Migraine comorbidities

Britt Talley Daniel MD


Migraine Comorbidities

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, 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.

The Mini Neurology Series Volume 1: Migraine


Girl reading 130 kb text



The Mini Neurology Series Volume 1: Migraine

In a world of big scientific books on headache and migraine there is a plea for a smaller book. This is it! A short but rather complete  36 page book on the definition of migraine, the lifestyle to live to have fewer attacks, and acute and preventive therapy of migraine. Throw in a short chapter on one of the most important subjects on migraine–medication overuse headache, and comments on sinus headache and allergy headache and you’ve got it…the first book in the Mini Neurology Series, on Migraine.

Go to www.amazon.com/books and enter Britt Talley Daniel, to get both of my books on migraine:  the big book, Migraine, which is in the second edition and one of the largest, well documented books written on the subject of migraine, and this new book in the Mini Neurology Series which is condensed, but covers the most important facts, and only 36 pages in length.

Also look at:  Migraine, my full textbook on the subject and Transient Global Amnesia, the only book in the world available now on the subject on Amazon.

The Mini Neurology Series:  Volume 2:  Carpal Tunnel Syndrome

The second book in the Mini Neurology Series, Carpal Tunnel Syndrome is written by a Neurologist trained in Electromyography, the Gold Standard diagnostic test for Carpal Tunnel Syndrome. The book reviews the anatomy, pathology, associated medical issues, workup, and treatment of the syndrome written in a succinct, and to the point style, and just the right book for the affected patient, medical student or neurology resident, or experienced physician wanting to know more about it. Hot off the press and from Amazon downloaded to your Kindle or as a print book from Createspace–The Mini Neurology Series Volume 2 Carpal Tunnel Syndrome.

Available as an eBook or print book.  Go to www.Amazon.com/books and enter Britt Talley Daniel,
scroll down to the book you want.

Are you in a mysterious mood?  Check out my two books on that great crime solver, MacArthur Donne MD.

Or, do you just want to know more about medicine in the early twentieth century in England and America and take that one and only trip on the Titanic?  Then read, Titanic:  Answer From the Deep, all on Amazon.com/books/Britt Talley Daniel.

You don’t have to own a Kindle hardware to read Kindle eBooks,

The Kindle app can be downloaded to any computer, iPad, or cell phone.

And if you read, please leave a review about the book you read on Amazon.

Thanks a lot.

Britt Talley Daniel MD

Mini MigraineDetails
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General article on migraine

Britt Talley Daniel MD

Dallas, Texas


 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 that18% of women have migraine, while 6% of men have it.  Migraine is said to be the most common chronic human health problem for women.  People with migraine often have motion sickness (60%) either in childhood or adulthood.  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.  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.

There are two types of Migraine

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

A. At least five attacks fulfilling B-D.

B. Attacks lasting 4-72 hours (untreated or unsuccessfully treated).

C. At least two of the following characteristics:

1. Unilateral (one sided) location.

2. Pulsating (throbbing) quality.

3. Moderate or severe intensity (inhibits or prohibits daily activities).

4. Aggravation by walking stairs or similar routine activity.

D. At least one of the following:

1. Nausea and/or vomiting.

2. 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.

2. 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 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 Lortab (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 doctors 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 plan for Migraine

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 too much can cause medication overuse headache.  Caffeine is confusing to some patients because they know that it may be used to treat headache, but need to learn that if taken daily it can cause frequent headaches.

Eat Three Meals a day.  A small breakfast will suffice.  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.

Exercise aerobically for 20 minutes, 3 to 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 aerobics, jogging, cycling, swimming, rowing, cross-country skiing, and stair-stepping.  It is usuall 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, Midrin or a half of a Tryptan drug before you work out.  If you still get a work out headache, then try swimming.

Set your sleep/wake cycle to rise and go to sleep at the same time every day-even through the weekend.  Avoid oversleeping Saturday morning or falling asleep for that seductive two hour nap on Sunday afternoon.  Set an alarm for 10-15 minutes for a short, energy restoring nap.

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.   Leave that depressing, stressful job, or get counseling and try to change a personal relationship that is causing problems.

