Timothy C. Hain, MD, Chicago IL.
last updated 1/2003.
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Bookmarks in this document: Treatment approaches, Specific Drugs, Addiction, Rebound Headache, Migraine in Women, Alternative Therapies, Foods
Also see the AMA review article on treatment
Migraines are recurrent headaches separated by symptom-free intervals and accompanied by nausea and light sensitivity. Migraines are often accompanied by visual symptoms and are relieved by sleep; furthermore there is usually a throbbing quality. More often than not there is a family history of migraine. Formal criteria have been defined. Persons with migraine are often prone to become motion-sick. Psychological testing shows unsurprisingly that people with an active migraine headache score more poorly on cognitive tests (Meyer JS et al, 2000).
Although migraine headache is usually unilateral, opposite sides of the head are characteristically affected during different attacks. About 20% of Migraine's are preceded by an "aura" (see picture on the right), meaning visual symptoms, dizziness, numbness, or weakness. In fact, about 1% of the time, the aura may dominate the migraine, and there may be minimal or no headache ! Migraine auras should last 5 to 60 min. Visual auras begin in central field of vision and move to the periphery. Another common visual aura is a scotoma (black spot). There are also sensory auras -- they often move from hand to arm to face and ipsilateral tongue.
Aura mimics include AVM, TIA, and some focal seizures.
There are numerous defined variants of migraine.
Tension headaches are presently thought by some to be a milder type of migraine. They are usually described as a dull ache in the back of the head, over the ears, in the forehead or in a tight band round the neck. Like migraine, tension headaches are made worse by stress, but they are not truly caused by stress.
Other medical problems such as brain tumors or aneurysms are rare in people with headache, but need to be considered, especially in headaches of recent onset.
WHO GETS MIGRAINE ? About 11 million Americans have significant problems with migraine headaches and about 10% of the population get migraines, at least occasionally (Stewart et al, 1994; Lipton et al, 2002). Women are especially likely to get migraine (3:1 female:male ratio, 4:1 during childbearing years). The age group between 30 and 45 has the peak incidence, roughly 25%. Women get more migraine than men because of hormonal fluctuations, and the incidence appears to be increasing in women recently (Rozen et al, 1999). About 4% of children have migraines.
WHAT CAUSES MIGRAINE ? Migraines are generally thought to be caused by a chemical abnormality in the brain due to a combination of familial tendency, trigger factors such as stress, sleep disturbance, hormonal fluctuations, and certain foods. While in the past Migraine was felt to be related to vasospasm, presently it is thought that the blood flow changes are not primary. Instead, it is felt that Migraine is related to abnormal sensitivity to sensory inputs (Goadsby PJ, 2001). Nevertheless, there is recent evidence in the other direction -- migraine is associated with a mutation in a gene that controls a potent vasoconstrictor (Tzourio et al, 2001)
Our most effective medications for migraine (ergots, triptans) manipulate a blood chemical called serotonin. Medications that manipulate another neurotransmitter (dopamine), are also often effective treatments for migraine although they have side effects and dopamine is unlikely to he a central problem (Mascia et al, 1998). Recently it has been proposed that a bacterial infection, Helicobacter pylori, is a cause of as much as 40% of migraine (Gasbarrini et al, 1998). Whether this will be borne out is unclear and this idea does not reflect the present consensus. Migraine does not appear to be related to allergy or immune disturbances in most instances.
HOW ARE MIGRAINES DIAGNOSED ? The diagnosis is made through identification of characteristic features of the headache and examination. In most cases, no X-rays or blood tests are required to make the diagnosis, but in persons with severe and recent headaches, neurological findings, or complicated medical histories, the physician may recommend an MRI or CT scan (Silberstein, 2000). Imaging is generally not necessary if the examination is normal and the headache pattern is unchanged. Lumbar punctures are obtained when subarachnoid hemorrhage is suspected or meningitis. MRI scans may reveal white matter lesions in young persons with migraine. When these are seen, it is the author of this review's policy to encourage the patient to consider use of migraine prophylactic medications (see following sections), and avoid vasoconstrictor medications such as "triptans".
