Headache Help (13 page)

SIDE EFFECTS
: Drowsiness, sedation, and fatigue. Flulike withdrawal symptoms may occur if medication is used for a long time and then suddenly stopped.

HEADACHE HELP TIP: PHARMACIST PREPARATIONS

Many pharmacists can prepare different forms of certain medications, which are not otherwise commercially available.

• S
  UPPOSITORIES
  For patients too nauseated to take a pill. Many kinds of mixes are available, such as a pain reliever with an antinausea medication.
  
• L
  OZENGES
  Particularly good for children who won’t swallow pills but also useful for combining a pain reliever with an antinausea medication.
  

5. DHE (D
IHYDROERGOTAMINE
) I
NJECTIONS

DHE has been available for more than fifty years for relieving migraines. Before that, ergotamine tartrate, a similar medicine but one with more adverse effects, was used. In addition to constricting arterial blood vessels mildly, DHE probably works by also modulating serotonin. This medication is safe, well tolerated, and very effective, particularly if you are willing to give yourself an injection (it is not available in premeasured auto-injectors so you must draw the medication up into a syringe). It is not as effective as sumatriptan but lasts longer and carries no risk of rebound headaches. Recently, new ways of administering DHE have made it more practical. It can now be taken through an IV, injection, or as a nasal spray. Injections are still the best way to get quick headache relief, but the nasal spray is the easiest route and can be effective.

DHE is not a good choice for people who are pregnant, have angina, poorly controlled high blood pressure, or poor circulation in their hands or feet, or are over age sixty.

TYPICAL DOSE
: As an injection, 1 mg (one vial) is typical, but 0.5 to 1.5 mg is not uncommon. Although DHE does not cause rebound headaches, 5 mg in a week should be the limit. DHE may be used for two days in a row.

SIDE EFFECTS
: Although there are many possible side effects, they are unlikely to last more than a day, and serious side effects are very rare. Most side effects last less than an hour.

Nausea is very common, so it’s often a good idea to take antinausea medication (such as Reglan, Compazine, Tigan, or Phenergan) about ten minutes before you take DHE. If you get stomach upset or heartburn but no nausea, try an antacid like Rolaids or Turns.

Flushed feeling or heat in the head, or leg cramps or aching in the legs, are common sensations. The nasal spray can cause nasal congestion.

Muscle tension, mild headache, and tightness in the chest or throat may occur briefly. Numbness or burning at the injection site may be prevented by icing the area before the injection. Diarrhea lasting about a day may occur, especially with intravenous administration.

HEADACHE HELP TIP: WATCH THAT GRAPEFRUIT JUICE

Grapefruit juice may make certain drugs stay in your system longer than they should. By inhibiting an enzyme that helps metabolize some drugs (sedatives, antianxiety agents, calcium blockers, certain statins [prescribed for high cholesterol], and antidepressants), grapefruit juice can aggravate side effects and render the drugs more potent and dangerous. Grapefruit juice should also be avoided with certain antibiotics (erythromycin, azithromycin, and clarithromycin). These lists are by no means complete.

ANTINAUSEA MEDICATION

Nausea may occur not only as a side effect of a migraine, but as a side effect of medication as well. If you are susceptible to nausea, you may want to keep some antinausea medication on hand. Most of these drugs are sedating, which many migraine sufferers find helpful. The pills are less effective than the suppositories, which are less effective than injections you can give yourself. If you experience severe nausea, keep both pills and suppositories on hand.

QUICK REFERENCE GUIDE: ANTINAUSEA MEDICATIONS

1. OTC A
   NTACIDS
   , V
   ITAMIN
   B
   ₆
   ,
   OR
   E
   METROL
       Gentle medications you can buy without a doctor’s prescription.
   
2. P
   ROMETHAZINE
   (P
   HENERGAN
   )
       Mild and effective yet very sedating.
   
3. P
   ROCHLORPERAZINE
   (C
   OMPAZINE
   )
       Very effective, but anxiety, sedation, and/or agitation are common.
   
4. M
   ETOCLOPRAMIDE
   (R
   EGLAN
   )
       Mild, but well tolerated; mild fatigue or anxiety common.
   
5. T
   RIMETHOBENZAMIDE
   (T
   IGAN AND
   O
   THERS
   )
       Less effective than others but well tolerated and useful in children. Lozenges can be made by some pharmacies.
   
6. C
   HLORPROMAZINE
   (T
   HORAZINE
   )
       Extremely effective, but lasting sedation is common. Used when other antinausea drugs have failed.
   
7. O
   NDANSETRON
   (Z
   OFRAN
   )
       Nonsedating, few side effects, but expensive.
   

1. O
VER-THE
-C
OUNTER
A
NTACIDS
, V
ITAMIN
B
₆
,
OR
E
METROL

These preparations are available without a doctor’s prescription and include antacids such as Turns, Rolaids, or Mylanta. They can sometimes help settle your stomach during a migraine.

Vitamin B
₆
occasionally helps, but limit yourself to one tablet a day. Sometimes, ginger is useful for combating nausea.

Emetrol, an over-the-counter antinausea medication, may help alleviate migraine nausea. It is a phosphorated carbohydrate solution (also called Calm-X, Naus-a-way, and Nausea-tol). One or two tablets every three or four hours, as needed, are usually recommended.

