Think over-the-counter painkillers and prescription medications like ergotamine and triptans are your only options for treating chronic migraines? Think again!
Tune in to learn about surprising methods of migraine prevention like magnesium supplements, Botox injections, anti-depressants and more. Get expert suggestions for adding treatments like these to your arsenal.
And, as always, experts answer questions from the audience.
Announcer:
Welcome to this HealthTalk show. Before we begin, we remind you that the opinions expressed on this show are solely the views of our guests. They are not necessarily the views of HealthTalk or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.
Now here’s your host, Rick Turner.
Rick Turner:
Hello and welcome to our show, Top 10 Unexpected Migraine Treatments. I’m Rick Turner.
A lot of sufferers are treating their migraines with standard medications only to be left frustrated and still experiencing persistent attacks. The good news is if you suffer from migraines, you might have more options than you think, and you may be able to find them in unexpected places. During this show, we’ll hear from our expert guests about these surprising new options for treatment and prevention of migraines, and find out if they really work.
Joining us for the program is Dr. Brian Loftus. Dr. Loftus is a neurologist and an adjunct associate professor in the Department of Neurology at Baylor College of Medicine in Houston. He was also deputy chief of neurology at the Methodist Hospital in Houston and is a former president of the Harris County branch of the Texas Neurological Society. Dr. Loftus specializes in the treatment of headaches, seizures, neuropathic pain, multiple sclerosis, hyperhidrosis and simple dystonias. He has been named a Texas Monthly Super Doctor and an H-Texas Magazine Top Doctor numerous times. Dr. Loftus is currently in private practice at Bellaire Neurology and he joins us. Welcome, Dr. Loftus.
Dr. Brian Loftus:
Thank you for having me.
Rick:Also joining us for the program is Dr. John Claude Krusz. Dr. Krusz is the medical director of the Anodyne Headache and Pain Care Center in Dallas, Texas. Since 1987, he has been in private practice in Dallas evaluating and treating pain and headache disorders with a special focus in the fields of brain injury, sleep and mood disorders, and neuropsychiatry/neurobehavioral disorders. He is engaged in clinical research projects regarding new uses for available medications for headache pain, cognitive enhancement and mood. He’s also looking at novel ways of treating headache patients with botulinum toxin. Dr. Krusz is also the vice president of the American Board of Electroencephalography and Neurophysiology (ABEN) and is on the board of directors of the Texas Pain Society. Welcome, Dr. Cruz.
Dr. John Claude Krusz:
Good evening. It’s my pleasure to be on HealthTalk tonight.
Rick:Dr. Loftus, before we talk about these novel migraine treatments I mentioned in the opening, can you quickly tell us about how we’ve been treating migraines traditionally?
Dr. Loftus:In the older days before the ‘90’s and the advent of the triptans, people were basically treating migraines by putting patients to sleep. What made sumatriptan or Imitrex the first revolutionary treatment was it was the first time we could treat acute migraine and restore people to normal function. As the ‘90’s have progressed, we’ve learned more about the prevention of migraines. Unfortunately, only a small percentage of patients who ought to get that therapy currently are.
Rick:How are we doing with that, Dr. Loftus? Are these treatments effective?
Dr. Loftus:There are a number of very effective treatments for people with frequent migraines. And there are a number of acute treatments that treat most patients, although there still is an unmet need.
Rick:How commonly are over-the-counter drugs used to treat migraines?
Dr. Loftus:They’re used very commonly. Nonspecific narcotics are used quite a bit as well. And if they are effective, then for the most part they are fine. But for most patients with severe migraines, the over-the-counter drugs are not particularly effective.
Rick:
Dr. Krusz, how concerned should patients be about having this poison, essentially, injected into their bodies? How safe is it, do we know long term?
