Integrative Therapies
Good scientific evidence:
5-hydroxytryptophan (5-HTP): Supplement use of 5-HTP may help balance serotonin in the body. Serotonin is the brain chemical associated with sleep, mood, movement, eating and nervousness. There is evidence from several studies in both children and adults that 5-HTP may be effective in reducing the severity and frequency of headaches, including tension headaches and migraines. Fewer pain-relieving medications may be needed when taken with 5-HTP; however, many of the available studies show that more proven pharmaceutical drugs may work better than 5-HTP for headaches. Further research is needed. 5-HTP is generally safe when used in recommended dosages. Use with caution if taking antidepressant medications.
Butterbur: Butterbur (Petasites hybridus) is a perennial shrub, found throughout Europe as well as parts of Asia and North America. Pain relief and headache prevention are traditional uses of butterbur. Recent pre-clinical studies suggest anti-inflammatory and vasodilitary (blood vessel opening) properties of butterbur, thereby supporting a possible mechanism of action. A small number of human trials report efficacy of butterbur for migraine prevention when taken regularly for up to four months. This evidence is compelling enough to suggest benefits of butterbur for migraine prevention, although additional evidence from larger, well-designed studies is necessary. The use of butterbur during pregnancy and lactation should be avoided due to a lack of safety studies. Butterbur should not be used if there is an allergy to plants in the Aster family, including ragweed, marigolds, daisies, and chrysanthemums.
Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. Manipulation is the skilled, gentle, passive movement of a joint (or spinal segment) either within or beyond its active range of motion. The use of spinal manipulative therapy for the relief of tension or migraine headache has been reported in several controlled human trials and systematic reviews. Overall, the quality of studies is not high, with incomplete reporting of design, inconsistent use of techniques between studies, and variable results. Despite these methodologic problems, overall the evidence suggests some benefits in the prevention of episodic tension headache. Effects on migraine headache have not been demonstrated. Better quality research is necessary in this area before a firm conclusion can be drawn.
Feverfew: Feverfew (Tanacetum parthenium) leaves have long been used orally for the treatment or prevention of headache, and there is a scientific basis for this use. Pre-clinical studies have reported anti-inflammatory and blood vessel dilation (opening) effects. Several controlled human trials have been conducted in this area with mixed results. Overall, these studies suggest that feverfew taken daily as standardized capsules may reduce the incidence of attacks in patients who experience chronic migraine headaches. Feverfew may cause an increase in bleeding and drug interactions. Do not use feverfew if pregnant or nursing, or if allergic to plants in the aster family, including ragweed, marigolds, daisies, and chrysanthemums.
Guided imagery: The term "guided imagery" may be used to refer to a number of techniques, including metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Therapeutic guided imagery may be used by therapists to help patients relax and focus on images associated with personal issues they are confronting. Initial research suggests that guided imagery may provide added benefits when used at the same time as standard medical care for migraine or tension headache.
Hypnotherapy: Hypnotherapy involves the power of suggestion while the individual is in a deep, relaxed state. Several studies report improvements in severity and frequency of tension headaches following several weekly hypnosis sessions. Early research suggests that hypnosis may be equivalent to other relaxation techniques, biofeedback, or autogenic training.
Unclear or conflicting scientific evidence:
Acupressure: Acupressure, or shiatsu, has been used in China and Japan for thousands of years for health and healing. Self-administered acupressure (in the temple region or others) is reported to help tension or migraine headaches in early studies.
Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. Although traditionally used to help patients with migraine headaches, there is inconclusive evidence in support of acupuncture for chronic migraine or tension headache. Although the majority of available studies have shown a trend in favor of acupuncture over placebo, most have been small and methodologically flawed. Blinding and follow-up have not been adequate in most studies, and approaches to placebo-control are variable. Larger trials with clear blinding and controls are necessary before a recommendation can be made for or against acupuncture for this indication.
L-arginine: L-arginine, or arginine, is a semi-essential amino acid needed by the body. Arginine is a precursor of nitric oxide, which causes blood vessel relaxation (vasodilation). Preliminary studies suggest that adding arginine to ibuprofen (Advil®, Motrin®) therapy may decrease migraine headache pain. Arginine is generally regarded as safe in recommended dosages.
Coenzyme Q10 (CoQ10): Coenzyme Q10 (CoQ10) is produced by the human body and is necessary for the basic functioning of cells. There is promising good evidence from one randomized and controlled trial and one open label trial to support the use of CoQ10 treatment in migraine prevention or treatment. Properly designed, larger trials of longer treatment duration are needed to confirm these findings. CoQ10 is generally regarded as safe in recommended dosages.
Gamma linolenic acid (GLA): GLA is a dietary omega-6 fatty acid found in many plant oil extracts. One open-label, uncontrolled study has examined the effect of fatty acids, including GLA, on severity, frequency and duration of migraine attacks. Better-designed clinical trials are required before recommendations can be made. Eighty-six percent of patients experienced a reduction in the severity, frequency, and duration of migraine attacks, while 90% of patients had reduced nausea and vomiting. GLA use may increase the chances of bleeding.
Melatonin: Melatonin is a natural hormone that is used for the improvement of sleep patterns. Several small studies have examined the possible role of melatonin in preventing various forms of headache, including migraine, cluster, and tension-type headache (in people who suffer from regular headaches). Limited initial research suggests possible benefits in all three types of headache, although well-designed controlled studies are needed before a firm conclusion can be drawn. Melatonin should not be used for extended periods of time. Caution is advised when taking melatonin supplements as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise directed by a doctor.
Progressive muscle relaxation: Progressive muscle relaxation involves isolating one muscle group, creating tension for eight to ten seconds, and then letting the muscle relax and the tension go. Individuals can sit (in a comfortable chair), lie on a bed, or lie on the floor (on a comfortable rug or carpet). Muscle groups (including the head, shoulders, arms, hands, stomach, legs, and feet), one at a time, are tensed, then relaxed. This technique has been reported effective in headache prevention, but more studies are needed.
Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. Early research suggests that reflexology may relieve pain from migraine or tension headaches, and that pain medication requirements may be reduced. However, study in this area has not been well designed or reported scientifically, and further evidence is necessary before a firm conclusion can be reached.
Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Preliminary evidence suggests that relaxation techniques may be helpful for the reduction of migraine headache symptoms in adults. Study of relaxation in children with headaches has yielded unclear results. Additional research is necessary before a firm conclusion can be drawn.
Riboflavin (vitamin B2): Several studies suggest benefits of high-dose riboflavin in preventing migraine headaches. Further research is necessary before a firm conclusion can be drawn.
Soy: Soy (Glycine max) is a plant in the pea family (Fabaceae), and is native to southeastern Asia. Soy has been a dietary staple in Asian countries for at least 5,000 years. Soy supplements have been reported to help with symptoms associated with menopause, including headache. One study of a phytoestrogen (plant estrogen) combination showed a reduced number of migraine attacks suffered. Further research is needed. Use of soy supplements may cause drug interactions. Soy should not be used if the patient is pregnant or breastfeeding, unless otherwise directed by a doctor. Until better research is available, it remains unclear if dietary soy or soy isoflavone supplements increase or decrease the risk of developing breast cancer.
Transcutaneous electrical nerve stimulation (TENS): TENS is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Acupuncturists can use TENS by sticking Japanese acupuncture needles into two sites and taping the needles down with surgical tape to prevent them from moving. Practitioners then hook the needles up to a TENS device and an electrical current is applied. The current now travels into the needles, which stimulates points on the body to get the "chi" or energy to flow in a healthy manner. Preliminary controlled trials suggest that TENS may have some benefits in patients with migraine or chronic headache. Additional well-designed research is necessary before a firm conclusion can be reached in this area.
Therapeutic touch (TT): Therapeutic touch practitioners hold their hands a short distance from the patient without actually making physical contact. The purpose of this technique is to detect the patient's energy field, allowing the TT practitioner to correct any perceived imbalances. Therapeutic touch may reduce pain in patients with tension headache, based on preliminary research.
Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Preliminary evidence suggests that yoga may effectively reduce the intensity and frequency of tension or migraine headaches, and lessen the need for pain-relief medications.
Prevention
Keeping a diary: A diary can help an individual determine what triggers the migraine attack. Writing down when a migraine attack begins, how long each phase lasts, responses to medications, foods eaten in the 24 hours preceding an attack, any unusual stresses before the attack, and how the individual feels and what they were doing when a migraine attack begins is important.