Acute Therapy

Medication to be taken when the Migraine starts.

Aspirin (5 grains)with caffeine (60 mg) (Excedrin,Vanquish), Excedrin Migraine also has acetaminophen, 2-3 at onset, then repeat every hour X 2.  Limit to 2 treatment days a week.  Rebound potential.

Nodolor generic for Midrin (Tylenol for pain & a mild tranquilizer for muscle relaxation; isoheptadine for vasoconstriction of a migraine headache)  The dose is 2 at onset and then 1 every hour to 5.  Limit to 2 treatment days a week. Max 15/month.  Rebound potential.

Cambia (diclofenac) an NSAID (nonsteroidal antiinflamatory drug) approved by the FDA for acute treatment of migraine.  Dose is 1 at onset, may repeat in 4 hours.  Rebound potential.

Migranol  now generic DHE-45 Nasal spray 4mg/ml.  One spray (0.5 mg dihydroergotamine) to each nostril is taken at onset and the dose may be repeated X 1.  The half life is 10 hours.  This drug may be used for medication overuse headache.

DHE-45 for Intramuscular injection 1 cc at onset of a migraine.  Has to be drawn up from a bottle like insulin and injected in the muscle.  May repeat in 6 hours. Used for treating medication overuse headache.  Look to YouTube to learn about IM injections.


General triptan rules—don’t use with a personal or strong family history of coronary artery disease or uncontrolled hypertension.  Limit the dose in children, the elderly (over 65 years old.), and patients with basilar artery or long aura symptoms.

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 or burning, warm or hot feeling, dizziness, or drowsiness.

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, with one repeat dose within 24 hours (max 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 (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.  Rebound potential. Limit to 2 treatment days/week.

Treximet (sumatriptan 85 mg/naproxen 500mg).  Studies show this may be more effective than Imitrex alone.  Rebound potential.  Limit to 2 treatment days/week.

Alsuma  an epi pen type injection, 6mg sumatriptan, may repeat in 1 hour, rebound potential, Limit to 2 treatment days/week.

Sumavel DosePro transdermal injection of 6 mg sumatriptan may repeat in 1 hour, rebound potential, Limit to 2 treatment days/week.

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).  Also comes as a dissolvable tablet 2.5/5 ZMT and as a nasal spray 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).  Max 30 mg/day.  Rebound potential. Limit to 2 treatment days/week.

Axert (Almotriptan)   Comes as a 6.25 and 12.5 mg tablet.  Take at onset, may repeat in 2 hours.  The only triptan approved for ages 12-17 years old.  Rebound potential. Limit to 2 treatment days/week.

Relpax (Eletriptaan) —20 and 40 mg tablet.  The 40 mg tablet seems to work the best.  If there are no good results the 40 mg tablet may be repeated 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.  Duration 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) 2.5 mg tablet It has a very long duration (26 hour half-life) and lasts four times longer than any other triptan,  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.

Chronic or Preventive Therapy (taken daily)

Preventive Therapy of Migraine

Beta Blockers–Inderal (Propranalol) Comes as LA (Long Acting) an oral capsule 60, 80, 120, or 160 mg once a day, or as an oral tablet 10, 20, 40, 60, 80, and 90 mg given in divided doses.  The initial dose is 40-60 mg and the typical dose is 40-240 mg/day.  Blocadren (Atenolol) Comes as an oral tablet 25, 50, 100 mg given in divided doses.  The initial dose is 25 mg and the typical dose is 50-100 mg.  Common side effects—fatigue, depression.  Serious side effect–bradyarrhythmia.  Beta Blockers are contraindicated in patients with asthma or severe COPD, 2nd and 3rd degree AV block, severe sinus bradycardia, and Raynaud’s syndrome.

Antidepressant—Elavil (amitriptyline) Comes as an oral tablet 10, 25, 50, 75, 100, and 150 mg given usually at bedtime.  The initial dose for migraine is 10 mg and up to 30 mg may be used.  Side effects come with antidepressant psychiatric doses of 100-150..Pamelor (nortriptyline) Comes as a 25 mg oral tablet and oral capsule 10, 25, 50, 75 mg.  The initial dose is 10 mg and the typical dose is 25-150 mg given at bedtime.  Common side effects—weight gain, constipation, and sedation, cardiac dysrhythmias.