Dr. Krusz:
I have seen patients who have had Botox botulinum toxin injections for 10 or 15 years for neck muscle spasm problems. In some small percentage of people, you can get a fading out of the effect due to formation of antibodies to the toxin, and the same number of units doesn’t work as well. Other than that, there are very few long-term downsides. Despite the horrible sounding name and the idea that this is, after all, a very potent toxin when you compare it to other toxins, it is exceedingly safe and relatively risk-free giving it in the way that that we are using it currently.
Rick:
I want to move on to some non-traditional approaches to treating migraines. One of them is magnesium. Dr. Loftus, can you tell us how magnesium is used to treat migraines?
Dr. Loftus:
A lot of people are using oral magnesium for migraines. Typically, if a doctor writes it (the prescription), it will be the form of magnesium oxide because we know that gets absorbed through the GI tract and gets into the bloodstream. You don’t want to take Milk of Magnesia, which is a magnesium product that is a laxative, because it does not get into the blood supply. The problem is while I think it’s pretty clear that there’s at least a good percentage of migraine patients, if not all of them, whose magnesium level in their brain is somewhat low, it is not at all clear that oral magnesium can fix that. Probably the body’s regulatory catalytic enzymes that move things back and forth are going to prevent the magnesium level from rising sufficiently to get it to the brain. So controlled data on the use of oral magnesium, while limited, is not very convincing. You can overcome that by using IV magnesium, and for some very refractory patients for which all other things have failed, I do give weekly IV magnesium with some success in headache prevention. But they are pretty few and far between because the cost is quite high, although to date the insurances have paid for it.
Rick:
Do you think people with migraines are deficient in magnesium? Should they be taking supplements?
Dr. Loftus:
There’s a body of data that suggests that in the brain the magnesium level is low. What is not clear is that if taking a supplement will fix that because it’s the body’s regulation of magnesium that may be off. And you can’t overcome that. On the other hand, I think everyone taking a multivitamin a day and extra magnesium is perfectly safe. And some people say it’s helpful, but the proof is not there for oral forms.
Rick:Are there any side effects of magnesium that we know of?
Dr. Loftus:No, there are not any side effects in the dose that you would take as a supplement, with one exception: if you have renal disease (kidney problems). If so, you should not take magnesium without speaking to your doctor.
Rick:Dr. Krusz, talk to us about anticonvulsants and how those are used to treat migraines.
Dr. Krusz:Well, first of all, if I have to log in my objections to the term anti-convulsants because they scare physicians and patients. I don’t want to take a seizure drug. I don’t have seizures. Well, we’re not treating seizures. Why don’t we call the category of medicine a neuromodulating agent or a neuronal stabilizing agent? Those are much more neutral terms and more descriptive of what the medicines do mechanistically. A lot of these medicines – there are about 10 or 11 of them in this large family some of whom have official approval for migraine suppression and most of whom do not–have been researched and published on, at least in small trials and even in double-blind trials, for suppressing migraines and other headaches. They do a lot of different things. For instance, there are medications that are approved like Depakote (valproic acid), which has had approval since 1994. In 1993 a medication called Neurontin (gabapentin) was brought to market, and is used off-label for headaches and migraines. In ‘96, we had a medicine called Topamax (topiramate). And Topamax has subsequently had official approval from the FDA for migraine prophylaxis, migraine suppression. In ‘95, we had medicine called Lamictal (lamotrigine). In ‘97, we had a medicine called Gabitril (tiagabine). In the year 2000, we had three come out: Keppra (levetiracetam), Trileptal (oxcarbazepine) and Zonegran (zonisamide). And in 2005, we had a medicine called Lyrica (pregabalin). So that’s the family. And although they all can get used and some can be used in conjunction with others, they often do get used for headaches, pain, mood disorders and things of that nature.
As far as what they do, some of them affect calcium channels, which are important in pain transmission and probably migraine pathophysiology. Some affect sodium channels, important in neuropathic pain and important, likely, in lots of pain syndromes. Some of them affect calcium obliquely. Some of them affect transmitters that are the bad guys. And if you inhibit the bad guys, you can help the good guys do a better job. In essence, we think about migraines as, perhaps, an inability to filter out painful signals coming in from the head, face and shoulders. And if we help put in filters with these so-called “anti-convulsives” or neuromodulators, what we’re really doing is taking down the excessive signaling that’s coming into the spinal cord and, hopefully, filtering out excessive painful signals. That’s a little simplistic but is one way of looking at the use of this category of medicine.