Dietary factors: Identifying and avoiding foods that consistently trigger headaches may be important in helping to reduce the occurrence of migraine headaches. Eat meals at regular times daily and do not skip meals.
Stress reduction: Integrative therapies that reduce stress, such as yoga, therapeutic touch, and relaxation techniques, are important in reducing migraine attacks.
Regular sleep patterns: It is important for migraine sufferers to get adequate consistent sleep every night. Healthcare professionals generally recommend eight hours of uninterrupted sleep nightly.
Regular exercise: Regular aerobic exercise reduces tension and can help prevent migraines. If a doctor agrees, choosing an aerobic exercise, such as walking, swimming, or cycling, may help decrease migraine attacks. Warm up slowly, however, because sudden, intense exercise can cause headaches.
Caffeine intake reduction: Limiting caffeine consumption to less than two caffeine-containing beverages a day may be of benefit for reduction of migraine attacks.
Light modification: Avoiding bright or flashing lights, and wearing sunglasses, if sunlight is a trigger, may help reduce migraine attacks.
Smoking cessation: Smoking cessation is important in decreasing migraine attacks, as smoke can be a potential allergen that triggers a migraine. Also, nicotine, one of the components of tobacco, stimulates vascular activity in the brain that may trigger a migraine attack.
Saturday, January 24, 2009
headache- preventive medicatin
Preventative medication may be prescribed for patients who have frequent migraine attacks (three or more a month), those who do not respond consistently to acute treatment, and when specific medicines are contraindicated because of other medical conditions (such as stroke or bleeding in the brain). Studies have reported that as many as 40% of these patients may benefit from preventative treatment. The U.S. Food and Drug Administration (FDA) has approved four prescription drugs for migraine prevention. These include the beta-blockers propranolol (Inderal®) and timolol (Blocadren®), and the anticonvulsants topiramate (Topamax®) and divalproex sodium (Depakote®).
Anticonvulsants: Anticonvulsant medicines, normally used for seizures, have been used to prevent migraine headaches. Examples of anticonvulsants that have been used are valproic acid (Depakote®, Depakote ER®, Depakene®), phenobarbital, gabapentin (Neurontin®), and topiramate (Topamax®). Control of the cortical spreading depression (CSD), is thought to be the reason for anticonvulsant effectiveness in preventing migraine attacks. Side effects include fatigue (tiredness), nausea, vomiting, and trembling.
Beta-blockers: Beta-blockers are a class of drugs that safely slow the heart beat and decrease blood pressure. Beta-blockers have been used for many years to prevent migraine headaches. In migraine prevention, beta-blockers help dilate (open) blood vessels in the brain, which may prevent the vascular (blood vessel) symptoms associated with a migraine attack, including vasoconstriction (blood vessel narrowing) and vasodilation (blood vessel widening). Beta-blockers can also help reduce physical symptoms associated with migraine attacks, such as anxiety, heart palpitations, and shaking,
Beta-blockers used in migraine prevention include propranolol (Inderal®), atenolol (Tenormin®), metoprolol (Lopressor®, Toprol XL®), and nadolol (Corgard®). Beta-blockers generally are well tolerated in most individuals. They can aggravate breathing difficulties in patients with asthma, chronic bronchitis (inflammation of the bronchial tubes), or emphysema (loss of lung function). In patients who already have slow heart rates (bradycardia) and heart block (defects in electrical conduction within the heart), beta-blockers can cause dangerously slow heartbeats. Beta-blockers can aggravate symptoms of heart failure. Other side effects include drowsiness, diarrhea, constipation, fatigue (tiredness), insomnia, nausea, depression, dreaming, memory loss, and impotence (loss of sexual performance).
Calcium channel blockers (CCBs): CCBs are a class of drugs normally used for high blood pressure, angina (chest pain), and arrhythmias (abnormal heart rhythms). CCBs also appear to alter serotonin (a brain chemical). Serotonin imbalances are a causative factor in developing a migraine. CCBs used in preventing migraine headaches are diltiazem (Cardizem®, Dilacor®, Tiazac®), and verapamil (Calan®, Verelan®, Isoptin®).The most common side effects of CCBs are constipation, nausea, headache, rash, edema (swelling of the legs with fluid), low blood pressure, drowsiness, and dizziness. Drinking grapefruit juice or eating grapefruit may cause levels of CCBs to rise, potentially leading to life threatening arrhythmias (irregular heart beats). Healthcare professionals recommend that individuals taking CCBs not consume grapefruit juice.
Hormone replacement therapy (HRT): For women with hormonal imbalances that may be causing the migraines, hormone replacement therapy (HRT) may be used, including estrogen and progesterone. HRT, however, may cause side effects such as blood clots, an increased risk of developing some types of cancers, and heart disease. Menstruating women at risk for migraines may be placed on oral contraceptives for HRT. Pre-pubescent girls that are at risk for migraine attacks will not be treated with HRT, but with other methods such as beta-blockers and anticonvulsants.
Lifestyle: Lifestyle changes, including decreasing stress levels, increasing exercise levels, and controlling the diet, have a major impact on migraine prevention and development. Lifestyle factors that are important in the prevention of migraines include regular sleep patterns, regular exercise (level depends upon the individual), limiting stress, limiting caffeine consumption to less than two caffeine-containing beverages a day, avoiding bright or flashing lights, and wearing sunglasses if sunlight is a trigger. Identifying and avoiding foods that trigger headaches is important. Healthcare professionals recommend keeping a food journal, where the individual writes down everything they have for each meal of the day. Then review the diary with a healthcare professional. It is impractical to adopt a diet that avoids all known migraine triggers; however, it is reasonable to avoid foods that consistently trigger migraine headaches. Triggers vary from one individual to another.
Tricyclic antidepressants (TCAs): TCAs are thought to prevent migraine headaches by altering the balance of serotonin, a neurotransmitter in the brain. Low levels of serotonin are thought to be a causative agent in migraine attacks. Chronic stress and depression can cause elevated levels of the stress hormone cortisol, which is produced in the adrenal glands. Cortisol can in turn cause imbalances in serotonin, leading to a migraine attack. The tricyclic antidepressants that have been used in preventing migraine headaches include amitriptyline (Elavil®), nortriptyline (Pamelor®, Aventyl®), doxepin (Sinequan®), and imipramine (Tofranil®). Side effects include constipation, dry mouth, low blood pressure (hypotension), increased heart rate, (tachycardia), urinary retention, sexual dysfunction, and weight gain. TCAs may cause excessive sedation and fatigue (tiredness).
Others: Other drugs less commonly used for migraine prevention include anti-serotonin medications, including methysergide (Sansert®), which prevent migraine headaches by constricting (making smaller) blood vessels and reducing inflammation of the blood vessels. Cyproheptadine (Periactin®) is an antihistamine that increases serotonin activity and is used occasionally in migraine prevention. Low levels of serotonin are a cause of migraine attacks.
Acute (Immediate):
Over-the-counter (OTC) treatments: The U.S. Food and Drug Administration (FDA) has approved three over-the-counter (OTC) products to treat migraine attacks. Excedrin® Migraine (a combination of aspirin, acetaminophen, and caffeine) is indicated for migraine and its associated symptoms such as head pain. Advil® Migraine and Motrin® Migraine Pain (both are ibuprofen) have anti-inflammatory action and are approved to treat migraine headache and its pain.
Triptans: The triptans attach to serotonin receptors on the blood vessels and nerves and thereby reduce inflammation and constrict (narrow) the blood vessels. A reduction in inflammation decreases pressure on nerves in the trigeminal nerve system (nerves in the cranium or head), which decreases the pain signals to the brain and stops the headache. Traditionally, triptans, which are prescription medicines, were prescribed for moderate or severe migraines after over-the-counter (OTC) analgesics such as ibuprofen (Advil®) and other simple measures failed. Newer studies suggest that triptans can be used as the first treatment for patients with migraines that are causing disability. Significant disability is defined as more than ten days of at least 50% disability during a three month period.
Triptans should be used early after the migraine begins, before the onset of pain or when the pain is mild. Using a triptan early in an attack increases its effectiveness, reduces side effects, and decreases the chance of recurrence of another headache during the following 24 hours. Used early, triptans can be expected to abort more than 80% of migraine headaches within two hours. Triptans include sumatriptan (Imitrex®), almotriptan (Axert®), naratriptan (Amerge®), rizatriptan (Maxalt®), zolmitriptan (Zomig®), frovatriptan (Frova®), and eletriptan (Relpax®).