Depakote (Divalproex sodium) Comes as a delayed release oral capsule 125 mg, oral tablet 125, 250, 500 mg, and oral tablet extended release 250, 500 mg. The initial dose for migraine is 250-500 mg and the typical dose for migraine is 750-1500 mg given in divided doses.  Common side effects  alopecia, weight gain, nausea, and tremor.  Serious side effect  pancreatitis, liver failure, and thrombocytopenia.  Depakote should never be given to fertile women since it carries a class D risk for pregnancy.

Topamax (Topiramate) Comes as an oral capsule 15 and 25 mg and oral tablet 25, 50, 100, and 200 mg.  Doses for migraine the usual final dose is 100 mg and the drug is titrated up weekly starting with 25 mg and increasing the dose by 25 mg/week to decrease the risk of side effects to 50 mg taken twice a day– Common side effects—paresthesiae, weight loss, cognitive/psychiatric side effects including cognitive dysfunction, word finding difficulty, somnolence and fatigue, acute myopia and secondary angle-closure glaucoma (patients should be cautioned to seek medical attention if they experience blurred vision or ocular pain), oligohidrosis and hyperthermia—decreased sweating and increased, metabolic acidosis with lowering of serum bicarbonate levels (especially children in hot weather), and kidney stone formation.


In case of pregnancy all regular drugs for Migraine prevention and acute therapy should be stopped as during pregnancy the only medications most women may take  are vitamins and iron.  The patient should check with their obstetrician to see what drugs he or she allows for pain during pregnancy.  Usually this is Tylenol and caffeine.  Rarely patients with very severe migraine may be given one of the preventive drugs, except Depakote which has an X rating for pregnancy and which should never be considered for a patient who is fertile.  Also rarely triptans may be used safely during pregnancy and are commonly used by headache specialists.

Sinus Headache

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 rhinosinusitis headache because of similarity of location of the headache.  A group of patients can be identified who have of all the features of migraine without aura and clinical features of 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.  Sinus CAT scan is required to differentiate migraine in the sinus areas from acute rhinosinusitis.

Patients with what they call “sinus headache” usually localize the pain to behind the eyes, the forehead, or the cheeks.  Many of these patients have no purulent nasal discharge, a cardinal requirement of acute rhinosinusitis, an infection in the sinus areas.  This myth about sinus headache has been taught to Americans by TV ads since the 50’s by the pseudoephed industry.  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.

Allergy and Migraine

Allergy and migraine are separate medical problems sometimes existing in the same person.  The word “allergy” is not listed in the index of the 2013 International Classification of Headache.  Allergic symptoms may be an aggravating factor for the occurrence of migraine attacks.  Many different chemicals cause vasodilation and therefore aggravate migraine and is why MSG, chocolate, tyramine in aged cheese, and nitrates in hot dogs may result in migraine headache.  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, not from an allergic reaction.

Medication Overuse Headache

Medication overuse headache or rebound headache is very common and occurs usually in migraine patients who overtreat with caffeine, NSAIDS, barbiturates, and triptans.  In general only 2 treatment days per week are allowed.  One may have fewer headaches by taking less headache medicine.  The only way to treat rebound headache is to completely get off of the daily drugs for several weeks or months and the headaches will lessen.

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).

Birth control  pills, estrogen patches, IUDs, or intramuscular contraceptives Coronary vasodilators for angina-Nitroglycerin, Nitrates

Antacids  Tagamet (Cimetidine)

Decongestant overuse-pseudoephedrine (Advil sinus, Dristan)

Analgesic overuse-Excedrin, Tylenol, Advil

SSRIS-Selective Serotonin Receptor Inhibitors-for treatment of Depression, Anxiety and Panic Disorder-Prozac (Fluoxetine), Paxil (Paroxitinel).

Bronchodilators-Theophylline, Aminophylline.

