Preventive Medications For Headache
Preventive Medications For Headache
by Lawrence Robbins, MD
Author’s note: this guide presents the author’s opinion and clinical experience. Medications must be individually prescribed and used only in conjunction with treatment by a physician. Side effects, as listed in each medication’s PDR description, must be accepted and understood. Some of the medications and treatments listed do not have an official FDA indication for the condition discussed. This guide is not a prescription and does not represent a standard consensus of treatment.
A preventive is chosen with regard to the type of headache and presenting comorbidities—e.g., anxiety, depression, GI upset, medication sensitivities, etc.—and is individualized toward the patient’s needs. In using such medication, a realistic goal is to decrease the tension headache severity by 70%, not to completely eliminate the headaches. It is wonderful when the headaches are 90% improved, but the idea is to keep the medication and any side effects to a minimum. Trial and error is often used to find the best preventive approach for a person and preventive medications may take weeks to become effective. The doses often need to be adjusted and thus patience is necessary with these medications. The physician needs to be available for phone consultations pertaining to the patient’s headaches and medicine. In the long run, preventive medications are effective for approximately 50% of patients.
What Patients Need to Know Prior to Starting a Preventive
Most patients need to be willing to settle for moderate improvement in their head-aches. Preventives may take three to six weeks to work, and there may be only a 50% improvement. The patient must accept this, and be willing to tolerate the possible side effects. Further, patients must be willing to change medications when necessary. They need to be aware that what is effective for someone else may not work for them. Most preventive medications are utilized in medicine for another purpose. Patients should be informed that amitriptyline (Elavil«), for instance, is also used for depression, usually in much higher doses. Patients using Elavil should be told why and be reassured that it is not because they are depressed.
Side effects are possible with any medication. A patient has to be prepared to endure mild side effects in order to achieve results. We cannot stop one medication and switch to another because of very mild side effects. Most patients are usually willing to put up with mildly annoying side effects. Fatigue, however, is a major reason for patients abandoning a preventive medication. Headache patients commonly complain of fatigue, and tend to give up on medications that increase tiredness.
Natural Supplements and Herbs for Headache
Feverfew, Petadolex« (butterbur), and magnesium oxide have all proven effective in double-blind studies as migraine preventives. Of these, Petadolex has been the most effective. Omega-3 fatty acids may help headaches, and are an excellent supplement for general good health.
• Petadolex is commonly used in Europe, and this herbal preparation has been successful in preventing migraines in several well-designed blind studies. The usual dose is 50 mg., twice a day. Earlier concerns about carcinogenesis with this family of herbs have decreased with Petadolex, which is a purified form of the herb butterbur. Patients have occasionally experienced GI upset or a bad taste in the mouth, but Petadolex is usually well tolerated. It is prudent to stop it every three months or so. Petadolex is available by calling 1-888-301-1084 or through www.petadolex.com.
• Magnesium is a naturally occurring mineral that helps many systems in the body to function, especially the muscles and nerves. It has been shown that magnesium levels in the brain of migraine patients tend to be lower than normal. Magnesium oxide is used as a supplement to maintain adequate magnesium in the body. A dose of 400 or 500 mg. per day can be used as a preventive; tablets are found in most pharmacies. However, mild GI side effects may limit use. There are also complications from drug interactions, and kidney and other diseases.
• Feverfew has been demonstrated to be mildly effective in some patients for prevention of migraine headache. Feverfew can cause a mild increased tendency toward bleeding, and should be discontinued two weeks prior to any surgery. The problem with many herbal supplements is quality control. The amount of parthenolide (the active ingredient in feverfew) varies widely from farm to farm; certain farms consistently have better quality than others. Eclectic Institute uses a process that freeze-dries the herbs, making the product highly reliable. It is available in health food stores and at Whole Foods. The usual dose is two capsules each morning. Patients occasionally will be allergic to feverfew, and it should not be used during pregnancy.