2. P
ROMETHAZINE
(P
HENERGAN
)

Though mild and effective, promethazine can have a strong sedative effect and will often make you fall asleep; this effect, however, may be just what you want. Safe for children, the medication may cause sudden, involuntary jerking movements (extrapyramidal side effects), but they are temporary and rare and shouldn’t cause concern. Promethazine is available as a pill or a suppository, and some pharmacists will make them into oral lozenges.

TYPICAL DOSE
: 25 to 50 mg by mouth or in a suppository, every three to four hours, as needed.

SIDE EFFECTS
: In addition to fatigue, promethazine occasionally makes you feel dizzy or lowers your blood pressure.

3. P
ROCHLORPERAZINE
(C
OMPAZINE
)

Compazine is a very effective antinausea medication but produces side effects—somewhat more frequently than the other antinausea medications.

In addition to being available in long-acting pill form and suppositories, Compazine can be taken intravenously and sometimes helps to relieve pain.

TYPICAL DOSE
: 10 to 25 mg by mouth, 5 or 25 mg in suppositories, or 5 to 10 mg by injection, every three to four hours, but no more than 60 mg a day.

SIDE EFFECTS
: Involuntary movements, anxiety and agitation, fatigue.

4. M
ETOCLOPRAMIDE
(R
EGLAN
)

Because Reglan is well tolerated, with only mild side effects, it is commonly used before IV DHE, which may be given in an emergency room for quick relief of severe pain. Adding Reglan to aspirin or an NSAID can enhance the effect, because Reglan boosts the absorption of NSAIDs and aspirin.

TYPICAL DOSE
: 5 to 10 mg every four hours, as needed, but no more than 30 mg a day.

SIDE EFFECTS
: Mild fatigue or anxiety and restlessness, occasional involuntary jerking.

5. T
RIMETHOBENZAMIDE
(T
IGAN
, A
RRESTIN
, B
ENZACOT
, B
IO
-G
AN
, S
TEMETIC
, T
EBAMIDE
, T
EGAMIDE
, T
ICON
, T
IGECT
-20, T
RIBAN
, T
RIBENZAGAN
)

Tigan is somewhat less effective than the other antiemetics (antinausea medications) but may be prescribed for children and has few and minimal side effects.

Tigan is available in pills and suppositories, and some pharmacists will make oral lozenges.

TYPICAL DOSE
: 250 mg by mouth or as a suppository or injection, every three hours, as needed.

SIDE EFFECTS
: Fatigue, occasional involuntary jerking, dizziness, blurred vision, and low blood pressure.

6. C
HLORPROMAZINE
(T
HORAZINE
, P
ROMAPAR
, S
ONAZINE
)

Although this medication is the most effective one for relieving nausea, it has more side effects than other antiemetics and is usually reserved for when they fail. The medication also helps with pain, however, and the suppositories can often prevent a trip to the emergency room by sedating you, inducing sleep, and thereby stopping the nausea.

TYPICAL DOSE
: 25 to 50 mg by mouth or in a suppository, every three hours, as needed.

SIDE EFFECTS
: Long-lasting sedation. May also cause dizziness and, occasionally, involuntary jerking and slurred speech.

7. O
NDANSETRON
(Z
OPRAN
, Z
OFRAN ODT
)

This nonsedating antinausea medication, used primarily for cancer patients receiving chemotherapy, is highly effective, with remarkably few side effects. It rarely causes the sedation that the other antinausea medications bring on. However, it is expensive. Zofran ODT dissolves on the tongue.

TYPICAL DOSE
: One tablet (4 or 8 mg) every six to eight hours, as needed.

SIDE EFFECTS
: Though rare, nervousness, diarrhea, or constipation may occur.

CASE STUDIES

Here are two sample case studies to show you how a doctor might manage occasional migraines with abortive medications. Although many cases are simple, we have chosen two complex ones to take you through the rational trial-and-error process that a headache doctor might use.

D
ANIEL

I
NITIAL VISIT
:
Daniel, a hard-driving executive, is forty-three years old and has had migraines for twelve years. His father and grandfather also had migraines. He is a perfectionist in his work and suffers from very cold hands and feet. He has a history of motion sickness as a child, and his eyes are very sensitive to light.

Daniel reports that none of the over-the-counter medications have helped his migraines, which are so severe that they keep him from functioning. Because he suffers from only two a month, Daniel’s doctor does not place him on daily preventive medication. However, because his migraines are severe, last two days, and are accompanied by nausea and vomiting, they discuss daily preventive medication as a possibility for the future. (Patients who find such medication worthwhile usually have four to five migraines a month or chronic daily tension headaches.) Daniel does not have significant risk factors for heart problems.

The doctor first briefs Daniel on the importance of watching for headache triggers and using relaxation methods. Then he prescribes Compazine suppositories for the nausea and Imitrex Nasal Spray for the headache. As an alternative, if Imitrex is not effective, the doctor also gives Daniel Esgic (butalbital, caffeine, and acetaminophen) as a painkiller. (He warns Daniel that the generic painkillers, particularly the butalbital-type medications, may not work as well as the brand names.)