It's a long question but, I have suffered from headaches all my life. Migraines mainly when I was younger included with that was vomiting and not being able to sleep. Now I am 24 and have headaches everyday, tension headaches mainly and a migraine about twice a month. I have made several complaints to my doctor and nothing was ever done. I have since switched doctors and was recently sent to the pain specialist who gave me a very vague description stating that I get 2 types of headaches one is tension (I worry to much) For that he prescribed me Amitriptylyne 10mg. The other type of headache he said was neurological problem, and didn't provide much information. I started taking the medication about 3 weeks ago, and I am still getting headaches but, now they are more severe and accompanied with feeling really hot and dizzy. Also I have gotten 2 migraines since taking the pills. I was wondering if maybe you could give me some type of
explanation as to where these headaches are coming from. And what steps could be taken to be rid of them completely. Also do I need a CAT scan of my brain?
Reply from Dr.
Thank you for your question. You seem to be describing 2 separate types of
headache consistent with the diagnosis of a mixed migraine and tension-type.
This disorder is formally referred to as a Coexistent Migraine and Chronic
Tension-type Headache. Before we discuss your particular type of headache it is
important to discuss each of the components, which constitute your mixed
headache syndrome individually to help gain insight and understanding.
For the sake of clarity I will classify headaches very simply into the
following 3 basic types:
1. Headaches due to Organic Causes
2. Vascular Headache (Migraines, Cluster and it's variants)
3. Tension-type (e.g. muscle contraction)
HEADACHES DUE TO ORGANIC CAUSES
These include brain tumors, brain 'bruises' due to injury (e.g. hematomas or
subarachnoid hemorrhage), infections (e.g. meningitis, encephalitis, abscess),
abnormalities in blood vessels (aneurysms, AVM), abnormalities in the brain
fluid (CSF) pressures (cerebral edema), cranial arteritis, major neuralgias, and
The following questions will help to identify whether your headache is due
to an organic cause:
1. Do you have a headache that is new or different from your usual headache?
2. Did your headaches start after an accident or an illness?
3. Do you suffer from headaches that begin during or after physical activity,
coughing or sexual activity?
4. Do you have neck stiffness or inability to put your chin on you chest, or
pain radiating to one or both of your legs when bending your neck?
If your answer to ANY of the above questions is a YES, then you should
immediately see your physician to take a thorough headache history, followed by
a complete neurological physical examination to rule out an organic cause for
Organic causes of headaches may have morbid consequences and their therapy is
dependant on the cause, and immediate treatment is often indicated. Hence this
discussion will primarily focus on the last 2 types of headaches, which seem to
be pertinent to your condition.
Common to all types of vascular headache is a tendency to vascular
dilatation, which precipitates the headache phase. The vascular dilation is due
to various triggers including:
- Menstrual periods
- Foods containing vasoactoive substances and vasodilators such as nitrates
Vascular headaches include:
- Migraine (with or without aura)
- Toxic vascular headache
- Hypertensive headache
Tension-type headaches are characterized by the "muscle
contraction" which occurs with these headaches. They are further
Most people experiencing episodic tension-type headaches will use simple,
over the counter (OTC) analgesics to obtain relief. Chronic tension-type
headaches are usually linked to depression or anxiety. Osteoarthritis of the
neck or chronic poor neck (cervical) posture or cervical inflammation (myositis)
may also cause tension-type headaches.
Migraine is defined by the Classification Committee of the International
Headache Society (IHS) as: Idiopathic, recurring headache disorder manifesting
in attacks lasting 4 to 72 hours. Typical characteristics of migraines are:
- One-side of the head (unilateral location)
- Pulsating quality
- Moderate or severe intensity
- Aggravation by routine physical activity
- Association with nausea
- Avoidance of bright light (photophobia) or loud noise (phonophobia)
Cause of Migraine (Pathophsiology)
Erin, you asked about the cause of your migraines. Up to 10 years ago it was
thought that migraines were caused by an increased blood flow to the head,
resulting in distended blood vessels that put pressure on nerve fibers in the
brain resulting in pain. This is known as the 'Vascular Theory' of migraines.