• Long Chain Fatty Acids (omega-3 fatty acids) may play a role in headache prevention, and possibly be useful against anxiety, hypertension, arthritis, high lipids, depression and heart disease. We usually recommend fish oil or flaxseed oil, 1000 mg. capsules, two to four per day. In studies on depression, as many as eight capsules per day have been utilized. Fish oil capsules may be more effective than flaxseed oil. Fatty fishes such as salmon and tuna contain more oil than others. Look for the brands with the highest amounts of EPA/DHA listed on the label.
First Line Preventive Medications for Migraine
• Topamax« (topiramate). Topamax is FDA approved as a migraine preventive. A generic is available, but is not always as effective. This anti-seizure medication is utilized for migraine, CDH, and cluster headache. It does not irritate the liver. Sedation and cognitive side effects (such as confusion or memory problems) may limit its use. Topamax often decreases appetite, which leads to weight loss; this is unusual among headache preventives. The starting dose is 25 mg. once or twice daily; this may be pushed to 100 mg. once or twice per day. 100 mg. daily is the usual dose. It is usually well-tolerated in lower doses and may be effective as a mood stabilizer for some milder bipolar patients. GI upset may occur. Acute glaucoma has been a rare side effect. The risk of forming kidney stones is increased by the use of Topamax. Bicarbonate levels should be monitored, as Topamax may cause a dose-related metabolic acidosis.
• Depakote« (Valproate). This seizure medication is a long time staple, popular for migraine prevention. It is usually well tolerated in the lower doses utilized for headaches. The generic may not be as effective. Liver functions need to be monitored in the beginning of treatment. Side effects include lethargy, GI upset, depression, memory difficulties, weight gain and alopecia. Dosage ranges from 250 to 1500 mg. per day, in divided doses. The average dose is 500 to 1000 mg. per day. Levels need to be checked for toxicity on the higher doses. Depakote is also one of the primary “mood stabilizers” for bipolar. Available in 125, 250 and 500 mg. tablets. Depakote ER, 500 mg., is an excellent long-acting tablet that may be dosed at once daily. Depakote 250 ER is also available. As with most preventives, Depakote needs four to six weeks to become effective. It is FDA-approved for migraine prevention. Depakote should not be used during pregnancy.
• Beta Blockers. Effective for migraine. Long-acting (LA) Inderal« (propano-lol) capsules may be dosed once per day. Occasionally effective as a preventive for daily headaches. Sedation, diarrhea, lower GI upset and weight gain are common. Very useful in combination with amitriptyline. Dosage begins with the long-acting at 60 mg., and is usually kept between 60 and 160 mg. per day. Lower doses are sometimes effective, such as 20 mg. of propranolol twice a day. Other beta-blockers are also effective, such as metoprolol (Toprol« XL) and atenolol. Some of these are easier to work with than propranolol because they are scored tablets, and metoprolol and atenolol have fewer respiratory effects. Depression may occur. Beta blockers are useful for those with concurrent hypertension, tachycardia, panic, anxiety, and mitral valve prolapse. A new beta-blocker, nebivolol (Bystolic«), may be helpful, and has fewer side effects.
• Amitriptyline (Elavil« and other tricyclics). Effective, inexpensive and also useful for daily headaches and insomnia. Use in low doses at night. Sedation, weight gain, dry mouth and constipation are common. Starting dose is 10 mg., and titrated up to 25 or 50 mg.; can be pushed up to 150 mg. or decreased to 5 mg. Other tricyclic antidepressants such as doxepin and protriptyline can be effective for migraine. Nortriptyline is similar to amitriptyline, with somewhat fewer side effects. These are also used for daily tension-type headaches. Pro-triptyline is one of the few older antidepressants that does not cause weight gain. However, anticholinergic side effects are increased with protriptyline. While the SSRIs are utilized, they are more effective for anxiety and depression than for migraine. Tricyclics are more effective for pain than are the SSRIs.
