Britt Talley Daniel MD picture and biographic information

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Britt Talley Daniel MD is a practicing neurologist from Dallas, Texas. Trained in medicine at the University of Texas Medical Branch in Galveston and in Neurology at the Mayo Clinic, Dr. Daniel served his country as a staff neurologist LCDR, USNR at Balboa Hospital in San Diego, California at the end of the Vietnam conflict. After this he was on the senior staff as a neurologist at Scott and White Clinic in Temple, Texas and an Associate Professor of Neurology at Texas A&M University Medical School. Moving to Dallas to start a private practice, Dr. Daniel taught at the University of Texas Southwestern Medical School as a Clinical Associate Professor of Neurology. Currently he is a member of the American Academy of Neurology, the American Headache Society, and the American Association of Neuromuscular and Electrodiagnostic Medicine. His EMG lab has been declared an Accredited Laboratory of Exemplary Status. Married and with 5 grown children, Dr. Daniel is a lifelong folksinger and guitar picker. He is also the author of 5 medical textbooks: Migraine 1st and 2nd editions, Transient Global Amnesia, The Mini Neurology Series: Volume 1 Migraine, Volume 2 Carpal Tunnel Syndrome, and Volume 3 Panic Disorder. He has written a transgenerational novel about a medical family from England who relocates to America aboard the haunted Titanic, entitled: Titanic: Answer from the Deep. He has published 2 stories about a mystery solving physician entitled: The Mysteries of MacArthur Donne, Book 1 And If Thine Eye Offend Thee, Book 2 The Case of the Organic Chemist.
Please, if you read any of my books, review them on Amazon. I would really appreciate it.
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General Migraine Article

Migraine is a genetic, inherited condition involving the brain, the trigeminal nerve, and cranial blood vessels which consists of symptoms of episodic headache with intervening periods of normal health.  It is familial in occurrence and about 80% of patients who have migraine will have someone in their family with it.  Migraine occurs in women about three times as often as men.  The American Migraine study found that 18% of women have migraine, while 6% of men have it.  Migraine is said to be the most common chronic human health problem for women.  Something like 98-99 % of headache is either tension headache (70%) or migraine (30%). People with migraine often have motion sickness (60%) either in childhood or adulthood.  They may get a headache after drinking alcohol, especially wine or beer.  This may come “at the end of a drink” even though not much has been consumed.  They have a sensitive brain and affected individuals may get attacks following exposure to bright sunlight, flashing lights or patterns, heat, nervous excitement, or fasting.  Women often begin with headaches at menarche, when they have their first period, and they may keep this pattern until menopause.  A popular myth about migraine is that it goes away after menopause for women.  For some it does, for others their headaches continue.  About 70% of women with migraine get headaches during the monthly estrogen withdrawal which occurs just before they start to bleed.  They may have little headache during pregnancy, only to have the attacks return with resumption of the menstrual cycle.  These same women may have an increase in frequency, intensity, and type of migraine attacks with the use of birth control pills or estrogen.  The other 30% of women with migraine may notice no particular relationship to their menses or estrogen levels.  These are likely different genes for migraine.  Migraine attacks may be precipitated by relaxation after stress—the weekend, holiday, or vacation headache.  Headaches may come from oversleeping, anxiety, or depression.  The patients with migraine should consider that they have an over excitable brain and that the attacks follow this over stimulation.

The vasodilator peptides calcitonin gene-related peptides (CGRP), substance P, and neurokinins are found in the cell bodies of trigeminal neurons.  CGRP levels increase during migraine.  Also sterile neurogenic inflammation can occur in response to the vasoactive peptides substance P and Neurokinins which are released by the trigeminal vascular system.  The 5-HT 1D receptors have a prejunctional location at the neurovascular synapse between the trigeminal nerve and the dural vasculature.  The Triptans are serotonin receptor specific agonists that abort migraine.  There are also 5-HT 1D receptors located centrally at the trigeminal ganglion which when activated inhibit the conduction of pain signals from the site of the neurogenic inflammation and vasodilatation in the meninges to the second order brainstem neurons mediating pain during migraine.  5-HT1D receptors located in the nucleus tractus solitarius of the brainstem inhibit central nausea and vomiting.  All Triptans activate both 5-HT1D and 5-HT1B receptors and all Triptans have central and peripheral effects in humans.

Major comorbidities of migraine are: respiratory-allergies and asthma, cardiovascular system-mitral valve prolapse, hypertension, angina/myocardial infarction, Raynaud’s syndrome, stroke, gastrointestinal-functional bowel disorders/irritable bowel syndrome, neurologic-epilepsy and essential tremor, and psychiatric-depression, mania, panic disorder, bipolar disorder, and generalized anxiety disorder.

There are two types of Migraine

A. Migraine without aura, according to the 2004 International Classification of Headache is diagnosed by a headache pattern fulfilling the following criteria:

  1. At least five attacks fulfilling B-D.
  2. Attacks lasting 4-72 hours (untreated or unsuccessfully treated).
  3. At least two of the following characteristics:
  4. Unilateral (one sided) location.
  5. Pulsating (throbbing) quality.
  6. Moderate or severe intensity (inhibits or prohibits daily activities).
  7. Aggravation by walking stairs or similar routine activity.
  8. At least one of the following:
  9. Nausea and/or vomiting.
  10. Photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

Migraine without aura used to be called “common” migraine because it is the most prevalent type of migraine, consisting of about 70% of all attacks.  Typically, the patient has one-sided headache (migraine comes from a French word that means half of head or hemicrania), nausea and vomiting, photophobia (fear of light), sonophobia (fear of sounds), and goes to sleep in a quiet, dark room.  This is often called sick headache, sinus headache, heat or sun headache, menstrual headache, letdown headache (a headache that comes during a weekend, vacation, or holiday), cold front or weather change headache (from a drop in the barometric pressure), or nocturnal headache (middle of the night, end of a dream headache.)  The patient may not know he has migraine but comes for treatment and diagnosis of headache.

B. Migraine with aura. This used to be called “classical” migraine and consists of an aura, usually followed by headache. 30% of migraine attacks are like this.  The aura may be visual, such as seeing wavy lines, spots, or holes, or half of things.  The aura may also consist of slowly spreading numbness in one hand or the face on the same side, or a temporary disturbance of language (aphasia.)  The aura symptoms may be frightening and much more concerning than the headache.  The patient usually knows he has migraine when they come in and mainly want treatment.  Aura may occur without headache.

The current international classification for headache lists Cluster Headache as an entity separate from migraine, although they have many similar features.  Many persons with cluster headache have family members with migraine.  Cluster headache predominates in men, four times as frequent as in women.  The age range is usually mid- twenties to about sixty.  These are very severe, quick onset, one sided headaches which consist of pain around the eye, temple, or cheek.  There may be characteristic accompanying symptoms on side of the face, such as: drooping of the upper eyelid, smallness of one pupil, sweating above the eye, redness of the eye, tearing of one eye, nasal congestion, or drainage of clear fluid.  The headaches come in time periods called clusters which usually last 6-8 weeks and consist of 1-8 headaches a day, lasting 20-40 minutes.  The patient usually gets up and paces around the room.  Nausea, vomiting, and sensitivity to light and sound may occur, but are not as prominent as that which occurs with migraine.  The onset to peak of the headache is very quick—often in minutes.  The headaches may track the clock, coming at the same time every day and they may characteristically occur one to two hours after going to sleep.  During the cluster period drinking alcohol may aggravate the headache, but not at other times.  The patients often have a driven, type A workaholic nature.  Hydrocortisone (prednisone, medrol dosepack) given orally for 7-10 days for cluster, will sometimes stop the attack while the patient stops the daily drugs that are causing the headache pattern.

The patient with migraine needs to understand that although the condition cannot be cured, since it is part of the genetic makeup, effective treatment exists.  Adequate rest of seven to eight hours of sleep a night, a short nap at midday and regular hours for going to sleep and arising, including the weekend, may help set the individual’s internal biologic clock.  Fasting, missing meals, oversleeping, alcohol, bright sunlight, and heat should be avoided.  Daily caffeine in beverages or medication should be eliminated.  Regular aerobic exercise taken three or four times a week may help relieve anxiety and stress and help the headaches.  For some patients relaxation training or formal psychological counseling may be helpful.  Prescribed medication should be taken early on in the course of the headache without delay, attempting to “nip the headache in the bud,” before it is fully developed.  Migraine should be treated early and when it is mild.  Extra supplies of medication should be stashed away at work, in the car, and at home.  If a headache comes on at night during sleep, the patient should take his dose of medication, and attempt to return to sleep.  In general sleep is one of nature’s best treatments for migraine and the individual who ”changes his life,” stops an activity, goes home from work, takes his medication and lies down in a quiet, dark room will fare well.  The idea is to “learn to live” and “give into” the condition rather than ignore it and have the headache win.

Analgesic, pain killer, or narcotic type medications usually fail to treat migraine successfully.  Taking Tramadol (a typical narcotic) and going to sleep for the rest of the day is not successful treatment.  A program of outpatient self-management wherein the patient takes his medication and stops the headache is desired.  The patient who has to go to the emergency room or the doctor’s office for repeated injections is somewhat of a treatment failure.  For patients who experience more than 3-4 migraines a month, chronic preventive therapy may be helpful.

Lifestyle treatment for Migraine

Lifestyle Issues.  I highly recommend that all of these ideas be followed by all migraine/cluster patients.