However, recent research indicates that this is not so. Rather, the current
understanding of the origin of migraine is that it is a complex brain disorder,
originating in the brain stem. This 'Brain Stem Theory' suggests that the
ultimate mechanism of head pain in migraine is due to trigeminal nerve
activation via the brainstem generator, which results in the release of
vasoactive peptides from nerve endings, causing vasodilatation and inflammation.
This theory states that there exists "migraine generators" or
pacemakers in the brain stem, and that migraine occurs when there is an
imbalance in activity between brain stem nuclei. Thus, blood vessels play only a
secondary role in migraine genesis (pathophysiology).
Diagnostic Features of Migraine
Up to 70% of migraine sufferers have a positive family history of migraine
headaches. 70% of all migraine sufferers are females and 70% of these describe a
relationship between their headaches and their menstrual periods.
The onset of migraine usually starts in the teens and early twenties.
Migraine tends to diminish in the 5th and 6th decades.
Headache triggers include
- Fasting or missing a meal
- Vasoactive substances in foods
- Periods (menses)
- Changes in barometric pressure
- Changes in altitude
Medications that may precipitate migraine include:
- Reserpine (An MAO antidepressant)
- Nitrates (used for angina heart condition)
- Indomethacin (an NSAID)
- Birth Control Pill (Oral contraceptives)
- Post-menopausal hormones
Personality features of migraine sufferers are a topic of hot debate amongst
neurologists and they do include perfectionism, rigidity and compulsiveness.
Migraine patients tend to build environments too great to handle.
Does any of this sound familiar Erin?
Clinical Features of Migraine
Migraines are usually unilateral headaches but may occur bilaterally or even
switch sides. They are recurring headaches with a frequency of 2 to 8 attacks
per month. The duration of each attack is 4 to 24 hours, although some attacks
The severity of pain varies from moderate to incapacitating. The pain is
often described as throbbing or pulsating. Other associated symptoms include:
- photo- and/or phonophobia
- Pale face
- Vertigo (abnormal sensation of motion)
- Tinnitus (a ringing or buzzing sensation in the ear(s)
Prodromal symptoms associated with migraine with aura include (in order of
- Blind spots (scotomas)
- Fortification scotomata (zigzag or scintillating figures)
- Unformed flashing of lights (photopsia)
- Visual and auditory hallucinations
Premonitory symptoms may precede an attack of migraine with or without aura.
These symptoms include:
- Bursts of energy
- Extreme hunger
Types of Migraine include
1. Migraine with aura
2. Migraine without aura
3. Complicated Migraine (e.g. neurological symptoms persist after the migraine
a. Hemiplegic Migraine
b. Ophthalmoplegic Migraine
c. Basilar Migraine
4. Menstrual Migraine
5. Migraine Equivalents
Treatment of Migraine
Migraine treatment can be divided into 4 types
1. General treatment measures
2. Abortive therapy
3. Pain relief measures
4. Prophylactic therapy
General treatment measures include
a. Maintain regular sleeping schedule
Migraine attacks may be precipitated by fatigue or oversleeping. On
weekends, holidays and during vacations, you should still awaken at the same
time each day.
b. Maintain regular meal schedule
Missing a meal or fasting may trigger migraine attacks. Meals should be
consumed at the same time daily, and you should eat breakfast at a regular time
each day to avoid the weekend or holiday migraine.
Migraine sufferers may benefit from a tyramine-restrictive diet and
should avoid most foods containing vasoactive substances (e.g. chocolate,
caffeine, alcohol, no aged, canned or processed meats (these have nitrites), no
MSG, any foods containing nitrites, nitrates or tyramine, avoid all yeast
products, no fermented or pickled foods, no aged cheeses. Avoid these beans:
broad, fava, garbanzo, Italian, lima, navy, pinto, pole, snow peas, sauerkraut,
no onions (except for flavoring), no olives and no pickles. You should also
avoid alcohol and caffeine containing substances.