• Naproxen (Naprosyn«, Naprelan«, Anaprox«, Aleve«, and other NSAIDs). Useful in younger patients; once a day dosing. Sometimes helpful for daily headaches, but particularly useful for menstrual migraine. Non-sedating, but frequently causes GI upset. Effective as an abortive and may be combined with other first line preventive medications. The usual dose is 500 or 550 mg., once a day, but this may be pushed to twice a day. Other anti-inflammatories can be utilized for prevention of migraine. As with all anti-inflammatories, GI side effects increase as people age, and so these are used much more in the younger population. With daily NSAIDs, blood tests are needed to monitor liver and kidney function.
• Verapamil. Reasonably effective for migraine; once a day dosing with the slow release (ER) tablets. Usually non-sedating, and weight gain is uncommon. Occasionally helpful for daily headaches. May be combined with other first line medications, particularly amitriptyline or naproxen. Constipation is common. Starting dose is 1/2 of a 240 mg. ER tablet, increasing quickly to one 240 mg. tablet per day. May be pushed to 240 mg. twice a day, or decreased to 120mg. or 180 mg. per day. With doses higher than 240 mg. daily, an EKG needs to be done.
• Natural Supplements and Herbs. Many patients prefer to start with the natural preventives. Petadolex, a safer form of the herb butterbur, has been the most effective natural preventive. It has held up well in multiple trials. It is widely used in our office and effective for all ages. See previous section titled “Natural Supplements and Herbs for Headache.”
Second Line Migraine Preventive Therapy
• Botulinum Toxin Injections. Botulinum Toxin A (Botox«, Dysport«) has been studied extensively in migraineurs. Approximately 50% to 60% of patients have significant relief after botulinum injections. Low doses are usually used (50 to 100 units total per patient, in 8 to 12 injections) primarily in the frontal and temporal areas. While it is expensive, Botox is relatively safe and only takes a few minutes to inject. One set of injections can decrease the headaches for 1 to 3 months. Posterior (occipital) or upper cervical injections are starting to be investigated and appear to have some utility. Botulinum toxin may be safer than many of the medications that are utilized for headache.
• Gabapentin (Neurontin«; generic available). Neurontin is an anti-seizure medication that has been de-monstrated to be useful in migraine and tension headache prophylaxis. Tablets are available in 100, 300, 400, 600 and 800 mg. sizes. The usual dose for headache prevention is 600 to 2400 mg. per day. In a large study on migraine, doses averaged around 2,300 mg. per day, but lower doses are usually prescribed. Some patients do well with very low doses (200 or 300 mg. per day). Sedation and dizziness may be a problem. However, Neurontin does not appear to cause end-organ damage, and weight gain is relatively minimal. Neurontin can be used as an adjunct to other first line preventive medications. The generic, gabapentin, is now widely in use. A newer drug, Lyrica« (pregabalin), has a similar mechanism of action to gabapentin. Lyrica is an anti-seizure drug, but is useful for preventing pain. Side effects are similar to those of gabapentin. The dose of Lyrica varies from 25 mg BID to 150 mg TID.
• Polypharmacy. Two first line medications are used together. The combination of two preventives is more effective than one drug alone. Depakote is often combined with an antidepressant. Amitriptyline may be combined with propranolol, particularly if the tachycardia of the amitriptyline needs to be offset by a beta-blocker; this combination is commonly used for “mixed” headaches (migraine plus chronic daily headache.)
The NSAIDs may be combined with most of the other first line preventive medications. Thus, naproxen is often given with amitriptyline, propranolol or verapamil. Naproxen is employed simultaneously as a preventive and abortive medication. Poly-pharmacy is commonly employed when significant comorbidities (anxiety, depression, hypertension, etc.) are present.
• Tizanidine and Cyclobenzaprine. A safe, non-addicting muscle relaxant, tizanidine is useful for migraine and CDH. The usual dose is one or two 4 mg. tablets qhs; the 4 mg. tablets are double-scored, so that patients may begin with 1/4 or 1/2 tablet. Sedation and dry mouth are common. Tizani-dine may be used on as needed basis for milder headaches, or for neck or back pain. A 2 mg. tablet is also available. Cyclobenzaprine (10mg) is helpful for sleeping, and helps some with migraine and chronic daily headache. A half- tablet maybe used. Sedation is a common side effect.