MR angiography can be used to diagnose vascular malformations. MR venography can be used for saggital sinus thrombosis. MR also may detect low-pressure type headaches, tumors, as well as the Chiari malformation. Fortunately all of these are rare.
Persons with prolonged auras (> 60 min) should get coagulopathy testing--to look for lupus antibody, anticardiolipin antibody, protein's C and S, factor V Leiden.
HOW ARE MIGRAINE'S TREATED?
The best strategy seems to be adjust the intensity of treatment to the severity of ones migraine condition (stratified care). It doesn't work as well to start cautiously, and then escalate if the first treatment doesn't work (Lipton et al, 2000). There are (at least) 6 different ways to manage Migraine. In all instances, it is best to keep a "log" of headaches, such as a diary, in order to determine whether or not a particular treatment is effective.
1. Avoid trigger factors:
2. Simple non-drug treatment that should be tried first
3. Pain medications
4. Prophylactic medications: For those who have more than 2 severe headaches/month and in patients with complicated migraine (migraine with stroke-like features), a daily medication may be worth while. These are generally highly effective (about 75% effective), but do require daily regular use. Examples are: Amitriptyline (Elavil), Corgard, Depakote, Inderal, Klonapin, Nardil, Verapamil (Calan, Isoptin). These drugs seem to work via several pathways: some are beta-blockers (e.g. Inderal, Corguard), some are calcium channel blockers (e.g. verapamil), some work via mysterious routes (e.g. Depakote, Nardil, amitriptyline, Klonapin), and some work through serotonin pathways . More information about these is in the next section.
5. Acute, specific medications (also called "abortive" medication): For those who have severe but infrequent headache. Highly effective, especially Imitrex (sumatriptan). There are numerous others in the same family -- Zomig, Maxalt, and Axert, and Frova to name a few brand names. There are also older drugs, called ergots, that have similar effects but have more side effects -- examples of these types of drugs are: Cafergot, DHE, and Ergotamine. Drugs that are dopamine blockers include Metoclopramide and prochlorpromazine.
6. Nausea medications: For those with prominent nausea. Highly effective, but cause some major side effects. Examples are: Compazine, Phenergan, Reglan, Thorazine, Tigan. These drugs also have some utility as abortive agents, presumably because of their effects on the dopamine pathways.
Lipton RB and others. Stratified care vs. step care strategies for migraine. JAMA 2000;284;2599-2605
Migraine prevention drugs
In a recent review (Silberstein, 2000), medications for prevention were grouped into 5 categories: Group 1 are medications with proven efficacy and mild-moderate adverse events. Group 2 are medications with lower efficacy. Group 3 are medications based on opinion. Group 4 are medications with proven efficacy but serious potential side effects. Group 5 are medications proven to have limited or no efficacy. The author of this review usually starts patients with verapamil, and proceeds on to try propranolol and then amitriptyline should verapamil be ineffective.
Calan (Verapamil). (Group 2) Used for prevention. Usual dose is 120 to 240mg per day, SR. SR means sustained release. An effective drug that takes about 2 weeks to work. It is a member of the L-channel calcium channel blocker family. Other calcium channel blockers are generally ineffective (i.e. nicardipine, nifedipine), but Diltiazem is a group 3 drug (possibly effective). About 50% of users develop mild constipation. Sometimes lowers blood pressure. About 1% of users develop palpitations (fluttering feeling in chest). It is usually best to stop taking this drug if you develop palpitations. Safe in patients with asthma, and especially good in patients who also have high blood pressure. Should start with dose mg roughly = weight of patient. Combined use of verapamil or other calcium channel blockers and beta-blockers should, in general, be avoided. Not for use in pregnancy. Verapamil is effective in hemiplegic migraine (Yu and Horowitz, 2003). Flunarizine is a similar drug to verapamil, available in Europe. Flunarizine is at least as effective as propranolol (see later). Flunarizine is likely more effective than verapamil because it combines calcium channel and dopamine blocking activity in a single preparation (Afran et al, 1998).