  1. Decaffeinate yourself either slowly by decreasing by one cup of coffee or two colas every three days or do it quickly-cold turkey. The reason is that caffeine is a vasoconstrictor and can give medication overuse headache.  Caffeine is the number one drug in America causing an increase in the intensity and frequency of migraine.  Caffeine is addictive.  Caffeine is confusing to some patients because they know that it may be used to treat headache, but they need to learn that if taken frequently, more than 2 days a week, it can cause medication overuse headache, previously called–rebound headache.
  2. Eat Three Meals a day. A small breakfast will suffice, for example a single sweet roll or a piece of toast with juice.  Remember breakfast means “break the fasting of sleep.”  If you don’t eat and without your knowing it, your pituitary gland will sense your low blood sugar and send out a hormonal signal that will cause vasodilatation of your cerebral arteries and start your “hungry headache” migraine.  Three meals a day is advised for all medically accepted weight loss programs (Jenny Craig/Weightwatchers).  Most mothers will feed their children three meals a day but not themselves.
  3. The American Heart Association recommends that all persons exercise Aerobically for 20-30 minutes, 3-4 times a week. Aerobic exercise means that you do an activity that gets your heart rate at a certain desired target range and keeps it there for the entire workout.  Consult tables for your age heart range at bookstores, the YMCA, or your local fitness center.  The more aerobic the exercise, within heart rate limits for age, the better.  You can treat migraine, anxiety/panic disorder, depression, tension headache, and sleep problems with aerobic exercise.  There are hundreds of scientific articles over the past 20 years proving that exercise works for headache therapy.  Aerobic exercise is:  dance aerobics, jogging, cycling, swimming, rowing, cross-country skiing, and stair-stepping.  It is not walking, lifting weights, stretching, or playing most games, like tennis or racquetball.  If you are already exercising and still have bad headaches, consider increasing your exercise program.  Exercise is something you can do for yourself to take control of your headaches.  It takes determination, time, and effort.  Some migraine patients get a “work out headache” if they get hot.  If this happens to you then try to work out so you don’t get so hot.  Exercise in front of a fan or in air conditioning.  Take ibuprofen, Excedrin, or a half of a Triptan drug before you work out.  If you still get a work out headache, then try swimming.
  4. Set your sleep/wake cycle to rise and go to sleep at the same time every day-even through the weekend. Adults should sleep between 7 to 8 hours every night.  Migraine may be treated by sleep RESTRICTION.  Avoid oversleeping Saturday morning or falling asleep for that seductive two-hour nap on Sunday afternoon.  Set an alarm for 15-20 minutes for a short, energy restoring nap. If you never learned how to take a short nap, then learn.  It can be done.
  5. Try to destress your life. Talk over your daily life problems with your friends, family, preacher, priest, or rabbi.  Develop a support system to sustain you in life, built up of key people that are there for you when you need them.  Plan time to relax and spend on hobbies or interests.  Normal people have hobbies which is something you do for fun and relaxation, that is creative and not goal or money-making oriented.  Children and family are not hobbies.  Please look up the word “hobby” in the dictionary if you think this.  Turn off that cell phone, computer, or IPad and get a life.   Plan three day weekends four or five times a year rather than one two-week holiday in August.  Leave that depressing, stressful job, or get counseling and try to change a personal relationship that is causing problems.
  6. Don’t take too much caffeine, over the counter drugs, triptans, or painkillers for headache. In general, all migraine patients should limit all such drugs to no more than 2 days per week.  The migraine process generates neurochemicals which are released in the brain and that inflame the thalamus, trigeminal nerve, and cerebral arteries.  These neurochemicals stay in the body 3 days and once they inflame the brain they are repeatedly released every time other pain killers, caffeine, Advil, Tylenol are consumed, starting a process of continuous headache.  I once saw a man taking 10 Excedrin migraine pills for over fifty years (10 X 65= 650 mg) and he had a headache all that time until I convinced him to stop Excedrin.  There is no data that opioid narcotics help migraine headache, they just cause problems and shouldn’t be used for “rescue treatment.”  The U.S. is now going through a change in the use of opioid narcotics and barbiturate drugs since they cause people to die in their sleep, are addictive, and cause medication overuse headache.  Narcotics should be used only for persons who are in pain and near the end of life, for acute trauma, or surgery, only for a month and then stopped.  Death from opioid narcotics is a top problem now in America.  Butalbital has been banned in every country in the world except Canada and the U.S. because it causes medication overuse headache.  The word “narcotic” comes from the Greek word that means “sleep.”  In Texas the number one reason for the State Medical Board to restrict physicians concerns their use of opoid medications and more licenses are restricted or revoked regarding this issue than any other.

Vascular Headache

Vasodilation phase of a cerebral artery

  1. Migraine—a genetic, inherited problem; you’re born with it and die with it. All migraines are vascular headaches and all migraine patients may have different vascular headaches more easily than normal persons.
  2. A hangover—defined as someone who drinks too much, gets drunk, goes to sleep, and then awakens the next day feeling awful while complaining of a bad, generalized, throbbing headache.
  3. Caffeine withdrawal headache. Usually occurs within hours or a half a day.  A similar medication withdrawal headache occurs with pseudoephedrine (Sudafed) which is found in many sinus/decongestant medications.
  4. Fever—as can occur with any illness such as an upper respiratory infection. The face of a person with fever may be flushed and red.  The tiny arteries in the skin of the face are vasodilated and the same thing happening in the brain may cause headache.
  5. Concussion-Post concussion Syndrome
  6. Mountain Sickness/Decompression Sickness
  7. Analgesic Rebound Headache

Factors that may promote vasodilatation include a low blood sugar, oversleeping, fever, or exercise that increases the core body temperature.

Sinus Headache

Defined by the International Classification of Headache Disorders 2nd Edition as

  1. Frontal Headache accompanied by pain in one over more regions of the face, ears or teeth and fulfilling criteria C and D
  2. Clinical, nasal endoscopic, MRI and/or CAT scan imaging and/or laboratory evidence of acute or acute-on-chronic rhinosinusitis.
  3. Headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis
  4. headache and/or facial pain resolved within 7 days after remission or successful treatment of acute or acute-on-chronic rhinosinusitis

Clinical evidence may include purulence in the nasal cavity, nasal obstruction, hyposnia/anosmia and/or fever.  Chronic sinusitis is not validated as a cause of headache or facial pain unless relapsing into an acute stage.  Migraine and tension-type headache are often confused with headache committed to rhinosinusitis because of similarity location of the headache.  A group of patients can be identified who have of all the features of migraine without aura and additionally, concomitant clinical features such as facial pain, nasal congestion and headache triggered by weather changes.  None of these patients have purulent nasal discharge or other features diagnostic of acute rhinosinusitis.  Therefore, is necessary to differentiate headache attributed to rhinosinusitis from so-called “sinus headaches”, a commonly made but nonspecific diagnosis.  Most such cases fulfill the criteria for migraine without aura with headache either accompanied by prominent autonomic symptoms in the nose or triggered by nasal changes.

If you don’t have these symptoms, then you don’t have a true sinus headache.  Patients with what they call “sinus headache” usually localize the pain to behind the eyes, the forehead, or the cheeks.  When I was a medical student I was instructed that pain in this area should be migraine, but most Americans haven’t heard this it.  The American Academy of Neurology has said that 80% of patients with what they call “sinus headache” have a diagnosis of migraine made by a neurologist.  Many of these patients have no purulent nasal discharge which is a cardinal requirement of true sinus headache, an infection in the sinus areas.  This myth about sinus headache is taught to the American public by erroneous advertising such as Tylenol sinus ads on TV.  This misconception doesn’t exist in Europe.  It is a marketing idea made up in America to sell pseudoephedrine type drugs to the unwary consumer.  It is common to have more than one type of migraine headache.  Many persons accurately name their worst, often one sided headaches as migraines, but they are not aware that their milder, front of the head “sinus headache” may be migraine too.

Allergy and Migraine

This is easy.  There is no allergy headache.  It is not even listed as a diagnosis in the index of the 2004 International Classification of Headache.  Sure, if your nose is running all the time and you’re sneezing and you feel bad because of allergic rhinitis, you might have more tension headache or migraine then, because you are all stressed out and sick, but there is no direct allergic pathophysiologic mechanism causing headache.  Let me define an allergic reaction.  An allergic reaction is an antigen-antibody reaction, where the antigen is a foreign protein like cedar pollen and the antibody is another complex protein made by your immune system.  Gamma E is made following an allergic reaction and is a general blood test that can be obtained to see if an allergic reaction is occurring.

Many different chemicals cause vasodilation and therefore aggravate vascular headache.  This happens commonly in migraine individuals and is why MSG, chocolate, tyramine in aged cheese, and nitrates in hot dogs may aggravate migraine.  There is a relationship between the ingestion of such a chemical and headache, but the headache comes because of vasodilation caused by the offending chemical (i.e. chocolate) NOT from an allergic reaction (antigen-antibody reaction, immune system, Gamma E liberation.)

Medication Overuse Headache

The International Classification of Headache III describes Medication Overuse Headache (MOH), old name Rebound Headache, as a syndrome related to overtreating.  Chronic Daily Headache is a term that implies having headache over 15 days a month, 8 of which are like migraine.  A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly.  MOH may come from overtreating with simple pain killers like caffeine, Tylenol or Advil, opioid narcotics, pain killers with barbiturates, or triptans.  Patients typically rotate to different drugs and take many drugs at the same time that may cause MOH.  After awhile the preexisting headache problem, which is usually migraine, but may also be tension type headache, becomes transformed from an intermittent to a chronic headache problem.  It is like what happens to the patient who drinks a lot of coffee every day and then gets a headache when they don’t.  When the brain becomes sensitized to these drugs repeat dosing causes neuro-inflammatory chemicals to be released in the brain which keeps the headache going.