• Ace inhibitors and ARBs. There have been a number of studies on this category of blood pressure meds; ARBs are preferred due to the minimal side effects. Examples include Cozaar« (losartan), Benicar«, and Atacand«. For the patient with hypertension and migraine, these may be useful. Side effects include dizziness, among others, but they are usually well tolerated, with no sedation/ weight gain.
• Antidepressants (Effexor« XR, Cym-balta«, Pristiq«). Effexor XR is an excellent antidepressant; used primarily as a SSRI at lower doses, and at 100 to 150 mg., norepinephrine is also increased. The generic form of Effexor may not be as effective. The antidepressants with dual mechanisms (serotonin and norepinephrine are more effective for pain and headache. Doses vary from 75mg to 225mg, and Effexor XR is particularly useful for anxiety with depression. Pristiq is an excellent newer version of Effexor. Duloxetine (Cymbalta) also has a dual mechanism of action, and has been useful for pain.
When to Proceed Quickly to Two Simultaneous Preventives
With most patients, we utilize one preventive medication at a time, beginning with low doses and slowly raising the dose as needed. Most patients appreciate the approach, and are willing to wait for the medication to work.
At times, patients can become ex-tremely frustrated with their headaches, and desire quick results. When these patients suffer from moderate or severe chronic daily headache, or with severe migraines, pushing ahead at a faster rate with a preventive approach is justified. For instance, amitriptyline and verapamil, or amitriptyline and propranolol may be initiated at the same time. Alternatively, doses of a single medication may be increased rapidly. The initial amount of preventive medication utilized for a patient depends upon the severity of the headaches and the frustration level of the patient.
Patients with new onset of severe headaches, typically daily headaches plus migraine, are often extremely upset and frustrated with the pain. In this situation, pushing preventive medication at a faster pace is justified. Of course, patients need to be willing to put up with certain side effects.
Third Line Migraine Prevention for Refractory Patients
In my practice, long-acting opioids are the most commonly utilized approach for refractory chronic migraine. They include:
In a small, select group of severe headache patients, particularly those with severe, chronic daily headaches and migraines, long-acting opioids have some demonstrated utility. The best candidate for long-acting opioids (LAOs) is the person who has done well on short-acting opioids (SAOs) and who does not have characteristics of a personality disorder and has not been addicted in the past.
The advantages of long-acting opioids include:
• avoidance of mini-withdrawals through-out the day and the “end-of-the-dose” phenomenon,
• consistent dosing of one or two times daily decreases the obsession with the next dose,
• maintenance of stable blood levels,
• avoidance of the acetaminophen, aspirin and NSAIDs that are components of many short-acting preparations,
• probable diminished risk of significant abuse,
• better compliance, with less psychological dependency on the drug.
Disadvantages of the long-acting opioids include:
• social stigma,
• fatigue and constipation,
• difficulty in obtaining scripts, with no refills available,
• need for frequent office visits and monitoring,
• risk of opioid-induced hyperalgesia,
• risk of abuse, although probably less than the SAOs,
• interactions with other sedating drugs and alcohol risk of overdose.
Using higher doses of the opioid rarely works in the long term, in my experience. It places the patient at increased risk of addiction and abuse, and complicates withdrawal. Given the great variation in individual responses, it may be thought that the opioid should be increased or “pushed” to whatever level is beneficial to the patient. However, medical and regulatory considerations should be limiting factors in keeping the opioid dose at a low level. The choice of opioid may be a key factor; some have been shown to have less abuse potential. The long-acting fentanyl patch is subject to less abuse than Oxycodone CR. Taken once or twice daily, the long-acting morphine preparations such as Kadian, Embeda« or MS-Contin have not been subjected to widespread abuse. Methadone may be more effective than some of the other medications, but has a litany of problems associated with it. Besides the social stigma, high protein binding is a risk, which may lead to irregular drug levels, difficulty with withdrawal, and an increased risk for sudden death. If methadone is used, it should be started at a very low dose of no more than 5-10 mg. a day and titrated slowly. Patients placed on methadone require close monitoring and other sedatives must be reduced or discontinued.