Carbamazepine (Tegretol) is not effective as a preventive (group 5). A related anticonvulsant, oxcarbazepine (Trileptal) has had some limited success in treating refractory migraine (only about 25% response, Krusz, 2000). Oxcarbazepine is not FDA approved for this indication.
Cyproheptadine (periactin) is a preventive medication mainly used in children. Weight gain is common.
Depakote (sodium valproate). Group 1. Also used for prevention. Usual dose is 250, three times/day. Should not be used in women of childbearing age who are not using birth control. Some authors suggest that this drug is effective for persistent migraine aura (Rothrock, 1997). There are many possible reasons for it working and at this writing, it is not clear which one is correct (Curter et al, 1997).
Elavil (amitriptyline). Used for prevention (Group 1). Usual dose is 50 mg at night but the starting dose is usually 10 mg. Some people do well with just 10 mg. Works very well, but takes 2-6 weeks to work. Amitriptyline doesn't lower the blood pressure. Dry mouth and sleepiness main side effects. Weight gain is also common. Elavil is very inexpensive ! Similar tricyclic type drugs include nortriptyline, doxepin and protriptyline. Amitriptyline is more likely to have serious side effects when used by people with heart block or urination problems or persons over the age of 60.
Fluoxetine (Prozac). Group 1. This medication, a member of the SSRI family (which also includes Paxil, Zoloft, Celexa, and Luvox), is listed as a "group 1" medication for therapy (Silberstein, 2000). There is some evidence that another SSRI, paroxetine (Paxil) improves chronic daily headache (Langemark and Olesen, 1994; Foster and Bafaloukos, 1994). Not everyone agrees that there is good evidence that the SSRI's help (e.g. Goadsby, 2002)
Gabapentin (Neurontin). Group 1. This anticonvulsant is a prophylactic drug for treatment of Migraine (Silberstein, 2000). Gabapentin (strangely enough) does not affect Gaba-b receptors or other commonly studied receptors. It may nevertheless increase glutamate-dependent GABA synthesis and it also binds to the calcium channel. Adverse effects include sleepiness, dizziness, fatigue and weight gain associated with increased appetite. Neurontin is relatively expensive and not very potent.
Inderal LA (propranolol, Group 1) and other beta-blockers such as timonol (group 1). Members in group 2 include atenolol, metaprolol and nadolol. Used for prevention. The usual dose is 60 mg LA in the morning or twice a day. Works as well as Verapamil, but generally has more side effects. Pulse may be slowed. Has a mildly calming effect. Nadolol (Corgard) has a similar effect. Both Inderal and Corgard are non-selective beta blockers. More selective beta blockers include metoprolol (Lopressor, Toprol, dose 25-75 at bedtime) and Atenolol (Tenorman). These may have less side effects than the unselective beta blockers. In general, beta-blockers shouldn't be used by persons with asthma, depression, heart failure, diabetes, or taking allergy shots. This is not an absolute prohibition and in some cases beta-blockers are helpful depending on the overall situation. Combined use of verapamil and beta-blockers should also, generally speaking, be avoided.
Magnesium. Dietary supplements of magnesium as well as intravenous injections of magnesium have been reported to be effective in migraine (Peikert et al, 1996; Mauskop, 1998). It is presently considered a group-2 drug. Brain magnesium has a complicated relationship to migraine (Boska et al, 2002). Magnesium is usually taken as a dietary supplement, in combination with calcium. No prescription is necessary.
Methysergide (Sansert): Very effective but potentially dangerous. Taken in a dose of 2mg TID. Every 6 months, you MUST stop this medication for one month. There is a danger of poor circulation. This drug is a last resort. Some authors recommend getting a CT scan of the kidney area one year after initiating treatment. This drug has recently become unavailable in the US (as of 1/2003).
NSAIDS (non-steroidal anti-inflammatory drugs) are generally group 2. Examples are aspirin, fenoprofen, flurbiprofen, ketoprofen, mefanamic acid, naproxen. Celebrex and Vioxx are low-side effect members of this family. Indomethacin is not effective for prevention (group 5) although perhaps effective as an abortive treatment.
