SEPTEMBER 2005 MEETING NOTES
TOPIC: “TALK IT OVER NIGHT”
The September 13, 2005 meeting of the East Bay Headache Support Group featured
Michael Stein, MD, who answered questions in a “Talk It Over Night” format for the ten
in attendance. Dr. Stein is the co-founded the group and serves as its medical advisor.
Dr. Stein started off the discussion by talking about Butterbur. He mentioned a new product called Migravent, “a non-prescription dietary supplement whose active ingredients have been proven to reduce the frequency and intensity of migraine attacks,” according to www.migravent.com. Migravent includes Butterbur Extract (Petadolex), Riboflavin, Magnesium and Feverfew extract.
Dr. Stein noted that the butterbur root has some substance in it that could be bad for you if not removed first. Asked if this stuff was safe, Dr. Stein answered that magnesium and riboflavin are safe and probably feverfew is safe also.
One participant asked Dr. Stein about taking selenium for prevention of migraine. She heard about it on the radio, but Dr. Stein didn’t know about it. He doesn’t think selenium is an element that is naturally in the body.
Another person said he took feverfew and it absolutely worked…it gave him a headache. Dr. Stein said he’s never heard how feverfew was discovered as a preventive for headaches. When he was in Spain last spring he visited a farmer’s market and noticed lots of herbs for sale, with some for headache prevention. He stated that in Europe, homeopathy and herbs and supplements are more the norm than in the United States.
Dr. Stein asked the audience: What’s the first thing patients ask him when he says he will prescribe a medication? The answer: “What are the side effects?” But he said that people don’t ask about side effects of herbs and supplements.
One participant commented that the warning brochure for every prescription he’s gotten has included the statement: may cause headaches. Dr. Stein stated that for the last four years or so he has been conducting research studies on headache medications. All participants (including the people receiving a placebo) are asked what side effects they are experiencing. Headache is a common side effect reported, but he stated that it could be a very small percentage. He said this is also a comment on the medical/legal atmosphere: “Prescription bottles have to have all sorts of warnings on them.”
Dr. Stein said we have to look at the therapeutic gain: If 30% get relief with the medication, then that’s a 50% gain.
The ghost in the machine—the placebo effect. What is it? Hope, mind over matter? Up to about 100 years ago, most medications were placebos. Dr. Stein said that what helped the patients was just that the doctors were giving them something.
Excedrin Migraine versus regular Excedrin: what’s the difference? Dr. Stein asked the participants if they took it. He said that some people have said that Excedrin Migraine works on their migraines, but that regular Excedrin does not. Dr. Stein then told the group that the only difference between the two products is the name—they both have the same ingredients!
One participant said that she was fascinated with the article on red-tinted lenses in the group’s latest newsletter (September 2005). She sent it on to her ophthalmologist to get his reaction. Dr. Stein said he attends American Headache Society meetings frequently, but has never heard of red-tinted contact lenses being used for migraineurs.
Dr. Stein stated, “There is not a medication on the market that started out as a headache medication. They were developed for something else, such as hypertension, epilepsy, psychological problems, wrinkles, etc., and patients discovered that their headaches improved while taking them.”
A participant stated that psychotherapy has helped her with reducing her migraines—it reduced her stress level.
Another participant described her headache symptoms to Dr. Stein and asked for advice. She has had headaches for 40 years, always one-sided, and for the past 15 years she’s been experiencing a tingling sensation all down her left side. She didn’t describe it as numbness, more a tingling sensation. She said she has a chronic daily headache (CDH), but it’s more intense when she has a really bad headache. She has low blood pressure all the time. She stated that she’s already had 3 MRIs. She has vertigo, and also has been falling down, with no warning—but doesn’t black out. Dr. Stein said she needs to be evaluated—he recommended that she get a work-up by a neurologist.
Dr. Stein said that one in five people experiences an aura (warning) with migraine. He said auras typically last about 30 minutes, and if longer it’s called a prolonged aura. Some auras are sensory (not motor) as opposed to visual. Vertigo can also be a migraine aura. The aura usually ceases once the headache starts, but for some people the aura lasts.
Dr. Stein said that chronic daily headache (CDH) in a person with history of migraine is now called a migraine, and not necessarily a rebound headache.
Vertebral basilar migraine is a condition that Dr. Stein has rarely seen in all his years of treating headache patients. He said the vertebral basilar artery supplies your brain stem. The patient gets dizzy, goes blind, passes out, and then the headache starts. Dr. Stein suggested that the participant who described her vertigo and falling down could possibly be experiencing vertebral basilar migraine. He said the fine print for Imitrex and other triptans state that they are not to be used for people with vertebral basilar migraine.
Dr. Stein talked to the group about the triptans, which have made a positive difference in many migraineurs’ lives. Following in italics is some information found on the About.Com Web site (http://headaches.about.com/cs/druginfo/a/triptan_over.htm) regarding the triptans:
Following is a list of the triptans to date along with when they were approved in the United States by the FDA. Some of them were available in European countries before they became available in the U.S.
