TeriGuide 

Hi, Dr. Robbins. Welcome!

Dr. L. Robbins 

Hi everybody...Teri....

DonHost 

Hi Dr Robbins.....have read and heard a lot about you for many years!

TeriGuide 

Jasmine?

Jasmine 

oh thank you, Dr. Robbins... I'd like to know your thoughts on Pfizer's new medication Relpax --isn't out in the US yet

Dr. L. Robbins 

Relpax is nothing too special ... a me too med ... not terrific, I am surprised that they are releasing it. Axert is actually better, and Pfizer now owns Pharmacia who has Axert.
  

TeriGuide 

Would you compare it to any of the other triptans?

Dr. L. Robbins 

I think it has more side effects than most, and efficacy is not any better...it did not look good in comparative studies.

Jasmine 

thank you

Dr. L. Robbins 

I do like the Triptans a lot..I just summarized an article, Triptans vs. Analgesics, on my site (www.headachedrugs.com) We published it this month in HEADACHE. In that article, we asked 670 people who have had any triptan what they like, and 70%% prefer triptans over pain meds and the others BUT... most people have 3 or 4 abortive meds around, and 50%% of people take something else before or with a triptan...

TeriGuide 

That's interesting. I always reach for a triptan first.

Donna 

I prefer the Maxalt MLT. It always works for me within about the first 15 to 20 minutes of us.

Dr. L. Robbins 

Maxalt is terrific... It combines good efficacy and is well tolerated...

TeriGuide 

I'm sticking with Imitrex so I have choice of tab or injection.

Dr. L. Robbins 

Imitrex still is #1, despite the competition..

Barblovesroses 

Dr. Robbins, Thanks so much for sharing with us - I use Axert for abortive - works for me in the way Imitrex used to work. I also have fibromyalgia - do you have any idea why so many migraine patients also seem to have fibromyalgia? I have a really tough time getting mine under control.. am presently taking topamax for preventive and with it have finally gotten mine down from 4-6 days to 3-4 days week for first time in nearly 3 years.

Dr. L. Robbins 

Fibro, in the end, may well have a genetic/serotonin basis, just like migraines....sort of the same chemical processes in the brain, but more lower down in the spinal cord...

Jasmine 

who diagnosis fibro...a rheumatologist?

analisa 

which would be the same reason many of us have depression? (the serotonin issue)

Dr. L. Robbins 

FMNETNEWS is a very good website/organization, with a great newsletter

Barblovesroses 

I think I get their newsletter but I will make sure its one I get

Dr. L. Robbins 

Rheumatologist usually, but also most good docs (neuro/FP/INT)

Barblovesroses 

My neuro sent me to a rheum to confirm diagnosis

Dr. L. Robbins 

Other neurotransmitters (glutamate being one of them) are fertile ground for new headache meds

Joyce 

but when will they be available

Donna 

I've just been through a really rough spell, and though I take Topamax and Sansert on a daily basis I've been on IV Depakote and Dexamethasone for the past week to abort a really bad cycle. This has worked well for me twice in the past 6 months. After the IV barage, I go back to my regular PO routine. Why does the IV Depakote break up the attake so well?

TeriGuide 

Donna, you may want to talk to your doc now. I just got an FDA notice that Sansert is discontinued.

Dr. L. Robbins 

Yes, with Sansert hard to find, it will be tough for those where it was the only med that worked.

Donna 

I've just recently been put on a ""drug holiday"" from the Sansert. On Methergine right now.

Dr. L. Robbins 

Methergine can work but is also difficult to find We use a compounding pharmacist for this.

Donna 

My pharmacist is concerned about me taking it (the methergine) for any length of time. They are afraid of side effects long term as it is usually a short-term med.

Dr. L. Robbins 

Methergine has not been tested long-term, it may carry the same risks as Sansert for the long haul.

Joyce 

what about glutamate blockers in the future? I get 20 minutes or more of chest pain from triptans so taking them scares me

Dr. L. Robbins 

Many years till available of these newer generations such as glutamate, nitrous oxide meds

Joyce 

how much chest pain from a triptan is too much?

Dr. L. Robbins 

triptan chest pain is usually not cardiac (but can be). More than mild, I quit that drug and do something else..

lesherb 

Dr. Robbins, I suspect I have more than just migraines, not rebounds but a general headache of some sort which affects more frequently than a migraine attack. What can be used to prevent these headaches in medicinal form, the usual migraine preventatives or something different?

Dr. L. Robbins 

lesherb, I would suggest reading a lot about chronic daily headache and migraine, and finding a good headache specialist

lesherb 

Thank you.

Barblovesroses 

Why are insurance companies so resistant to paying for compounded medications?

Dr. L. Robbins 

insurance companies try and avoid paying for anything,...

