Ask the Clinician with Dr. John Claude Krusz for About Headaches and Migraine: Question and Answer #3 for 4/29/03

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Headaches & Migraines

Dr. Krusz is a recognized expert in the fields of
headache and Migraine treatment and pain treatment
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Please Note: We receive far more questions than can be answered in this format. In many cases, our Guide, Teri Robert, has already researched the topic of the question and may have information already published on this site. Some questions answered here will be answered by Teri. Dr. Krusz will be reviewing her answers before they're posted to see if he can offer additional input.

QUESTION:
My name is Lynn, and I have had chronic migraines for the last 30 years (I'm 47). They have interfered with my life to the extent that I was forced to leave a very enjoyable law practice in 1994; to my dismay, this did not relieve the headaches in any way, and for a time, they got steadily worse. Over the years I have tried every treatment method from drugs to biofeedback to acupuncture. Recently (for the last two years), I have been treated with Methergine and with Neurontin (4x daily), which seems to have reduced the headaches to a level which at least allows me to get out of bed most days for most of the day. I also take Effexor XR for the depression associated with the migraines. My neurologist is Herbert Markley, who practices in Worcester, MA (I live in Maine), and I think he's great. I am also participating in a chronic pain management program here in Maine.

My questions are these:

(1) how can I get off drugs? I am very concerned about long-term side effects, and I'm sick of being dependent on these chemicals.

(2) since I'm on Methergine, I cannot take Imitrex, which I had taken previously, with more or less success. Apart from going up to the local hospital for Demerol, what can I take to control the pain? I have a history of taking too much Fioricet, and went off it completely for a while, when I started with the Imitrex under Dr. Markley's care; however, I can't find anything else which will control the pain enough either to allow me to sleep till the migraine passes, or to get out of bed and participate at least to some extent in life. OTC meds, like Excedrin, aspirin, ibuprofen, tylenol, Excedrin Migraine, etc., are of absolutely no benefit. Is there anything else in the pharmacology, either OTC or by prescription (which, obviously, I'd run by my physician for his input) which could help me?

(3) Finally, Dr. Markley wants me to try the new Botox therapy; my insurance carrier (Aetna Blue Cross Blue Shield) seems to be dragging its feet, as it has been since November that we've been trying to get insurance approval. What do you think of the therapy, and what, if anything. do you suggest I do about getting the insurance company to get off the dime and give some answer - even a "No" answer would be preferable to silence, as then I could appeal, and follow the rest of the procedure to its conclusion.

Thank you for your prompt reply.

Lynn Spann Bowditch

REPLY: Dear Ms Bowditch:
Chronic migraine headaches are a very difficult-to-treat subtype. While I do not prescribe Methergine, it can be both helpful and can also have side effects. Judicious use of this compound is always a safer bet. Neurontin is probably one of the least problematic medications as it is not metabolized, stored or processed by the liver. For long-term use, it is an acceptable choice, providing it gives value. The studies showing efficacy for migraines took dosing to 3600mg per day, in three divided doses. While folks feel "stuck" on medications and resent taking them daily, they do better if they understand the medication as a biochemical tool. It seems like the triptan medication, Imitrex, was helpful and there are now 7 of them in the marketplace. Perhaps negotiating off the Methergine would re-establish better control acutely and reduce the need for trips to the ER. Unfortunately Demerol is converted into a neurotoxic metabolite and my personal wish is that it be banned from use in the hospital. It can, like other opiates, induce rebound headaches. There are a number of newer analgesics that don't have the downsides of traditional "pain'killers", like tolerance and do not come with added acetaminophen. For example, tramadol can be used for the pain of headache, as can tizanidine. The latter would be very sleep promoting, which sounds like an additional issue for you. OTC meds should be avoided as they ARE the enemy. They create analgesic rebound, which is also difficult to get rid of. The newer neuronal stabilizing agents (those that came after Neurontin, and there are 6, all have been published on for prophylaxis treatment of chronic migraines. I have used botulinum toxins successfully but they seem to work best for particular patterns of migraine. If the migraine begins at the base of the neck and is on one side predominantly (50-75% of the time or more), then botulinum toxin may have value. Also, I don't place it into a muscle; rather, I use it in the skin itself (intradermally). This is a new type of delivery for the toxin. There is a lot to be found out about proper use of these toxins.
Hope some of these thoughts help. Good luck in finding relief! John Claude Krusz

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