Rick:Are there any side effects that people should be aware of with these?
Dr. Krusz:Well, each medicine has its own bag of worms, if you will.
Rick:Sure.
Dr. Krusz:Depokote (valproic acid) is an older drug. It needs liver enzyme checks and can cause weight gain. It should probably be used with caution in young women that may have polycystic ovarian disease. Topamax (topiramate) has a good side effect, it can inhibit appetite, but it also has a statistically higher increased likelihood of producing kidney stones. Others may have other side effects. Although, in general, the latest crop of medications will tend to be not needful of any laboratory testing, and the newer ones are a little easier to use than the old medicines that we had 15 years ago.
Rick:Are they used preventively?
Dr. Krusz:
Yes. They would be used as a prophylaxis or a suppressive therapy for migraines and even other headaches.
Rick:
Dr. Loftus, tell us about how anti-depressants are being used to treat migraines.
Dr. Loftus:
The granddaddy of them all is Elavil or amitriptyline. It’s been out forever. Its primary advantage, quite frankly, is that it’s very cheap, probably $5 or $10 a month. It is an older drug, and it does have more side effects than some of the newer drugs, particularly in making people sleepy. And the dosing that’s used to treat migraine is much lower than the dosing that is used for depression. So I would echo Dr. Krusz in saying that the fact we call them anti-depressants for the ones that we also use for migraine is a completely arbitrary decision. So Elavil we think from a mood standpoint works on two neurotransmitters, one being the serotonin system and the other one being the norepi (norepinephrine) system.
Also, a drug that came out in the ‘70’s that was revolutionary was Prozac (fluoxetine), which has some anti-migraine benefits as well. I think that Prozac is probably the one with the best data to support its use for migraine prevention. Then Effexor (venlafaxine) came out about 10 or 15 years ago. At high doses, Effexor works on both the serotonin and the norepi system, and it seems to have a modulating input into the brain and into the pain structures. Effexor has two very well-done blinded studies that show it is a good migraine prevention agent. But for reasons that I don’t know, the company never pursued a formal FDA indication for this drug and migraine.
There’s a newer drug out of this same class called Cymbalta (duloxetine), and it’s my hope that they will look at it as a migraine drug. It is a more balanced SSNRI (selective serotonin and norepinephrine reuptake inhibitor) drug than Effexor, and I find it somewhat easier to use. I use a lot of it in my practice. Basically, I started with faith that it should work because it’s a close cousin to Effexor, and it is my opinion that it does work. But there are no well-done published data at this point, although I hope to get some funding, and I hope this will be studied in probably in the next year or two.
Rick:
Dr. Loftus, am I correct in assuming that to date no anti-depressant is FDA-approved to treat migraines?
Dr. Loftus:
I believe that’s true. Elavil (amitriptyline), which we all use to treat migraines, is still considered an off-label use. But there are headache consortium guidelines that everybody will accept for Elavil being used for migraine, and Effexor (venlafaxine) and Prozac (fluoxetine) would be on the list of drugs that also have some use in migraine. The guidelines came out long before Cymbalta (duloxetine) was placed on the market.
Rick:
You touched on the stigma attached with the name, anti-depressants. Are patients generally reluctant to use these to treat their migraines? And, if so, how do you help them over that?
Dr. Loftus:
The stigma of anti-depressant drugs is probably a little worse than the stigma of anti-seizure drug. I try to explain to the patient if I don’t think that they are depressed to not worry about the fact that that’s what it’s called because if your mood is normal, these drugs don’t change your mood, and they don’t change your personality. Now, if somebody is depressed and anxious – the drugs are also approved as anxiety drugs – I will explain to them that I think they need it for that as well and that we’re trying to treat two diseases with one drug, and I consider that a positive. Generally, by the time the patients come and see me in need of a prevention agent, which is most of those in my practice because I am a headache specialist, they’re pretty accepting that they need help, and they expect the physician to help them. And that usually comes in the way of drugs. But we shouldn’t overlook the other things that need to be done as well.