The usual dosing range in my practice is: methadone, 5 to 40 mg. per day; morphine, 20 to 90 mg. per day; oxycodone, 20 to 60 mg. per day; fentanyl patch, 12.5 to 50 mcg. per day. Opioids may be combined in low doses with stimulants. Stimulants may help the pain and also offset fatigue. Patients must be aware of, and accept, the risks of these medications.
Daily or Frequent Triptans
Some patients respond only to triptan medications (sumatriptan, naratriptan, rizatriptan, almotriptan, zolmitriptan, frovatriptan, eletriptan). Short-lasting adverse events are often encountered with triptan use. These include paresthesias, fatigue, chest heaviness, jaw or neck discomfort, etc. Chest symptoms are, with rare exceptions, not of cardiovascular origin. Cardiac ischemia due to triptan use is rare. Triptans do constrict coronary vessels, but it is a mild and short-lived effect. Despite widespread triptan use, the number of adverse cardiac events has been limited. Echocardiography and electrocardiography generally are normal after triptan use, even in the presence of chest symptoms.
The primary issue with frequent triptan use, assuming rebound headache is not present, is long-term adverse events. The cardiovascular system would be the most likely for possible long-term sequelae. Chronic ischemic changes, valvular abnormalities, or fibrosis are theoretical considerations. To date, there is no evidence of long-term triptan use producing any of these adverse events. This has not been systematically studied, however. The number of patients throughout the world who have utilized triptans on a near-daily basis is unknown. Until these patients have been studied, it is reasonable and prudent to do cardiac monitoring, as well as hematologic tests.
When prescribed for headache patients, stimulants (dextroamphetamine, meth-ylphenidate, phentermine, Adderall«, Vyvanse«) may be beneficial for various comorbidities, such as attention deficit hyperactivity disorder (ADHD), depression, and fatigue. In addition, stimulants do not cause the weight gain that is seen with a number of other current headache preventives. Amphetamines have been shown to possess intrinsic analgesic properties, primarily through brain catecholamine activity. They also intensify the analgesic effects of certain opioids. Stimulants have been utilized to counteract the sedation encountered by opioids. An excellent review article on stimulants as adjuncts for opioids concluded that, “The evidence suggests that amphetamine drugs may enhance the effect of opioids and, at the same time, decrease somnolence and increase cognitive performance.”
Advantages of stimulants include enhanced cognition and alertness, with no weight gain.
Disadvantages primarily revolve around the side effects, such as anxiety or insomnia. Abuse may certainly occur, but it is uncommon in adults. Stimulants should be considered in patients with certain comorbidities. The few studies to date have indicated a positive role for stimulants, but further studies on stimulants for headache would help to clarify that role.
Monoamine Oxidase Inhibitors (MAOIs)
For those with refractory chronic mi-graine and unipolar depression, MAOIs may be of help. MAOIs are sometimes effective for treatment-resistant depression. They are also effective for alleviating anxiety. MAOIs were commonly prescribed in the 1980s but, with the advent of SSRIs and triptans, they fell out of favor. Careful patient selection is crucial when using the MAOIs. Patients need to strictly observe the restrictions on diet and medications. I usually prescribe low doses of phenelzine (Nardil«) 15 mg. tablets, starting with one tablet at night and increasing after a week to two tablets at night. If no response is noted after three to four weeks, I usually push the dose to three tablets. Five tablets a day (75 mg.) is the usual maximum. By always using the MAOI at night, the patient is less likely to encounter a food interaction. Side effects include insomnia, weight gain, sedation, and orthostatic hypotension.