The most common side effects of triptans are facial flushing, tingling of the skin, and a sense of tightness around the chest and throat. Other less common side effects include drowsiness, fatigue (tiredness), and dizziness. These side effects are short-lived and are not considered serious. Triptans are not used in pregnant women and are not generally used in young children.
In patients with severe nausea, a combination of a triptan and an anti-nausea medication, such as prochlorperazine (Compazine®), may be used.
Ergots: Ergots, like triptans, are medications that abort migraine headaches. Examples of ergots include ergotamine preparations (Cafergot®) and dihydroergotamine preparations (Migranal®, DHE-45®). Ergots, like triptans, cause constriction (narrowing) of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and the produce more negative effects on the heart than the triptans. Therefore, the ergots are not as safe as the triptans. Ergots are used to help stop the vasodilation (blood vessel widening) associated with a migraine attack. The ergots also are more prone to cause nausea and vomiting than the triptans. The ergots can cause prolonged contraction of the uterus and miscarriages in pregnant women.
Midrin: Midrin is used to abort migraine and tension headaches. It is a combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild sedative). The combination medication can help take care of three potential factors associated with a migraine attack, including vasodilation, pain, and anxiety. Midrin® is most effective if used early during a headache. However, because of its potent blood vessel constricting effect, it should not be used in patients with high blood pressure, kidney disease, glaucoma (increased pressure in the eyes), atherosclerosis (hardening of the arteries), liver disease, or in patients taking monoamine oxidase inhibitors (MAOIs) including phenelzine (Nardil®), isocarboxazid (Marplan®), and tranylcypromine sulfate (Parnate®).
Other prescription medications: Some attacks may not be eliminated by acute therapy, and the individual requires pain-relieving measures. Due to the severity of the headaches, some patients may require a narcotic analgesic, including oxycodone (Percocet®), codeine, or meperidine (Demerol®). If the individual is experiencing frequent migraine attacks, the habitual use of opiate analgesics should be avoided. Opiates can cause addiction (both physical and mental) and may also cause rebound headaches, which are headaches that occur when the pain medicine no longer provides relief.
Butorphanol (Stadol NS®) is an opiate-like drug available for injection and intranasal (in the nose) administration. The normal dosage of Stadol NS® is one spray into the nostril, which usually relieves migraine symptoms in 15-30 minutes. This drug can be used every hour for relief. The use of Stadol NS® may result in dependency if used regularly for pain relief. Side effects include nausea and vomiting, nasal irritation, and sedation.
Butalbital, a barbiturate medication, is also used for the immediate relief of migraine headache pain. It is used in various prescription combinations with aspirin, acetaminophen, caffeine, or codeine (an opiate pain medication). These medications are potentially addicting and are not used as initial treatment. They are sometimes used for patients whose headaches fail to respond to over-the-counter (OTC) medications but who are not candidates for triptans either due to pregnancy or the risk of heart attack and stroke. Products include butalbital and acetaminophen (Axocet®, Bupap®, Cephadyn®, Phrenilin®, or Sedapap®); butalbital, acetaminophen, and caffeine (Fioricet®, Esgic®); butalbital and aspirin (Axotal®); butalbital, aspirin, and caffeine (Fiorinal®); butalbital, acetaminophen, caffeine, and codeine (Fioricet #3 with Codeine® or Fioricet w/ Codeine®); and butalbital, aspirin, caffeine, and codeine (Fiorinal #3 with Codeine® or Fiorinal w/ Codeine®).
Anticonvulsants: Anticonvulsant medicines, normally used for seizures, have been used to prevent migraine headaches. Examples of anticonvulsants that have been used are valproic acid (Depakote®, Depakote ER®, Depakene®), phenobarbital, gabapentin (Neurontin®), and topiramate (Topamax®). Control of the cortical spreading depression (CSD), is thought to be the reason for anticonvulsant effectiveness in preventing migraine attacks. Side effects include fatigue (tiredness), nausea, vomiting, and trembling.
Beta-blockers: Beta-blockers are a class of drugs that safely slow the heart beat and decrease blood pressure. Beta-blockers have been used for many years to prevent migraine headaches. In migraine prevention, beta-blockers help dilate (open) blood vessels in the brain, which may prevent the vascular (blood vessel) symptoms associated with a migraine attack, including vasoconstriction (blood vessel narrowing) and vasodilation (blood vessel widening). Beta-blockers can also help reduce physical symptoms associated with migraine attacks, such as anxiety, heart palpitations, and shaking,
Beta-blockers used in migraine prevention include propranolol (Inderal®), atenolol (Tenormin®), metoprolol (Lopressor®, Toprol XL®), and nadolol (Corgard®). Beta-blockers generally are well tolerated in most individuals. They can aggravate breathing difficulties in patients with asthma, chronic bronchitis (inflammation of the bronchial tubes), or emphysema (loss of lung function). In patients who already have slow heart rates (bradycardia) and heart block (defects in electrical conduction within the heart), beta-blockers can cause dangerously slow heartbeats. Beta-blockers can aggravate symptoms of heart failure. Other side effects include drowsiness, diarrhea, constipation, fatigue (tiredness), insomnia, nausea, depression, dreaming, memory loss, and impotence (loss of sexual performance).
Calcium channel blockers (CCBs): CCBs are a class of drugs normally used for high blood pressure, angina (chest pain), and arrhythmias (abnormal heart rhythms). CCBs also appear to alter serotonin (a brain chemical). Serotonin imbalances are a causative factor in developing a migraine. CCBs used in preventing migraine headaches are diltiazem (Cardizem®, Dilacor®, Tiazac®), and verapamil (Calan®, Verelan®, Isoptin®).The most common side effects of CCBs are constipation, nausea, headache, rash, edema (swelling of the legs with fluid), low blood pressure, drowsiness, and dizziness. Drinking grapefruit juice or eating grapefruit may cause levels of CCBs to rise, potentially leading to life threatening arrhythmias (irregular heart beats). Healthcare professionals recommend that individuals taking CCBs not consume grapefruit juice.
Hormone replacement therapy (HRT): For women with hormonal imbalances that may be causing the migraines, hormone replacement therapy (HRT) may be used, including estrogen and progesterone. HRT, however, may cause side effects such as blood clots, an increased risk of developing some types of cancers, and heart disease. Menstruating women at risk for migraines may be placed on oral contraceptives for HRT. Pre-pubescent girls that are at risk for migraine attacks will not be treated with HRT, but with other methods such as beta-blockers and anticonvulsants.
Lifestyle: Lifestyle changes, including decreasing stress levels, increasing exercise levels, and controlling the diet, have a major impact on migraine prevention and development. Lifestyle factors that are important in the prevention of migraines include regular sleep patterns, regular exercise (level depends upon the individual), limiting stress, limiting caffeine consumption to less than two caffeine-containing beverages a day, avoiding bright or flashing lights, and wearing sunglasses if sunlight is a trigger. Identifying and avoiding foods that trigger headaches is important. Healthcare professionals recommend keeping a food journal, where the individual writes down everything they have for each meal of the day. Then review the diary with a healthcare professional. It is impractical to adopt a diet that avoids all known migraine triggers; however, it is reasonable to avoid foods that consistently trigger migraine headaches. Triggers vary from one individual to another.
Tricyclic antidepressants (TCAs): TCAs are thought to prevent migraine headaches by altering the balance of serotonin, a neurotransmitter in the brain. Low levels of serotonin are thought to be a causative agent in migraine attacks. Chronic stress and depression can cause elevated levels of the stress hormone cortisol, which is produced in the adrenal glands. Cortisol can in turn cause imbalances in serotonin, leading to a migraine attack. The tricyclic antidepressants that have been used in preventing migraine headaches include amitriptyline (Elavil®), nortriptyline (Pamelor®, Aventyl®), doxepin (Sinequan®), and imipramine (Tofranil®). Side effects include constipation, dry mouth, low blood pressure (hypotension), increased heart rate, (tachycardia), urinary retention, sexual dysfunction, and weight gain. TCAs may cause excessive sedation and fatigue (tiredness).
Others: Other drugs less commonly used for migraine prevention include anti-serotonin medications, including methysergide (Sansert®), which prevent migraine headaches by constricting (making smaller) blood vessels and reducing inflammation of the blood vessels. Cyproheptadine (Periactin®) is an antihistamine that increases serotonin activity and is used occasionally in migraine prevention. Low levels of serotonin are a cause of migraine attacks.