Migraines may be triggered by smoking or second-hand smoke, strong odors
such as paint, perfume, cleaning solutions, exhaust fumes and certain lighting
including fluorescent lighting, bright lights and strobe lighting. These should
be identified and avoided accordingly.
e. Coping Strategies
Stress may be impossible to avoid, but do try to learn to handle stress
and also practice some relaxation methods. Try to learn to identify your
particular stressors and to avoid these triggers. Progressive relaxation and
deep breathing exercises may be of particular help.
Medical Therapy of Migraines
The severity, frequency and impact on your daily life and ability (or lack
of) to function will influence the type of therapy to be selected by you and
Migraine Abortive Therapy
If you have less than 2 migraines per month, then any of the following or in
combination abortive therapies may be selected
(Note: In the listings for medications the generic name is followed by the trade
name, the method taken, and the dosage.)
Ergotamine tartrate, (Cafergot), pill taken by mouth, Take 2 tablets immediately at onset, may repeat every 30 min. up to 6 tabs/day, or 10 tabs/week.
Ergotamine tartrate with caffeine, (Wigraine), same as above, each tab contains 100 mg caffeine.
Ergotamine tartrate suppository, (Cafergot 2 mg suppository), Insert 1 supposiytory per rexctum immediately at onset, may repeat in 1 hour, up to 2 suppositories/day, or 5 suppositories /week.
Ergotamine tartrate must not be used if you suffer from any of:
cerebrovascular disease, cardiovascular disease, peripheral vascular disease,
severe hypertension, ischemic heart disease, kidney or liver disease. This drug
should also be used cautiously if you have a peptic ulcer or recent infection.
Dihydroergotamine, (D.H.E.), Intramuscular subcutaneous 0.5 ml injection; Inject 1 mg at onset, may repeat at hourly intervals, up to 3 mg/day, maximum 20 mg/week.
Migranal (Intranasal 1 mg sprays), Take 2 mg at onset, one spray in each nostril; repeat in 15 minutes, up to 3 mg/day.
D.H.E. causes less nausea than ergotamine tartrate but should also be given
in combination with metoclopramide (Maxeran) 10 mg every 8 hours for 3 days
after each injection to treat intractable migraine. Due to its vasoconstrictive
properties, DHE cannot and must not be given to people with poor circulation,
ischemic heart disease, uncontrolled hypertension, impaired kidney or liver
function, hemiplegic or basilar migraine, pregnancy or sensitivity to this drug.
Sumatriptan (Imitrex) injection, (subcutaneous injection), Inject 6 mg at onset, may repeat in 1 hour, up to 12 mg/day.
Sumatriptan (Imitrex) tablets (100 mg pills), Start with 50-100 mg at onset. If ineffective, dose can be repeated in 2 hours, up to 200 mg max.
Sumatriptan (Imitrex) nasal spray (Intranasal 20 mg sprays), Apply one spray in one nostril at onset. may repeat within 2-24 hours, limited to 2 sprays/day.
Zolmitriptan (Zomig) 2.5 mg pill. Take 1 pill at onset. If ineffective may repeat in 4 hours, up to 5 mg/day.
Naratriptan (Amerge) 2.5 mg pill. Take 1 pill at onset. If ineffective may repeat in 6 hours, up to 5 mg/day.
Rizatriptan (Maxalt) 10 mg tablet. Take 1 tablet at onset. If ineffective, may repeat in 6 hours, up to 20 mg/day.
Due to their vasoconstrictive properties, any triptan cannot and must not be given to persons with the following conditions: poor circulation, ischemic heart disease, uncontrolled hypertension, impaired kidney or liver function, hemiplegic or basilar migraine, pregnancy or sensitivity to this drug.
Aspirin with caffeine (Excedrin Extra Strength) pill by mouth. Take 2 tabs at onset, may repeat in 4 hours. If headache persists, see doctor to evaluate.
