MD's Pushing Drugs:


What is the current treatment for the outbreak of cluster headaches, both during flare-ups and as prevention? Currently I've not found anything that prevents, and the only medication that works during outbreaks is Stadol; however, I'm afraid of addiction.

If this is a patient with episodic cluster headaches, then the best fast treatment is usually a shot of steroid or a prednisone taper.

Normally we start at 40 milligrams and drop the dose by 5 milligrams every five days. Other medications that can be used preventatively include Topomax, Depakote, Verapamil, Methergine, Sinequan, and lithium. Some people have found even melatonin can be helpful.

To treat acute attacks, the best therapy is oxygen by mask at 15 liters for 10 minutes. Other acute treatments include Imitrex, subcutaneiously, DHE 45, lidocaine drops, and Toradol injections.

Stadol nasal spray is addictive, but if used only during attack time can probably be managed.

I have what my doctor calls silent migraines or chronic daily headaches. I have them every day and they vary in intensity, instead of getting terrible pain I get dizzy about three to four times a week. I get all the pain in the back of my neck at the base of the skull. I have had all the tests done to rule out inner ear disorders by three different ENTs. I have also had MRI, four CT scans, and blood work done. Everything was normal. I have tried a lot of preventatives such as Verapamil, Inderal, Nortriptyline. I am now taking Diazepam 2 milligrams twice daily and 30 milligrams of Elavil at bedtime. Sorry, but I wanted you to know some history.

I was wondering if you suggest I see some special type of doctor I haven't seen or if there are any medications I should ask the doctor about? Right now I am seeing a neurologist.

I think chronic daily headache and dizziness, either lightheadedness or the spinning sensation we call vertigo, can live together in the same patient. Usually a neurologist or headache specialist can deal with both. If the dizziness is truly vertigo or a spinning sensation then sometimes seeing someone who specializes in vertigo, or a physical therapist who helps with balance retraining, can be useful. A headache specialist can sometimes add some extra information to a chronic problem, and perhaps more tools for treatment.

Headache specialists can be found by looking at the National Headache Foundation web site, or you could call our clinic at 1-800-HEADACHE, but if we're not convenient perhaps a referral can be made in your area.

"There are actually only three drugs approved by the FDA for the prevention of migraines, which is pretty sad."

Unlike most people (from what I can tell), I wake up with my migraines. I have a prescription for Imitrex, but it doesn't seem overly effective. Is this because I'm not able to take the med as the migraine starts?

That's an excellent question. We clearly know that patients can treat their migraines more effectively if they can get their medication on board within 20 to 30 minutes. Our triptan medications, like Imitrex, clearly work much more effectively when given early. Unfortunately, 40%of our patients wake up with their migraines.

There are two approaches to this:

The first is the way you might use your Imitrex. If you're on tablets and you wake up with frequent migraines then injection will speed relief, as it will work more quickly.

The second approach involves recognizing symptoms we call prodrome. About 60% of migraine patients have symptoms that precede their migraine attacks from three to six hours, and are generally reproducible, or they can predict them because they've had had a history of migraines for so long. These symptoms include:

  • Carbohydrate craving
  • Yawning Neck pain
  • Light sensitivity
  • Nausea
  • Irritability
  • Tracking this could be done with a headache diary, and if you recognize a prodrome, treating before you went to bed that night might be helpful.

What are the most prescribed medications for migraines?

When we talk about medicines we prescribe for migraine we actually split it into three categories:

  • Acute medicine, or medicines we use to stop a specific migraine attack
  • Preventative drugs, or medications we give if people have frequent or difficult-to-treat migraines
  • Analgesic or rescue medicine, something to get rid of the pain if we haven't caught it in time

The most common acute medicine is the family called the triptans, of which Imitrex was the first, but there are currently seven on the market, including Maxalt, Zomig, Relpax, Axert, Amerge and Frova. Other drugs that are also effective in reversing a migraine include the ergot compound; the one we use most in this family is DAG 45, which comes both in a nasal spray and injection. Another drug often put in this class, although not proven to be effective, is Midrin. These drugs should not be used in patients with coronary artery disease or poorly managed hypertension. Other reversal drugs or acute drugs include the nonsteroidal anti-inflammatory drugs.

The preventative drugs are really divided based upon the class of medication they are and co-existing disorders or conditions that the patient might have. There are actually only three drugs approved by the FDA for the prevention of migraines, which is pretty sad. These medications are Depakote, which is an antiseizure drug, and two beta blockers, which are blood pressure medicines, Inderol and Timolol.

We know from clinical experience in smaller studies that there are other medicines that can help prevent migraine, so some of the antiseizure drugs, such as Topomax and Neurontin, are used. Tricyclic antidepressants, such as Elavil, work on chronic pain and migraine as well as other types of blood pressure medicine. So there are many choices.

The third category is the analgesics or rescue medicine, and these are generally either nonsteroidal anti-inflammatory drugs, or medications containing opiates or some of the atypical antipsychotic medication. These medicines can all work on pain, but don't necessarily reverse the process of migraine. In other words, they can get you to sleep or get you comfortable if nothing else has worked.

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209 White Horse Pike Haddon Heights NJ 08035 USA
Dr. Stephen J. Markus Haddon Heights, NJ general, cosmetic, & restorative dentist. (856) 546-0665