Rick:There are a couple other classes of treatments for migraines that I want to touch on. Dr. Krusz, can you tell us about beta blockers? How are they used to treat migraine?
Dr. Krusz:Beta blockers are a rather older category of medicine that was originally used for blood pressure control and also to control heart rate and certain cardiac rhythm disorders. It was found serendipitously that people on beta blockers tended to tell their physicians, “Hey, my migraines are better as well.” Then when it was formally looked at, it turned out that there was a benefit to a migraineur in terms of fewer and softer, easier to treat migraines when they were on beta blockers. This spawned a number of studies, and one of the original beta blockers, propranolol, trade name Inderal, has an official FDA approval for migraine prophylaxis, so does another beta blocker called timolol (Blocadren or Timolide), although I personally have never prescribed it. So two beta blockers have official approval, although there are five, six, maybe seven members in the family, and sometimes others get used. I’m not aware of any recent or ongoing studies to get approval for any of the other beta blockers for headache or migraine.
Regarding how these agents work, although they relax blood vessel walls, that’s not the mechanism of action. Relaxing the blood vessel is not what it’s all about. It turns out that beta blockers like other categories of suppressive medicines, which may or may not be on-label, have effects on a particular family of serotonin receptors, and there are seven or eight families of receptors. But the family of receptors that is most important is the type 2 receptor. And if you block the type 2 receptor or antagonize it, that has implications for a lot of different categories of medicine that have completely different actions otherwise but yet may have a common mechanism through 5HT2 [type 2 serotonin receptor] to suppress migraine frequency and severity.
Rick:Is that similar to the effect that some anti-depressants might have?
Dr. Krusz:Yes, as a matter of fact, amitriptyline has been thought to work through 5HT2 as well. Calcium channel blockers are also thought to work through that mechanism. So it seems to be a commonality at least for a number of different medicines, and it wasn’t clear years ago why these medicines work. But once that commonality was understood, it became a little clearer.
Rick:Dr. Krusz, what are the common side effects of beta blockers?
Dr. Krusz:The most common problems are they can impede or impair exercise tolerance. So for somebody who’s an athlete, trainer, or phys ed teacher that may not be the best choice. Also, if you’re an asthmatic it can worsen asthma. It can certainly worsen depression and can create nightmares. And, if the dose is high enough, weight gain can be a problem. So there are some downsides to the beta blockers. But most people who visit me have been through two or three beta blockers and lots of other things. So unless somebody’s got hypertension or a fast heart rate or rhythm disorder along with their migraine, at that point it would be fair to think about a beta blocker. If they don’t and they’ve tried two or three beta blockers there may not be that much benefit in trying a fourth one.
Rick:Dr. Loftus, Dr. Krusz has mentioned calcium channel blockers are also used to treat migraine – how so?
Dr. Loftus:There’s one in particular which is used in migraine prevention called verapamil, and that is of the class of drugs that is probably considered the best. At least it’s the most widely used. And I would say it is not as good as some of the other things that we have spoken about to date. But it would certainly be among the B list of drugs that we use. They are relatively side effect-free. And for that reason, they are popular drugs to use but probably not as good for the patients.
Rick:So there’s not a lot of downside but it sounds like not a lot of upside either.
Dr. Loftus:I would agree.
Rick:
We mentioned magnesium earlier, but let’s talk about some of the other alternative or natural, if you will, treatments that are being looking at for migraines. Dr. Krusz, can you tell us about vitamin B2 and how it’s being used to prevent migraines?