There are two features to this syndrome:

  1. Daily or very frequent headaches which may come with sensitivity to light and sound, nausea, and irritability
  2. This syndrome causes serotonin, a calming brain neurochemical, levels to drop so the patient may also develop anxiety, depression, poor concentration, panic attacks, and insomnia, which also are core symptoms of the disorder.

Drugs that can cause this syndrome are:

Caffeine, such as Excedrin, BC Powder, Vanquish; pseudoephedrine (Sudafed) the decongestant in over the counter sinus meds, such as Tylenol sinus or Advil sinus, or the D in Allegra-D; Ergotamine drugs—Cafergot, Triptans—Imitrex, Maxalt, Zomig, Axert, Frova, Relpax, or Amerge; NSAIDS—(Nonsteroidal Anti-inflammatory Drugs) such as Motrin (ibuprofen, Advil), Naprosyn/Anaprox (Alleve), Miloxicam, and Tylenol; Narcotics—Vicodin (hydrocodone, Narco), Tramadol, Demerol, Nucynta, OxyContin, Tylenol with codeine; Drugs with barbiturates– Fiorinal, Fioricet, Phrenilin, Esgic, generic butalbital.

The International Headache Society criteria for medication overuse headache are:

Triptans or Ergotamine intake >10 days/month (like sumatriptan)

Non-opioid simple analgesics >15days/month (like Tylenol, caffeine, or Advil)

Opioids or Analgesics combined with barbiturates >10days/month

The best treatment for medication overuse headache is stopping the offending drugs, usually on 1 day, or sometimes by tapering over several weeks if the patient has been on a high dose of an opioid or barbiturate for a long time.  Unless the patient is treated with cortisone, also called “Bridge Medication” a terrific headache would come after stopping their pain killers.  The patient should stay off all pain killers on the list above during this time.  Cortisone treatment may be: one or two weeks dose of oral cortisone, as prednisone 20 mg 3X/day for 7 days or Medrol Dosepak, for the chemical brain inflammation.  For spikes of headache DHE given IM or as Migranol nasal spray every 3 hours, or Timidol eye drops, or Alleve may be used for acute treatment of headache.  The time for clearing of MOH varies from several weeks to 1-2 months, depending on the type, amount, and duration of previous medication abuse.  Clearing may be noted by 5 headache free days after which regular acute migraine Rx may resume.   After this the patient should limit painkillers to no more than 2 days/ week for the rest of their life.   Preventive medications such as topiramate, amitriptyline, valproic acid, or beta-blockers should be started to reduce the number of monthly migraines.  50% of patients with MOH have depression, 40% have generalized anxiety disorder (GAD) or panic disorder which may need treatment and 50% of patients with MOH get it again.

Stop the following drugs:

Do: the migraine lifestyle—

Take:  For prevention 10 mg amitriptyline every night for the next few months, a drug which can decrease migraine by 50 % and promote sleep, or propranolol, topiramate, or Depakote (not for fertile women.)

For acute treatment either Migranol Nasal Spray every 3 hours as needed, or DHE 1cc Intramuscularly every 6 hours as needed, or Timidol eye drops 0.25% sol, 1 in each eye as needed for headache, may repeat in 1 hour, or if too expensive—take Alleve (naproxen) 200 mg every 12 hours once or twice a week.

For reduction of brain inflammation- either 20 mg or prednisone 3X a day for 7 days or a Medrol dose pack.

For nausea use either Zofran 4 mg every 4-6 hours or Phenergan 25 mg orally every 4-6 hours.

Be patient with this problem, it takes a while to improve and the time depends upon how long you have taken the offending drug and which drug you have used.  For example, 3 weeks of overtreatment with caffeine or Advil may take 2-3 weeks to clear, while 12 months of butalbital 2-3/day may take 2-3 months.

Try to regularize your life during the detox time—rest your eyes and your body, but don’t sleep during the day (maintain a normal sleep/wake schedule.)  Stay hydrated with fluids.

Other treatments that may help headache are ice packs, lying down with your eyes closed for a short rest, prayer, and mild exercise.  Don’t develop the practice of treating every headache with medication, try to bear through some of them without treatment.

The Migraine Timing Cycle

Migraine in the brain has 4 stages: 1 Trigeminal activation, the sensory pain fibers in the fifth cranial nerve send pain to the face or back of the head, usually on one side, 2 within 20-40 minutes the ganglia in the brain of the trigeminal nerve and the arteries start to release 3 toxic neurochemicals which last 3 days and inflame the brain and dilate the arteries,3 arterial vasodilatation occurs with the pulsing blood from the heart stretching the chemically inflamed arteries, 4 the thalamus, which is the pain center of the brain is inflamed by the chemicals and migraine process usually about 3-4 hours into the headache causing severe headache and allodynia (the head is sensitive to touch.)

Treatment of menstrual migraine

 Definition: Migraine headaches that come two days before, during, or two days after monthly menstrual flow.

General:  Don’t ignore your cycle but instead plan for it.  Give into it and don’t fight it.  Relax your personal and job schedule.  Get lots of rest and exercise.  Eat right.

Medication: Treat several days before, during, and after the menstrual cycle if the migraine doesn’t come consistently at the same time or if you have irregular periods.  If the migraine usually comes the day before you bleed and you have regular periods, then start treating that day.  A variety of drugs may be tried and the following list is from simple, cheap, and few side effects to complicated, expensive, and possible side effects.

Drugs to Try for acute therapy:  Over the counters:  Any of the over the counter drugs—Tylenol (acetaminophen), Advil (ibuprofen), or Aleve (naproxen).  Taken as 1-2 X/day.

Triptans:  oral Imitrex (sumatriptan) 100 mg, Zomig (zomatriptan) 2.5/5 mg, rizatriptan 10mg, Axert (almotriptan) 12.5 mg, Relpax (eletriptan) 40 mg, Amerge (naratriptan) 2.5 mg, Frova (frovatriptan) 2.5 mg, taken as one half 1-2 X/day.  Frova and Amerge are used for menstrual migraine due to their long half-life: Frova-26 hours, and Amerge-6 hours.

Preventive drugs: Any of the group of drugs that may be used for prevention may work.  They may be taken every day during the menstrual cycle or every day.  Common drugs here are Inderal (propranolol), Tenormin (atenolol), Elavil (amitriptyline), or Topamax or Trokendi XR (topiramate.)  Depakote should not be used as it is completely contraindicated in menstruating females and has a highest level X rated warning from the FDA.

Treat with caution:  Many doctors prescribe estrogen based birth control pills, estrogen IUDs, estrogen patches and pellets  to persons with migraine.  These drugs can all make the experience of migraine worse.  They are all relatively contraindicated by the FDA for patients with menstrually related migraine and migraine without aura, but they are absolutely contraindicated for women with migraine with aura for risk of stroke.  Other problems are that estrogen treatment is called “a class 1 carcinogen” that is, a drug that may cause cancer.  The incidence of breast cancer in 1960 before the pill came out was 6% but now it is 8%.  The Mayo Clinic published an article on a 6% risk of breast cancer in women.  Also these estrogen treatments can cause an abortion by making cervical mucus thick so that an embryo can’t move down the tube and implant in the uterus.  IUDs work by scraping an implanted embryo off the uterine wall, like a lawnmower cuts grass.

Elizabeth Loder published a book on menstrual migraine and is a Professor of Neurology at Harvard.  She was the lead author of the article below and I quote from this article.

Loder E, Rizzoli P, Golub J. Hormonal management of migraine associated with menses and the menopause: a clinical review.  Headache.  2007;47(2):329-340.

”Hormonal treatment of migraine is not a first-line treatment strategy for most women with migraine.  Evidence is lacking regarding its long term harms and migraine is a contraindication to the use of exogenous estrogen in all women with aura and those aged 35 or older.  The harm to benefit balances of several traditional non-hormonal therapies are better established.“

 Migraine Comorbidities/Aliases 

Comorbidity refers to the greater than coincidental association of two conditions in the same individual.  The medical conditions that link to migraine are:

Respiratory-allergic rhinitis and asthma 17%

Cardiovascular-hypertension, angina/myocardial infarction, Raynaud’s syndrome, stroke, congenital heart defect-mitral valve prolapse, patent foramen ovale (PFO) and atrial septal defect (ASA)

Endocrinological-thyroid disorders

Gastrointestinal-ulcer disease, ulcerative colitis, and irritable bowel syndrome 60%

Rheumatologic-fibromyalgia 17%

Neurologic-epilepsy, tension-type headache, and essential tremor

Psychiatric-mood disorders, depression 50%, bipolar disorder, generalized anxiety disorder 34%, panic disorder, agoraphobia, chronic fatigue 20%, obsessive-compulsive disorder.

Migraine aliases

In the lay population migraine maybe called by false names, or aliases, or pseudonyms.  Attention to this list is instructive regarding when to treat a migraine.  All the names on the list below are false names for migraine.

Sinus head

Menstrual headache

Hungry headache

Wake up headache

Nocturnal or middle of the night headache

Allergy headache

Work out headache

Weekend, holiday, Saturday morning, or Sunday morning headache, let down headache

The point here is that “sinus headache” or wake up headache should be Treated as a migraine, at onset, usually with a triptan.


Frequency of Migraine Triggers

I It’s an easy thing to look at, and everybody needs to watch what they eat, but food as a trigger for migraine is not the big issue.  The big issue is stress.  Look at the table (Kelman Cephalalgia 2007;27(5):394-400) below which lists various triggers and their frequency. Stress is at the top and food is near the bottom.

