MARCH 13, 2001 MEETING
TOPIC:  “OVERLOAD SYNDROME AND NOXIOUS STIMULI IN MIGRAINE”

Dr. Jonathan B. C. Humphrey was the guest speaker for the March 13, 2001 meeting of the East Bay Headache Support Group.  The meeting was held in the Ball Auditorium at John Muir Medical Center with 28 people in attendance.

Dr. Humphrey is a Board Certified Family Practitioner in Danville with special training and interest in migraine headaches, and overload syndrome including fibromyalgia, bipolar and other related mood disorders.

As a starting point for his presentation, Dr. Humphrey asked, “Why is a family doctor speaking about headaches?”  And he answered his own question by saying that the family doctor acts as a filter for patients.  Typically health insurance companies and HMO’s require people to visit their family doctors first, before they can be referred to specialists.

Dr. Humphrey said that when the triptan medications first were introduced for treatment of migraine headaches, it was exciting.  The whole subject of migraines seemed to come out of the backrooms—people aren’t so afraid to talk about their headaches as they once were.  This allows him (he said he was both privileged and honored) to find out about his patients’ stressors and other things that might be triggering their headaches.

The migraine phenomenon is most interesting to Dr. Humphrey, and he likes to focus on this type of headache.  He added that there are whole different types of migraine syndrome.  For a diagnosis of migraine, doctors are looking for moderate to severe head pain that is throbbing or pounding, and is usually unilateral (on one side of the head).  There may also be photo and/or phono sensitivity (the patient is bothered by bright light or zigzag lines, etc., or is sensitive to loud noises).  

Dr. Humphrey’s theory of migraine is that it is generated from the brainstem and is an overloading process.  The brain processes incoming stimuli (information), and too much can bring on a headache.  Noxious stimuli (something negative or bad) could cause a headache, but in migraine actually the body could rebel against any stimuli.  He said that some people can blow a fuse clearly due to stimuli or fluctuations in stimuli.  For example, a change in hormone levels or in medications taken could bring on a migraine.

As a family doctor, Dr. Humphrey told the audience that he’s found that everyone’s body gets something when they become overloaded.  Some people have migraines, while others may have diarrhea, or asthma, or… (you name it, people have it).

For decades the theory about migraine headaches was that the body’s blood vessels went through a vasoconstriction phase (aura) and then a vasodilation phase (pain).  But now the phenomenon is thought of as a neuro-chemical storm.  The surging storm moves across the cortex, and it causes some vasoconstriction and some dilation, plus an inflammation around the blood vessels.  He said there is a spring-type mechanism that’s being loaded - a sensitization.  If a patient receives treatment for awhile, he/she can desensitize so the headaches stay away, but after stopping treatment, the headaches can come back.

Dr. Humphrey said that when the fuse goes, stimulation of the trigeminal nerve can bring pain.  He said we used to treat with antibiotics for supposed “sinus” headaches, but now doctors have found that many of those headaches were actually migraines which can be successfully treated with triptans.  He added that when a patient tells him he is experiencing facial pain, Dr. Humphrey explores the possibility of migraine.

Dr. Humphrey was asked, “What if a person develops a migraine after getting a good night’s sleep?”  And he answered that there could be other stressors that need to be discovered.  The patient could have a stiff neck, or he could be getting too much sleep which is triggering his headache.

Asking his audience for examples of noxious stimuli, Dr. Humphrey created the following list:

·        smells  ·        change in weather/change in barometric pressure/change in altitude  ·        hormones

·        too little sleep/too much sleep  ·        noises  ·        missing meals  ·        fast food/alcohol  ·        caffeine

·        stress  ·        kids  ·        MSG  ·        TMJ (temporomandibular joint disease)  ·        any kind of neck problem 

·        posture  ·        exercise/or lack of exercise  ·        virus  ·        allergies  ·        anything that irritates your face

·        tooth problem  ·        head injury 

Dr. Humphrey said that if your foot, neck, etc. hurts, they all merge into one pain.  But he added that we shouldn’t go on a witch hunt to find out every stressor that could trigger our migraines.

Some other overload syndromes are:

·        fibromyalgia  ·        insomnia  ·        bipolar experience (biorhythm):  hyperexcitation, then profoundly depressed; ·        irritable bowel syndrome   

Dr. Humphrey then turned to the topic of treatment for headaches.  He said it is important to explore, to use a method of trial and error to find what works for you.  Use abortive medicines to treat your headaches.  He then mentioned common over-the-counter medications such as Tylenol, Advil, Motrin.  He said sometimes these will work, but then not work after awhile.  One should go back and try them again another time. **Word of warning from the East Bay Headache Support Group:  it is possible to develop rebound headaches from the overuse of over-the-counter medications.  Use with caution.