Acute (Immediate):
Over-the-counter (OTC) treatments: The U.S. Food and Drug Administration (FDA) has approved three over-the-counter (OTC) products to treat migraine attacks. Excedrin® Migraine (a combination of aspirin, acetaminophen, and caffeine) is indicated for migraine and its associated symptoms such as head pain. Advil® Migraine and Motrin® Migraine Pain (both are ibuprofen) have anti-inflammatory action and are approved to treat migraine headache and its pain.
Triptans: The triptans attach to serotonin receptors on the blood vessels and nerves and thereby reduce inflammation and constrict (narrow) the blood vessels. A reduction in inflammation decreases pressure on nerves in the trigeminal nerve system (nerves in the cranium or head), which decreases the pain signals to the brain and stops the headache. Traditionally, triptans, which are prescription medicines, were prescribed for moderate or severe migraines after over-the-counter (OTC) analgesics such as ibuprofen (Advil®) and other simple measures failed. Newer studies suggest that triptans can be used as the first treatment for patients with migraines that are causing disability. Significant disability is defined as more than ten days of at least 50% disability during a three month period.
Triptans should be used early after the migraine begins, before the onset of pain or when the pain is mild. Using a triptan early in an attack increases its effectiveness, reduces side effects, and decreases the chance of recurrence of another headache during the following 24 hours. Used early, triptans can be expected to abort more than 80% of migraine headaches within two hours. Triptans include sumatriptan (Imitrex®), almotriptan (Axert®), naratriptan (Amerge®), rizatriptan (Maxalt®), zolmitriptan (Zomig®), frovatriptan (Frova®), and eletriptan (Relpax®).
The most common side effects of triptans are facial flushing, tingling of the skin, and a sense of tightness around the chest and throat. Other less common side effects include drowsiness, fatigue (tiredness), and dizziness. These side effects are short-lived and are not considered serious. Triptans are not used in pregnant women and are not generally used in young children.
In patients with severe nausea, a combination of a triptan and an anti-nausea medication, such as prochlorperazine (Compazine®), may be used.
Ergots: Ergots, like triptans, are medications that abort migraine headaches. Examples of ergots include ergotamine preparations (Cafergot®) and dihydroergotamine preparations (Migranal®, DHE-45®). Ergots, like triptans, cause constriction (narrowing) of blood vessels, but ergots tend to cause more constriction of vessels in the heart and other parts of the body than the triptans, and the produce more negative effects on the heart than the triptans. Therefore, the ergots are not as safe as the triptans. Ergots are used to help stop the vasodilation (blood vessel widening) associated with a migraine attack. The ergots also are more prone to cause nausea and vomiting than the triptans. The ergots can cause prolonged contraction of the uterus and miscarriages in pregnant women.
Midrin: Midrin is used to abort migraine and tension headaches. It is a combination of isometheptene (a blood vessel constrictor), acetaminophen (a pain reliever), and dichloralphenazone (a mild sedative). The combination medication can help take care of three potential factors associated with a migraine attack, including vasodilation, pain, and anxiety. Midrin® is most effective if used early during a headache. However, because of its potent blood vessel constricting effect, it should not be used in patients with high blood pressure, kidney disease, glaucoma (increased pressure in the eyes), atherosclerosis (hardening of the arteries), liver disease, or in patients taking monoamine oxidase inhibitors (MAOIs) including phenelzine (Nardil®), isocarboxazid (Marplan®), and tranylcypromine sulfate (Parnate®).
Other prescription medications: Some attacks may not be eliminated by acute therapy, and the individual requires pain-relieving measures. Due to the severity of the headaches, some patients may require a narcotic analgesic, including oxycodone (Percocet®), codeine, or meperidine (Demerol®). If the individual is experiencing frequent migraine attacks, the habitual use of opiate analgesics should be avoided. Opiates can cause addiction (both physical and mental) and may also cause rebound headaches, which are headaches that occur when the pain medicine no longer provides relief.
Butorphanol (Stadol NS®) is an opiate-like drug available for injection and intranasal (in the nose) administration. The normal dosage of Stadol NS® is one spray into the nostril, which usually relieves migraine symptoms in 15-30 minutes. This drug can be used every hour for relief. The use of Stadol NS® may result in dependency if used regularly for pain relief. Side effects include nausea and vomiting, nasal irritation, and sedation.
Butalbital, a barbiturate medication, is also used for the immediate relief of migraine headache pain. It is used in various prescription combinations with aspirin, acetaminophen, caffeine, or codeine (an opiate pain medication). These medications are potentially addicting and are not used as initial treatment. They are sometimes used for patients whose headaches fail to respond to over-the-counter (OTC) medications but who are not candidates for triptans either due to pregnancy or the risk of heart attack and stroke. Products include butalbital and acetaminophen (Axocet®, Bupap®, Cephadyn®, Phrenilin®, or Sedapap®); butalbital, acetaminophen, and caffeine (Fioricet®, Esgic®); butalbital and aspirin (Axotal®); butalbital, aspirin, and caffeine (Fiorinal®); butalbital, acetaminophen, caffeine, and codeine (Fioricet #3 with Codeine® or Fioricet w/ Codeine®); and butalbital, aspirin, caffeine, and codeine (Fiorinal #3 with Codeine® or Fiorinal w/ Codeine®).
Headche...
The prodrome: The prodrome (sometimes called pre-headache) may be experienced hours or even days before a migraine attack. The prodrome is considered a warning sign for individuals suffering migraine attacks that an episode is imminent. For the 30-40% of individuals with migraines that experience prodrome, the warning signs can give the individuals opportunity to abort the migraine attack using conventional and integrative therapies. Symptoms typical of the prodrome include food cravings, constipation or diarrhea, mood changes (such as depression or irritability), muscle stiffness (especially in the neck), fatigue (excessive tiredness), and increased frequency of urination.
The aura: The aura is the most familiar of the phases. Auras are sensory phenomena that can follow the prodrome and usually last less than an hour. The symptoms and effects of the aura vary widely, and include visual hallucinations (such as flashing lights, wavy lines, spots, partial loss of sight, blurry vision), olfactory hallucinations (smelling odors that are not there), tingling or numbness of the face or extremities on the side where the headache develops, difficult finding words and/or speaking, confusion, vertigo (dizziness), partial paralysis (loss of muscle coordination), auditory hallucinations (hearing noises that are not there), decrease in or loss of hearing, and reduced sensation or hypersensitivity to feel and touch.
Approximately 20% of individuals with migraines experience aura. As with the prodrome, migraine aura can serve as a warning, and sometimes allows the use of conventional or integrative therapies to abort the episode before the headache begins. Some individuals can experience aura without a headache, termed "silent" migraine.
The headache: The headache phase is generally the most unbearable part of a migraine episode. The effects of a headache are not limited to the head only, but affect the entire body. Migraine headaches usually are described as an intense, throbbing or pounding pain in the temple area, although the pain can be located in the forehead, around the eye, or the back of the head. The pain usually is on one side of the head (unilateral), although about a third of the time the pain is bilateral (both sides). Unilateral headaches typically change sides from one attack to the next. Although migraine headache pain can occur at any time of day, statistics have reported the most common time to be 6 a.m. It is not uncommon for individuals with a migraine headache to be awakened by the pain. The headache phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it is termed status migrainosus, and medical attention should be sought. Symptoms of the headache phase of a migraine include pain worsened by physical activity, phonophobia (sensitivity to sound), photophobia (sensitivity to light), nausea and vomiting, diarrhea or constipation, nasal congestion and/or runny nose, depression or severe anxiety, hot flashes and chills, dizziness, confusion, and either dehydration or fluid retention, depending on the individual. The combination of disabling pain and symptoms such as nausea or vomiting often prevents sufferers from performing daily activities.
The postdrome: Once the headache is over, the migraine episode is still not over. The postdrome, or post-headache, follows immediately afterward. The majority of individuals with a migraine take hours to fully recover, while others take days. Most individuals in a postdrome phase are fatigued (excessively tired) and have a "hangover" feeling. These feelings may often be attributed to medications taken to treat the migraine, but may well be caused by the migraine itself. Postdromal symptoms have been shown to be accompanied and possibly caused by abnormal cerebral (brain) blood flow and altered electroencephalogram (a measure of brain electrical impulses) readings have been reported for up to 24 hours after the end of the headache stage. In cases where prodrome and/or aura are experienced without the headache phase, the postdrome may still occur. The symptoms of prodrome include decreased mood levels (especially depression) or feelings of well-being and euphoria, fatigue, poor concentration, and comprehension, and lowered intellect levels.
