Pharmacological Interventions
(Drug Treatment) for Headache

There are two approaches to drug treatment for headache. One is to treat the acute episodes of headache with a medication which will relieve the head pain and associated symptoms like nausea, vomiting, difficulty with bright light, difficulty with noise and improve the disability caused by a headache attack. These medications are referred to as abortive headache agents. Secondly, preventive medications, which are taken daily, help to reduce the frequency and severity of headache.

Abortive Agents

There are specific and non-specific medications used as abortive agents. Specific medications are medications which are useful only for a primary headache condition like migraine and cluster headache. Whereas, non-specific medications are general pain medications, which are used also for other pain conditions, such as, pain from fracture of the arm and pain from surgery.

There are two specific medications used for headache therapy to abort an attack of migraine - triptans and ergot compounds (ergotamine and DHE).

Triptans

The triptans are highly effective, specifically developed migraine medications useful for acute episodes of migraine as well as acute attacks of cluster headache. There are many triptans available including Imitrex, Zomig, Amerge, Maxalt, Axert and soon Relpax and Frovaelan. We use these medications depending on the type of headache the patients have and the type of attacks they suffer from. Triptans are available in tablet form, melt tablet form, nose spray and injections. Triptans are generally not used in patients with known coronary artery disease or very high uncontrolled blood pressure.

Triptans are very safe medications and help patients a lot if they are taken early enough. Therefore, we ask patients to take triptans at the very onset of the headache and to keep the tablets with them wherever they are.

Ergotamine

Apart from triptans, other useful acute medications are medications containing ergotamine (Cafergot, Ercaf, etc.) and DHR. These medications can be combined with arthritis medicines like naproxen sodium or ibuprofen. Combinations of triptans or ergotamine with naproxen sodium or ibuprofen are very useful.

Non-specific Medications

We do not generally encourage the use of pain medication. These include narcotic pain medications like codeine (Hydrocodone, Tylenol #3, Vicodin ES, etc). We also tend to stay away from other narcotic pain medicines like propoxyphene (Darvocet, Darvon, Stadol, etc). We do not use Demerol. Occasionally in very specific cases, we may use long-acting morphine-like medication under close monitoring. In general, the Houston Headache Clinic does not believe in using narcotics or any habit-forming pain medications for acute attacks of headaches, particularly on an ongoing basis.

Combination pain medications such as Fiorinal, Fioricet, Esgic, Phrenilin, etc, which contain caffeine as well as butalbital, a sedative barbiturate, are also not used at the clinic, because they very often create what is known as analgesic rebound. Rebound headaches are common in people with migraine and primary headache disorders. Those who take the medications listed above may end up with daily or near daily headache, which becomes very resistant to treatment. This condition is referred to as rebound headache. Fiorinal, Fioricet, Esgic, etc are common causes of rebound headache. Similarly, medications which contain caffeine (particularly Excedrin Migraine, which contains 65 mg of caffeine), are also known to cause rebound headache. Therefore, we discourage patients from taking those medications, whether it is prescription or nonprescription, because they interfere with the total control of the headaches.

Preventative Medications

The second approach to treatment of recurrent headache is to use medications to prevent headache from beginning. There are a number of medications of various classes that are useful. These include

	Beta-blockers like propranolol (Inderal), nadolol (Corgard), timolol (Blocadren);
	Calcium channel blockers like verapamil;
	Antiepileptic drugs like Depakote, Neurontin, topiramate (Topamax), zonisamide (Zonagram), Keppra, Lamictal, etc. The antiseizure medications are useful because they reduce the hyperexcitability of the brain. We use these medications starting with smaller doses, gradually increasing it over a period of a few weeks and staying on it for at least two months, before the medications are pronounced effective or not effective.
	Antiserotonin agents are used including methysergide (Sansert), methylergonovine (Methergine).
	Tricyclic antidepressants like amitripyline, nortriptyline, protriptyline are widely used also. They are more effective in patients with frequent headaches, those with difficulty sleeping, and those with associated depression.
	Vitamin B2 and magnesium are also used at our clinic on a long-term basis for certain types of migraines.
	The SSRIs like Prozac, Zoloft, Paxil, Celexa, etc are also used as adjuncts in the treatment of headache. By themselves, they have not been shown to have any definite effect on migraine headache, but when migraine patients have associated depression, those medications may help.
	Miscellaneous drugs, which include atypical antipsychotics like Zyprexa, Geodone and also other agents like lithium carbonates, are used in related cases.

In summary, there are a number of choices for acute treatment of migraine headaches as well as preventive headaches. The preventive treatment has to be taken on a daily basis. The acute treatment should be taken only when the patient has a headache which needs acute relief.

Again, the philosophy of the Houston Headache Clinic is to avoid using narcotic pain medicines and medicines which contain caffeine and butalbital, because all of them cause rebound headache, making the headache more chronic, persistent, intractable, and difficult to treat.

Breaking the Cycle of Headache

Patients who have daily (or near daily) headache or continuous prolonged migraine need special treatment to break the cycle of headaches. There are a number of intravenous medications used for that. These intravenous medications include:

• DHE plus Regian intravenous every six hours for five or six days depending on the severity of the condition,
• Intravenous Depacon given every eight to ten hours for three or four days,
• Intravenous magnesium sulphate,
• Intravenous Decadron.

These are given in the hospital, while the patient is being detoxified from pain medications. The hospital stay therefore would include detoxification and intravenous medications to break the cycle of headache and initiation of the preventive treatment program.