This is the only OTC preparation to receive approval for the indication for
the acute treatment of mild-to-moderate headache without associated vomiting and
Naproxen sodium (Anaprox) 275 mg tablets. Take 825 mg (3 tablets) initially, and 550 mg (2 tablets) after 1 hour
Other NSAIDS of comparable efficacy include Ibuprofen (Advil, Motrin), Ketoprofen (Orudis) and plain Aspirin.
Ketorolac (Toradol) (Intramuscular 60 mg injections). Administer at onset of headache.
Intramuscular Toradol is advantageous in that it is fast acting, well tolerated, a non-narcotic, and is non-habituating.
Chlorpromazine (Thorazine), Intramuscular 50 - 100 mg injection. Administer at onset of headache.
Prochlorperazine (Compazine), Intramuscular 10 - 25 mg injection. Administer at onset of headache.
I carry these agents in my office and find them effective due to their
antinauseant and sedative effects. In addition, their specific neurotransmitter
effects (e.g. dopaminergic and adrenergic actions) may provide specific
therapeutic action consistent with the current brain stem theory of migraines.
Lidocaine -- (Intranasal drops) Administer 15 drops of 4% solution to the nostril on same side of headache. May be repeated in 5 minutes, up to 4 times/day.
Intranasal Lidocaine drops (4%) may be very effective in the acute setting, but relapse is common and tends to occur early after treatment
PAIN RELIEF MEASURES
Complete resolution of the migraine attack may not be achieved by abortive
therapy and analgesics may be indicated. These agents include OTC analgesics:
- Acetominophen (Tylenol)
- Ibuprofen (Motrin, Advil etc)
- Naproxen sodium
- Ketoprofen (Orudis)
Over consumption of these agents, particularly OTC analgesics containing
caffeine, can produce serious side effects. Withdrawal from caffeine-containing
drugs may trigger the caffeine withdrawal headache. These drugs should be
avoided if you have frequent migraine attacks.
Other pain-relief measures for the acute migraine include:
- Narcotic analgesics
- Transnasal butorphanol
- Cold packs
Narcotic analgesics used in relief of acute migraine attacks include:
- Meperidine (Demerol)
- Butalbital/Aspirin/Acetominophen/Caffeine/with or without codeine (the
- Propoxyphene (Darvon)
Although these are effective in pain relief, their tendency of habituation
and dependency indicates that their use should not be used with frequently
occurring migraine attacks.
The antiemetics have been discussed above.
Transnasal Butorphanol (Stadol):
Stadol is a totally synthetic mixed agonist-antagonist opioid analgesic. Its
rapid absorption via the transnasal route is enhanced by its lipophilic nature.
Migraine sufferers have used cold packs for many years. The use of ice packs
or bags, along with pressure, may reduce the pulsating pain associated with an
acute migraine attack.
PROPHYLACTIC THERAPY OF MIGRAINES
Prophylactic therapy is indicated if the headache frequency is more than 2
migraine attacks per month and produces disability lasting 3 or more days per
month. It is also indicated if abortive therapy medication is required more than
twice per week. Several agents have been used successfully in migraine
Propranolol. Inderal. 80-240 mg daily in divided doses
Inderal. LA. 60-160 mg in once daily doses
Timolol maleate. Blocadren. 5-30 mg daily
Nadolol. Corgard. 40-80 mg daily
Atenolol. Tenormin. 50-100 mg twice daily
Metoprolol. Lopressor. 50-100 mg twice daily
Beta-blockers are especially useful in migraine patients with concomitant
hypertension, angina pectoris and thyrotoxicosis. Beta-blockers should be
avoided in asthma, congestive heart failure, chronic obstructive lung disease
and certain cardiac arrhythmias. Do not give beta-blockers if you're on insulin,
oral diabetic medication or MAO inhibitors (e.g. Nardil).
Calcium Channel Blockers
Verapamil. Isoptin. 240-360 mg daily in divided doses
Verapamil also has antiplatelet effects that add to its efficacy in migraine.
