Dr. Krusz is a recognized expert in the fields of
headache and Migraine treatment and pain treatment
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     My husband has suffered from migraines for almost 20 years. He has previously been under the care of headache specialists at two major mid-west headache centers. After trying several classes of preventatives, the only medication which was effective for preventing the migraines was Nardil, but he finally had to stop taking it because it only allowed him to sleep 3-4 hrs per night, he could not take anything when he did get an occasional migraine, and because he lived under the constant fear of eating something that might cause a fatal reaction. He had minimal success with the triptans, but I question whether he was ever on a high enough dose. His physician prescribed 50 mg. of Imitrex and chewed him out if he took more (he's 6'3" and 225 pounds). We found that 100 mg. at least took a 10 HA down to a 3 or 4, but it usually returned. Every new triptan that came out, the Dr. let him try the lowest dose available, but he had no effective, lasting relief. He has refused to even try the newer ones (Frova, Axert, Relpax). The only med that even touches the pain is Demerol, which his family physician provides by injection at the office. One of the headache specialists suggested that his headaches were rebound, but after detoxing from the Demerol and going through 6 months of sheer agony, without taking any analgesics, not even an aspirin, he was still having about 2 per week. He stopped seeing the HA specialists when they told him they had nothing else to offer, so he is getting the prescriptions he uses from the family doc. He still presently has about 2 headaches per week. He takes Zofran and Zanaflex by mouth, along with Demerol and Vistaril by injection, for severe HA. He takes Klonopin for sleep and Lexapro for depression. Until recently, he was on a 50mg Fentanyl patch, in hopes of not having to use the Demerol for pain relief. He could use less Demerol, but not stop using it altogether.
     My question has several parts: Would the pain med/opiate substitute Bruprenorphine be worth trying and should he be seeing a pain specialist, since none of the standard preventatives seems to work? Has the MAO-B selegiline been shown to have any preventative effects for HA (since it has a lower risk profile, perhaps not the side-effects of MAO-A's)? Would it be worth trying the newer triptans, even if he's been a "non-responder" to the other triptans? (I have read that some "non-responders" are not actually non-responders, but when given higher doses, get relief.) Any help you can give would be most appreciated, since he has not been able to work a steady job since 1996, and he either needs to get better or go on disability.
Thank you!

REPLY:
I'll answer the different parts of your question in the order they came up: buprenorphine may have some limited benefit but probably not as a long-term primary treatment option. Besides, it has to be given into the muscle, unless compounded. Seeing a pain specialist may not get your husband very far, since many do no want to see headache patients. I personally don't get it, but many times an arbitrary division is made between and headache management. Most pain management center are run by anesthesiologists, and they don'y, by and large, have an interest in headache treatment. I don't know of any decent data with selegiline for migraine prevention. Newer triptans at least have the benefit of a longer half-life, which may be desirable. Size of the patient does matter and more aggressive dosing sometimes works better. But, doctors are afraid to go beyond what they perceive are "limits", often dictated by the package insert. Sounds like the best bet is a true headache specialist, since many new agents can successfully reduce the frequency of headaches.

Good luck.
John Claude Krusz

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