Stress concerns personal insight, work/family relationships, time, travel, eating, exercise, faith, getting along.  It’s a tough series of issues that sometimes needs to worked out with migraine patients.

Trigger                                                                                     Frequency

Stress                                                                                      79.7%

Hormones (in women)                                                         65.1%

Not eating                                                                               57.3%

Weather                                                                                  53.2%

Sleep disturbance                                                                 49.8%

Perfume or odor                                                                    43.7%

Neck pain                                                                                38.4%

Light (s)                                                                                    38.1%

Alcohol                                                                                    37.8%

Smoke                                                                                     35.7%

Sleeping late                                                                          32.0%

Heat                                                                                        30.3%

Food                                                                                        26.9%

Exercise                                                                                   22.1%

Sexual activity                                                                        5.2%


Preventive Therapy for Migraine

Preventive therapy is daily medication for patients who:

Experience 3-4 or more migraines per month

Present with medication overuse headache

Who prefer this type of treatment

Have significant pain that hampers their life.

Take a lot of over the counter, narcotic, opioid or barbiturate pain killers

Don’t get enough relief from the medications they are currently taking

Have side effects from drugs used for acute therapy

Preventive treatment might not be an option for patients who:

Can control their headaches with anti-inflammatory drugs (NSAIDS) like naproxen or


Have other health conditions that don’t allow taking preventive drugs

Might have preventive drugs that don’t mix well with the other medications they take

Prefer treatments that don’t involve taking medications.

Can get relief from relaxation therapy, stress-management, or biofeedback

Prefer a medical device called Cefaly, which is an FDA approved treatment for migraine prevention.  It is worn on the head, delivers electrical impulses, and is used once a day for 20 minutes.

Are pregnant, as migraine usually improves in the 2nd or 3rd trimesters

American Academy of Neurology recommendations for preventive drugs:

Level A established as effective–Divalproex sodium, sodium valproate, Topamax (topiramate), Trokendi XR, Frovatriptan (long acting triptan–26 hours) for menstrually related migraine short term,

OnabotulinumtoxinA (Botox)–physician injects onabotulinumtoxinA into the muscles of the forehead and neck.  When effective, the treatment is repeated every 3 months.

Metoprolol, propranolol, timolol, frovatriptan

Level B—probably effective—amitriptyline, nortriptyline, venlafaxine

Level C—possibly effective ACE inhibitors (Lisinopril), angiotensin receptor blockers (candesartan), alpha-agonists (clonidine), carbamazepine

General statement

All of the listed drugs above for prevention may reduce headache significantly.  However, there are special considerations for patients with multiple medical problems using these drugs.  Patients who are anxious and can’t sleep or have depression may be given amitriptyline or nortriptyline.  Amitriptyline is also the go to drug for patients who have limited funds or no insurance drug coverage since it is so cheap, often just 3-4 dollars a month.  Persons who have epilepsy and migraine and overweight should be offered topiramate, or Trokendi XR but this drug shouldn’t be given to patients with a history of kidney stones.  Patients with tremor, hypertension, or migraine may be given a beta blocker which may treat all three conditions.  Thinking this way, the doctor and the patient may get a double treatment effect from a single preventive medication.

Panic Disorder

Bill’s heart pounded so hard and fast that his chest started hurting and he broke out in a sweat.  He thought he might be dying and was reduced to terror, suddenly, without cause.  Then, almost as quickly as the attack occurred, it faded away.  Thinking he had had a heart attack, Bill rushed to an emergency room, where he was examined and told everything was all right.  But several days later, he had another attack, and others followed.  Bill worried a lot that he was losing control of his life and might even be going crazy.  He reported avoidance of social activities, moodiness, poor sleep, and a low level of energy.

Eventually, Bill was diagnosed as having panic disorder.  The doctor explained that panic disorder results from a chemical imbalance in the brain that triggers attacks like Bill had been having.  The doctor reassured Bill the attacks were not a sign of mental weakness or personal failure.  Instead, they’re a sign that the body’s alarm mechanism, which prepares us to fight or run for safety, is out of order.  The doctor assured Bill that his intense feelings of losing control or dying could be overwhelming or frightening but that no one had ever died from a panic attack.  After a period of treatment with medication and psychological therapy,  Bill now lives a more normal life.

Everyday people like Bill are rushed into emergency rooms with symptoms that might indicate anything from heart disease to asthma.  About a third of the time, what they are experiencing is a panic attack—an unprovoked explosion of bodily sensations and fear.  It has been shown that most panic disorder patients consult physicians other than psychiatrists 10 or more times before their condition is accurately diagnosed.

Panic disorder is characterized by sudden, brief episodes of physical and mental symptoms which, by definition, occur spontaneously or “out of the blue,” to differentiate it from anxiety attacks that have never occurred spontaneously and have always been secondary to a specific reason.  For anxiety attacks the patient should have insight or a reason as to why the event occurred.  Anxiety would come after a sudden attack by an assailant who wanted to kill you.  There would be an evident reason for the symptoms resulting from such an attack.  This is not true with panic disorder. Both panic attacks and anxiety turn on the brain’s “fight or flight” mechanism.

The essential feature of a panic attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 physical or psychological symptoms.  The attack has a sudden onset and builds to a peak rapidly, usually in 10 minutes or less.  The attack also is often accompanied by a sense of imminent danger or impending doom and an urge to escape.  The physical symptoms are: pounding or rapid heart rate, sweating, trembling or shaking, shortness of breath or smothering, choking, chest pain/tightness or discomfort, nausea or abdominal distress, feeling dizzy/lightheaded or faint, numbness or tingling sensations, and chills or hot flushes.  The psychological symptoms are: derealization/feeling of detachment, fear of losing control or going crazy, and fear of dying.

The patient may report an intense desire to flee from wherever the attack is occurring.  Patients commonly arrive at an emergency room or other medical setting believing that their symptoms represent a heart attack, stroke, or some other catastrophic medical condition.  Panic attacks may become associated with a variety of situations in which patients feel an attack is more likely to occur, from which they would be unable to flee or get  help quickly if an attack occurred, or in which they might be embarrassed if others should notice they are having an attack.

In reality, a panic attack is often not apparent to an observer, which is why a patient can successfully disguise this condition from others.  The development of agoraphobia (fear of being in crowds or around other people) is common and is defined as fear of places or situations in which the patient feels ”trapped.”  Patients may not have thought through why they fear or avoid situations when they initially present for treatment.  As a result of this fear, they restrict travel or need a companion to enter phobic situations.  Common agoraphobic situations are traveling in a car, bus, train, airplane, driving on highways, bridges, tunnels, heavy traffic, being in stores, malls, restaurants, elevators, theaters, church/temple, sitting in a meeting, standing in line, or being home alone.

The cause of panic disorder is still uncertain, but there are theories.  A biologic basis is supported by a large volume of research.  Certain chemicals may provoke panic attacks, in most panic attack victims, but not in most other people.  Some of these chemicals are lactate, caffeine, and cocaine.  Medications used to treat panic disorder have been shown to block these attacks.  PET scans which reveal the metabolism of the brain show a chemical abnormality in a particular area of the brain of panic patients compared with people who do not have panic disorder.  The fact that panic disorder runs in families also suggests a genetic, biologic component to the disease.  Psychological theories regarding causes of panic disorder stress the idea that childhood stresses, such as the death of a parent, can predispose a person to phobic reactions.  The type of personality that avoids conflict by suppressing feelings and avoiding confrontation is more likely to develop panic disorder.  Panic disorder is closely linked to depression, generalized anxiety disorder, tension type headaches, and migraine.

Women get panic disorder about twice as often as men, but some experts suspect that males may be underreported.   A large government study revealed that 1% to 2% of the adult population will get panic disorder at some point in their lives.  That’s 2-3 million Americans.  In addition, another 4% to 5% of adults report having panic attacks and symptoms of agoraphobia who do not qualify for a full diagnosis.  The onset of panic disorder has a peak in late adolescene and a second peak in the mid 30s. In general, the treatments now available help reduce or alleviate the symptoms of panic disorder, so that people can lead more normal lives, but do not provide an actual cure.

General treatment of panic disorder includes attention to adequate rest (7-8 hours a night), regular aerobic exercise (20 minutes 3 X a week), a moderate work schedule (workaholism is defined as more that 55hrs/week), and regular vaction time off.  Patients with panic disorder should not drink any alcohol at all because it does the same thing the benzodiazepine drugs do, such as Xanax, in that it turns off the part of the brain that starts the fight or flight response.  However, because the effect of alcohol only lasts 2 hours, withdrawal symptoms and rebound occur, making panic symptoms worse after the alcohol is metabolized.