The most commonly reported side effect is constipation.
Clonidine. Catapres. 0.1 mg three times daily (max dose 2.4 mg/day)
Side effects of this medication may include drowsiness, dry mouth and
Amitriptyline. Elavil. 50-100 mg at night. Class: TCA
Doxepin. Sinequan. 50-150 mg at night. Class: TCA
Imipramine. Tofranil. 50-150 mg at night. Class: TCA
Nortriptyline. Aventyl. 50-150 mg at night. Class: TCA
Desiprimine. Norpramine. 50-150 mg at night. Class: TCA
Protriptyline. Vivactil. 15-40 mg three times daily. Class: TCA
Maprotiline. Ludiomil. 75-150 mg at night. Class: TCA
Trazodone. Desyrel. 50-300 mg at night. Class: TCA
Phenelzine. Nardil. 15 mg three times daily. Class: MAOI
The efficacy of these drugs is believed to be independent of their
antidepressant actions and may be due to possible analgesic effects.
Naproxen. Naprosyn. SR 550 mg two times daily (commonest)
Ketoprofen. Orudis. 75 mg three times daily
Tolmectin sodium. Tolectin. 200 mg three times daily
Fenoprofen calcium. Nalfon. 300 mg every 6 hours or 600 mg daily
Aspirin --- 325-650 mg daily
The NSAIDS have been used effectively in migraine prophylaxis due to their
effects on the prostaglandins and inhibition of inflammation. However, their
daily use is associated with a high risk of side effects, particularly stomach
ulcers or kidney damage.
Divalproex sodium. Depakote. 250-500 mg twice daily, up to 1250 mg/day
This anticonvulsant has been widely and successfully used in migraine
prophylaxis. Side effects of this medication include: drowsiness, sedation,
unsteadiness, anorexia, nausea, vomiting, and hand tremor and hair loss.
Cyproheptadine. Periactin. 4 - 16 mg daily
Periactin is an antihistamine with mild to moderate antiserotonin activity.
It is very useful in treating childhood migraines more so than with adults.
Ergotamine tartrate. Bellergal. S one tablet twice daily with Phenobarbital Aand Bellafoline
Methysergide maleate. Sansert. 2 mg three times daily
Sansert is a lysergic acid derivative, which is closely related to the ergot
alkaloids. Its effectiveness is believed to be linked to blocking the
inflammatory and vasoconstrictor effects of 5-HT. Long-term therapy with Sansert
is associated with severe side effects including fibrotic syndromes of the
heart, lung and retroperitoneum. Therefore, it should only be used in select
patients who have been refractory to other forms of therapy.
MENSTRUAL MIGRAINE PROPHYLACTIC THERAPY
These drugs should be started 2 days prior to and continued throughout the
Naproxen sodium. Anaprox. 250 mg three times daily
Mefenamic acid. Ponstan. 250 mg three times daily
Ketoprofen. Orudis. 75 mg three times daily
Fenoprofen calcium. Nalfon. 600 mg three times daily
NON-PHARMACOLOGICAL THERAPY OF MIGRAINES
Behavioral approaches can be divided into 3 general categories: those that
attempt to alter one's thinking and coping responses (relaxation and cognitive
therapy); those that intend to alter your physiologic responses (biofeedback);
and those that attempt to change your behavioral response to pain (operant
Relaxation and Cognitive Therapy
Relaxation techniques can be easily taught, and may be enhanced by self-study
at home, using tape recordings to stimulate progressive relaxation or guided
Cognitive behavioral therapy focuses on the relationships between cognition,
feelings, and behaviors, and how these parameters contribute to the experience
Biofeedback techniques have been widely used in patients with migraines. The
theory behind biofeedback is that it is possible to train yourself to control
your autonomic body systems using the biofeedback of normally unavailable
physiologic information. In the treatment of migraine the most common
biofeedback techniques include biofeedback on skin temperature of the hands, or
on EMG activity of the frontal muscles of the skull. The lack of scientific
validation contrasts with the generally favorable treatment reports of
uncontrolled trials, which leaves the physician faced with the paradox of
whether or not to refer you for this treatment. Personally I feel that if your
motivated and have the resources you may strongly wish to consider this mode of
therapy in addition to any medication your physician prescribes. Biofeedback
will foster feelings of hope, self-mastery and control, enhance relaxation
skills, assist in developing coping strategies, and may help you gain insight
into the emotional and environmental aspects of your headaches.