Migraine headache symptoms in children: Migraines typically begin in childhood, adolescence or early adulthood and, in general, may become less frequent and intense as the individual grows older. About half of all school-aged children in the United States have experienced some type of headache. During childhood, boys and girls suffer from migraine at about the same rate. However, during their adolescent years, more girls are affected most likely due to hormonal changes. Also, both aging men and women may suffer from secondary headaches, such as tension or cluster headaches, more often than children under 18 years of age.
Children's migraines tend to last for a shorter time, but the pain can be disabling and can be accompanied by nausea, vomiting, lightheadedness, and increased sensitivity to light. A migraine headache tends to occur on both sides of the head in children (bilateral) and visual auras are rare. Children often have premonition signs and symptoms, such as yawning, sleepiness or listlessness, and a craving for foods such as sugary foods and chocolate. Children may have all of the signs and symptoms of a migraine headache (nausea, vomiting, increased sensitivity to light and sound, aura), but no head pain. These migraines can be especially difficult to diagnose.
Diagnosis
Diagnosis of a migraine headache is based on the history of symptoms, physical examination, and neurological (nerve) tests. The tests are performed to rule out other neurological and cerebrovascular (blood vessels in the brain) conditions, including bleeding within the skull (intracranial hemorrhage), blood clot within the membrane that covers the brain (cerebral venous sinus thrombosis), cerebral stroke or lack of oxygen to the brain (called an infarct), dilated blood vessel in the brain (cerebral aneurysm), excess cerebrospinal fluid in the brain (hydrocephalus), inflammation of the membranes of the brain or spinal cord (meningitis), low level of cerebral spinal fluid (CSF), nasal sinus blockage, postictal headache (occurs after a stroke or seizure), and brain tumor.
Computed tomography (CT scan): A computerized axial tomography scan, or CT scan, is an x-ray procedure which combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. An intravenous (into the veins) dye is injected into the individual. Then the patient is placed under a large donut-shaped x-ray machine, which takes x-ray images at many different angles around the body. These images are processed by a computer to produce cross-sectional pictures of the body.
A CAT scan is a very low-risk procedure. The most common problem is an adverse reaction to intravenous contrast material. Intravenous contrast is usually an iodine-based liquid given in the vein, which makes many organs and structures, such as the brain and blood vessels, much more visible on the CAT scan. There may be resulting itching, a rash, hives, or a feeling of warmth throughout the body. These are usually self-limiting reactions and go away rather quickly. If needed, antihistamines (such as diphenhydramine or Benadryl®) can be given by injection or orally to help relieve the symptoms. A more serious reaction to intravenous contrast is called an anaphylactic reaction. When this occurs, the patient may experience severe hives and/or extreme difficulty in breathing. This reaction is quite rare, but is potentially life-threatening if not treated. Medications taken to reverse this adverse reaction may include corticosteroids (steroids, such as prednisone or Deltasone®), antihistamines, and epinephrine.
In migraine patients, a CT scan is performed to rule out an underlying brain abnormality, such as a tumor, when migraines are new or when there is a change in their character or frequency. CT scans may not be as reliable as newer diagnostic techniques, such as magnetic resonance imaging (MRI), but are less expensive.
Electroencephalogram (EEG): An electroencephalogram (EEG) records electrical signals originating in the brain (called brain activity). This test is used to detect malfunctions in brain activity, such as seizures or migraines.
EEGs are generally performed in a hospital or specialized laboratory. Sometimes the individual having the test will be told to stay up late the night before and to avoid caffeine drinks on the morning of the test. Some EEG tests are made with the patient sitting in a chair. Others are performed with the patient lying down on a couch. The EEG technologist applies small metal disks to several places on the scalp. The hair should be washed on the morning of the test with no additional chemicals, hair sprays, cleansers, cosmetics, or setting gels applied. A special glue, which is washed out afterwards, is used to attach the electrode disks to the scalp. A cap with the wires already attached may be used instead of the glue.
During the test, the technologist may ask the person to breathe deeply through the mouth for a short time. This may make the person feel slightly dizzy or produce a numb feeling in the hands or feet, but this goes away when normal breathing is started again. The technologist may shine a blinking light into the person's eyes, or ask him or her to open and close them rapidly a few times. The average EEG test may last 35-40 minutes.
Children should be told what to expect during an EEG test, and can be encouraged to "practice" on a doll or stuffed animal beforehand.
Lumbar puncture: Lumbar puncture, or spinal tap, is performed to detect infection and determine levels of white blood cells (immune system cells), glucose, and protein in the cerebrospinal fluid. This test involves withdrawing a small amount of fluid from the spinal cord area and examining it under a microscope. The individual lies down on their side on an examination table. There are steps to make sure that the individual does not feel pain during the spinal tap. A topical anesthesia cream (such as Emlon®) on the skin of the back where the spinal tap will be performed (about 30 minutes to one hour before). After the skin is numbed, some doctors also inject liquid anesthesia such as lidocaine into the tissues right under the skin to prevent any further pain. Next, the doctor places a small needle through the skin and then forward through the space between the vertebrae (spine) in the lower back until it enters the space that contains the spinal fluid. When the needle goes into the skin, the individual will not feel sharp pain, only perhaps some pressure. The spinal fluid drips out through the needle into tubes, is collected, and sent to a lab for analysis. This procedure can be uncomfortable for the patient. Side effects can be headaches, pain, infection, or bleeding. Each of these complications are uncommon with the exception of headache, which can appear from hours to up to a day after LP. Headaches occur less frequently when the patient remains lying flat for one to three hours after the procedure. Patients may be given pain medications (such as morphine) or sedatives (such as alprazolam or Xanax®) before and after the procedure. These drugs can cause drowsiness, sedation, and can lead to physical dependence.
Magnetic resonance imaging (MRI): An MRI (magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The patient may be given a sedative, such as alprazolam (Xanax®), to decrease anxiety and stress associated with the procedure. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body.
An MRI in patient's with migraines may be performed for a more complete evaluation of the brain, and can visualize blood vessels in the brain to detect aneurysms (tears in blood vessels) and other vascular abnormalities that can be causative agents in migraines.
Treatment
Many factors may contribute to the occurrence of migraine attacks, including diet, sleep, hormonal changes, changes in brain chemistry, and heredity. They are known as trigger factors. When identified, avoidance of trigger factors reduces the number of headaches a patient may experience. Trigger factors may be targets of drug therapy also.
Treatment for migraine attacks is divided into two categories, including acute (immediate) or prophylactic (preventative). Acute treatment is used during a migraine to stop or slow the progress of the attack, and preventative (or prophylactic) treatment tries to prevent migraine attacks from occuring.
The aura: The aura is the most familiar of the phases. Auras are sensory phenomena that can follow the prodrome and usually last less than an hour. The symptoms and effects of the aura vary widely, and include visual hallucinations (such as flashing lights, wavy lines, spots, partial loss of sight, blurry vision), olfactory hallucinations (smelling odors that are not there), tingling or numbness of the face or extremities on the side where the headache develops, difficult finding words and/or speaking, confusion, vertigo (dizziness), partial paralysis (loss of muscle coordination), auditory hallucinations (hearing noises that are not there), decrease in or loss of hearing, and reduced sensation or hypersensitivity to feel and touch.
Approximately 20% of individuals with migraines experience aura. As with the prodrome, migraine aura can serve as a warning, and sometimes allows the use of conventional or integrative therapies to abort the episode before the headache begins. Some individuals can experience aura without a headache, termed "silent" migraine.
The headache: The headache phase is generally the most unbearable part of a migraine episode. The effects of a headache are not limited to the head only, but affect the entire body. Migraine headaches usually are described as an intense, throbbing or pounding pain in the temple area, although the pain can be located in the forehead, around the eye, or the back of the head. The pain usually is on one side of the head (unilateral), although about a third of the time the pain is bilateral (both sides). Unilateral headaches typically change sides from one attack to the next. Although migraine headache pain can occur at any time of day, statistics have reported the most common time to be 6 a.m. It is not uncommon for individuals with a migraine headache to be awakened by the pain. The headache phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it is termed status migrainosus, and medical attention should be sought. Symptoms of the headache phase of a migraine include pain worsened by physical activity, phonophobia (sensitivity to sound), photophobia (sensitivity to light), nausea and vomiting, diarrhea or constipation, nasal congestion and/or runny nose, depression or severe anxiety, hot flashes and chills, dizziness, confusion, and either dehydration or fluid retention, depending on the individual. The combination of disabling pain and symptoms such as nausea or vomiting often prevents sufferers from performing daily activities.