Medical treatment consists of using benzodiazepine drugs such as Xanax (alprazolam), taken once a day as XR 1-2 mg, or short acting .25-.5 Xanax which lasts 4 hours and can be dosed as needed or up to 3-4X/day.  Also Klonopin (clonazepam) 0.5 mg which lasts 6 hours and can be taken as needed or up to 3/Xday.  These drugs act acutely and will shut off the brain now.  They often will be given at the start of treatment with an SRI type drug to cover panic symptoms and any nervous or jittery symptoms that may come while the SRI is starting to work.   SRI means Serotonin Receptor Inhibitor and refers to a class of drugs that are used to treat depression, generalized anxiety, and panic disorder.  They increase the “nice, calming” brain neurochemical, serotonin, but they take several weeks to work.  Prozax, Zoloft, Paxil, Effexor, and Celexa all take about 3-4 weeks to kick in.  This is called induction.  Lexapro can start working in 7-14 days.  During the beginning induction period the patient, who is already experiencing panic symptoms, may get more nervous and jittery.  It has to be explained to the patient that he has to endure these startup symptoms.  Xanax or Klonopin may be given to cover these “getting on the medicine” symptoms and then they may be discontinued in a few weeks when the SRI starts to take effect.  Once the SRI starts to work, the Xanax or Klonopin may be tapered and sometimes discontinued.  A problem with the use of SRIs is that sometimes the patient has to be tried on several different drugs to get one that fits them—that relieves their symptoms but doesn’t cause side effects.  Consider that in this selection and use of the medication the doctor only has clinical guidelines to go by; it’s like treating diabetes without a blood sugar, or hypertension without taking the pressure.  Some patients feel like stopping the medication at the beginning, but this should be avoided without calling the office, talking to the doctor, taking the Xanas and Klonopin regularly and daily, and attempting to persevere.  In fact toughness and resilence is sometimes required here and the patient will then be rewarded with feeling much better later.  You just have to hold on, especially with drugs like Prozac or Zoloft which take three to four weeks to work.  Lexapro works faster.

Some doctors use Betablockers like Inderal or Aetenolol or the older antidepressants like Elavil (amitriptyline) or Pamelor (nortryptyline)  to treat panic disorder, but the current American Psychiatric Association  recommendation is to use an SRI drug.  They just work better.  Also since Xanax and Klonopin are benzodiazepine drugs and are classified as narcotics and can conceivably be abused, some doctors use Buspar, a nonbenzodiazepine drug which is a minor tranquilizer for anxiety which is not classified as a narcotic.  They just don’t work as well as Xanax and Klonopin and in America something like about 60% of patients with anxiety or panic disorder are treated with benzodiazepines.

Treatment options for difficult to treat panic disorder is attention to lifestyle issues, a full dose of an SRI, Xanax 4X/day or Klonopin 3X/day, cognitive psychotherapy with a counselor for 3-6 months,  consultation with a psychiatrist, and behavioral therapy.  Not every patient needs this full court press type treatment (a basketball term), but some do.  Another problem with treatment is that because panic disorder is a psychiatric syndrome, patients commonly just don’t want to admit to themselves and to others that they have such a problem and they resist treatment.  They commonly state “I just don’t like to take medication,” as if anyone does.  However, once these patients are on therapy for the first time they may feel normal and they may revert back to further attacks when they stop the medication.  Sometimes it is difficult for the doctor to know how long to use the medication, but some patients do well with long-term therapy for years.  If the patient has only had one or two panic attacks, treatment with a benzodiazepine drugs when the attack occurs may be all that is needed, but if the attacks are more severe, then more aggressive therapy as needed.  Maintenance treatment with medication is recommended for at least 12-24 months in most patients, and in some cases, indefinitely.

A last problem with the use of serotonin receptor drugs is that when the patient comes off of them, especially if they are stopped suddenly, they may have withdrawal symptoms.  This is worse with short acting drugs like Paxil and not so bad with longer acting drugs like Prozac.  The symptoms of discontinuation can include insomnia, vivid dreams, an electric shock sensation, nausea and vomiting, fatigue, myalgia, chills, crying spells, and anxiety/agitation.  Simply going back on the medication at the same dose will stop the symptoms.  Short acting serotonin receptor inhibitor drugs like Paxil should be tapered slowly by 5 mg a week.  In general the physician can consider stopping therapy gradually over 2-6 months.

Criteria for a diagnosis of Panic disorder.

Recurrent unexpected panic attack, defined as a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

(1) palpitations, pounding heart, or accelerated heart rate

(2) sweating

(3) trembling or shaking

(4) sensations of shortness of breath or smothering

(5) feeling of choking

(6) chest pain or discomfort

(7) nausea or abdominal distress

(8) feeling dizzy, unsteady, lightheaded, or faint

(9) derealization (feelings of unreality) or depersonalization (being detached from          oneself)

(10) fear of losing control or going crazy

(11) fear of dying

(12) paresthesias (numbness or tingling sensations)

(13) chills or hot flushes


General triptan rules—don’t use with a personal or strong family history of coronary artery disease.  Don’t use with uncontrolled hypertension.  Limit the dose in children, the elderly (defined here as over 65 years old.), and patients with basilar artery or complicated migraine (aura symptoms over 40 minutes.)  Don’t mix the triptans or take with ergotamine within 24 hours.

Common triptan side effects–chest tightness or pressure, near fainting, neck/back pain which may be burning, warm or hot, dizziness, or drowsiness.

Triptans and SSRIs/SNRIs—the FDA has erroneously reported that there is a rare risk of development of serotonin syndrome in patients who take these drugs.  The risk is estimated to the less than 0.03% of patients and life threatening events are less than 0.002%.  In a recent review none of the migraine experts recommended that Triptans and SSRIs or SNRIs be discontinued unless symptoms arise.  The symptoms of serotonin syndrome are restlessness, hallucination, loss of coordination, tachycardia, changes in blood pressure, fever, nausea, vomiting, or diarrhea.  This risk is likely not real and factitious although the FDA hasn’t yet changed their advice.

Imitrex (sumatriptan) most effective when given via a gun type injector.  The medicine comes in a vial with a needle and is loaded into the injector like a bullet.  The medicine is then injected subcutaneously by pushing a trigger.  This is a very slick, high tech system.  The dose is 1 injection (6mg) at the onset of a migraine, may be repeated at 1 hour for a total dose of 12 mg/24hrs.  An oral pill exists also: 25 mg (for kids) or 50, 100 mg (for adults).  The usual dose is 50-100 mg at the onset of headache, may repeat at 2 hours (max 200mg/day).  An Imitrex nasal spray is also available as 1-10 mg squirt per nostril per migraine.  For Imitrex the highest drug levels are obtained with the shot, medium drug levels with the pills, and low drug levels with the nasal spray.  Some patients find the Imitrex nasal spray tastes bad when it goes down the back of the throat.  Imitrex went generic December 2008.  Rebound potential. Limit to 2 treatment days/week.

Sumavel DosePro SQ needle free.  This is a transdermal, one time use, application supplying 6 mg of sumatriptan subcutaneously by a pressure jet through the skin.  Dose is 1 at onset, may repeat in 1 hour.  Rebound potential.  Limit to 2 treatment days/week.

Alsuma (sumatriptan injection) This is an “epi-pen” type system with a medication loaded syringe and needle which may be given subcutaneously.  Dose is 1 at onset, may repeat in 1 hour, Rebound potential.  Limit to 2 treatment days/week.

Treximet (sumatriptan 85 mg, naproxen 500mg).  The “new” Imitrex which has the triptan, sumatriptin and an NSAID, naproxen.  Studies show this may be more effective than Imitrex alone.  Rebound potential.  Limit to 2 treatment days/week.

Tip regarding subcutaneous injections—YouTube has instructional videos on how to do this on the internet.

Zomig (Zolmitriptan) should decrease the dose by 50% if taken with Tagamet (Cimetidine).  Comes as a 2.5 mg or 5 mg tab to be taken one as needed for migraine, trying the 2.5 mg dose size first and moving up to 5 mg (max 10mg/day).  Dose at onset 2.5 or 5 mg, may repeat in 2 hours.  Also comes as a dissolvable tablet 2.5, 5 ZMT and as a nasal spray 2.5, 5 mg. Rebound potential.  Limit to 2 treatment days/week.

Maxalt (Rizatriptan) comes as a MLT (melt in your mouth) 10 mg wafer and 5, 10 mg tablets. Both are absorbed in the stomach and the MLT, which some patients consider more convenient, is absorbed slower than regular Maxalt. Should reduce the dose by 50% if taken with Inderal (Propanalol).  Dose is 1 at onset, may repeat in 2 hours, or take another dose 2 later.  Maxalt is the only triptan that can be dosed 3 tablets/day.  Max 30 mg/day.  Rebound potential. Limit to 2 treatment days/week.

Axert (Almotriptan)   Comes as a 6.25 and 12.5 mg tablet. In controlled clinical trials, single doses of 6.25 mg and 12.5 mg of Axert tablets were effective for the acute treatment of migraines in adults, with the 12.5-mg dose tending to be more effective.  Dose is 1 at onset, may repeat in 2 hours.  Rebound potential. Limit to 2 treatment days/week.

Relpax (Eletriptan)  Comes as a 20 and 40 mg tablet.  The 40 mg tablet seems to work the best.  Dose is 1 at onset, may repeat at 2 hours.  Contraindicated with Antifungals, Macrolide Antibiotics, and Protease Inhibitors.  Rebound potential. Limit to 2 treatment days/week.

Amerge (Naratriptan)—2.5 mg tablet which is the initial dose.  May repeat in 2 hours.  Amerge is a specialty niche migraine medication for those whose migraine generator in the brain produces a long, slow onset profile.  This drug stays around long enough to outlast this type of migraine.    The duration of activity is long—6 hours as opposed to 2-3 hours for most of the other triptans, except Frova.  Rebound potential. Limit to 2 treatment days/week.

Frova (frovatriptan) — The newest of the triptan group and like Amerge it is a niche, specialty triptan for migraineurs with long duration headache generators.  It has a very long duration (26 hour half-life) and lasts four times longer than any other triptan.  Thus, it may become the drug of choice for menstrual migraine.  Taking birth control pills or Inderal may increase blood levels of Frova.  Treat with an initial 2.5 mg dose, may repeat in 2 hours.  Rebound potential. Limit to 2 treatment days/week.