Dr. Krusz:
Vitamin B2 is known as riboflavin and is one of the B family of vitamins. It particularly has an effect in what we call the powerhouse of the cell, the mitochondrion. The mitochondrion is a sub-cellular particle that manufacturers the energy that the cell needs to do its activities. And, apparently, it’s possible that a deficit or too low of mitochondrial energy production might play a role in migraine pathophysiology. There are some theoretical and some clinical studies that tend to support this. And certain groups in Europe have done studies with high dose riboflavin (vitamin B2) being effective to suppress migraines. And the dosage used is about 400 milligrams a day, which is probably a hundred times what the body needs on regular daily intake. So it is used in very high dosages. But, fortunately, B vitamins are water-soluble; they’re not stored in fat, so there’s very little downside other than the cause to try the medication. Also, the studies tend to have to be done for two to four months or longer before you see a benefit.
Rick:
Another substance used is called coenzyme Q10. Explain that for us, Dr. Loftus.
Dr. Loftus:
Coenzyme Q10 is another compound that is very important for the mitochondria. There has been a small but well-done double-blind study by Dr. Richard Lipton on this compound, and it does seem to be quite effective for the prevention of migraines. The dose that has been studied is 300 milligrams a day. And in the study 100 milligrams was taken three times a day. Although in my practice, I tend to use 150 milligrams twice a day because it’s very hard for patients to take drugs three times a day. The cost runs people about $50 a month, so it’s actually more expensive than some of the prescription drugs but less expensive than some of the others. It seems to have very little downside. Although in a study of Parkinson’s patients, unfortunately, it did not seem to help the Parkinson’s, and there was some constipation reported with the drug. So that seems to be the side effect that it can give.
Rick:
Dr. Krusz, talk to us about a couple of herbs, butterbur and feverfew.
Dr. Krusz:
Butterbur is extracted from a root, and the root contains alkaloids called petasins. And these petasins can relax blood vessels and other smooth muscles in the body. Dr. Lipton, who’s a pre-eminent headache researcher and epidemiologist, participated in the study in 2004 showing that butterbur root extract is an effective preventive treatment for migraines. So that’s one herb that gets some use. And presumably it has an effect on smooth blood vessels. It also can be helpful to asthma, unlike beta blockers that can help headaches but worsen asthma.
With respect to feverfew, it is the plant extract that inhibits certain blood cells called platelets from sticking to each other, and it was thought that that somehow may play a role in the production or maintenance of headaches. A large group in Germany has studied feverfew and found out it had a favorable benefit to risk ratio and decreased the number of migraine attacks per month, and the results were statistically significant. So these are two other treatment options that are not synthetic chemicals.
Rick:
Does it go without saying that one should go to one’s doctor as opposed to one’s health food store initially to get some advice on these treatments?
Dr. Krusz:
I would thoroughly agree with that.
Rick:
We have an e-mail from West Springfield, Pennsylvania that says, “I have taken Topamax (topiramate) and have had a lot of side effects, and it did not work. Would it be a good idea for me to try another medication in this class?” Dr. Loftus, what do you think?
Dr. Loftus:
Absolutely, in the sense that if you fail Topamax, that is different enough from valproic acid, which is the other most frequently used anti-convulsive. The side effects from one drug do not mean there are side effects to the other. So they should discuss with their physician as to the other better preventatives that could be tried and the potential side effects and risks of each of them in order to choose which one to try next.
Rick:We have a question from Susan in San Carlos, California, and I will direct this to Dr. Krusz, “Where on your body do you get the Botox shot?” I presume she means for migraines.
Dr. Krusz:It’s a very broad question because different folks have different protocols for where they put the Botox (botulinum toxin type A). For instance, I mentioned we’re participating in a nationwide study for chronic daily migraines, and that study involves injecting 31 sites on the forehead, the sides of the head, the back of the head and some of the shoulder muscles. I would probably not do that for my patients normally. I tend to be a little more selective about where I put the Botox or Myoblock (botulinum toxin type B), and I tend to focus on if the headache is worse on the left side, we may concentrate on that side and not necessarily just do a shotgun approach. So there are some what we call fixed dose, fixed site protocols, and they are the ones that are being used because they’ve been used in studies over and over again. On the other hand, we don’t tend to put it into muscle other than when participating in the study. And we tend to use the medication just underneath the skin to ask the question about what the mechanism of action is. So it comes down to the headache pattern. Where is its location, and how can we use the botulinum toxin effectively?