The postdrome: Once the headache is over, the migraine episode is still not over. The postdrome, or post-headache, follows immediately afterward. The majority of individuals with a migraine take hours to fully recover, while others take days. Most individuals in a postdrome phase are fatigued (excessively tired) and have a "hangover" feeling. These feelings may often be attributed to medications taken to treat the migraine, but may well be caused by the migraine itself. Postdromal symptoms have been shown to be accompanied and possibly caused by abnormal cerebral (brain) blood flow and altered electroencephalogram (a measure of brain electrical impulses) readings have been reported for up to 24 hours after the end of the headache stage. In cases where prodrome and/or aura are experienced without the headache phase, the postdrome may still occur. The symptoms of prodrome include decreased mood levels (especially depression) or feelings of well-being and euphoria, fatigue, poor concentration, and comprehension, and lowered intellect levels.
Migraine headache symptoms in children: Migraines typically begin in childhood, adolescence or early adulthood and, in general, may become less frequent and intense as the individual grows older. About half of all school-aged children in the United States have experienced some type of headache. During childhood, boys and girls suffer from migraine at about the same rate. However, during their adolescent years, more girls are affected most likely due to hormonal changes. Also, both aging men and women may suffer from secondary headaches, such as tension or cluster headaches, more often than children under 18 years of age.
Children's migraines tend to last for a shorter time, but the pain can be disabling and can be accompanied by nausea, vomiting, lightheadedness, and increased sensitivity to light. A migraine headache tends to occur on both sides of the head in children (bilateral) and visual auras are rare. Children often have premonition signs and symptoms, such as yawning, sleepiness or listlessness, and a craving for foods such as sugary foods and chocolate. Children may have all of the signs and symptoms of a migraine headache (nausea, vomiting, increased sensitivity to light and sound, aura), but no head pain. These migraines can be especially difficult to diagnose.
Diagnosis
Diagnosis of a migraine headache is based on the history of symptoms, physical examination, and neurological (nerve) tests. The tests are performed to rule out other neurological and cerebrovascular (blood vessels in the brain) conditions, including bleeding within the skull (intracranial hemorrhage), blood clot within the membrane that covers the brain (cerebral venous sinus thrombosis), cerebral stroke or lack of oxygen to the brain (called an infarct), dilated blood vessel in the brain (cerebral aneurysm), excess cerebrospinal fluid in the brain (hydrocephalus), inflammation of the membranes of the brain or spinal cord (meningitis), low level of cerebral spinal fluid (CSF), nasal sinus blockage, postictal headache (occurs after a stroke or seizure), and brain tumor.
Computed tomography (CT scan): A computerized axial tomography scan, or CT scan, is an x-ray procedure which combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. An intravenous (into the veins) dye is injected into the individual. Then the patient is placed under a large donut-shaped x-ray machine, which takes x-ray images at many different angles around the body. These images are processed by a computer to produce cross-sectional pictures of the body.
A CAT scan is a very low-risk procedure. The most common problem is an adverse reaction to intravenous contrast material. Intravenous contrast is usually an iodine-based liquid given in the vein, which makes many organs and structures, such as the brain and blood vessels, much more visible on the CAT scan. There may be resulting itching, a rash, hives, or a feeling of warmth throughout the body. These are usually self-limiting reactions and go away rather quickly. If needed, antihistamines (such as diphenhydramine or Benadryl®) can be given by injection or orally to help relieve the symptoms. A more serious reaction to intravenous contrast is called an anaphylactic reaction. When this occurs, the patient may experience severe hives and/or extreme difficulty in breathing. This reaction is quite rare, but is potentially life-threatening if not treated. Medications taken to reverse this adverse reaction may include corticosteroids (steroids, such as prednisone or Deltasone®), antihistamines, and epinephrine.
In migraine patients, a CT scan is performed to rule out an underlying brain abnormality, such as a tumor, when migraines are new or when there is a change in their character or frequency. CT scans may not be as reliable as newer diagnostic techniques, such as magnetic resonance imaging (MRI), but are less expensive.
Electroencephalogram (EEG): An electroencephalogram (EEG) records electrical signals originating in the brain (called brain activity). This test is used to detect malfunctions in brain activity, such as seizures or migraines.
EEGs are generally performed in a hospital or specialized laboratory. Sometimes the individual having the test will be told to stay up late the night before and to avoid caffeine drinks on the morning of the test. Some EEG tests are made with the patient sitting in a chair. Others are performed with the patient lying down on a couch. The EEG technologist applies small metal disks to several places on the scalp. The hair should be washed on the morning of the test with no additional chemicals, hair sprays, cleansers, cosmetics, or setting gels applied. A special glue, which is washed out afterwards, is used to attach the electrode disks to the scalp. A cap with the wires already attached may be used instead of the glue.
During the test, the technologist may ask the person to breathe deeply through the mouth for a short time. This may make the person feel slightly dizzy or produce a numb feeling in the hands or feet, but this goes away when normal breathing is started again. The technologist may shine a blinking light into the person's eyes, or ask him or her to open and close them rapidly a few times. The average EEG test may last 35-40 minutes.
Children should be told what to expect during an EEG test, and can be encouraged to "practice" on a doll or stuffed animal beforehand.
Lumbar puncture: Lumbar puncture, or spinal tap, is performed to detect infection and determine levels of white blood cells (immune system cells), glucose, and protein in the cerebrospinal fluid. This test involves withdrawing a small amount of fluid from the spinal cord area and examining it under a microscope. The individual lies down on their side on an examination table. There are steps to make sure that the individual does not feel pain during the spinal tap. A topical anesthesia cream (such as Emlon®) on the skin of the back where the spinal tap will be performed (about 30 minutes to one hour before). After the skin is numbed, some doctors also inject liquid anesthesia such as lidocaine into the tissues right under the skin to prevent any further pain. Next, the doctor places a small needle through the skin and then forward through the space between the vertebrae (spine) in the lower back until it enters the space that contains the spinal fluid. When the needle goes into the skin, the individual will not feel sharp pain, only perhaps some pressure. The spinal fluid drips out through the needle into tubes, is collected, and sent to a lab for analysis. This procedure can be uncomfortable for the patient. Side effects can be headaches, pain, infection, or bleeding. Each of these complications are uncommon with the exception of headache, which can appear from hours to up to a day after LP. Headaches occur less frequently when the patient remains lying flat for one to three hours after the procedure. Patients may be given pain medications (such as morphine) or sedatives (such as alprazolam or Xanax®) before and after the procedure. These drugs can cause drowsiness, sedation, and can lead to physical dependence.
Magnetic resonance imaging (MRI): An MRI (magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The patient may be given a sedative, such as alprazolam (Xanax®), to decrease anxiety and stress associated with the procedure. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body.
An MRI in patient's with migraines may be performed for a more complete evaluation of the brain, and can visualize blood vessels in the brain to detect aneurysms (tears in blood vessels) and other vascular abnormalities that can be causative agents in migraines.
Treatment
Many factors may contribute to the occurrence of migraine attacks, including diet, sleep, hormonal changes, changes in brain chemistry, and heredity. They are known as trigger factors. When identified, avoidance of trigger factors reduces the number of headaches a patient may experience. Trigger factors may be targets of drug therapy also.
Treatment for migraine attacks is divided into two categories, including acute (immediate) or prophylactic (preventative). Acute treatment is used during a migraine to stop or slow the progress of the attack, and preventative (or prophylactic) treatment tries to prevent migraine attacks from occuring.
Albuterol
Albuterol
Generic Name: albuterol inhalation (al BYOO ter all)
Brand names: Accuneb, ProAir HFA, Proventil, Proventil HFA, Ventolin HFA
What is albuterol?
Albuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs.
Albuterol is used to treat or prevent bronchospasm in people with reversible obstructive airway disease. Albuterol is also used to prevent exercise-induced bronchospasm.
Albuterol may also be used for other purposes not listed in this medication guide.
Important information about albuterol?
It is important to keep Albuterol on hand at all times. Get your prescription refilled before you run out of medicine completely. Keep using all of your other medications as prescribed by your doctor.
Call your doctor right away if you feel that albuterol is not working as well as usual, or if it makes your condition worse. If it seems like you need to use more of any of your medications in a 24-hour period, talk with your doctor.