Benzodiazepine withdrawal Xanax (Alprazolam), Valium (diazepam), Ativan (lorazepam)

Certain foods-listed below

Aged Cheese-cheddar, Brie, Camembert, Gruyere, Stilton (tyramine)

Bananas, figs, and raisins

Beer, wine (especially red wines), champagnes, vermouth, hard liquor

Dairy 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


Chemicals-listed below

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).

How to tell migraine from other types of headache

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

Being one sided is the most common feature of migraine

Migraine can also occur in the neck and work forward to behind one eye

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

Migraine comes with nausea which usually occurs 1-2 hours into the headache


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

is usually mild to moderate (1-5)

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


Migraine aliases:  that is, names people call what is usually migraine.  Usually these conditions should be treated at onset as if they were a migraine.


Sick Headache

Sinus Headache

Menstrual Headache

Allergy Headache

Hungry/fasting  Headache

Nocturnal Headache

Wake up Headache

Let down, holiday, weekend Headache

Saturday/Sunday morning Headache

Sun/Heat Headache

Barometric change Headache

Work out headache


Recognizing these patterns should help the patient treat at onset, like keeping their triptan and a glass of water at bedside to take if they wake up with a “nocturnal headache.”  Migraine should always be treated as quickly as possible because stage 2 where the chemicals come out occurs generally at 20-40 minutes after the start of the migraine and triptans block the release of the chemicals.


Migraine timing cycle:  1) Trigeminal activation, the fifth cranial nerve, the sensory nerve of the face is turned on by the migraine process and pain comes to the eye, forehead, face, sinus, jaw.  2) 20-40 minutes later the neurochemicals CGRD, Neurokinan A, and Substance P are released by the migraine process from ganglia onto the Trigeminal nerve, the arteries, and later onto the Thalamus.  3) At 2 hours the arteries vasodilate and are inflamed.  4) Past 3 hours the thalamus, also known as the pain center of the brain is turned on by the migraine process.  Migraine is a chemical inflammatory condition affecting the 5th nerve, the arteries, and thalamus.


The slide below show the 4 phases of the migraine timing cycle.



 Four stages of a Migraine



This slide show the 4 phases of a migraine which starts at 1 with Trigeminal Activation.  After 20-40 minutes phase 2 Neuropeptide Release Occurs and the inflammatory chemicals are released. The triptans are 5-HT D and B Receptor inhibitors so they block the release of the neurochemicals if the patient treats early.  Then at phase 3, which is about 2 hours into the typical migraine, the Meningeal arteries are vasodilated.  Now the trigeminal nerve, the ganglia which release the neuropeptides, and the meningeal arteries are in the skull but not part of the central nervous system.  Past 3 hours then the Thalamus is turned on and inflamed and this is the main pain center for the central nervous system.  If I drop a brick on my foot, the nerves in the tissues of my foot send a signal up the nerves in my leg, through the spinal cord, and to the thalamus in the brain, where pain is registered.  Phase 4 is also called central sensitization and this is the worst and most painful part of a migraine.  Then, since migraine is usually an episodic disorder the headache goes away in 4-72 hours and the process stops.  Within a day or so the neuropeptides in the brain are metabolized and leave the body through the liver and then the toilet.

However, if one overtreats with certain drugs (caffeine, NSAIDS, Tylenol, pseudoephedrine, triptans, hydrocodone, or butalbital drugs) then episodic migraine may be transformed to Chronic migraine which is defined as >15 migraine days a month.  This occurs because the body doesn’t have enough time to eliminate the drugs or the released neuropeptides and they stay in the brain and active this system so that 1-2-3-4 occur continuously, resulting in frequent, oftentimes daily headache.  In the 1988 International Classification of headache this syndrome was named “Rebound headache,” but this has been replaced by “Medication Overuse Headache.”


In general all migraine patients should limit caffeine, painkillers, and triptans to only 2 days a week.  This is the most that the body can tolerate and get rid of the drug and the neurochemicals without transforming into more frequent headaches.


See drawing below.

episodic to chronic migraine 001


BTD /6/20/2013

Migraine and Panic Disorder

Britt Talley Daniel MD

7777 Forest Lane  Suite B-220

972 566-4556

Dallas, Texas  75230

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

At least one of the attacks followed by one month (or more) of one (or more) of the following:

Persistent concern about having additional attacks.