Rick:
I have an e-mail from Port Jefferson, New York, “My daughter has tried several of the things in the categories that you have mentioned for her migraines and daily headaches.” I think the unspoken part of this e-mail is that nothing has worked because the next question is, “What do you recommend now?” Dr. Loftus?
Dr. Loftus:The most important thing to look at in patients who fail multiple preventatives that hopefully the doctor looked at the first time is the concept of rebound headache. Rebound headache is when the acute migraine medicine you are taking leads to more migraine. And chronic daily headache is virtually always from underlying migraine disease that has transformed itself or has become chronic daily headache, which to neurologists is more than half the days. So when somebody fails multiple preventatives, it is many times because they are taking pain medicine every day, and that pain medicine is causing the rebound. There are multiple studies that show nothing works for prevention when patients are on a drug that’s causing rebound. This is commonly overlooked because the rebound medicine could be Excedrin Migraine or it could be their sleep pattern or too much caffeine in their diet. It does not necessarily have to be a prescription medication. Many times, physicians fail to ask about non-prescription medicines, and patients neglect to write them down on the medication list at the doctor’s office. These non-prescription drugs are many times at the root of the problem of patients who are having headaches every day.
Rick:Dr. Krusz, what’s your perspective on that when other treatments have all failed?
Dr. Krusz:I would certainly agree with Dr. Loftus about medication overuse headache. It’s a huge concern. My other concern is twofold. One is the quality of the sleep pattern because 96 or 97 percent of people who see us for the first time don’t have an adequate sleep pattern, or it’s not as optimal as it could be. And that has implications for headache and pain. The other things that patients come in with are anxiety and depression. They’re angry about what they’ve been living with. They’re angry at the loss of lifestyle. These issues have to be addressed as well.
There’s a medicine called tizanidine (Zanaflex), which I have probably over 3,000 patients on. It helps people sleep, and it also has anti-headache, anti-pain, anti-anxiety effects, and it’s on the market officially for muscle relaxation. So people who have scalp and shoulder tightness can often benefit as well. So that’s another choice that’s separate from anything that’s been discussed today in terms of treatment. Also, seeing a physiologist, doing biofeedback, meditation and Tai Chi aquatics, and not missing meals – these are all very important issues.
Rick:Our next e-mail comes from Minot, North Dakota, “What dosing do you recommend when using anti-depressants for migraine prophylaxis only and not for depression as well?” Dr. Loftus?
Dr. Loftus:The typical dosing of amitriptyline (Elavil) would be somewhere between 10 and 50 milligrams an evening, building up slowly because of the side effects and adjusting the dose for patient response. The dosing of Effexor (venlafaxine) for migraine has to be 150 to 225 milligrams, maybe even as high as 300 milligrams, a day typically given in a couple of divided doses. And the dosing of Cymbalta (duloxetine), quite frankly, is not really known. Most people are using the standard 60 milligrams a day that we use for everything else, but I certainly have plenty of folks who are doing extremely well on 30 milligrams. If we look at the data on amitriptyline as an anti-depressant to guide us, you’re having to give 150 to 300 milligrams of that drug a day compared to the 10 to 50 milligrams for migraine. So it would be expected that the anti-migraine dose of Cymbalta would be much less than the anti-depressant dose, and the anti-depressant dose for that drug is known to be 60 milligrams once a day. The drug is priced exactly the same for every pill size, so there is no financial savings to give a smaller dose. I think most of us tend to just give the standard 60 milligrams.
Rick:
Our next e-mail follows on the subject of depression. John from Sacramento, California, writes, “I suffer from depression and migraines. Can one drug help for both?” Dr. Cruz?