Triptan special considerations:

Relpax—contraindicated with antifungals, macrolide antibiotics, protease inhibitors

Maxalt—decrease dose by 50% with Inderal

Frova—-decrease dose with BCP and Inderal

Zomig—decrease dose with Tagamet

Medications or Food that may aggravate Migraine

Antihypertensive drugs-such as Reserpine (Brand name- Ser-ap-Es, Hydropres), Hydralazine (brand name-Apresoline), and Nifedipine (Brand name-Caalan), Oral pill (such as Brand name-Orthonovum, Alesse), patch, and intramuscular contraceptives (Depoprovera) and estrogens (Estrace, Estradiol) for replacement therapy, Coronary vasodilators for angina-Nitroglycerin, Nitrates, Antacids-Cimetidine (Brand name-Tagamet), Decongestant overuse-pseudoephedrine (Brand name-Advil sinus, Dristan), SSRIS-Selective Serotonin Receptor Inhibitors-for treatment of Depression, Anxiety and Panic Disorder-Fluoxetine (Brand name-Prozac), Paroxetine (Brand name-Paxil), Bronchodilators-Theophylline, Aminophylline, Benzodiazepine withdrawal-Xanax (Alprazolam), Valium (diazepam), Ativan, (lorazepam).

Aged Cheese-cheddar, Brie, Camembert, Gruyere, Stilton (tyramine),Bananas, figs, and raisins, Beer, wine (especially red wines), champagnes, vermouth, hard liquor, airy products such as ice cream, milk, yogurt, whipped and sour cream, fermented and pickled foods such as pickled herring, Most citrus fruits like oranges, grapefruit, and lemons (Octopamine), Nuts, peanuts, peanut butter, Soya products, vinegar, Pods of broad beans-lima, navy, pea pods,Yeast containing products such as fresh breads, sourdough, and donuts, Avocados, Anchovies, Onions, and Sauerkraut, Pork, Pizza, chicken livers, Chocolate, Caffeine in coffee, tea, and colas, and over the counter medications such as Excedrin and BC Powder, MSG (Monosodium glutamate) which is found in Chinese food, Accent seasoning, Lawry’s Seasoned Salt, canned soups, snack chips, some processed meats and nuts, and TV dinners, Saccharin or aspartame found in diet sodas, drinks, and foods, Sulfites found in shrimp and processed potatoes, store bought potato mix, Benzoic acid which is a food preservative, Nitrates used as a preservative in bologna, salami, pepperoni, and hotdogs, Aspartame, a table top sweetener, used in foods and drinks (NutraSweet).


Risk Factors for developing Atherosclerosis

From the American Heart Association

 1)  Genetics – your own family’s history of heart disease/stroke.

2)  Obesity.

3)  Cholesterol Level – less than 200 in general; also LDL cholesterol, homocysteine, fibrinogen, low-density lipoprotein, and C reactive protein.

4)  Hypertension-a blood pressure over 130 systolic or 90 diastolic.

5)  Smoking.

6)  Diabetes.

7)  Level of Activity – all persons should do 20 minutes of Aerobic Exercise three times a week.  Aerobic exercise is defined by the heart rate.  There are published tables for desired heart rates for different ages of life.  If you do an activity that gets your heart rate in the target area, then that is aerobic exercise.  Common  types of aerobic exercise are jogging, Jane Fonda type exercises, a rowing machine, treadmill, stepper, cardioglide machine, cross country skier machine.  Walking, playing golf or tennis, even racquetball are not aerobic exercise, because the heart rate doesn’t get high enough.

Athero (fat), sclerosis (hardening) means hardening of the arteries and is a generalized disease process affecting all the major arteries in the body, mainly the heart and arteries to the brain.  Atherosclerosis is a complex, multifactorial disease process with genetic and environmental factors. In the United States the number one cause of death over age 50 is heart disease from atherosclerosis.  The number three cause of death is stroke, again from atherosclerosis.  There are no “chemical roto-rooters” to open up arteries.  Surgeons and cardiologists may do this in selected cases if the disease process is focally present in one area, like the carotid artery going to the brain, or a coronary artery supplying the heart.  The idea is to try to live a type of life that reduces the risk factors of atherosclerosis–quit smoking, lose weight, treat hypertension, care for your diabetes, watch your cholesterol, and exercise aerobically.

A research report studying 40,000 patients for 40 years showed that persons who exercised lived two years longer than persons who did not.  This was at Framingham, Massachusetts, the oldest heart disease study group in America.

Exercise may be considered to be like a drug.  It promotes the relaxing response, helps reduce tension, and increases endorphins which are internal brain chemicals that decrease pain.  Exercise may help migraine, tension type headache, anxiety, panic disorder, insomnia, and depression.

The Autonomic Nervous System and the Pituitary Gland

 The Autonomic Nervous System consists of a series of nerves that extend from the spinal cord to organs in the body.  It is controlled by deep nuclei in the brain and responds to automatic cues in our lives.  An example of Autonomic Nervous Activity would be crying in response to emotional feelings.  Sadness triggers nerve cells in the parietal cortex in the brain which then descend down the brain stem and flow out nerves that go to the lachrymal gland in the eye.  Salivation is a similar activity.  When we consider eating food, or we smell food, our brains cause our salivary glands to secrete saliva.  We don’t think to make this happen, it just happens.  Remember Pavlov, the Russian physiologist, and his dog.  He could ring a bell and then feed the dog and it would salivate.  Then he trained the dog to salivate in response to the bell alone.

The lie detector test is an example of  the function of the Autonomic Nervous System.  For the test they measure four parameters of autonomic function–heart rate, breathing rate, sweating, and blood pressure.  Then they wire you up and ask you a lot of questions and analyze the data.  If the questions or your answers stir up an emotional response, then your body may answer for you through the Autonomic Nervous System and the examiners know how you feel without needing to ask you.

Certain medical illnesses involve alteration of the autonomic nervous system enough to cause symptoms.  These illnesses are migraine and tension headache, irritable bowel syndrome, peptic ulcer disease, hypertension, and bronchial asthma.  A hole in the stomach caused by a peptic ulcer can erode into a major artery and cause the patient to bleed to death; a pretty severe, but possible result from too much acid in the stomach.  Psychological illnesses relating to overfunction of the Autonomic Nervous system are Anxiety and Panic Attacks.  The patient with Anxiety usually has insight into what is going on their life to cause symptoms, while Panic Attack patients do not.  Panic Attacks occur randomly, unrelated to what one is doing.  Persons suffering from the symptoms of Panic Attacks need strong reassurance of the meaning of their symptoms plus understanding of their nervous system.  The Autonomic Nervous System functions whether we want it to or not.

The deep brain nuclei that influence the spinal cord and the Autonomic Nervous System can also stimulate the Pituitary Gland and cause hormonal discharge.  Again, like the Autonomic Nervous System, a lot of Pituitary Gland function happens regularly every day without our knowledge.  However, if we get temporarily excited, such as might happen if  someone pulls out in front of you while driving on Central Expressway,  we might develop shaking or palpitation of the heart from the effect of Adrenaline secretion.

Alcohol is the number one drug in the world that is used to control unwanted symptoms from  the Pituitary Gland or the Autonomic Nervous System.  The phrase, “I had a drink to settle my nerves,” considers how Alcohol works but the problem with it is that it is a toxin to the brain, the liver, and peripheral nerves.  It also creates addiction and withdrawal symptoms.  Minor tranquilizers such as Xanax shut off the unwanted signals from deep brain nuclei that turn on the Pituitary Gland or the Autonomic Nervous System and can be used for treatment.  They only last 4 hours so 3 or 4 doses per day may be necessary.  Serotonin Receptor Inhibitors, like Prozac, Zoloft, Celexa, Lexipro, and Paxil, can help treat these symptoms also but they take about 4 weeks of daily treatment to work (except Lexipro which may work in 7-10 days).

Generalized Anxiety Disorder

Approximately 40% of persons who have migraine will have stress or anxiety issues.  The most common medical diagnosis here is called generalized anxiety disorder which may be abbreviated as GAD.  Migraine and GAD are comorbid which means that they occur more likely statistically together than would be expected.  Migraine is said to be a genetic problem while anxiety is discussed as familial.

Many persons will say, instead of admitting anxiety, that they have “pressure or stress or worries” but all these are really about the same thing.  The DSM-IV is the large standard diagnostic text book from the American Psychiatric Association which lists psychiatric diagnoses and the check list below details how a doctor might diagnose GAD.

DSM5 Criteria For the Diagnosis of GAD (Generalized Anxiety Disorder)

The patient experiences excessive anxiety and worry

The anxiety is difficult to control

The anxiety is on several subjects

Symptoms occur for more days than not (or > 50% of the time) for the past six months

The patient experiences significant distress or social impairment (withdrawn, sees no one)

There may be at least three ancillary symptoms:

Ancillary Symptoms

Restlessness/mental tension (time pressure)


Poor concentration

Irritability (for intrapersonal relationships)

Muscle tension (tension in neck, shoulders, back, teeth clenching or grinding)

Sleep disturbance


Focus of anxiety/worry is not another disorder (for example, panic disorder)

Not part of a mood disorder, psychotic disorder, or pervasive developmental disorder

Not substance related

Not organic

DSM5= Diagnostic and Statistical Manual of Mental Disorders, fifth edition

Cognitive Behavioral Therapy-CBT

Cognitive behavioral therapy is a skill one may learn based on analyzing the thoughts we have in our head, which are irrational, and then making rational responses to those thoughts.  We tend to think in terms of sentences which relate to our origins, parenting, and education.  Feelings are thought to be irrational and specific for that individual.  For instance, someone from a foreign country does not have the same pride or memories of America that an American may have with seeing the flag or hearing the Star Spangled Banner.  The patient tries to identify the irrational thoughts as they occur and at that moment replace it with a rational response which is less ego deflating and mentally healthier.  This new approach stresses changing a patient’s self-defeating beliefs such as “I must be perfect” and “I must be loved by everyone” by demonstrating their irrationality and rigidity.  Using cognitive analysis people can understand their errors in light of the core irrational beliefs and then construct a more rational position.