Dr. Humphrey stressed that for a migraine headache you should not first take an over-the-counter medication, then a Vicodin (or other prescription painkiller), and finally as a last resort, a triptan medication.  He said you should take the triptan first.  Triptans currently available by prescription include Imitrex, Amerge, Zomig and Maxalt.

Preventive medications were then discussed.  A preventive medication is used to put insulation (like a raincoat) around the brainstem.  There are many preventive medications available that one can try.  Editor’s Note:  Sometimes you need to try many different medications before you find the one that works for you.  Don’t despair.  Dr. Humphrey said that doctors will often prescribe the same medications to treat migraine that they use for other disorders such as IBS (irritable bowel syndrome) and bipolar syndrome.

There are different classes of preventive medications.  There are neuroleptic (anti-seizure) medications, such as Depakote, Tegetrol, Dilantin, Topamax.  Dr. Humphrey said there are three rules to follow in taking these medications:

·        Start low  ·        Go slow  ·        Build it up for three months before deciding whether it is helping or not.

He added that neuroleptic medications are probably the most effective in preventing migraine headaches.  Be aware that if your health insurance plan does not cover prescription drugs, you can expect to pay $300 to $400 per month for preventive medications.  One member of the audience spoke up saying that her share of the pharmacy bill for twelve Maxalt tablets (an abortive triptan medication) per month is $186. 

Another class of preventive medications is the tricyclic antidepressants.  Some examples are Elavil, Pamelor, Nortryptilene.  These are muscle relaxants, and tend to be cheap and readily accessible.  Dr. Humphrey stated that “As you take preventives, you might find that your abortives work better.” 

An audience member then asked Dr. Humphrey about taking magnesium for the prevention of migraine headaches.  Dr. Humphrey answered that he hasn’t studied magnesium, but he knows it’s important.  Dr. Stein, medical advisor of the East Bay Headache Support Group, then added that some members of the support group take supplemental magnesium.

A third class of preventive medications is antihypertensives.  These are beta blockers and calcium channel blockers, and include Inderal, Verapamil, and Lisinopril.

Lithium is another medication used as a preventive for migraine headaches.  Dr. Humphrey added that this is a very safe medication.  He said that depression is a negative stimulus, so taking medication for depression is good.

Dr. Stein mentioned that taking anti-inflammatory medications also can help in preventing migraines.

Dr. Humphrey was asked if he has had any experience with botox injections.  He replied that he thinks interest in botox will die down soon.

Getting back to abortive medications, Dr. Humphrey mentioned the use of oxygen and lidocaine.  Inhaling pure oxygen has been found to alleviate pain for some cluster headache sufferers.  He said that one doctor ablates a nerve in his cluster headache patients with some success.

Dr. Humphrey said it is important to try to understand where your triggers are.  Be positive and explore other avenues.  Don’t give up, and try different medications.

He was then asked about acupuncture by an audience member, but Dr. Humphrey said he had no real answer to give on it.

He stressed that people should not diet.  We need to eat several meals a day—don’t skip any, as you don’t want a flux in your blood sugar level.  Dr. Humphrey said that gout sufferers don’t get their painful conditions from eating foods with high levels of uric acid, but rather when they change their diet.

An audience member commented that she got a very bad migraine while flying on a commercial plane, while another one said she discovered that when she goes to high altitudes her headaches go away.  Dr. Humphrey gave some tips to help headache sufferers reduce noxious stimuli when travelling: 

·        Be aware of poor posture (especially in your neck).  ·        Get up and walk about.  ·       Don’t try to read for long periods of time.  ·        Take a medication before the flight takes off (such as Amerge). 
·        Always keep your headache medications with you, just in case.

Dr. Humphrey was asked about detoxifying yourself using seaweeds, and he replied that it is a mystery.  But he added, “If it works for you, fine.”

Dr. Stein asked Dr. Humphrey, “What is your approach to treating menstrual migraines?”  And Dr. Humphrey responded that he will try a variety of estrogens on his patients.  Or perhaps he will have the patient take an abortive (triptan) medication as a preventive, about three to four days prior to the onset of menstruation.  Or he might try having her take daily doses of Elavil all month as a preventive.  Dr. Humphrey made the comment that PMS is real—and that it was probably valuable back in the era of the caveman, when bears were chasing humans as part of the food chain.