Wellbutrin (buproprion) has been reported useful in small studies for migraine, cluster and chronic daily headaches. Wellbutrin has no clinically significant effect on serotonin neurotransmission.
Zonegran, another anticonvulsant, may have some anti-migraine effects too. Like Topiramate (see section on agents of uncertain efficacy), it is a carbonic anhydrase inhibitor (among other things). Zonegran may also be associated with weight loss. It is too early to say with this new drug whether it will have a role in migraine prevention.
Medications that are not effective in preventing migraine include acebutolol, carbamazepine, clomipramine, clonazepam, clonidine, indomethacin, nicardipine, nifedipine, and pindolol (Silberstein, 2000)
Migraine abortive drugs
Imitrex (sumatriptan) is an example of a category of drugs called triptans. At this writing, this category includes sumatriptan, naratriptan, zolmitriptan, rizatriptan, almotriptan and eletriptan. These drugs are all group-1 agents. These are 5HT-1B and 1D (serotonin) receptor agonists. Some also affect 5HT-1F. Immitrex was first released as an injection given under the skin (subcutaneously) at time of headache. Presently triptans are also available as a pill (50-100 mg is best for Imitrex), as a nasal spray and as a sublingual preparation (Maxalt and Zomig). The sublingual forms are generally preferred because of fast and effective action. A recent addition is Frova, which has a very long half-life (about 26 hours). The triptans are very effective for migraine (about 60-85% relief from active drug vs. 20-40% in placebo) but also very expensive (roughly $30/injection or squirt). There are now some agents which cost a littleless -- Axert for example is about $10/dose. The triptans usually relieve nausea as well as headache. These drugs are also reported somewhat effective for tension headache (Lipton et al, 2000)
Because of the high cost, some pharmacy programs limit quantities to about 4 uses/month. For the injection form, chest pain occurs in 3-5% of patients, usually from esophageal spasm. For the nasal spray, a bitter taste in the mouth is the most common side effect (Ryan et al, 1997). Sumatriptan can be used up to twice/day. Surprisingly, sumatriptan is not effective in children (Hamalainen, 1997). Triptans shouldn't be used by persons with heart trouble or blocked arteries (MaasenVandenbrink et al, 1998). Triptans should not be used within 24 hours of using an "ergot" type medication. Use in hemiplegic or basilar migraine is generally contraindicated. In the author's practice, these drugs are also avoided in persons with MRI evidence of small infarcts, which is not at all uncommon in persons with severe migraine. Coadministration with MAO inhibitors is contraindicated (see preventive treatments). See table under "addictive medications" for guides for use.
Similar medications to sumatriptan (Imitrex) are zolmitriptan (Zomig), rizatriptan (Maxalt). Amerge (naratriptan) is a slower onset, more prolonged version. Frova is a very long half-life triptan. Axert (almotriptan) is also somewhat longer lasting. Some pharmacy programs limit use of Zomig to 6 tablets/month of the 2.5 mg form, or 3 tablets of the 5 mg form, and Amerge to 9 tablets. It is generally felt that it is unreasonable to use triptans more often than every other day. Triptans can lead to rebound (withdrawal) headaches (Limmroth et al, 1998). Inappropriate use of medication including dependence is certainly possible and, because of it's high price, may impact health care spending significantly (Gaist et al, 1998)
An older similar medication, DHE (dihydroergotamine), also group 1, is less used because of greater incidence of side effects. DHE and other ergots are broader in their action than the triptans and this is probably the reason for their increased side effects vs. the triptans. Nevertheless, DHE is now been recent released as a nasal spray preparation (Migranal). DHE are contraindicated in patients with renal or hepatic insufficiency, coronary, cerebral or peripheral vascular disease, and uncontrolled hypertension. These agents are also contraindicated in women who are or may be become pregnant. Caution should be used with ergots in lactating women, in patients also receiving peripheral vasoconstrictors, 5-HT1 agonists, propranolol, nicotine and macrolide antibiotics (PCS, 1999).
As basic research suggests that these medications inhibit firing in trigeminal pain pathways via 5HT1B and D receptors (Goadsby and Hoskin, 1998), in theory at least, this group might also relieve other types of head pain such as sinus headache, tension headache, and toothache.