Operant Behavior Therapy
An operant is a behavior that may be influenced by a reinforcer or reward
that follows the behavior. Operant pain behaviors may include straightforward
responses to pain as crying and moaning. More destructive operant behaviors may
include requests for excess medications, requests for attention from physicians
or other family members, financial incentives for disability, or avoidance from
work. Operant behavior therapy is generally reserved for more functionally
disabled patients who have a significant psychosocial component to their
migraine. The basic premise of operant behavior therapy is to decrease the
operant reinforcers for pain behaviors, while increasing reinforcements for
ALTERNATIVE THERAPIES FOR MIGRAINES
Acupuncture is the most widely used alternative therapy used to treat
migraine. The foundation of acupuncture is based on the concept of vital energy
called qi (pronounced "chi"). Well-being depends on the harmonious
flow of qi, while pain is the result of an imbalance of qi. Acupuncture attempts
to restore the appropriate balance by stimulating specific points arranged along
energy meridians in the body; there are some 700-800 acupuncture points. A
variety of acupuncture techniques are used. The most familiar is the insertion
of needles, but acupuncture points may also be stimulated by using pressure
(acupressure), heat (moxibustion) or electric current.
Recently, there has grown an increasing interest in various herbal
therapies, vitamins or elimination diets.
The terms "tension" or "muscle contraction" headaches
have been used interchangeably for several years. The Classification Committee
of the International Headache Society (IHS) has established the term
"tension-type" headache as the correct label for these headaches.
The tension-type headache is a manifestation of the body's reaction to:
- Emotional difficulties
- Repressed hostility
The physiological response includes:
- Reflex dilatation of the external cranial vessels
- Contraction of the skeletal muscles of the:
The IHS defines tension-type headaches as recurrent episodes of headache
lasting minutes to days. Pain is usually:
- A pressure or tightening sensation
- Of mild to moderate severity
- On both sides of the head (bilateral location)
- Not worsened by physical activity
Tension-type headaches are identified as being either chronic or episodic.
The distinguishing feature between these 2 types is the frequency of chronic
tension-type headaches to be at least 15 days per month for at least 6 months.
The pain of these headaches is described as steady and nonpulsating and may
be depicted as:
- Bitemporal or bioccipital tightness
- Band-like sensations around the head
- Vice-like ache
- A weight
- Pressure sensations
The site of the headache is primarily the:
- Back of the head or neck
This pain is usually bilateral (as opposed to migraines which is usually
one-sided). The pain may spread (radiate) to other areas, such as the neck or
shoulders. Shivering or exposure to cold may exacerbate the pain.
Chronic tension-type headaches are often a manifestation of an underlying
psychological conflict, such as anxiety or depression. I hope Erin that your
examining physician(s) have reviewed with you any potential sources of conflicts
including family, work, school, relationship, social or sexual problems you may
TREATMENT OF TENSION-TYPE HEADACHE
If you experience a sudden attack of episodic tension-type headache, relief
can usually be obtained with OTC analgesics, such as:
- Acetominophen (Extra Strength Tylenol 500 mg)
- Ibuprofen (Motrin, Advil etc.)
Caffeine has also been proven to be effective as an add-on (adjuvant) to
OTC's in this setting. Usually up to 2 large cups of caffinated coffee with 1 or
2 of the above OTC's should do the trick.
However, the treatment for chronic tension-type headache is not as obvious,
and not as easy. Due to the chronic nature of these headaches, adding a
benzodiazepene is not recommended and should be avoided. A nonaddicting
anxiolytic (e.g. buspirone) should be considered. Buspirone is a selective
5-HT(1A) serotonin receptor-partial agonist with a low incidence of sedation.