Dr. Krusz:
Yes. I tend to favor the SSNRIs (selective serotonin and norepinephrine reuptake inhibitors) like Effexor (venlafaxine) or Cymbalta (duloxetine) because I think the overall data with the Prozac (fluoxetine) family is a little weaker on migraines. It’s okay on chronic daily headaches though. On the other hand, I think that certainly can be approached that way. My strongest suggestion is for this gentleman to see the local area headache specialist and discuss which medication could be useful to him for his migraines and depression.
Rick:
Rebecca in Houston, Texas, wants to know, “What are the best and safest treatments for migraine before and during pregnancy?” Dr. Loftus?
Dr. Loftus:
That’s a very good question, and unfortunately we have fewer options when somebody wants to get pregnant. The good news is once you are pregnant, in general migraines get better. So I think the drug that most doctors would like to use first as a preventative, if you need one, is the beta blocker propranolol (Inderal). It’s a very good drug. I will sometimes use Botox (botulinum toxin type A) when I know a patient is not pregnant but wanting to get pregnant because the toxin is only circulating in the bloodstream in a very small amount for just a few days and then it’s gone. But the effect of the treatment lasts for a few months. I also use coenzyme Q10, although there are no formal studies on it. It’s just hard to imagine how a natural compound could be harmful. And then, unfortunately, we have the tradeoff between risk and benefits because the other drugs are not known to be safe.
Rick:
Dr. Loftus, you mentioned that migraines in women often get better while they’re pregnant. Is that assumed to be because of hormonal changes?
Dr. Loftus:
Yes, that’s the underlying presumption. We think that estrogen withdrawal is the worst for migraines, and progesterone is probably somewhat protective for migraines. And during pregnancy, you don’t get the withdrawal in estrogen, and your progesterone levels are higher. So both of those things factor in, and most women do better once they are pregnant.
Rick:
Our next e-mail comes from Chelsea in Largo, Florida. She says, “I took Topamax, and my liver didn’t do so well. So I had to stop it. Are there other preventative medications to help out in my situation?” Dr. Krusz, what do you think?
Dr. Krusz:
Certainly, any of that large family of neuronstabilizing or neuromodulating agents would be fine. The one exception perhaps, if there was a liver problem, would be Depakote (valproic acid) since you have to check liver enzymes, and they can be affected by the medication. On the other hand, some of the other newer ones don’t affect liver enzymes, and in my experience I have never caught Topamax (topiramate) doing anything to liver enzymes, although I’m aware of case reports from a European study looking at that medication for obesity where liver enzyme changes were noted. So it’s possible that this is an example of something like that or just a rare effect on liver enzymes. In general, the other items, although they’re not approved officially, and would be off-label use, things like Lamictal (lamotrigine), Keppra (levetiracetam), Trileptal (oxcarbazepine), Zonegran (zonisamide) and Gabitril (tiagabine). Those have no liver enzyme effects that I’m aware of and don’t require liver enzyme checks. Although somebody who’s had a history of liver enzyme problems, I would probably check for liver enzymes anyway.
Rick:
We got an interesting e-mail from Tamela in Lincoln Park, Michigan, who writes, “I have constant migraines. And when I need to go to the hospital for treatment, which is one or two times a month, they act like I’m a drug addict – any suggestions? I don’t have a primary care physician at the moment.” Dr. Loftus?
Dr. Loftus:
The suggestion is to find a good headache neurologist in your part of the country. There has to be one. Unfortunately, not everybody likes to take care of headache patients, so I would call up the doctor’s office first and ask them, before you schedule, how much of their practice is headache patients. And if they’re not answering a third or more, then I’d find someone else because you’re obviously having very severe headaches that you’re having to go to the ER that much. There’s really nothing good that happens for a migraine patient when they go to an ER. It’s a load, noisy environment. Many times, they get CAT scans, which, quite frankly, aren’t needed. And it’s not a pleasant experience even without the fact that sometimes they’re looked on as being drug-seeking. If the ER doctors were smarter in this area, they would be using non-narcotics to try to treat her headaches when she goes there. I don’t know that they have not, but ERs are geared for emergencies and are not designed to take care of people with migraines.