Jasmine 

amen

Donna 

Why does the Depakote IV work to break up my really bad intractable migraine cycles?

Dr. L. Robbins 

Depacon(iv) has a number of possibilities as to why it works.. I have used it quite a bit.. it stabilizes GABA, a neurotransm system crucial in chronic daily headache  and migraine ..it is a safe approach, in general

<Mollymae> 

Is there anything showing any promise that is newer than Topamax?

Dr. L. Robbins 

Nothing great as far as daily preventives. We very much need better daily preventives

Joyce 

What is the max Topamax dose you use?

Dr. L. Robbins 

300 or 400 mg daily, but I average 50mg daily..low doses..

Donna 

So many people are scared of the side effect of Topamax. Why has it gotten such a bad rap?

Joyce 

cause it makes you so very stupid.... who wants to be stupid..  200mg a day

Dr. L. Robbins 

topomax does have significant side effects.. memory. nausea, occasionally depression, etc etc

Barblovesroses 

Do women who have migraines become worse following surgical menopause continue to have problems with them into their 70's/80's

Dr. L. Robbins 

No, the hormones usually eventually get settled and the headaches often improve very much in the late 40's and 50's anyway...

Barblovesroses 

I sure hope thats the case...

Joyce 

At 47 I am not better( worse after surgical menopause), maybe in the next decade????

Dr. L. Robbins 

Several things happen as one gets into the 50's, that can help headaches.. arteries stiffen, hormones settle, brain chemical changes, kids move out (that is a joke)...

TeriGuide 

Do most of your patients do better with a single preventive or a combination of preventives?

Dr. L. Robbins 

I try and use just one but some need more.. the idea is to minimize meds, and get a balance between headaches and meds

Jasmine 

amen. mine have lessened since I've been on disability, but I know not everyone has that option. disability has let me detox

Jasmine 

DonHost 

In March, I had a Doc admit me to the hospital and put me on a Demerol IV Drip at 5mg every 15 minutes. I had lived with levels 8-9-10 for 10 years and it brought it down to zero and never about level 4. It lasted for a good number of months. 2 weeks ago, another Doctor put me in again for the treatment, but changed it to 10mg every 10 minutes and also added a 75mg Duragesic patch. Both times i was in the hospital, it was on the IV Drip for 4 days. This time I got no results from the treatment. With all that said, do you think that perhaps the increase in dose as well as the patch may have been too much to work? Or what do you think? He said he will do it again at the same lower dose that worked, but do you think going back to the lower dose may not work after trying the high dose treatment? (hope I made sense) *smile*

Dr. L. Robbins 

Don, I do not usually put anyone in the hosp., and iv narcotics do not usually help after you leave.. but the long-acting narcotics can help (the patch, methadone, Kadian, etc etc)

DonHost 

Thank You

<migrainemama> 

I have been on Lamictal since August and have just gotten up to 200mgs.,What is the highest dose of this med. that you use on your patients/

Dr. L. Robbins 

300mg of lamictal... it is a good med, very effective for depression of bipolar.. we see alot of mildly bipolar people who have migraines

<migrainemama> 

I have done well on it so far and have had no side effects

TeriGuide 

What's your take on the theory that there's a kind of ""headache continuum,"" with all headaches from the same source, just affecting eople in varying degrees?

Dr. L. Robbins 

I have been talking about the headache continuum. for over a decade now.. it is a very valid and proven theory...migraine at one end, tension at the other

Donna 

Where do we get into rebound headaches? My headache specialist is totally against narcotics because of them. What do you think? There is a lot of info out now about the triptans and rebound headaches.

Dr. L. Robbins 

Rebound is, in general, overdiagnosed.. People are told not to take any abortives. Rebound with triptans does certainly occur but is much less of an issue than with analgesics, such as a lot of Excedrin

<drpepper606> 

Seems my worst migraines are ones that I wake up - ones that became fullblown during the night. My choices are Amerge, Fiorinal, or Percocet generic. Which might be the best to try first?

Dr. L. Robbins 

I would usually use Amerge first, maybe with Fiorinal, and save percocet for if it is severe or nothing is working...

Barblovesroses 

I used imitrex very successfully for several years, but following my hysterectomy when my migraine frequency increased to the 4-6 day week range, it became ineffective for me and we switched to other triptans finally settling with axert. I wonder if axert stops working would I be successful if I tried going back on imitrex? One ER visit we tried an imitrex injection which did nothing. Do people ever get to the point where they can go back to a medication they once used that had stopped working for them?

Dr. L. Robbins 

Yes, if you go off a med, such as Imitrex, for awhile it can work again...or you could try a different triptan...

lesherb 

My doctors refuse pain killers and when I get into a situation where I want relief or death, I can only get myself to the ER for a shot of Demerol. Isn't there something I can take at home? I do not vomit and I'd love to avoid the inconvenience and cost of an ER visit. What do you prescribe as a RESCUE medication for your patients?