Similarly, caffeine and caffeine-containing analgesics should be avoided to
prevent caffeine withdrawal headaches.
The nonsteroidal anti-inflammatory drugs (NSAIDS) may be used in the abortive
therapy of these headaches.
Tricyclic antidepressants (TCA's) are the agents of choice in the
prophylactic treatment of chronic, tension-type headaches associated with
depression. These agents may be effective independent of their antidepressant
actions as they have been recognized for their analgesic effects. The selection
as to which TCA to choose is often dependent on the presence of any sleep
disturbance. Amitriptyline and Doxepin are indicated for their sedative effects.
Others who do not require a sedative effect may respond well to Protriptyline.
The most commonly used TCA's used in chronic, tension-type headaches are:
- Amitriptyline (Elavil)
- Doxepin (Sinequan)
- Protriptyline (Triptil, Vivactil)
- Nortriptyline (Aventyl)
- Desiprimine (Norpramine)
- Imipramine (Tofranil)
Nontricyclic agents are the second generation of antidepressants. They are
not associated with the anticholinergic side effects as present with the above
mentioned TCA's. These include:
- Maprotiline (Ludiomil)
- Trazodone (Desyrel)
- Fluoxetene (Prozac)
- Bupropion (Wellbutrin)
Biofeedback has also demonstrated efficacy in the treatment of chronic,
tension-type headaches. EMG training has been effective in decreasing the
severity of acute headaches as well as diminishing the frequency of these
attacks. Psychological counseling may be indicated for those patients with
COEXISTING MIGRAINE AND TENSION TYPE HEADACHE
Now Erin, you are describing a combination of both tension-type and migraine
headache. These were previously called "mixed headache syndrome", but
is now properly classified as a coexisting migraine and tension type headache.
These types of headaches are usually associated with the following symptoms:
- Daily, chronic, tension-type headache
- Hard or "sick" migraine headache
- Increased susceptibility of habituation to analgesics or ergots
You describe yourself as suffering from headaches "all your life,"
which is not uncommon in this type of headache. Erin, it is important that you
are clear and certain as to exactly how many different type of headaches you
Your situation is not uncommon in that your currently have been treated
without success after such a long time. I am sure that it took a long time to
establish the exact type of headache you have which as lead to your current
state of frustration.
Because of the frequency and severity of your headaches I would not be
surprised if you have had a long past history of habituation to analgesics
(possibly narcotics), both over the counter (OTC) and prescribed. It is also
common with patients suffering with your condition to be using large amounts of
caffeine-containing analgesics and often complain of caffeine withdrawal
headaches when these drugs are stopped. You may be consuming large amounts of
ergotamine preparations and also experience ergot rebound headaches when you
attempt to discontinue these drugs as well. Others suffering such as you may
become dependant on benzodiazepenes (valiums, lorazepam, lectopam, xanax etc.).
Now, Erin before we attempt to "Humpty-Dumpty" you back together it is
important that any habituation agent (narcotic, analgesic, or benzodiazepene) be
discontinued totally. This seems to be the case in your condition.
TREATMENT OF COEXISTING MIGRAINE & TENSION TYPE HEADACHE
Erin, many patients suffering with coexisting migraine and tension-type
headaches are suffering from an underlying depression. Consequently,
antidepressants have been recognized as the drug of choice for prophylactic
treatment of your syndrome. These drugs may be effective in treating both the
underlying depression as well as their analgesic effects.
Due to the complex nature of this syndrome, the use of combination therapy is
often indicated. If all else fails you treating physician will consider your
tricyclic antidepressant in combination with an MAO inhibitor. But this is very
serious "big-gun" therapy which really should be instituted in an
in-patient hospitalized basis due to the potential serious side-effects as well
as necessary medical monitoring. Only experienced physicians (trained
neurologists should undertake this course of action).