The MAOIs have a reputation as being somewhat dangerous and difficult to use. Despite this reputation, MAOIs are usually well-tolerated. The hypertensive crisis that may occur with a food interaction is due to a number of factors, primarily the amount of tyramine, an amino acid, absorbed into the bloodstream. The tyramine content of food has been difficult to accurately establish, but there are lists of tyramine-rich foods to avoid. Look online or ask a dietician for the MAOI diet.” When patients consume low doses of phenelzine at night, while avoiding the major tyramine-rich foods, interactions are less likely.
Repetitive IV DHE Therapy
Treatment with intravenous dihydroergotamine (IV DHE«) is helpful for patients with frequent migraine, severe daily headache, and status migraine. DHE has a long track record with a good safety profile. Weeks of headache improvement are often seen. IV DHE is useful in patients who are withdrawing from analgesics. The protocol can be done in the office or hospital. In the office, the first dose of 1/3 mg. is given and, if it is well tolerated, the subsequent doses are 1/2 or 1 mg. Oral Reglan« is usually given prior to the DHE to combat nausea. Three or four doses are given over two days in the office, and up to nine may be given in the hospital. The IV DHE is usually well tolerated and effective. Side effects include nausea, heat flashes, muscle contraction headache, leg cramps, diarrhea, and GI pain. After the DHE, patients are continued on prevention medication. Occasionally, Migranal« (DHE) nasal spray, used daily for several weeks, is effective.
Levadex«, the newer form of inhaled DHE, is awaiting approval by the FDA. In recent trials, patients with allodynia, menstrual migraine, migraine with nausea and vomiting, severe migraine and those treating late in their migraine cycle responded well to Levadex.
First Line Chronic Daily Headache Preventive Medications
• Valproate (Depakote), Amitriptyline (Elavil), Topamax. See section titled “First Line Preventive Medications for Migraine.”
• SSRIs (Cymbalta, Pristiq and Effexor). Fewer side effects than amitriptyline, but are not as effective. More effective for anxiety and de-pression than for headache. Nausea, anxiety, sexual dysfunction, fatigue, and insomnia are common; weight gain is relatively common. SSRIs are helpful for migraine in some patients. Begin with low doses. All of the SSRIs have been somewhat useful for preventing chronic daily headache, and for migraine, to a lesser extent. The dose for headache is usually lower than that for depression. Considering tolerability, these are often the best choice for chronic daily headache. Any of these may also exacerbate headaches. See section on SSRIs. For Cymbalta, Pristiq and Effexor, see the section on antidepressants titled “Second Line Migraine Preventive Therapy.”
• Protriptyline (Vivactil«). Effective and non-sedating. While weight gain does not occur, dry mouth, constipation, and dizziness are common. Commonly used in the morning, as insomnia may be a side effect. May be used in the morning with a sedating tricyclic used at night. Usual dose is 5 to 15 mg. per day (lower than the dose for depression). This is the only tricyclic that tends not to cause weight gain. It increases norepinephrine, not serotonin.
• Nortriptyline (Pamelor«). A metabolite of amitriptyline, nortriptyline is better tolerated than amitriptyline, but less effective. Side effects are similar to amitriptyline, but less severe. Nortriptyline is useful in children, adolescents and the elderly and is occasionally helpful in migraine. Usual dose is 25 to 75 mg. per day; some patients do well on one 10 mg. capsule daily.
• Doxepin (Sinequan«). Very similar to amitriptyline. Begin with very low doses (10 mg. each night), as many patients cannot tolerate more than this amount. Usual dose is 25 to 75 mg. per day. Doxepin has the same side effects as amitriptyline, but is generally better tolerated. It primarily increases norepinephrine.
• NSAIDs. These are not as effective as the antidepressants for chronic daily headache but do not have the cognitive side effects. GI side effects are common, however. Hepatic and renal blood tests need to be monitored. NSAIDs are used more frequently in younger patients. Ibuprofen is available over the counter, but is short-acting. Naproxen (Naprosyn«, Napre-lan«, Aleve«, Anaprox«) is more effective than ibuprofen. Flurbiprofen (Ansaid«) and diclofenac sodium (Vol-taren«) are also utilized. As always, we attempt to use the minimum effective dose.