The more technical name for this class of medications is selective serotonin receptor agonists. Triptans are not pain medications as we traditionally think of them. Traditional pain medications don’t end the pain, they simply increase our tolerance to it─temporarily. Unless the migraine attack has run its course while a pain medication is working, the symptoms will return when the pain medication wears off. Triptans are termed abortive migraine medications. They cannot prevent migraines. They are used to abort a migraine attack, to stop the attack itself and the associated symptoms. Drugs in this class need to be taken early in the migraine attack to be most effective. In addition to migraine attacks, triptans are also sometimes helpful for cluster headaches.
Although these drugs belong to the same class and have many of the same characteristics, it is worth note that they also have differences. If one of these drugs does not work adequately for a person, it is well worthwhile to try other triptans before abandoning them altogether. Because they are selective serotonin receptor agonists, they work on different serotonin receptors, and thus may produce different results and effects.
Triptans should only be prescribed after a thorough examination to rule out contraindications. Those contraindications include:
 | uncontrolled hypertension |
| family history of coronary artery disease or heart attacks |
| history of stroke |
| risk factors for coronary artery disease |
| uncontrolled diabetes |
| high cholesterol levels |
Have triptans been associated with strokes? Dr. Stein answered, “Not in my experience.” After taking a triptan many people report experience tightness in their chests. Dr. Stein said that this has been figured out to be a spasm of the esophagus, and not heart-related. Triptans cause very minimal coronary artery constriction.
Dr. Stein stated a European study was done where lots of people with migraine received MRI scans and they saw unusual spots.
Migraine is associated with stroke, however. There is a slight risk of stroke if you are a migraineur, but the risk increases if you experience auras, and taking birth control pills and smoking further increase that risk.
One participant said that he has a relative who experienced vertigo, loss of balance and fell frequently, and was diagnosed with hydrocephalus. He added that he didn’t have any head pain though.
Dr. Stein stated, “Migraine is a brain-generated phenomenon.” It’s a brain problem and the pain can be felt in many different places, like the sinuses, TMJ, neck, eye, etc. That is why migraine patients go to allergists, dentists, orthopedists looking for help. It is referred pain.
A participant asked Dr. Stein is he’s ever prescribed Clonazapan, an anti-anxiety medication. Dr. Stein said it is a derivative of valium.
Migraine is co-morbid with many other conditions, according to Dr. Stein. Co-morbid means that two disease entities are seen together more often than just chance. So…if someone has depression, their chance of having migraine also is very high.
Dr. Stein has made an interesting observation from his years of treating headache patients: When taking new patients’ family histories of migraine patterns, he has noted that maybe the patients’ relatives didn’t suffer from migraines, but many had psychological problems such as anxiety, depression, panic attacks, alcoholism, etc.
Anxiety, depression, eating disorders, endometriosis or other menstrual irregularities, irritable bowel syndrome, interstitial cystitis are called “bio-behavioral disorders,” according to Dr. Stein. He added that fibromyalgia is considered migraine of the body, and he thinks there’s a real inter-relationship. “It could be down to the cellular level—there is something going on,” he said. He also made the statement that some MS (multiple sclerosis) patients get a migraine every time they take an immune-altering drug. Dr. Stein commented, “Migraine may be an immunological problem.”
Dr. Robin Young, a neurologist in Alameda, thinks that lupus causes migraine. If so, Dr. Stein said that a lot of people with migraine have undiagnosed lupus.
Does hypertension cause migraines? Dr. Stein answered, “No. Hypertension is a secondary cause of headaches. The headaches feel different—they are diffuse and not usually severe.”
Dr. Stein stated that migraines tend to peak in the 30’s, during the productive years of life, whereas hypertension and diabetes tend to occur later in life, when people are retired.
How do we measure migraine? Dr. Stein said that migraine is measured by asking the patient how it disables him/her. A MIDAS (Migraine Disability Assessment Questionnaire) score is given based on the answers. This is because we can’t scan the brain or look at someone to tell if he has a migraine.
One participant said she doesn’t work because of her headaches. Another commented that his doctor told him his migraines would go away.
Rebound headaches were discussed. Dr. Stein stated that the rule of thumb to keep out of a rebound situation is: Take no more than 2 doses of medication per week. But Dr. Stein said he preferred that his patients don’t take more than 1 dose per week.
Dr. Stein said there is some good news: The Allergen Company has selected him to do a site study of Botox for migraine. Subjects would receive Botox for free. He is looking for people with mild or moderate chronic daily headache (CDH), plus 2 migraines per week, but not severe migraines daily.
A participant commented that he ate a frozen juice bar recently and had an immediate severe headache which only lasted a very short time. Others participants suggested that perhaps it was an “ice cream headache.”
Then Dr. Stein was asked if he is a migraineur. He answered, “No, but I have had some auras, so maybe…”
The statement was made that sleep can help some migraines. Also, several participants agreed that vomiting seems to help their headaches. Some even make themselves vomit in an attempt to make the pain go away.
Though the group was small at this meeting, Dr. Stein led us in an informative discussion.
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.