Naproxen (Alleve 220 mg) and Ibuprofen (Motrin 200 or 400 mg). These medications are "non-steroidals". There are many others -- there is no reason to suspect that they vary in any significant way other than side effects. Recent additions to the family are the "cox-2" inhibitors such as Celebrex and Vioxx. These medications have less stomach side effects but cost a lot more than their older relatives. Non-steroidals or "NSAID" medications are both useful for pain at the time of headache, and may also help on a daily basis. Main problems with them are stomach irritation and diarrhea. Don't take large amounts as these drugs can damage the kidney and liver too. Take with food. Aspirin may work as well. Cost for one of the older type NSAID's is about 0.20 $/day.
Ergotamine tartrate (Wigraine) SL or suppository. Take at time of headache, repeat in 30 minutes if not effective. Wait 3 days before using again. Should NOT be used by persons with heart trouble or poor circulation. Coldness and tingling in the legs suggest a need to stop treatment. Otherwise, contraindications are similar to DHE (see above). Ergotamine is rarely used, being replaced by Imitrex.
Cafergot. This is another ergot preparation, a group 2. It is used at time of headache. Same dose and precautions as Ergotamine tartrate. Suppositories are more effective than the oral dose (maximum 2/day).
Droperidol has been reported as an effective acute treatment for migraine (Silberstein et al, 2003). Because droperidol has been associated with occasional life-threatening side effects, however, we do not recommend it for this purpose.
Isometheptane (Midrin). This is a group-2 drug. Take at time of headache, repeat in 30 minutes, up to maximum of 5. Wait 3 days before using again. Same precautions as ergotamine tartrate above. Midrin is not commonly prescribed at this writing.
Steroids, according to Silberstein (2000), are not effective acute therapies for migraine. Nevertheless, they are often used in a short course to "break" a severe bout of migraine or cluster headache. This suggests they may be effective subacute treatment.
Angiotensin-II receptor blockers. These medications, which are commonly used to treat hypertension, have also been reported to reduce migraine. In a study of 60 patients, candesartan was reported to reduce days with migraine, migraine severity and disability level (Tronvik et al, 2003). At this writing, it seems reasonable to consider this class of medication in persons in whom the standard treatments either have failed or which have unacceptable side effects. More traditional agents such as verapamil or a beta blocker, seem more likely to work and should be tried first unless there are contraindications.Botulinum toxin injection (BT, Botox). Injections of this medication that paralyzes muscles and removes wrinkles have been used to treat migraine. The injections are made into the neck muscles, muscles in the temples, or forehead. Surprisingly, it seems to reduce headache frequency and also vomiting. The mechanism is unclear and perhaps completely due to placebo effect or some other factor (often wrinkles are at the same time). Most studies to date are "open label" design, meaning that a placebo could easily be present. As people usually develop antibodies to botulinum toxin, it seems likely the this treatment will not afford permanent relief. Botox is also very expensive and not FDA approved for headache treatment.
Bromocriptine. This dopamine agonist was reported effective in reducing the frequency of menstrual migraine attacks when given daily (Herzog, 1997). This medication is not commonly used for this purpose. See other comments later in this document on Menstrual migraine.
Dopamine blockers: Haloperidol (Haldol), Prochlorperazine (Compazine), Domperidone, Chlorpromazine, Flunarizine, Metoclopramide have all been reported helpful for migraine (See Perotka article in reference list). These drugs would seem far more likely than many of the others above to produce significant side-effects. They are not used frequently.
Riboflavin. It has recently been reported that riboflavin taken in a dose of 400 mg/day was effective in improving migraine by at least 50% in 59% of 55 patients with predominantly common migraine (Schoenen et al, 1998). The therapeutic "gain" over placebo was 37% for attack frequency. Adverse effects were rare. See comments above r.e. Magnesium. This study is intriguing and it will take time to see if these findings are borne out.