Seek emergency medical attention if you think you have used too much of this medicine. An overdose of albuterol can be fatal. Extreme heat can cause the medicine canister to burst. Do not store your inhaler in your car on hot days. Do not throw an empty canister into open flame.
Before using albuterol
Before using Albuterol, tell your doctor if you are allergic to any drugs, or if you have:
heart disease, high blood pressure, or congestive heart failure;
a heart rhythm disorder;
a seizure disorder such as epilepsy;
diabetes;
overactive thyroid;
If you have any of these conditions, you may not be able to use albuterol, or you may need a dose adjustment or special tests during treatment.
FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether albuterol passes into breast milk or if it could harm a nursing baby. Do not use Albuterol without telling your doctor if you are breast-feeding a baby.
How should I use albuterol?
Use Albuterol exactly as it was prescribed for you. Do not use the medication in larger amounts, or use it for longer than recommended by your doctor. Follow the instructions on your prescription label.
Albuterol may increase the risk of asthma-related death. Use only the prescribed dose of this medicine and follow all patient instructions for safe use. Talk with your doctor about your individual risks and benefits of using albuterol.
When using the inhaler device for the first time, prime it by spraying 4 test sprays into the air, away from your face. Shake well before priming. Also prime the inhaler if you have not used it for 2 weeks or longer, or if you have dropped the inhaler.
The instructions below are for standard use of albuterol inhaler and nebulizer devices. Your doctor may want you to use your device differently. Use only the inhaler device provided with your medicine or you may not get the correct dose.
To use the inhaler:
Shake the canister well just before each spray.
Uncap the mouthpiece of the albuterol inhaler. Breathe out fully. Put the mouthpiece into your mouth and close your lips. Breathe in slowly while pushing down on the canister. Hold your breath for 10 seconds, then breathe out slowly.
If you use more than one inhalation at a time, wait at least 1 minute before using the second inhalation and shake the inhaler again.
Keep your albuterol inhaler clean and dry, and store it with the cap on the mouthpiece. Clean your inhaler once a week by removing the canister and placing the mouthpiece under warm running water for at least 30 seconds. Shake out the excess water and allow the parts to air dry completely before putting the inhaler back together.
To use the solution with a nebulizer:
Measure the correct amount of medicine using the dropper provided, or use the proper number of ampules. Place the liquid into the medication chamber of the nebulizer.
Attach the mouthpiece or face mask to the drug chamber. Then, attach the drug chamber to the compressor. Sit upright and place the mouthpiece into your mouth, or cover your nose and mouth with the face mask. Breathe slowly and evenly until you have inhaled all of the medicine (usually 5 to 15 minutes). The treatment is complete when the drug chamber is empty.
Clean the nebulizer after each use. Follow the cleaning directions that came with your nebulizer.
Call your doctor right away if you feel that albuterol is not working as well as usual, or if it makes your condition worse. If it seems like you need to use more of any of your medications in a 24-hour period, talk with your doctor.
It is important to keep Albuterol on hand at all times. Get your prescription refilled before you run out of medicine completely. Keep using all of your other medications as prescribed by your doctor.
Store Albuterol at room temperature away from moisture and heat. Extreme heat can cause the medicine canister to burst. Do not store it in your car on hot days. Do not throw an empty canister into open flame.
What happens if I miss a dose?
Use the medication as soon as you remember. If it is almost time for the next dose, skip the missed dose and use the medicine at the next regularly scheduled time. Do not use extra medicine to make up the missed dose.
What happens if I overdose?
Seek emergency medical attention if you think you have used too much of this medicine. An overdose of albuterol can be fatal. Overdose symptoms may include nervousness, headache, tremor, dry mouth, chest pain or heavy feeling, rapid or uneven heart rate, pain spreading to the arm or shoulder, nausea, sweating, dizziness, seizure (convulsions), feeling light-headed or fainting.
What should I avoid while using albuterol?
Avoid getting Albuterol in your eyes. If this does happen, rinse the eyes with water and seek medical attention.
albuterol side effects
Stop using Albuterol and get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Call your doctor at once if you have a serious side effect such as:
bronchospasm (wheezing, chest tightness, trouble breathing), especially after starting a new canister of this medicine;
chest pain and fast, pounding, or uneven heart beats;
tremor, nervousness; or
dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).
Less serious side effects may include:
headache, dizziness, nervousness;
sleep problems (insomnia);
cough, hoarseness, sore throat, runny or stuffy nose;
dry mouth and throat;
muscle pain; or
diarrhea.
This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.
What other drugs will affect albuterol?
Before using Albuterol, tell your doctor if you are taking any of the following medicines:
a diuretic (water pill);
digoxin (digitalis, Lanoxin);
a beta-blocker such as atenolol (Tenormin), metoprolol (Lopressor), propranolol (Inderal), and others;
an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate); or
other bronchodilators such as levalbuterol (Xopenex), bitolterol (Tornalate), pirbuterol (Maxair), terbutaline (Brethine, Bricanyl), salmeterol (Serevent), isoetherine (Bronkometer), metaproterenol (Alupent, Metaprel), or isoproterenol (Isuprel Mistometer).
This list is not complete and there may be other drugs that can interact with albuterol. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.
Generic Name: albuterol inhalation (al BYOO ter all)
Brand names: Accuneb, ProAir HFA, Proventil, Proventil HFA, Ventolin HFA
What is albuterol?
Albuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs.
Albuterol is used to treat or prevent bronchospasm in people with reversible obstructive airway disease. Albuterol is also used to prevent exercise-induced bronchospasm.
Albuterol may also be used for other purposes not listed in this medication guide.
Important information about albuterol?
It is important to keep Albuterol on hand at all times. Get your prescription refilled before you run out of medicine completely. Keep using all of your other medications as prescribed by your doctor.
Call your doctor right away if you feel that albuterol is not working as well as usual, or if it makes your condition worse. If it seems like you need to use more of any of your medications in a 24-hour period, talk with your doctor.
Seek emergency medical attention if you think you have used too much of this medicine. An overdose of albuterol can be fatal. Extreme heat can cause the medicine canister to burst. Do not store your inhaler in your car on hot days. Do not throw an empty canister into open flame.
Before using albuterol
Before using Albuterol, tell your doctor if you are allergic to any drugs, or if you have:
heart disease, high blood pressure, or congestive heart failure;
a heart rhythm disorder;
a seizure disorder such as epilepsy;
diabetes;
overactive thyroid;
If you have any of these conditions, you may not be able to use albuterol, or you may need a dose adjustment or special tests during treatment.
FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether albuterol passes into breast milk or if it could harm a nursing baby. Do not use Albuterol without telling your doctor if you are breast-feeding a baby.
How should I use albuterol?
Use Albuterol exactly as it was prescribed for you. Do not use the medication in larger amounts, or use it for longer than recommended by your doctor. Follow the instructions on your prescription label.
Albuterol may increase the risk of asthma-related death. Use only the prescribed dose of this medicine and follow all patient instructions for safe use. Talk with your doctor about your individual risks and benefits of using albuterol.
When using the inhaler device for the first time, prime it by spraying 4 test sprays into the air, away from your face. Shake well before priming. Also prime the inhaler if you have not used it for 2 weeks or longer, or if you have dropped the inhaler.
The instructions below are for standard use of albuterol inhaler and nebulizer devices. Your doctor may want you to use your device differently. Use only the inhaler device provided with your medicine or you may not get the correct dose.
To use the inhaler:
Shake the canister well just before each spray.
Uncap the mouthpiece of the albuterol inhaler. Breathe out fully. Put the mouthpiece into your mouth and close your lips. Breathe in slowly while pushing down on the canister. Hold your breath for 10 seconds, then breathe out slowly.
If you use more than one inhalation at a time, wait at least 1 minute before using the second inhalation and shake the inhaler again.
Keep your albuterol inhaler clean and dry, and store it with the cap on the mouthpiece. Clean your inhaler once a week by removing the canister and placing the mouthpiece under warm running water for at least 30 seconds. Shake out the excess water and allow the parts to air dry completely before putting the inhaler back together.
To use the solution with a nebulizer:
Measure the correct amount of medicine using the dropper provided, or use the proper number of ampules. Place the liquid into the medication chamber of the nebulizer.
