EBHSG - August 1996 Meeting Notes

EBHSG - AUGUST 1996 MEETING NOTES

TOPIC: "MAXIMIZING YOUR MEDS IN THE TREATMENT OF HEADACHES"

Darryl Nomura, PharmD, the Pharmacy Manager at Longs Drug Store in Martinez, spoke at the August 13, 1996 meeting. The title of his talk was "Maximizing your Meds in the Treatment of Headaches." 43 people attended this meeting, which was held in the Ball Auditorium at John Muir Medical Center from 7:30 to 9:00 pm.

"Our focus is on how to prevent headaches, to attenuate (lessen) the number of headaches we have, the frequency, and the severity."

Darryl asked the audience how many had migraines (a clear majority) and how many suffered from other types of headaches. There were two people who indicated they had cluster headaches, one male and one female. Darryl said the ratio of cluster headache patients is 5 men to 1 woman. Other headache categories he mentioned were: muscle contraction-tension headaches, and mixed muscle contraction+migraine.

In the treatment of headaches one must go through the following steps:

I. IDENTIFICATION OF THE HEADACHE

Type

Source

Timing

Frequency

Other influencing variables: Sex (gender)

Genetic disposition

History: onset, duration

Triggers: environmental, food-based, work related

Darryl told us the way to help identify food-based triggers is to keep a diary of everything you eat, such as MSG, Asian foods, etc. He said that MSG is found in every food that is classified as "fast food." His favorite statement is "If it doesn’t rot, don’t eat it." To illustrate, Darryl told us of a co-worker who used to have many migraine headaches. He was trying to help her to identify her headache triggers, when he noted that she ate fast food from the local Burger King every day. After persuading her to stop eating fast food, her headaches improved significantly.

Women also need to keep a menstrual history to see if migraines are related to their menstrual cycle. The estrogen trigger is very significant—the number one side effect of birth control pills is migraine headache, caused by the rapid shift in estrogen levels.

Don’t take birth control pills if you suffer from migraines. There are two big shifts— when you go on and when you go off. If you are on estrogen replacement therapy, he suggested using the "patch" in the lowest dose, to try to keep the estrogen level on an even keel. Darryl mentioned that even working with estrogens can trigger migraines, such as in the case of a woman who was employed in a facility which manufactured birth control pills.

Feverfew is an herb commonly used to try to prevent headaches. Darryl told us that he is leery of feverfew. There is no statistical proof that this herb works, and an overdose of feverfew causes paralysis of smooth muscle of the cranial arteries. Once paralyzed, the cranial arteries are unable to regulate blood flow and a hemorrhage of the brain can result. Also, this paralysis is irreversible. Darryl warned us to be careful using any herbal remedies.

II. TREATMENT SELECTION STRATEGIES

Darryl mentioned a Strategic Integrated Operating Plan, or SIOP, versus the Key in Lock Solution. We need to coordinate a plan of action. Ask yourself, "How does my body generate my headache?

Key points to general treatment of headaches:

1. Identify personal headache triggers: Consider your current medication list: oral contraceptives, estrogen replacement therapy, hypertension medications. 2. Keep strict sleep and meal schedules. 3. Employ coping strategies, such as biofeedback and relaxation techniques. 4. Use pharmacologic intervention: A) Preventative Therapy, B) Abortive Therapy, C) Pain Relief

A. PREVENTATIVE THERAPY

Darryl went through a list of drugs used for the prevention of migraines (if migraines occur more than twice a month):

Beta blockers: Example: Inderal. Have no direct effect on cerebral blood flow. Method of Action (MOA): inhibit seratonin uptake. May take 3-6 months to measure effectiveness. 70-80% of people taking beta blockers see some attenuation of migraine headaches. Darryl said that 50-60% of migraine headaches are seratonin-related. When there is a sudden release of seratonin, the blood vessels start to constrict, the platelets stick together, and the blood vessels start to dilate.

What does aspirin do? Aspirin is an ascetalator of platelets (keeps platelets from sticking together). Don’t take aspirin if you are allergic to aspirin, have asthma (especially if you’re middle-aged), taking Coumadin, or if you have a huge gastric ulcer (then take coated aspirin only).

Anti-depressants: Tri-cyclic antidepressants, such as amitriptyline (Elavil) taken at bedtime. Darryl: "Elavil is a dirty drug—keep away from children." MOA: increased seratonin blockade centrally. Side effects: decreased blood pressure, blurred vision, weight gain, dry mouth, intense dreaming, drowsiness, dry eyes (can’t wear contact lenses).

Calcium Channel Blockers: Verapamil (Calan, Isoptin). Not all Calcium Channel blockers work alike. MOA: Interfere with calcium’s role in smooth muscle contraction centrally (prevents influx of calcium into smooth muscle).