• Gabapentin (Neurontin«). See section titled “Second Line Migraine Preventive Therapy.” The newer Lyrica (pregabalin) may also be effective.
• Tizanidine (Zanaflex«) and cyclo-benzaprine. These are muscle relaxants. See section titled “Second Line Migraine Preventive Therapy.”
Patients with chronic daily headache, or those having more than three migraines per month that are not well-controlled, may be candidates for preventives. A preventive is chosen with regard to the type of headache and presenting comorbidities while keeping the medication dose and any side-effects to a minimum. Medication selection and dosing may require significant trial and error since what may work in one individual may not work in another. In using such medication, a realistic goal is to decrease the tension headache severity by 70%, not to completely eliminate it. This guide presents the author’s opinion and clinical experience but is not a prescription and does not represent a standard consensus of treatment.
Lawrence Robbins, MD, was awarded the 2008 Janet Travell Clinical Pain Management Award by the American Academy of Pain Management. He has been chosen as one of “America’s Top Doctors” every year since 2002. He has certificates in pain management and sychopharmacology. He has published two headache books—one for patients (Robbins L, and Lang S., Headache Help, 2nd edition, Houghton Mifflin. 2000) and one for physicians (Robbins L., Management of Headache and Headache Medications, 2nd edition, Springer Verlag. 2000)—and 205 articles and abstracts. He has served his patients in his Northbrook, Illinois headache clinic since 1986. Dr. Robbins is also an Assistant Professor of Neurology at Rush Medical College. He can be contacted at 60 Revere Dr., Suite 330, Northbrook, IL 60062; phone 847-480-9399; fax 847-480-9044 or you may visit his website at www.headachedrugs.com for additional headache information.
Ashkenazi A and Silberstein S. Archives of Neurology. 2008. 65(1): 146-149.
Atluri S and Sudarshan G. A screening tool to determine the risk of prescription opioid abuse among patients with chronic nonmalignant pain [abstract]. Pain Physician. 2002. 5(4): 447-448.
Biederman J, Wilens T, Mick E, Spencer T, and Faraone SV. Pharmacotherapy of attention-deficit hyperactivity disorder reduces risk for substance abuse disorder. Pediatrics. Aug 1999. 104(2): e20.
Chabal C, Erjavec MK, Jacobson L, Mariano A, and Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence and predictors. Clin J Pain. Jun 1997. 13(2): 150-155.
Conway S, Delplanche C, Crowder J, and Rothrock J. Botox therapy for refractory chronic migraine. Headache. 2005. 45: 355-357.
Dahlof CG and Mathew NT. Cardiovascular safety of 5HT1B/1D agonists - is there cause for concern? Cephalagia. 1998. 18: 539-545.
Dalal S and Melzack R. Potentation of opioid analgesia by psychostimulant drugs: a review. J Pain Symptom Manage. 1998. 16: 245-253.
Drago F, Caccomo G, Continella G, and Scapagnini U. Amphetamine-induced analgesia does not involve brain opioids. European J Pharmacol. 1984. 101: 267-269.
Dunbar SA, Katz NP. Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: Report of 20 cases. J Pain Symptom Manage. 1996. 11(3): 163-171.
Finkel R, Cubeddy LX, and Clark MA. CNS stimulants. In: Harvey RA, Champe PC, Finkel R, Cubeddy LX, Clark MA, eds. Lippincott’s Illustrated Reviews: Pharmacology, Fourth Edition. Lippincott Williams and Wilkins. Philadelphia, PA. 2008. pp 117-127.
Fishman SB. The opioid contract in the management of chronic pain. J Pain Symptom Manage. 1999. 18(1): 27-37.
Gallagher R. Opioids in chronic pain management: Navigating the clinical and regulatory challenges. J Family Practice. Oct 2004. (Suppl): S23-S32.
Goadsby PJ and Hargreaves R. Refractory migraine and chronic migraine: Pathophysiological mechanisms. Headache. 2008. 48: 799-804.