Irrational Thought                           Rational response

I must do everything perfectly.      I am lovable and acceptable no matter what the outcome.

Whatever I do is good enough considering the time I have and                                                             what I know at the time.

My peace of mind and health are more important than doing                                                               things perfectly.

I must achieve all my goals

every day.                                          Whatever I do today is good enough.

I judge my self worth solely

by achievement.                               My peace of mind and health are more important than letting                                                             this bother me.

Neither I nor others

are good enough.                             I am always doing the best with what I know at the time.

If it is out of my control I am not going to let it bother me.


I worry a lot about pleasing

others.                                                What others think our feel about me is their business.

I am responsible for my well-being.

I can best help others by allowing more time for my self.

I get stressed when I

can’t control a situation.                If it is out of my control, I don’t have to worry about it.

I will deliberately think of other things rather than dwell on                                                                  what can’t be changed.


Try YouTube video—CBT Panic Disorder, insomnia, GAD, or Depression

Ellis and Harper A New Guide to Rational Living. Wilshire Book Company, 1975

ISBN 0-87980-042-9. used for $1.


How to tell migraine from other types of headache

Migraine and Tension Type Headache are both primary headaches without certain cause, which have a normal physical exam, and tests, and which compromise 99% of all headaches.


One sided, it comes from the Latin word hemicrania which means half of head

Throbbing, pulsatile-can feel your heart beating in your head



Sensitive to light

Sensitive to sound

Severe (5-10) headache

disabling-patient misses work or social activities


Tension Type Headache


Usually generalized

Non-throbbing, feels like pressure or tight

Not associated with nausea, vomiting, or sensitivity to light or sound

Usually mild to moderate (1-5)

Patients stay in their life with these headaches, don’t leave work or miss social activities


BTD 081816

ICDH III Definition of Cluster Headache

At least 5 attacks fulfilling B-D below.

Severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes.

Attack is associated with at least one of the following signs on the side of pain:

Conjunctival injection                  Forehead and facial sweating

Lacrimation                                  Miosis

Nasal congestion                           Ptosis

Rhinorrhea                                   Eyelid edema

Frequency: from one every other day to eight per day

At least one of the following:

History, physical, and neurological examinations do not suggest disorders in groups 5-11 of IHS classification.

History and/or physical and/or neurological examinations do suggest other disorder, but it is ruled out by appropriate investigations.

Such disorder is present, but tension-type headache does not occur for the first time in close temporal relation to the disorder.


John Graham notes on treating migraine headache

John R.  Graham on medical progress and treatment for migraine

The New England Journal of Medicine November 10, 1955

It is important from the onset in prophylaxis that the physician, the patient, and the patient’s family have an understanding of the disease, the method of approach to the problem, and the limitations and duration of treatment.  All parties to the therapeutic program need to understand the following facts and behave accordingly:

That at present, there is no magic medicine or formula of treatment that universally “cures” migraine.

That the patient is “not to blame” for having inherited the migraine trait.

That the pain and misery of the migraine attack are very real and not “imaginary.”

That neither the patient, doctor, nor husband (or wife) should be intolerant, but rather all should work for better understanding of each other.

That the patient and family have the greater burden in therapy, and that the doctor is going to act as a friendly guide rather than as a “miracle man.”

That the whole program will require a considerable period, with frequent reviews of progress, temporary setbacks, changes of therapeutic signals and gradual re-education.

That the most rewarding long-term therapy will be concerned with adjusting the patient’s way of living to his or her capacities rather than with an endless round of medication.

That the patient cannot be expected to make all the necessary adjustments overnight.

That the changes in psychologic attitudes become real only through actual practice rather than through verbal instruction.

That there is definite hope for improvement through conscientious effort of both patient and physician, but that complete freedom from migraine is rarely achieved by any therapeutic program.

Errors in living

Presented below is a list of common deviations from hygienic living that many persons may well practice with impunity but that are frequently a source of headache to the sufferer from migraine.  Behind these errors in living lie attitudes in the patient that serve both to bring them about and to intensify the damage that they create.  Such errors may have to be arbitrarily eliminated at first, but as treatment progresses it is important and fundamental to ultimate success for the patient to gain insight into his attitudes and personality traits that brought them about and to attempt suitable alteration.  The errors are as follows:

Poor meals-skimpy breakfasts and lunches and large dinners eaten in a state of fatigue.

Irregular hours for meals.  Postponing lunch for an hour may give anyone a mild headache but may produce a bad sick headache for the migraine patient.

Morning deadlines.  Too little time is allowed between the rising hour and the scramble for school and the office.

Sleeping late on Saturdays, Sundays and holidays.  The patient with migraine needs a good deal of sleep-but not in the morning.  Excessive cerebrovascular dilatation probably takes place, and breakfast is delayed.  Conversely, getting to bed early is important since, to date, the only real cure for fatigue is rest.

Lack of breaks in the day.  A short rest in the morning and afternoon, regularly obtained, is helpful.

Overcrowded schedules.  Patients usually try to work in too many events in a day.  They need to spread their activities more evenly over several days.

Failure to take proper vacations.

Failure to get away from their own children periodically.

Excessive participation in community and church activities.

Over anxiety regarding preparations for guests, shopping trips and vacations.

Long automobile trips.  The migraine patient usually wishes to go the 500 miles in one day and ends up with a headache.

Acting as Chairman, because nobody else will accept.  Migraine patients do not delegate work to others.  They do it all themselves.

Making up for lost time.  As soon as the patient is over one attack, she usually rushes to repair her losses.  Consequently, the next attack comes sooner.

Suffering petty wrongs in silence until they mount to unbearable heights.  It would be better to settle differences while they are small.

Aiming for impossible goals and worrying when they cannot be obtained.

Lack of exercise.

Lack of recreation.


Allodynia and medication overuse headache

Allodynia comes from the words “allo” which means “other” and “dynia” which means “pain.”  Clinically it refers to pain produced by a non-painful stimulus, such as touch.  Allodynia is an uncomfortable heightened sensitivity to touch.   Normally it doesn’t hurt to touch the head or the brow or the temple, but during the late stages of a migraine or during medication overuse headache, a simple touch to the head or temple may be perceived as painful.  This is like a sunburn.  Normally if I touch my arm it doesn’t hurt but after a sunburn at the beach, my arm is painful to touch.  This is what allodynia is like.

Allodynia can be divided into: tactile allodynia-pain from touch or light pressure like a belt or bra strap, mechanical allodynia-pain from motion across the skin such as light massage or the touch of fabric, and thermal allodynia-pain from heat or cold that makes the limbs feel needle like, sharp pain.

The pain of allodynia can be provoked by combing or brushing the hair, shaving, showering, wearing glasses, or earrings.  The pressure of a strand of hair may feel like the jab of a hot knife.  Allodynia is the migraine patient who notes on the third day of headache suffering that it hurts her to brush her hair or lay her head on the pillow.

Allodynia occurs mostly in long duration episodic migraine attacks or in patients transformed to medication overuse headache by overtreatment of headache with analgesics.  The duration of migraine is 4-72 hours, as defined by the International Classification of Headache 2004.  Migraine is generally an episodic, paroxysmal disorder occurring at most 2 times a week.  One can easily see by doing simple math that multiplying 72 hours or 3 days by 2 equals 6 days.  This is why periodic migraine rarely occurs more than twice a week.  Daily headache or headache 3 or 4 days a week is usually Chronic Daily Headache (CDH), a syndrome defined as >15 headache days a week.  About 70% of persons with CDH have a common headache syndrome from overtreating with analgesics, caffeine, or triptans called Medication Overuse Headache.

An attack of migraine has 4 stages: 1) trigeminal activation, 2) neurochemical release, 3) arterial vasodilatation, 4) central sensitization of the thalamus in the brain.  In general patients with an attack of migraine are at stage 3 in two hours and after two hours they are in stage 4.  Thus, patients with long-duration (headaches lasting more than several hours) episodic migraine attacks spend most of the time in stage 4 central sensitization.  The general thinking is at all patients with medication overuse headache are continuously in stage 4 central sensitization.  Both of these circumstances can produce allodynia.

With episodic migraine the allodynia clears when the headache ends and the offending neurochemicals are metabolized and excreted.  The same thing occurs during treatment of medication overuse headache when the patient is detoxed off of analgesics, caffeine, or triptans and in time the offending neurochemicals are metabolized and consequently the headache clears.

BTD 10/22/09.

Betablockers for migraine prevention

Betablockers are “Vasonormalizers” which prevent dilation and constriction of arteries. Adrenaline is made in two varieties: Alpha—which works on the lungs, and Beta—which work on arteries.  Thus, the name Betablocker.  The archetype Betablocker drug is Inderal, known generically as propanolol.  This drug works to block some of the effects of adrenaline on arteries.

It has been approved by the Federal Drug Administration for the treatment of a large variety of medical problems which includes:  Migraine, Benign Essential Tremor, Hypertension, Angina (the chest pain heart patients get), and Cardiac Arrhythmias.

