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Subject: Headaches

From: Erin


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?
Thank you.

Reply from Dr. Bazos:

Dear Erin:

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)

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 TMJ disorders.

Alarm Signals
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 your headache.

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
- Fever
- Stress
- Weather
- Altitude
- Foods containing vasoactoive substances and vasodilators such as nitrates

Vascular headaches include:
- Migraine (with or without aura)
- Cluster
- Toxic vascular headache
- Hypertensive headache

Tension-type headaches are characterized by the "muscle contraction" which occurs with these headaches. They are further categorized into:
- Episodic
- Chronic

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
- Stress
- Fatigue
- Oversleeping
- Fasting or missing a meal
- Vasoactive substances in foods
- Caffeine
- Alcohol
- 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 are prolonged.

The severity of pain varies from moderate to incapacitating. The pain is often described as throbbing or pulsating. Other associated symptoms include:
- Nausea
- Vomiting
- photo- and/or phonophobia
- Pale face
- Vertigo (abnormal sensation of motion)
- Tinnitus (a ringing or buzzing sensation in the ear(s)
- Irritability

Prodromal symptoms associated with migraine with aura include (in order of frequency):
- 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
- Fatigue
- Extreme hunger
- Nervousness

Types of Migraine include
1. Migraine with aura
2. Migraine without aura
3. Complicated Migraine (e.g. neurological symptoms persist after the migraine attack)
 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.
c. Diet
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.
d. Environment
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 your physician.

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.)

The Ergotamines
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.

The Triptans
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 disability.

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.

The Phenothiazines
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.

Miscellaneous class
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

Complete resolution of the migraine attack may not be achieved by abortive therapy and analgesics may be indicated. These agents include OTC analgesics:
- Aspirin
- 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
- Antiemetics
- Transnasal butorphanol
- Cold packs

Narcotic Analgesics
Narcotic analgesics used in relief of acute migraine attacks include:
- Codeine
- Meperidine (Demerol)
- Butalbital/Aspirin/Acetominophen/Caffeine/with or without codeine (the Fiorinals)
- 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.

Cold Packs:
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 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 prophylaxis:

The Beta-Blockers
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.

Alpha Agonist
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 constipation.

The Antidepressants
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.

These drugs should be started 2 days prior to and continued throughout the menstrual flow.

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

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 conditioning).

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 imagery.

Cognitive behavioral therapy focuses on the relationships between cognition, feelings, and behaviors, and how these parameters contribute to the experience of migraine.

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 healthy behaviors.

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:
- Stress
- Anxiety
- Depression
- Emotional difficulties
- Fatigue
- Repressed hostility

The physiological response includes:
- Reflex dilatation of the external cranial vessels
- Contraction of the skeletal muscles of the:
- Head
- Neck
- Face

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
- Drawing
- Soreness

The site of the headache is primarily the:
- Forehead
- Temples
- 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 be experiencing.

If you experience a sudden attack of episodic tension-type headache, relief can usually be obtained with OTC analgesics, such as:
- Aspirin
- 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 severe depression.

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 experience.

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.

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 for habituation.

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 indicated."

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 present.

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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