Dr. Humphrey said that women taking birth control pills should be aware that recently it’s been determined that you don’t have to have a menstrual cycle every month.  He suggested that you go three to four months without having a period, and then bite the bullet and have a withdrawal bleed.  This might cut down on the frequency of your menstrual migraines.  He also suggested a new product called Serafem, a PMS inhibitor which might help.

Dr. Stein asked about combining agents, as in his neurology practice he does it a lot for his headache patients.  He said some doctors don’t like the concept of “polypharmacy.”  Dr. Stein said that good blood pressure control can be obtained by combining medications.

An audience member commented that she can’t handle the side effects from many of the medications she is prescribed, and she asked if migraine patients tend to be overly sensitive to medications.  Dr. Humphrey replied, “Yes, and my bipolar patients also seem to be overly sensitive.”  He emphasized that it is important to start with a really low dose of each new medication and then build up.

Dr. Humphrey said that when we treat depression with medication we get good results, and we also get good results in treating depression with psychotherapy.  But the best results are when both treatment options are used.

He made a personal observation about himself:  “I get to feeling supercharged on a busy day.  Then I practice biofeedback on myself to ratchet down.”

Another audience member asked Dr. Humphrey about the effect of posture on migraine.  She said that she tried massage therapy and found that certain muscles triggered her headaches.  And her therapist told her that she holds her head too far forward.  Dr. Humphrey commented that parents used to make certain their kids had good posture, but not anymore.

Dr. Humphrey said that the concept of referred pain is fascinating.  Physical therapy can do a lot using ultrasound and massage, and he noted that the physical therapist can get down to the joint level.

One person made the statement that “Whenever I have a strong headache I think maybe I have a tumor.”  Dr. Humphrey said that one could have a scan every five to ten years to make certain there are no tumors, and he said neurologists should look into their patients’ eyes during exams.

Foot reflexology was mentioned by an audience member, and Dr. Humphrey responded that he’s not an expert on reflexology, but he knows there is a referral in the brain.  One should explore it.

What about trigger massage?  Dr. Humphrey said this is a band-aid—it helps a little bit to massage trigger points.

He mentioned that for his patients diagnosed with fibromyalgia, he uses neurochemical support (a reuptake inhibitor).

Dr. Stein commented that in his practice he sees a lot of rebound headaches.  Dr. Humphrey said he doesn’t see a lot of this type of headache, and he added that he doesn’t prescribe many medications that cause it.  In his experience, he thinks the biggest culprit is caffeine intake.  He suggested that people try going off caffeine for a month—like Lent.  Dr. Stein said that Excedrin contains a large amount of caffeine, and that some of his patients will take 400 to 500 mg of caffeine per day (Excedrin and coffee).  Dr. Stein encourages them to “Let me treat your headaches for awhile” (without caffeine).

Dr. Humphrey was asked what he tells his postmenopausal women about hormone replacement therapy, and he answered that it’s good to be on a stable regimen of hormones.  He said that bipolarity is much more common in menopause.  He suggested that Premarin is not such a good choice for estrogen therapy. 

One of the women in the audience said that her first hormone replacement therapy was Premarin, but then she switched to estradiol, a natural estrogen, and now she uses the Climara patch.  And she’s noticed that her menstrual headaches have improved significantly with the patch, perhaps because it keeps her estrogen level on an even keel.

In finishing up his presentation, Dr. Humphrey commented that humans were meant to live only thirty to forty years, and then cash it in.  Now we’re artificially living longer, and also living in an artificial environment (it used to be a calm environment down on the farm, but now we live in cities with high stress levels).  He said we should not feel like failures because we are using medications.  It is OK to use medications to improve the quality of our lives.

One final question Dr. Humphrey answered for the group was:  “How do we lower our baseline (stimuli)?”  He said that sleep is the best mood stabilizer, and added that everyone nowadays is sleep deprived.  We are supposed to go to sleep when the sun goes down and wake up when it comes up, but instead we use artificial light and stay up long hours.  He also said that exercise is the best antidepressant.  And having frequent profound life experiences grounds you.  Set short term, medium term, and long term goals for yourself.

Discover your spiritual nature.  A long term goal might be to meditate.  Dr. Humphrey mentioned that he just helped his grandfather to die peacefully at home last week, and he said it was a very sobering, grounding experience for him.  Dr. Humphrey also mentioned psychotherapy.  He said there are three basic personality types, and it might help you to discover your type and how you respond to anxiety, and also to discover your love language.

This concluded Dr. Humphrey’s presentation.

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.