It comes in a short term (4 hour lasting) dose or in LA (long acting-24 hour) form.  Common doses are 80-320 mg/day.  For younger patients with migraine or tremor the dose may be discontinued safely at a low dose such as 80 mg/day, while older patients with heart disease and higher doses should have the dose tapered slowly.

Inderal is usually well tolerated and has few side effects, although like all drugs it has two pages of small print listing possible side effects.  The only potential side effect I warn patients about is that a small number of patients develop the so called “Inderal tired syndrome” after they start the drug, usually in the first week.  If this side effect develops, then the drug should be stopped and another betablocker selected.

How long the drug has to be given is not known at the beginning and depends on the clinical indications.  For tremor Inderal is usually given long term for years or life.  For migraine I commonly encourage the patient to consider using the drug for 3-6 months at first and then reassess this on follow up.  Many patients are able to get off the drug then although some patients with bad migraine are happy to continue.

Another betablocker that may be used for migraine prevention is Tenormin (Aetenolol) at 50-100 mg/day.


Topiramate for migraine prevention

Topamax (Topiramate)   100-200 mg per day.  This drug originally had an indication for treatment of epilepsy but Topamax was approved in the Fall of 2004 for preventive treatment of migraine also. It is one of the secondary drugs that may be used for treatment of benign essential or familial tremor.  It is also used for treatment of bipolar disorder. To start the drug has to be slowly added as 25 mg a night for a week and then increasing the dose to 25 mg twice a day for the second week.  The third week dose is 25 mg in the morning and two 25 mg tabs at night.  The fourth week the patient should switch to 50 mg twice a day.  The patient should then stay on this dose for several months to judge the effect on migraine reduction.

Side effects: psychomotor slowing, somnolence, word finding difficulty, numbness, pop drinks taste flat, weight loss, insomnia, anxiety, decreased sweating and hyperthermia, secondary angle closure glaucoma, kidney stones-especially in men, and metabolic acidosis.

A long acting version of the drug has been released called Trochandia XR which comes in doses of 25, 50, 100, and 200 mg.  This is one a day pill.  It has pellets which slowly dissolve to give a steady blood.  Generic topiramate taken twice a day sometimes gives more side effects which may not happen with this new drug.  It is approved for treating epilepsy and migraine by the FDA.  There is also a copay free card for insurances except Medicare and United healthcare.

For migraine-common doses are 100-200 mg a day.  For treatment of benign essential tremor-doses between 50-100 mg may be used.

Acute treatment of migraine

This refers to the medication you take for the headache you have now.

  1. Treat at onset. This means that if a person has a migraine start Monday morning at 8:00, they should take their acute therapy migraine drug then.  This is generally going to be a triptan or DHE or Cambia.  Don’t wait, thinking it’s not going to be “one of those.”  It very well may be a bad headache coming on.  Migraine headaches may start in the back of the head and move forward to the temple or behind one eye.  Treatment should begin while it is in the neck.  Migraine may start in the forehead, eye, or cheek area.  There is no “sinus headache” a term that is not in the International Classification of Headache.  Treat it as a migraine.  One of the acute onset Triptans should be used—Imitrex (sumatriptan), Zomig (zomatriptan), Maxalt (rizatriptan), Relpax (eletriptan), or Axert (almotriptan).  Frova and Amerge take several hours usually to start working and are mainly used for menstrual migraine.
  2. Take the right drug. In general, for severe migraine patients this is going to be a Triptan.  Yes, many patients with mild migraine can treat their headache with Excedrin, an NSAID, or pseudoephedrine, but the severe headache patients—the type that end up in the emergency room will usually need a Triptan.  Usually the Triptans will treat the whole migraine syndrome—headache, nausea, vomiting, photophobia, sonophobia—and they work best if taken at onset of headache.  However, a small percentage of patients will need to take something for nausea with the Triptan, such as oral 25 mg Phenergan (promethazine), or Zofran (odansetran) odt 4-8 mg.
  3. Take enough of the right drug. This is a dosing situation which varies from patient to patient.  Elephant rifle load for migraine remains injectable sc Imitrex (sumatriptan) which works the fastest, in 10 minutes, and gives the highest brain level of 100 mg.  Oral Imitrex (sumatriptan) 50-100 mg, Maxalt (rizatriptan) 10 mg, or Zomig (zomatriptan) 2.5-5.0 mg, Axert (almotriptan) 12.5 mg, or Relpax (eletriptan) 40 mg may be tried at onset of the headache.
  4. Naproxen The headache literature supports using any of the triptans with 2 Aleve (naproxen) 200 mg. These 2 drugs may provide better relief than the triptan alone.  The literature says only naproxen and there is no data for Advil, or Tylenol.
  5. Migraine causes confusion. Many studies reveal that migraine patients do poorly on cognitive testing after the headache starts.  This may relate to the slowness or lack of treatment many patients experience when they just can’t break from what they are doing and take their medication early.
  6. Triptans block the release of inflammatory neurochemicals. That’s how they work, but they have to be taken early in the migraine process before the chemicals are released.  In general, neurochemicals in migraine patients are released 20-40 minutes after the start of the migraine process.  No other drug in the world can do this and that’s why as of 2016 the latest drug approved by the FDA for treating migraine is another triptan—sumatriptan delivered via inhalation.


BTD 081616

Tips for sleeping well

Items 1 through 4 are called normal sleep hygiene and should be done by everyone.

  1. Establish a daily sleep/wake schedule. This means keeping a consistent time each day for waking up the morning and going to bed each night.  Try to stay within 30-60 minutes of these times every day.  This includes through the weekend, holidays, and vacations.  In general allow AT LEAST 7 -8 hours of sleep each night.  As we age, we need less sleep, so someone in his eighties may need only 6 1/2 hours, while teenagers may well need 9-10 hours.
  2. Be careful with naps. It’s okay in general to take a short nap after lunch, a siesta, but avoid a long nap.  If you can’t do this on your own, then set an alarm for a brief 15-30 minute nap.  If you have trouble falling asleep at night when you have napped earlier during the day, then eliminate the nap.  Just lie down and rest for 10-15 minutes instead during the day.  If you are the type who “never learned to rest” then, LEARN.  The relaxing response can be taught at any age.
  3. Be careful with caffeine and pseudoephedrine, both of which promote alertness. Caffeine lasts 8 hours.  If you go to sleep at night at 11 pm, then don’t drink any caffeine any later than 3 pm.  Pseudoephedrine is in a lot of over the counter sinus or cold medicines-such as Sudafed, or Tylenol Sinus.
  4. Regular physical exercise promotes sleeping well. The American Heart Association recommends that every body exercise aerobically for 20 minutes 3 times a week to decrease the risk of atherosclerosis.  As a physician I rarely see patients who do manual labor-carpenters, maids-who have trouble sleeping.  Exercise promotes the relaxing response.  A warning here is that some persons get too jived up after exercise to go to sleep.  They should exercise earlier during the day.  Exercise also induces endorphins, brain neurochemicals that reduce pain and promote calming.
  5. A low volume of a high calorie carbohydrate just before bedtime promotes sleep.  I’m talking about something like the proverbial “warm glass of milk.”  This has been studied scientifically and shown to work.  You have to be careful here with the calories and cholesterol.
  6. It’s okay to get out of bed and go to another room for awhile, if you can’t fall asleep when you first try. Then you may read , preferably something not too interesting , technical, or work related, for 10-15 minutes.  However, watching TV or doing housework are not good options.  They’re too stimulating.
  7. Home remedies, vitamins, food supplements, and over the counter sleeping pills don’t usually work for long term sleeping problems. Therefore avoid them.  This includes Benadryl which is in Tylenol PM, other antihistamines, and Chloral Hydrate.  Melatonin is a drug that may rarely work for small subset of patients with insomnia.  Unfortunately, it doesn’t work for everyone.  A dose of 3-12 mg of melatonin may be tried.
  8. Ambien is a class 4 narcotic, hypnotic sleeping pill that has been approved for chronic use. Some patients are drowsy after using it and may be up at night and perform automatic funtctions, like raiding the refrigerator.  Other hypnotics are Restoril.  Rozerem is a non narcotic drug that works on the melatonin brain stem system.
  9. Alcohol and minor tranquilizers (the Benzodiazepine drugs-Valium, Xanax, Ativan)-don’t work that well either because they don’t last all night and are not good long term options.
  10. The majority of patients who have chronic sleeping problems also have psychological reactions or conditions that interfere with sleep. Work directed toward resolving conflicts (psychotherapy) should be helpful. Sleep lab information states that half of patients in America with insomnia are anxious and a quarter of them are depressed.  These are the most common causes of trouble sleeping.
  11. The older antidepressant medications are, in general, safe for chronic sleep disorders. Examples here would be: Elavil (amitriptyline), Desyrel (trazodone), Tofranil, or Pamelor.  All of these drugs have a sedating quality which will allow normal physiological sleep.  They are not addictive or habituating.  They commonly have mild side effects of a dry mouth which improves with therapy.  These are the drugs that may be used for long term sleep disorders.  Trazodone comes as a 50 mg tablet and this works well for the majority of patients with trouble sleeping.  However, if this dose is too high the patient should break it in half and take 25 mg.  A maximum of 150 mg/night may be used.  If the patient doesn’t sleep all night on 50 mg then he should increase the dose by 25 mg /night per week until he sleeps all night.  The same approach may be used with amitriptyline where the dose may be started at 10 mg and can be just adjusted upward by 10 mg/night to about 75 mg until the patient sleeps all night.



BTD 9/1/06