Topiramate (Topamax). This anticonvulstant drug has a large number of pharmacological effects including enhancement of GABA, inhibition of glutamate receptors, sodium channels, and calcium channels. It also has a weak inhibition of carbonic anhydrase. Unlike most headache prevention medications, Topiramate often promotes weight loss. Typical doses are 25mg/day to 80 mg/d. Topiramate is expensive and has peculiar cognitive effects. The author of this review has never encountered a patient willing to tolerate its side effects.
Helicobacter Pylori eradication. It has been recently reported that eradication of this bacteria from the stomach will improve 20% of Migraine sufferers who test positive for Helicobacter (Gasbarrini et al, 1998). Whether this will be borne out is unclear.
ADDICTION TO HEADACHE MEDICATIONS
One is physically addicted when one takes a medication daily, and suffers withdrawal symptoms unrelated to the primary purpose of the drug, when one attempts to stop. Certain common patterns of drug use are generally considered addictive. For example, daily use of narcotics or use of sedative medications during the day usually indicates a physical addiction.
While few people want to be addicted to drugs, from time to time, these agents are needed to keep patients comfortable and productive. In this situation, there should be regular physician supervision and consideration of other approaches than the addictive medication.
If one wishes to stop an addictive medication, one must usually "wean" off. In general, this means cutting down the dose by a significant amount (say by 1/2), every week, until it is entirely stopped. Going "cold turkey" with addictive medications is usually a bad idea.
Narcotics of any kind (Tylenol #3, anything with codeine or hydrocodone, Darvocet, Darvon, Demerol, Vicodin, Percodan, Roxanal, Stadol, and many others. Drug dependence is characterized by repetitive use of a substance that results in problems in three or more areas of life such as : 1). Development of tolerance 2). Development of withdrawal 3). use of substance in larger amounts or for longer periods than intended 4). unsuccessful efforts to cut down on use of substance 5). spending a great deal of time in activities necessary to obtain substance 6). giving up social, occupational or recreational activities because of drug use 7) continuing to use substance despite physical or psychological problems associated with use.
Sedatives or drugs containing sedatives (Fiorinal, Fioricet, Valium, Ativan, Xanax, Klonapin, Equinil). Addiction consists of either daily excessive use (e.g. 5 Fiorinals/day), or significant withdrawal symptoms unrelated to the primary indication for the drug -- for example, unable to sleep after stopping Ativan, Valium or Xanax.
While not generally used for headache, amphetamines such as Dexadrine and Ritalin, and of course alcohol are also addictive.
Ergot drugs and Triptan drugs(DHE, ergotamine, any drug with "ergot" in the name, and anything with "triptan" in the name). The main problem here is "rebound" headaches. Recommendations for MAXIMUM use of medications follow.
|Medication||Maximum Recommended Use|
|Codeine||2 treatment days/week|
|Oxycodone (i.e. Percocet)||2 treatment days/week|
|Butalbital (i.e. Fiorinal)||2 treatment days/week|
|Proproxyphene (i.e. Darvon)||2 treatment days/week|
|Butorphanol (i.e. Stadol)||2 treatment days/week|
|Ergotamine tartrate||8 treatment days/month. Maintain 4 day gap between treatment days|
|Sumatriptan||6 treatment days/month or 2 treatment days/week|
Adapted from table 6 in: Solomon G, Cady R, Klapper J, Ryan R. National Headache Foundation: Standards of care for treating headache in primary care practice. Cleveland Clin. J. Med 64/7, 1997, 373-383
DRUGS THAT OFTEN CAUSE HEADACHE AS A SIDE EFFECT
We do not recommend that you stop prescription medications without the permission of your doctor. However, certain medications can trigger headaches. Note that some medications in the same category that cause headache, may relieve headache. There are far too many medications that cause Migraine to list here, however the most common ones are listed.
Migraine headaches often evolve or transform into daily headaches, and this pattern has been termed the "analgesic rebound headache". Common features are thought to be:
Some authors suggest that in addition there is tolerance to analgesic medication, and efficacy of usually effective medication is compromised by ongoing consumption of immediate relief medications. Whether rebound can occur from sumatriptan is unknown at this writing (1997). However, many authors feel that rebound can occur from ergot medications, so it does seem likely that sumatriptan shares this problem. Treatment involves withdrawal of analgesic medication. This sometimes must be done during a hospital setting.