Gourlay D and Heit H. Urine drug testing in pain and addiction medicine. In: Smith HS, Passik SD. Pain and Chemical Dependency. New York: Oxford University Press. 2008. pp 353-357.
Haas DC and Sheehe PR. Dextroamphetamine pilot crossover trials and n of 1 trials in patients with chronic tensiontype and migraine headache. Headache. 2004. 44(10): 1029-1037.
Inturrisi C. Opioid pharmacology for pain. In: Smith HS and Passik SD. Pain and Chemical Dependency. Oxford University Press. New York. 2008. pp 175-182.
Jaffe LA. The prediction of drug use among college students from MMPI, MCMI and sensation-seeking scales. J Pers Assess. Summer 1987. 51(2): 243-253.
Krishnan KR. Revisiting Monoamine Oxidase Inhibitors. J Clin Psychiatry. 2007. 68(suppl 8): 35-41.
Laux G, Volz HP, and Moller HJ. Newer and older monoamine oxidase inhibitors: a comparative profile. CNS Drugs. 1995. 3(suppl 2); 145-158.
Lester G. Borderline Personality Disorder. Treatment and Management That Works. Cross Country University Press. Nashville. 2005. pp 15-19, 88-91
Lester G. Personality Disorders in Social Work and Health Care. Cross Country University Press. Nashville. 2002. pp 28-79.
Levin M. Refractory headache: Classification and nomenclature. Headache. 2008. 48:783-790.
Lipton RB, Bigal ME, Diamond M, et al. Migraine prevalence, disease burden and the need for preventive therapy. Neurology. 2007. 68(5): 343-349.
Lipton RB and Bigal ME. Toward an epidemiology of refractory migraine: Current knowledge and issues for further research. Headache. 2008. 48: 791-798.
Low NC, et al. Prevalence, clinical correlates and treatment of migraine in bipolar disorder. Headache. 2003. 64: 53-59.
McIntyre RS, et al. The prevalence of migraine headache in bipolar disorder. Headache. 2006. 46: 9973-9982.
OK, what do you think? Many different options and treatments as PREVENTION!
Did you look up any of the side effects of any of the medications? Now read the "conclusion" Here it is, I will save you the trouble:
Patients with chronic daily headache, or those having more than three migraines per month that are not well-controlled, may be candidates for preventives. A preventive is chosen with regard to the type of headache and presenting comorbidities while keeping the medication dose and any side-effects to a minimum. Medication selection and dosing may require significant trial and error since what may work in one individual may not work in another. In using such medication, a realistic goal is to decrease the tension headache severity by 70%, not to completely eliminate it. This guide presents the author’s opinion and clinical experience but is not a prescription and does not represent a standard consensus of treatment."
In my humble opinion, may I suggest that very few or none of the patients that have the chronic daily headaches or 3x month migrainers were examined with the skilled hands of a Myofascial Trigger Point Therapist. I believe that almost every tension headache is caused or made worse by trigger points! And in this day of OTC med companies claiming that “Excedrin Migraine!” is effective for migraines, I will state that my sometimes weekly 3 day migraines were ALL DUE TO TRIGGER POINTS!
Were they checked well for food sensitivies? Chemical sensitivites, such as aspartame? Mold or "sick house" issues. Chiropractic issues such as the misalignment of the axis or atlas? All of these and many, many other things can CAUSE chronic headaches, tension and migraines! Cause!
In looking up the side effects of Myofascial Trigger Point Therapy, changing the diet, going on an elimination diet to look for food sensitivies and triggers, Cleaning up ones diet and getting away from processed food and artificial sweeteners… one might have a very difficult time finding any “side effects” At least negative ones! I will tell you that I "CURED" someone’s headaches by suggesting that she not eat any peanut butter for a week!
I believe that a visit to a good , trusted Chiropractor is also something that any person with headaches or migraines should do.
Noting any change after being out of ones home or workplace for a week or 2 can also be telling of possible molds, cleaners or chemicals. Some people might think that the lower stress of being on vacation is why they don’t have headaches, when it is actually being away form an environmental trigger!