Other more preferable agents are available as first line treatment in
combination or co-therapy. The use of TCA in combination with the beta-blocker
propranolol (Inderal 80-240 mg daily in divided doses) or the calcium channel
blockers (Verapamil 240-360 mg daily in divided doses or Nimodipine 30-60 mg
daily) has been effective for some patients with your condition. Once again this
should be administered in an in-patient setting.
The NSAIDS have also been effective in the prophylaxis of coexisting migraine
and tension-type headaches, similar to their action in both migraine and
tension-type headaches. These agents have also demonstrated efficacy in the
abortive treatment of the sudden acute headaches and do not have the potential
I hate to disappoint you Erin, but any drugs that may lead to dependency
problems should be avoided in syndromes such as yours.
Regarding whether or not you need any imaging studies (e.g. computer
tomography (CT scan) magnetic resonance imaging (MRI) or magnetic resonance
angiography (MRA)) there is much controversy in this matter. In 1994, the
American Academy of Neurology published practice guidelines regarding
brain-imaging tests in patients with headache, but with normal neurological
examinations. The following statement appears in the guideline summary:
"In adult patients with recurrent headaches that have been defined as
migraine - including those with visual aura, with no recent change of pattern,
no history of seizures and no other focal neurological signs or symptoms, the
routine use of neuro-imaging is not warranted. In patients with atypical
headache patterns, and/or a history of seizures, or physical examination
findings of focal neurological signs or symptoms, CT or MRI may be
Therefore, based on the information you have provided me in your question
Erin, I see no medical indication to warrant any brain imaging studies on you at
So there you have it Erin. Effective treatment of your headache should be
tailored to your individual needs, and should take into consideration your
preferences, the above mentioned treatment options and any other existing health
problems you may have. The initial choice between nonspecific (analgesic) and
specific abortive or prophylactic measures rests mainly on the severity and
frequency of your headaches with more important emphasis being placed on the
impact your headaches have on your life (e.g. has your headaches affected your
ability to function at home? with your family? relationships? at work? etc.,
etc. Non-pharmacological therapies have been discussed and may be used in
conjunction to the above-mentioned stepped-care or stratified-care medical
approach. It is important Erin that you involve yourself with informed reliable
knowledge about the origins and type of headache you are experiencing in keeping
with the health-coach philosophy.
In your particular situation it sounds as if you're being under treated with
a mere 10 mg of Amitriptyline. This medication I'm sure is also causing your
dizziness. I hope you are taking the Amitriptyline 1 – 2 hours before bedtime.
This tends to reduce incidence of dizziness and helps restore a more physiologic
REM sleep pattern. If this fails to show improvement you may consider suggesting
to your doctor that he consider trying another antidepressant from a different
class. Based on the information you provided to me I would consider placing you
on Wellbutrin 150 mg at nighttime. This should act as prophylactic therapy for
the migraine component of your headache and active therapy for the tension part
of your headache. For abortive treatment of acute migraine attacks, I would
start off with Extra-Strength Excedrin, which is OTC in the doses stated above.
If this fails then try higher doses of Advil. Again if this doesn't cut it then
go back to your pain specialist armed with the information above, and I'm sure
the two of you could develop a stepped-care plan to get your headaches
manageable. Again based on the information you have provided there is no medical
indication to pursue brain-imaging such as MRI or CT scan.
As you can see Erin, there are no quick fixes or quick cures. Headaches such
as yours are usually of a chronic nature and may require long-term and even
lifelong management - and in some cases - lifelong drug management. I hope the
above answer has provided you and other readers with sufficient information and
education regarding headaches, their triggers, optimal medical therapy, and
changes in headache character which that may indicate more serious conditions.
In this way you can work with your doctor to develop an effective
patient-physician partnership for management of your headaches.
Finally, an essential aspect in treating chronic, complex and difficult
conditions such as yours is continuity of care. Patients suffering from chronic
headaches often have run the gamut of physicians and therapies, and consistency
in treatment is very important. It is important to realize that therapy is
available and that you are not alone in combating this syndrome.
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