Worried that the implications of the attack or its consequences.

Tab The clinically significant change in behavior related to the attacks

DSM-IV Diagnostic and Statistical Manual of Mental Disorders Fourth Edition

What you should know about panic disorder by Pharmacia

Panic Disorder with or without agoraphobia by Nagy and Charney

Panic Disorder Wayne Katon  M.D. N Engl J Med 2006; 354:2360-7

American Psychiatric Association 1400 K St. NW Washington, DC 20005


National Mental Health Association 1021 Prince St. Alexandria, VA 22314


Migraine and Depression

Britt Talley Daniel MD

7777 Forest Lane Suite B-220

972 566-4556

Dallas, Texas 75230

Approximately 50% of patients with depression may have migraine.  The two conditions are said to be co-morbid which means they occur together more likely than by chance. According to the DSM-IV, a person who suffers from major depressive disorder must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at least a two week period. This mood must represent a change from the person’s normal mood; social, occupational, educational or other important functioning must also be negatively impaired by the change in mood. A depressed mood caused by substances (such as drugs, alcohol, medications) or which is part of a general medical condition is not considered to be major depressive disorder.

The symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one) and the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

This disorder is characterized by the presence of the majority of these symptoms:

Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). (In children and adolescents, this may be characterized as an irritable mood.)

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 of body weight in a month), or decrease or increase in appetite nearly every day.

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day

Fatigue or loss of energy nearly every day

Feelings of worthlessness or excessive or inappropriate guilt nearly every day

Diminished ability to think or concentrate, or indecisiveness, nearly every day

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Migraine and Generalized Anxiety Disorder

Britt Talley Daniel M.D.

7777 Forest Lane Suite B-220

972 566-4556

Dallas, Texas 75230

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.

DSM-IV 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

DSM-IV= Diagnostic and Statistical Manual of Mental Disorders, fourth edition

BTD 10/30/09

Migraine Aggravating Factors/Triggers

Britt Talley Daniel MD

7777 Forest Lane Suite B-220

Dallas, Texas 75230

Migraine Aggravating Factors/Triggers

Many patients refer to “migraine triggers” but ICDH II differentiates between a migraine trigger which is something that causes an attack within 24 hours, like red wine inducing a migraine, and an “aggravating factor” like stress which builds up over weeks to produce migraine.

Chabriat, et al,[i] wrote in 1999 in Headache on “Precipitating factors of headache.  A prospective study in a national control-matched survey in migraineurs and non-migraineurs.”  They screened prospective factors in a migraine and non-migraine group of patients who kept a diary for a 3-month period.  The most frequent precipitating factors in both groups were:

“fatigue and/or sleep, stress, food and/or drinks, menstruation, heat/cold weather, and infections in both groups.”

Kelman[ii] writing in Cephalalgia in 2007 on “The triggers or precipitants of the acute migraine attack” listed stress at a frequency of 79 % and food at 26.9 %.   The table of frequency of individual migraine triggers from his article was:

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%

Kelman is not going by ICDH-II here which refers to stress as an “aggravating factor”, not a “trigger.”  However, his list is interesting and I keep a copy of this article in my office to hand out.

Another observation here is that many patients will focus on the different foods that may aggravate migraine and not recognize stress in their lives which is the most aggravating feature of migraine.

i Danchot J, Michel P, Joire JE, Henry P.  Precipitating factors of headache.  A prospective study in a national control-matched survey in migraineurs and nonmigraineurs.  Headache.  1999;39(5):335-338.

[ii] Kelman L.  The triggers or precipitants of the acute migraine attack.  Cephalalgia. 2007;27(5):394-402.

Allodynia with episodic migraine and medication overuse headache

Britt Talley Daniel MD

7777 Forest Lane Suite B-220

(972) 566-4556

Dallas, Texas 75230

Allodynia with migraine 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.  Also read my article on the subject of Medication Overuse Headache on this blog.

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 that 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.  In time the offending neurochemicals are metabolized and consequently the headache clears.

BTD 10/29/09.