Reference: Seminars in Headache Medicine, Analgesic Rebound Headache, Vol #2, #3, Sept 1997.
Migraine in Women
Women have more migraine 3 times more commonly than men because of hormonal fluctuations. There is reasonable evidence that the increased incidence of migraines is caused by going from a high to a low estrogen state (Somerville, 1975). Boys and girls prior to puberty have equal rates. Several special considerations apply to women.
Hormones: In women with migraine, birth control pills should be stopped and hormonal supplementation should be stopped. If hormones cannot be stopped, say because of endometriosis, then they should be changed to a constant amount every day. It often takes 2-3 months for the beneficial effects of hormonal manipulations to take effect. Lupron "cycling" therapy, often aggravates migraine, and if practical considering the entire health picture, it should be stopped.
Increased headaches around menses are due to fluctuations in estrogen level (a withdrawal effect). Medications include:
Migraine often (77%) improves during pregnancy. Most clinicians advise avoidance of medication when at all possible, using instead dietary modification, ice, or simply rest.
If medications are deemed necessary, it is generally felt that no migraine specific medications (like "ergots") should be used during pregnancy because of the danger of inducing early labor. Nevertheless, a recent report suggested that there is no difference in pregnancy outcome when sumatriptan is used in the first trimester (Shuhaiber et al, 1998). Preventive medications cannot be used until the third trimester. Then some clinicians use amitriptyline or imipramine as both have a long record of safety during pregnancy. These should be withdrawn 2 weeks prior to estimated date of delivery. Inderal (propranolol) may reduce cardiac performance during delivery, and should be avoided if possible for this reason.
For pain, one may use acetaminophen (tylenol). Birth defects have not been attributed to acetaminophen after almost four decades of use worldwide. Aspirin and non-steroidal anti-inflammatory should be avoided in pregnancy (because of bleeding potential).
Foods and Migraine Headache
About 1/3 of all migraine sufferers are helped by avoiding certain foods or drugs. The following list includes the most common problem foods.
Monosodium Glutamate (MSG), also labeled Autolyzed Yeast Extract, Hydrolyzed Vegetable Protein, or Natural Flavoring: Major sources of MSG include certain soups, Chinese food and "fast" food, soy sauce, yeast, yeast extract, meat tenderizers (Accent), and seasoned salt. Many salad dressings also contain MSG. We advise you not to frequent restaurants that are unable to eliminate MSG from their food. If you turn red after eating something, it may have MSG in it. Headaches an hour or so after eating is the most common timing.
Sulfites (Potassium Metabisulfite). Used as a preservative on salads, seafood, avocado dip. Found naturally in wine and beer. Usually causes asthma symptoms, but can also cause headache.
Alcohol. Red wine, Beer, etc. Red wine is the most likely and vodka is the least likely alcoholic beverage to cause a migraine. Tension headaches may be relieved by alcohol, as opposed to migraine which is often worsened by alcohol.
Chocolate. Includes carob. Chocolate may cause a delayed effect -- the caffeine in chocolate prevents an early headache.
Cheeses, especially ripened or aged cheese (Colby, Roquefort, Brie, Gruyere, Cheddar, Bleu Cheese, Mozzarella, Parmesan, Boursalt, Romano). Cheeses less likely to trigger headache are cottage cheese and American cheese. Pizza may be a problem food. Headaches about 1 or 2 hours after eating are common pattern.
Caffeine. This is complicated. Overuse of caffeine may increase headaches via rebound. Some very sensitive people may develop rebound from as little as 30 mg, but in most people it takes 500 mg of caffeine/day (5 cups coffee).
Nitrates -- found in meat and certain medications for blood pressure and chest pain. Examples of foods are bacon, packaged lunch meats, sausage, hot dogs. Nitroglycerin, Isordil are examples of medications.
Alternative Headache Treatments
Acupuncture: Neutral recommendation. Works in about 40% of headaches, for uncertain reasons. Usually must be repeated on a weekly basis.