Rick:So her experience is not unique?
Dr. Loftus:Her experience, unfortunately, is all too common.
Rick:
We have an e-mail from Wheaton, Illinois, and this listener writes, “I’ve been taking Effexor for three years for my migraines, and it has helped so much. Now I am starting perimenopause, and I’m waking up with headaches again in the mornings, which has been a life-long issue. I’m wondering if it has to do with hormonal changes or is it that the medication is becoming non-effective over time?” What do you think, Dr. Krusz?
Dr. Krusz:That’s a difficult question to answer. Certainly medications can fade out biochemically. But on the whole, this lady’s hormones, particularly estradiol and testosterone, and, for that matter, progesterone are not what they were a decade or two decades ago. If I was a woman, I would be likely in favor of hormonal replacement therapy. In a lot of women who are perimenopausal, very judicious small doses of estradiol, given by patch or other methods, may sometimes be very efficacious in lowering the pattern or the tempo of the headache. Although initially in the first week or two of therapy, the headaches might increase before they decrease. Unfortunately, estrogen, testosterone and progesterone cut both ways. Some women given the same dose will respond with increased headaches, and other women given the same dose will have a lowering of their headache pattern. So it’s an intriguing question and is valid for this particular woman who is perimenopausal.
Rick:
Next, we have an e-mail from Port Jefferson, New York. This person writes, “How long does it take for a Botox treatment to work? Can it take up to six weeks to work even after a series of injections every three months?” Dr. Loftus?
Dr. Loftus:Most people get a response to Botox within a week or two, so six weeks out would make me suspicious that it was not the best drug for them. Although, occasionally, I’ve had patients who’ve had a number of successful rounds of Botox and then occasionally will have a round that for whatever reason just doesn’t seem to work as well as the prior round. And the next time, they’re fine again.
Dr. Krusz:
I would agree. We sometimes use the same dose in similar, same locations and sometimes get a a two-and-a-half-month response and sometimes get a four-and-a-half-month response. So there is variability. I remember a lady recently who normally gets fairly large doses with good response for six or seven months, and all of the sudden on the fifth or the sixth go-around several years down the road, I give her usual dosage in the same location, and she gets no response. We presumed that batch of Botox might not have been active, and the company was kind enough to give us two vials, so we could treat her without charge, and she responded with her usual six-month response.
Rick:We mentioned nine unexpected migraine treatments in the first part of our show. I’m sure that there are many more. Can each of you tell us one future treatment that we haven’t mentioned that you find exciting?
Dr. Loftus:There is the idea that having a hole in your heart between the right and left atrium left over from birth that’s called a PFO could be closed, and that could prevent migraines if people are having frequent migraines. There’s a nationwide trial that’s randomized to prove if this is true or not that they could look into called the ESCAPE trial that’s enrolling at this time.
Rick:Dr. Krusz?
Dr. Krusz:I have a specific interest in how to treat migraine, headache and pain flare-ups in the outpatient setting. And while I have 16 or 17 choices when I put in an IV line, one of my newer favorites is a medication called ketamine (Ketaset). It’s an anesthetic agent that has a very specific effect to block one of the bad guys (neurotransmitters) as I mentioned earlier. We are ready to show some data primarily on headaches at upcoming headache and pain meetings. Ketamine has been an interesting medication. It’s been used for many years and is still used in pediatric cardiology surgeries. I used it in some of my animal surgeries 35 years ago. It’s an understudied medication. So we’re always on the lookout for new things we can treat ongoing flare-ups with.
Rick:
Dr. Brian Loftus and Dr. John Claude Krusz, again, thank you both for joining us during this program. Thanks for joining us.
From HealthTalk, I’m Rick Turner.
