Britt Talley Daniel M.D.
7777 Forest Lane Suite B-220
(972) 566-4556
Dallas, Texas 75230
Migraine
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. 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
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 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.
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.
TREATMENT PLAN FOR MIGRAINE
Lifestyle Issues. I highly recommend that all of these ideas be followed by 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 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 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).
3. Exercise Aerobically for 20 minutes, at least 3 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-Jane Fonda type 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, Midrin or a half of a Tryptan 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. 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. 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.
ACUTE THERAPY
Medication to be taken when the Migraine starts. The drugs are listed in order of cheap and few side effects at the top to expensive and higher side effect profiles at the bottom.
Aspirin (5 grains) with caffeine (60 mg) (Excedrin, Vanquish) 2-3 at onset, then repeat every hour X 2. Limit to 2 treatment days a week. Rebound potential.
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. Try 2 Midrin and 2 Excedrin for “Turbo Midrin” if the migraine won’t respond to either alone. Rebound potential.
Cafergot (100mg caffeine and 1 mg ergotamine) The dose is 1-4 at the onset within the first 30 minutes of headache. Use the lowest dose needed to determine what your dose is and this is usually 2-3 Cafergots per headache. Not to be used within 24 hours of taking a Triptan. Limit to 2 treatment days a week. Max 12/month. If Cafergot makes you nauseated, pretreat with Reglan 5 mg. Rebound potential.
Ergo mar 2mg ergotamine SL (sublingually-under the tongue). May nauseate and if so then pretreat with Reglan 5 mg. Rebound potential. Limit to 2 treatment days a week. Max 4-5/week.
Migranol 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 X 1. No reported Rebound potential. It requires an injection but it can be very effective.
Nasal Oxygen for cluster patients, and some migraine patients with clusters of short, quick headache. Oxygen is delivered from a canister through plastic tubing to a mask at a flow rate of 6-10 liters/min.
Acute Therapy of the visual aura part of migraine with aura. 2 sniffs of 1% Isuprel (isoproternol) mistomerter 10 ml vial at onset of visual aura.
TRIPTANS:
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– 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.
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. 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.
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.
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. 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. If the headache returns, the dose may be repeated after 2 hours, but no more than two doses should be given within a 24-hour period. Rebound potential. Limit to 2 treatment days/week.
Relpax (eletriptan) —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. 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 tryptan 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.
Pharmokinetics Onset Half-Life Usual Dose Max Daily Dose
Imitrex (Sumatriptan)
Oral tablet PO 15 min 2 hrs 2 hrs 50-100 mg 200 mg
Nasal Spray 20 min 2 hrs 20 mg 40 mg
Shot-subcutaneous 10 min 15 min 4-6mg 12mg
Treximet 15 2 hrs one tablet two tablets
Zomig (Zolmitriptan)
Oral tab ZMT 30 min 3 hrs 2.5-5 mg 10 mg
Nasal Spray 10 min 3 hrs 5 mg 10 mg
Maxalt (Rizatriptan) 30 min 2 hrs 10-20 mg 30 mg
Axert (Almotriptan) 30 min 3-4 hrs 6.25/12.5 mg 25 mg
Relpax (Eletriptan) 30 min 4-5 hrs 40 mg 80 mg
Amerge (Naratriptan) 1-2 hrs 6 hrs. 2.5 mg 5 mg
Frova (Frovatriptan) 1-2 hrs 26 hrs 2.5 mg 7.5 mg
CHRONIC OR PREVENTIVE THERAPY (taken daily)
Preventive Therapy of Migraine and Cluster Headache
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 is 10 mg and the typical dose is 25-150 mg. 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. Serious side effects—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. The initial dose for cluster headache is 250 mg bid and a typical dose of 600 to 2000 mg may be used for cluster headache. Common side effects—alopecia, weight gain, nausea, and tremor. Serious side effect—pancreatitis, liver failure, and thrombocytopenia. Blood levels can be monitored.