Avoidance of drugs: Certain medications and recreational drugs cause headaches. For example, many cold capsules increase blood pressure. Alcohol commonly causes headache. Caffeine can be a problem (see end of this section). Read the PDR or ask your doctor. Avoidance is highly recommended.
Biofeedback: Used for headaches with a tension component. Neutral recommendation.
Chiropractic treatment: Not recommended because manipulation of the neck bones may lead to stroke. Nevertheless, some patients report successful reduction in migraines through chiropractic.
Diet: Highly recommended. Foods may provoke migraine, and your doctor may advise a trial of selected food withdrawal. See list of foods which may provoke migraine.
Drugs available in foreign countries. Flunarizine, a calcium channel blocker, is used extensively for migraine in Europe. It can be obtained legally through the mail, with an appropriate prescription. The usual dose is 5-15 mg daily. However, it seems unlikely that it is much better than drugs available in the US (Verapamil instead of Flunarizine).
Heat or Cold: Recommended. Some headaches, such as tension and sometimes sinus, benefit from heat to the head, such as from a hot shower. Others, usually including Migraine, get worse with heat but may respond to cold packs. Might be worth a cautious try. Don't burn yourself !
Herbal Medicines: Unsure. All herbals are categorized by the FDA as having insufficient data to ensure safety and efficacy.
Feverfew (Tanacetum parthenium, Chrysanthemum parthenium) is advocated to prevent migraine. It contains Parthenolide, a plant-related chemical. Legally, feverfew is a dietary supplement, because it was "grandfathered" into the US regulatory system. Average daily dose is 125 mg of dried leaves. Mouth ulceration occurs in roughly 10% of users of the leaf. This is attributed to contact dermatitis. Feverfew is also available as a capsule, which should not have this problem. Feverfew prolongs the bleeding time. Feverfew interacts with both the NSAIDS and steroids and patients on anticoagulants must be monitored closely. Contraindications include pregnancy and breast feeding. There is no information about the risks of long term use.
White willow bark (Salix alba), used to treat mild headache. Similar to aspirin in side effects . It is estimated that 1-5 Liters of white willow bark tea must be consumed daily to achieve therapeutic effects (in other words, it isn't very potent). Large amounts of intake has been associated with liver toxicity.
St. Johns wort (Hypericum perforatum). Used mainly as an antidepressant but a common component of herbal headache preparations. May interact with SSRI's, meperidine, dextromethorphan, tyramine-containing foods, sympathomimetic amines and trazodone. Can cause photodermatitis, orthostatic hypotension and serotonin syndrome.
Caffeine-containing herbs. Used for migraine to cause vasoconstriction. We see no point in using a herbal preparation for this purpose when there are better standardized preparations.
Lavender (lavandula angustifolia) used as extract, absorbed through the skin. Evening primrose oil (Oenothera biennis) also anecdotal evidence that it alleviates headache.
Magnesium and Riboflavin are dietary supplements that are reported to reduce migraine. Magnesium is usually taken as a combination calcium/magnesium supplement. Riboflavin (sold over the counter in 25, 50 and 100 mg tablets), is used in doses as high as 400 mg/day. This is an extremely high dose, 200 times higher than the RDA. While generally thought to be safe, this safety of this particular dose has not been well established.
Homeopathic: Homeopathy in the strict sense, using very tiny amounts of herbal substances, is not recommended except as a placebo. Herbal medicine (see above) might be helpful.
Massage: Recommended. Especially useful for tension headache. Massage of the temples may be helpful. However, we advise against compression of the arteries in the neck, as this may be dangerous !
Physical Therapy: Recommended after medical clearance (basically a neck X-ray). Useful for headaches due to arthritis in the neck. Not recommended if there is significant disk disease or unstable neck.
Relaxation and sleep: Highly recommended. Migraines are typically triggered by stress, and relieved by sleep. Oversleep may also trigger migraine. Stimulants (like caffeine) help headache in the short term, but may increase headache in the long term by disturbing sleep. Relaxation techniques and careful assessment of sleeping habits is highly recommended. Relaxation techniques such as used in TM are often helpful.
(c) 2002-2003 Timothy C. Hain, MD, all rights reserved