHE breaking the cycle of rebound headaches. The nortriptyline has helped prevent headaches, but her blood tests continue to show some liver irritation, which may have been caused by the nortriptyline. Her daily preventive medication is changed to paroxetine (Paxil), 10 mg each morning.

W
EEK
6:
The Paxil is not helping, so the dose is raised to 20 mg each morning. The liver tests have returned to normal. Heather is not allowed to consume any daily painkillers.

W
EEK
7:
The tension headaches are only about 25 percent improved with the Paxil, so Heather switches back to nortripty line and the dose is slowly increased to the point at which the headaches are 70 percent improved in severity. Her liver tests remain normal. The monthly migraines are gone.

Analgesic rebound headaches can be relatively easily controlled once someone is no longer taking pain medications. The key is to find a preventive medication that will work. In rare situations, in which all of the prevention approaches have failed, daily pain medications may be used in controlled amounts; twelve or fourteen tablets of an analgesic per day is unacceptable. Imitrex works well for Heather’s migraines.

T
HE FUTURE
:
If the nortriptyline stops working or produces unacceptable side effects in the future, there are many other options, including other antidepressants; beta-blockers, such as propranolol (Inderal); verapamil (Isoptin); and valproate (Depakote). Depakote may be the best option; Neurontin is also a possibility. For her migraines, Heather may consider Imitrex injections if the tablets are no longer effective.