Lithobid (lithium carbonate) Comes as an oral capsule 150 mg, 300 mg, 600 mg, oral tablet 300 mg, and oral tablet extended release 300 mg, 450 mg. The typical dose for cluster headache is 600-900 mg/day in divided doses. Common side effects–drowsiness, tremor, urinary frequency, thirst. Serious side effect—nephrotoxicity and hypothyroidism. Monitor blood level periodically.
Verapamil Comes as an oral capsule extended release 100, 120, 180, 200, 240, 300, and 360, oral tablet 40, 80, and 120 mg, oral tablet extended release 120, 180, and 240 mg, and oral tablet extended release 24 hour 180 and 240 mg. The initial dose is 80-160 mg and the typical dose for migraine and cluster headache is 160-480 mg although occasional higher doses up to 960-1200 mg have been used for cluster headache. Common side effects–constipation, congestive heart failure, pedal edema, AV block, dyspnea, and inhibition of sperm motility (possibly resulting in infertility). Serious side effects—hypotension and dysrhythmias. It is advised to check EKG at baseline, at dose escalation, and every 6 months for long-term maintenance. The EKG abnormalities are not dose-dependent and can occur in patients on doses as low as 240 mg/day. Some clinicians favor using the short rather than long acting preparation for ease with dose titration. “Neurological doses” (usually higher than 240 mg/d) have more potential serious heart block side effects than “cardiovascular doses” (80-240 mg/day).
Neurontin (Gabapentin) Comes as an oral capsule 100, 300, and 400 mg, and an oral tablet 100, 300, 400, 600, and 800 mg. Common side effects—edema, sedation, fatigue, and dizziness. The initial dose is 300 mg and the typical dose is 900-2400 mg per day. Topamax (Topiramate) Comes as an oral capsule 15 and 25 mg and oral tablet 25, 50, 100, and 200 mg. Doses for migraine and cluster headache are similar and the initial dose for is 25 mg and the typical dose is 75-200 mg. Most commonly a dose of 100 mg/day is attempted first and the drug is loaded 25 mg a night for a week and then increased 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 which is the usual maintenance dose.
Common side effects—paresthesiae, weight loss, cognitive/psychiatric side effects including cognitive dysfunction, word finding difficulty, somnolence and fatigue. Serious side effects are 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. Patients should be encouraged to push fluids to 6 glasses of water/day. Measurement of baseline and periodic serum bicarbonate is recommended.
VASCULAR HEADACHE
Vasodilation phase of a cerebral artery
A. 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.
B. 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.
C. 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.
D. 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.
E. Concussion-Postconcussion Syndrome
F. Mountain Sickness/Decompression Sickness
G. 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 2004 International Classification of Headache Disorders 2nd Edition as
A. Frontal Headache accompanied by pain in one over more regions of the face, ears or teeth and fulfilling criteria C and D
B. Clinical, nasal endoscopic, MRI and/or CAT scan imaging and/or laboratory evidence of acute or acute-on-chronic rhinosinusitis.
C. Headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis
D. 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
Medication overuse headache or Rebound headache is very common and occurs with vasoconstrictive drugs, any of the NSAIDS, barbiturates, and triptans. Vasoconstricitve drugs are: any medication with caffeine or ergotamine (Excedrin, Cafergot). NSAIDS are nonsteroidal anti-inflammatory drugs such as Motrin, Naprosyn, Advil, Tylenlol, or Alleve. Barbiturates are Fiorinal and Esgic. The triptans are Imitrex, Zomig, Axert, Amerge, Frova, Relpax, and Maxalt. The problem here is the daily use of any drug for headache. In general only 2 treatment days per week are allowed. Triptan rebound may occur at doses over 10 days/ month. 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 drug for several weeks or months and the headaches will lessen. Preventive medication won’t work for rebound headache.
The graphs below represent the temporal profile of migraine and stress that all medication for acute therapy should be taken AT ONSET.
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) (see Chapter 5).
Analgesic overuse-Excedrin, Tylenol, Advil (see Chapter 5).
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-Alprazolam (Brand name-Xanax), diazepam (Brand name-Valium, lorazepam (Brand name-Ativan).
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
Chocolate
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).
