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I am a strong believer in carefully evaluating migraineurs in the context of their other medical conditions. The approach to chronic headaches must include careful evaluation of behavioral problems such as anxiety and depression, sleep disorders such as sleep apnea( see page 12), and other conditions, including systemic illness such as autoimmune diseases and connective tissue disorders. Everything is important.
Patients commonly tell me that, when it comes to medication, they’ ve been on“ everything.” It is important to know whether those treatments matched the headache diagnosis. We also need to know whether the optimal dose of an appropriate medication was used for an adequate length of time, whether appropriate medications were used in synergistic combinations, or whether certain combinations of medications actually neutralized each other or produced side effects that led to their discontinuation. Often, medications are switched too quickly, before the medication has had a chance to work. It sometimes takes many weeks to know whether the medication will be beneficial. Keep at it, and don’ t give up!
— Edmund Messina, MD, Michigan Headache Clinic, East Lansing, Mich.
A CHILLING EFFECT
I take Premarin ®( conjugated estrogen tablets) for post-menopausal reasons. I’ ve had pre-menstrual migraines throughout my adulthood while menstruating. Recently I took Premarin before bedtime and woke up the next morning with a severe migraine and cold sweats, followed by uncontrollable nausea. Could the Premarin have triggered a migraine? Why am I having cold sweats?— Linda J. Migraines are often made worse by fluctuations in estrogen levels. Estrogen levels drop before menstruation, triggering migraines in some women. This is not the case in all women, but two out of three women stop having migraines after menopause when estrogen levels drop and remain stable. Taking Premarin causes estrogen levels to fluctuate again, resulting in recurrence of migraines. According to the manufacturer, 26 percent of women taking 0.625 mg of Premarin have headaches as a side effect. Cold sweats and nausea are also known side effects of Premarin.
— Alexander Mauskop, MD, New York Headache Center, New York, N. Y.
GOING OVERBOARD?
My 79-year-old mother has been experiencing severe headaches for 11 years. My theory is that she is addicted to paracetamol( an acetaminophen). She takes six to eight each day and has done so as long as I can remember. She gets the shakes when she is due for the tablets and, if she misses a dose, the headache completely consumes her. Her physician is happy to have her continue with the paracetamol as he says it is harmless, but I’ m not so sure that she should be taking it this regularly and for an incredible length of time. Could she be suffering from medication overuse headache? If so, what can we do to help her?— Julia W. When someone has medication overuse headache, the longer it exists, the harder it is to treat. With paracetamol, we also worry about its effects on the liver.
There are various strategies for substituting a preventive headache medication for overuse of an acute headache medication. It often requires hospitalization, and it’ s always a long, deliberate process that needs to be done under the care of a headache specialist.
— Mark Green, MD, Mount Sinai School of Medicine, New York City
Do you have a question or comment for NHF? Send it to info @ headaches. org.
8 HEAD WISE | Volume 2, Issue 4 • 2012