Cyproheptadine: Periactin. MOA: antihistamine—also blocks calcium transmission. Good for menstrual migraine. Side effect: weight gain.

Central Alpha Agonists: Clonidine (Catapres). Good for tyramine sensitive patients. Taken orally or via sustained action patch.

Non-Steroidal Anti-Inflammatories (NSAID’s): Naprosyn, Naproxen Sodium (Aleve), Aspirin, Acetaminophen (Tylenol), Ibuprofen (Motrin), Ketoprofen (Orudis). MOA: They block prostaglandin formation. Blocks platelet aggregation and seratonin release. Side effects: gastric upset—ulceration (Cytotec is a good drug to protect the stomach when taking anti-inflammatories.) Also can cause decreased renal blood flow (liver damage) and increased clotting times. There is a danger of high-dose rebounding.

A strategy for oral contraceptive users: After the 20^th day on oral contraceptives begin taking an NSAID on a daily basis. For pre-menstrual syndrome (PMS), begin after the 14^th day of your cycle.

Darryl suggested taking a daily (low) dose of baby aspirin--to reduce prostaglandins and ultimately headaches. Consider enteric coated tablets (to reduce stomach problems).

For cluster headache patients, he mentioned Corticosteroids (Prednisone) and Lithium.

B. ABORTIVE DRUGS

These are drugs used to get rid of a headache in the early stages. Abortive therapies are vasoconstrictors, such as:

Ergot Compounds (Ergotamine Tartrate, Sansert, DHE 45, Ergonovine). Oral ergots may decrease gastric motility—decreased absorption, i.e., Bellergal-S and Cafergot tablets. Side effects: Nausea/vomiting, anorexia (take Phenergan or Reglan to relieve nausea), decreased circulation: coldness, tingling, limb pain, nous clots.

Isometheptene (Midrin).

Sumatriptan (Imitrex), available in oral tablets or self-injection. Can take a maximum of 300 mg a day orally. Dose at two-hour intervals. Imitrex has been used 40 million times and there have been 100 cases of heart attack or death. You need to take Imitrex as soon as possible, before migraine becomes full-blown. It has been reported that Imitrex works for 8 out of 10 headaches. Some patients have reported using Imitrex once and then not getting another migraine for awhile.

Side effects: Cardiac problems (electrical). Don’t take if evidence of heart disease, angina.

Note: Do not take Imitrex if trying to get pregnant, or are pregnant. Medications are rated A, B, C, and X to classify their risk of causing birth defects. Imitrex is rated a "C."

Oxygen—for cluster headache patient. Use 100% oxygen from an oxygen tank for five minutes to abort an attack.

Topical 4% Lidocaine—Administered nasally. Lidocaine is the current "sexy" headache remedy. One-half of patients taking Lidocaine said it reduced their headaches. It anesthetizes an area in the nose.

C. PAIN RELIEF

There are over-the-counter analgesics, such as Aspirin, Excedrin, Tylenol, Motrin, Advil, Alleve. Remember to screen for appropriate usage—watch for gastric ulcers, liver damage, don’t use with alcohol. Side effects with salicylates (aspirin): prolonged bleeding, tinnitis, kidney problems, gout. Maximum dose of Motrin per day: 3200 mg. Warning: Lupus patients—don’t take Ibuprofen.

Prescription analgesics and tranquilizers: narcotics.

Watch for abuse/chronic tolerance, decreased effectiveness over time. The problem with using tranquilizers is that you end up not caring, so you miss the opportunity to look for your headache trigger.

After Darryl’s presentation, questions and comments about individual drugs were discussed. He said that aspirin does a better job of eating a hole in your stomach than Advil or Motrin. For every tablet of aspirin you take, you lose a teaspoon of blood.

Depakote: Work up to the dosage slowly. Have blood levels analyzed. Take Depakote with food, not on an empty stomach. Causes drowsiness, nausea.

Fiorinal with Codeine causes drowsiness. It is a combination drug that is easy to get hooked on. Codeine is a narcotic/analgesic. Fiorinal is a barbiturate (a tranquilizer).

Older people are more caffeine sensitive. Watch out for the caffeine in Excedrin.

Don’t cut an enteric- (acid resistant) coated tablet in half.

Prescription strengths of these drugs are becoming exceedingly high. Don’t add alcohol—can be disastrous.

In summary, "Maximizing your meds" involves evaluating each and every aspect of your life—including the pharmacist you select to provide your medical information and prescription needs.

The notes provided above were taken by an East Bay Headache Support Group volunteer and have not been reviewed by the speaker for accuracy. If you have any questions regarding the notes, please contact the EBHSG.

The intention of the East Bay Headache Support Group is to provide information and resources. It does not provide medical advice, which should be obtained directly from a physician.