Attach the mouthpiece or face mask to the drug chamber. Then, attach the drug chamber to the compressor. Sit upright and place the mouthpiece into your mouth, or cover your nose and mouth with the face mask. Breathe slowly and evenly until you have inhaled all of the medicine (usually 5 to 15 minutes). The treatment is complete when the drug chamber is empty.
Clean the nebulizer after each use. Follow the cleaning directions that came with your nebulizer.
Call your doctor right away if you feel that albuterol is not working as well as usual, or if it makes your condition worse. If it seems like you need to use more of any of your medications in a 24-hour period, talk with your doctor.
It is important to keep Albuterol on hand at all times. Get your prescription refilled before you run out of medicine completely. Keep using all of your other medications as prescribed by your doctor.
Store Albuterol at room temperature away from moisture and heat. Extreme heat can cause the medicine canister to burst. Do not store it in your car on hot days. Do not throw an empty canister into open flame.
What happens if I miss a dose?
Use the medication as soon as you remember. If it is almost time for the next dose, skip the missed dose and use the medicine at the next regularly scheduled time. Do not use extra medicine to make up the missed dose.
What happens if I overdose?
Seek emergency medical attention if you think you have used too much of this medicine. An overdose of albuterol can be fatal. Overdose symptoms may include nervousness, headache, tremor, dry mouth, chest pain or heavy feeling, rapid or uneven heart rate, pain spreading to the arm or shoulder, nausea, sweating, dizziness, seizure (convulsions), feeling light-headed or fainting.
What should I avoid while using albuterol?
Avoid getting Albuterol in your eyes. If this does happen, rinse the eyes with water and seek medical attention.
albuterol side effects
Stop using Albuterol and get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Call your doctor at once if you have a serious side effect such as:
bronchospasm (wheezing, chest tightness, trouble breathing), especially after starting a new canister of this medicine;
chest pain and fast, pounding, or uneven heart beats;
tremor, nervousness; or
dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).
Less serious side effects may include:
headache, dizziness, nervousness;
sleep problems (insomnia);
cough, hoarseness, sore throat, runny or stuffy nose;
dry mouth and throat;
muscle pain; or
diarrhea.
This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.
What other drugs will affect albuterol?
Before using Albuterol, tell your doctor if you are taking any of the following medicines:
a diuretic (water pill);
digoxin (digitalis, Lanoxin);
a beta-blocker such as atenolol (Tenormin), metoprolol (Lopressor), propranolol (Inderal), and others;
an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate); or
other bronchodilators such as levalbuterol (Xopenex), bitolterol (Tornalate), pirbuterol (Maxair), terbutaline (Brethine, Bricanyl), salmeterol (Serevent), isoetherine (Bronkometer), metaproterenol (Alupent, Metaprel), or isoproterenol (Isuprel Mistometer).
This list is not complete and there may be other drugs that can interact with albuterol. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.
Hair Removal
You've got it, you know you don't want it, and it can appear anywhere.
Unwanted hair is common on the upper lip, the chin, cheeks, on the back, legs, fingers, feet or toes. It can be caused by a variety of factors, including genetics, certain medications such as hormones or steroids, or even medical abnormalities, such as higher androgen (male hormone) levels or conditions of the endocrine system, such as polycystic ovarian syndrome.
Have you already tried plucking? Most people can get used to this painful method, but it won't work effectively on large areas covered with unwanted hair. There are several hair removal strategies, but be warned: None is 100% permanent.
Hair Removal Strategies
There are several ways to remove your unwanted hair, including over-the-counter methods and those administered under a doctor's care. With most of these methods, the hair eventually grows back.
Shaving
Your hair growth rate will determine how often you have to shave the affected region. Shaving is best for legs, arms or facial hair. However, this hair removal method can cause ingrown hairs in the pubic region.
Plucking
Plucking is the most painful method, but may be the most worthwhile when there are just a few hairs you want to remove. Examples include reshaping your eyebrows or pulling out those few stray hairs that may appear on your face, especially for a woman. You should not use this hair removal method for large areas because it can cause ingrown hairs or scarring.
Depilation
Be cautious when selecting hair removal creams over-the-counter: All creams are not the same. For instance, a hair removal cream designated for pubic hair should not be used to remove facial hair. The chemicals in these products dissolve the hair shaft and drawbacks can be significant. The chemicals can also cause superficial burns. If you have a history of allergic reactions, you may want to seek the advice of your doctor before trying any hair removal creams.
Hot Waxing
You can do this at home or you can also have it performed by a professional in a salon. Hot waxing can be messy and may leave some hairs behind because they can break off. Infection is one side effect to watch for. Still, many women use this hair removal method in the bikini area and for hair on the upper lip.
Laser Hair Removal
This is one of the longest-lasting methods and generally requires 3-4 or more treatment sessions, but it is not for everyone: your hair must be dark in color.
Laser hair removal The laser beam or a light pulse works to destroy the hair bulb itself. The treatment can be expensive and sometimes painful. Be sure to select a doctor or technician who is highly trained and knowledgeable. You may require multiple sessions, but it can be used on many parts of the body where unwanted hair may appear.
Electrolysis
There are two primary hair removal methods of electrolysis: galvanic and thermolytic.
Galvanic. Chemically destroys hair follicle. It is the oldest method used, but requires several treatments.
Thermolytic. Uses heat to destroy the hair follicle.
In either case, be sure to find a professional who is highly trained and knowledgeable with this hair removal method. Electrolysis can be used on all parts of the body to remove unwanted hair.
Oral Medications
If none of these hair removal methods seem to address your particular problems, ask your doctor about oral medications to inhibit hair growth.
There is a topical cream called Vaniqa, recently approved by the Food and Drug Administration for the slowing of facial hair growth in women. This cream slows growth, but will not remove the hair.
Unwanted hair is common on the upper lip, the chin, cheeks, on the back, legs, fingers, feet or toes. It can be caused by a variety of factors, including genetics, certain medications such as hormones or steroids, or even medical abnormalities, such as higher androgen (male hormone) levels or conditions of the endocrine system, such as polycystic ovarian syndrome.
Have you already tried plucking? Most people can get used to this painful method, but it won't work effectively on large areas covered with unwanted hair. There are several hair removal strategies, but be warned: None is 100% permanent.
Hair Removal Strategies
There are several ways to remove your unwanted hair, including over-the-counter methods and those administered under a doctor's care. With most of these methods, the hair eventually grows back.
Shaving
Your hair growth rate will determine how often you have to shave the affected region. Shaving is best for legs, arms or facial hair. However, this hair removal method can cause ingrown hairs in the pubic region.
Plucking
Plucking is the most painful method, but may be the most worthwhile when there are just a few hairs you want to remove. Examples include reshaping your eyebrows or pulling out those few stray hairs that may appear on your face, especially for a woman. You should not use this hair removal method for large areas because it can cause ingrown hairs or scarring.
Depilation
Be cautious when selecting hair removal creams over-the-counter: All creams are not the same. For instance, a hair removal cream designated for pubic hair should not be used to remove facial hair. The chemicals in these products dissolve the hair shaft and drawbacks can be significant. The chemicals can also cause superficial burns. If you have a history of allergic reactions, you may want to seek the advice of your doctor before trying any hair removal creams.
Hot Waxing
You can do this at home or you can also have it performed by a professional in a salon. Hot waxing can be messy and may leave some hairs behind because they can break off. Infection is one side effect to watch for. Still, many women use this hair removal method in the bikini area and for hair on the upper lip.
Laser Hair Removal
This is one of the longest-lasting methods and generally requires 3-4 or more treatment sessions, but it is not for everyone: your hair must be dark in color.
Laser hair removal The laser beam or a light pulse works to destroy the hair bulb itself. The treatment can be expensive and sometimes painful. Be sure to select a doctor or technician who is highly trained and knowledgeable. You may require multiple sessions, but it can be used on many parts of the body where unwanted hair may appear.
Electrolysis
There are two primary hair removal methods of electrolysis: galvanic and thermolytic.
Galvanic. Chemically destroys hair follicle. It is the oldest method used, but requires several treatments.
Thermolytic. Uses heat to destroy the hair follicle.
In either case, be sure to find a professional who is highly trained and knowledgeable with this hair removal method. Electrolysis can be used on all parts of the body to remove unwanted hair.
Oral Medications
If none of these hair removal methods seem to address your particular problems, ask your doctor about oral medications to inhibit hair growth.
There is a topical cream called Vaniqa, recently approved by the Food and Drug Administration for the slowing of facial hair growth in women. This cream slows growth, but will not remove the hair.
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