Dr. L. Robbins 

I do give narcotics, or make up a shot of Demerol or 2, I think narcotics are fine as escape meds

Joyce 

escape is a good word

lesherb 

so when are you opening up a practice in Daytona Beach?

Dr. L. Robbins 

Just before the Daytona 500

lesherb 

cool...I'll even put you up free of charge

TeriGuide 

Do narcotics cause rebound?

Dr. L. Robbins 

Narcotics can cause rebound certainly...

Jasmine 

Dr. Robbins, have any of your patients suffered from multiple chemical sensitivity? I became sensitized to perfumed coworkers after we moved into a small room. If not, who would be the right type of doctor to diagnose MCS?

Dr. L. Robbins 

I have had a few patients with MCS, and certain allergists diagnose and treat. Many do not believe in it, however...

Jasmine 

thank you

Dr. L. Robbins 

drpepper, there is a headache doctor in Chicago, Dr. Betsy Pepper....

Dr. L. Robbins 

I am adding a section onto my site called Dr. Robins opinions, just my opinions on all the various headache topics and controversies

TeriGuide 

Great!

Barblovesroses 

Thats a good idea Dr Robbins.

Joyce 

Do you have many pts with migraine and clusters

Dr. L. Robbins 

yes...many have mostly migraine, with 'cluster aspects', such as menstrual migraine with cluster aspects

Joyce 

how are cluster aspects different than a dx of clusters

Dr. L. Robbins 

cluster aspects are sharp pains around the eye, some eye tearing or nose stuffiness.. but the primary, main symptoms are mostly migraine.. as opposed to true cluster, which are very much different.

Joyce 

does oxygen still work though

Dr. L. Robbins 

Oxygen can help clusters, not all that useful for migraines...helps 60%% of clusters

Joyce 

O2 helps my ""clusters"" so I was wondering that's all....

TeriGuide 

Are you using Coenzyme Q10, Dr. Robbins?

Dr. L. Robbins 

I like COQ10, for the heart and maybe headache. Needs more study, but appears to be safe.

<Jan> 

Dr Robbins, you said 50%% of people take tryptans with something else; what do you suggest taking with a tryptan?

Dr. L. Robbins 

mostly we use nsaids with triptans (regular nsaids, such as ibuprofen or naproxen, or Cox2 inhibitors, Vioxx./Celebrex)

Barblovesroses 

I have heard that potassium can help with the tingling side effect from topomax? How much potassium do you suggest taking?

Dr. L. Robbins 

Potassium can counteract that side effect, low doses (doses are not studied well as yet)...

Jasmine 

Dr. Robbins, does your website discuss Candida or diet as they pertain to migraines?

Dr. L. Robbins 

We discuss diet, not so much yeast.

Jasmine 

thank you

Donna 

Every time I have bloodwork done my potassium and magnesium are low. My neuro says this is common with migraine patients. Do you see this to be true in your practice and if so why?

Dr. L. Robbins 

Potassium is not usually low in migraineurs, and neither is blood magnesium BUT.. the magnesium levels in the BRAIN are low, which has led to using magnesium oxide for prevention

Donna 

Thank you.

kiddin 

I have been taking singulair for about 2 months with great success but the last 1 1/2 weeks have been awful. just prior to this we were close to going to oxycontin

Dr. L. Robbins 

singulair had promise (it affects the immune system, as a leukotrine inhibitor, but studies on it have not panned out.. it is very safe, though)

kiddin 

is it possible to have stopped helping

Dr. L. Robbins 

Anything for cluster or migraine can wear out once you use it enough

kiddin 

I'm concerned as I was doing very badly prior to this try as recommended by neuro to my headache dr

<drpepper606> 

Last MRI showed I have arnold chiari malformation. My neurologist kind of blew it off. Should I be concerned? Jan, who just likes to drink Dr.Pepper

Dr. L. Robbins 

Depends how significant the Arnold Chiari is...usually we leave it alone, if you do not have other symptoms...

Donna 

I've had Chiari decompression. By the time I had it done it was causing seizure side effects that were tearing up my life. I knew it had to be fixed and it changed my life radically by that point. Before that, when there were no symptoms, I just left it alone.

lesherb 

why are only migraineurs subjected to rebound pain? I never hear of anyone taking narcotics for a broken bone, for example, end up with rebounds. Do you suppose it's because migraine pain is not really what's wrong? Migraine pain is just a symptom of some other serious problem?

Jasmine 

good question

Dr. L. Robbins 

Migraine people have a chemical predisposition to headache...others do not ... so migraineurs get headaches from certain narcotics (sometimes), while others do not. It is the 'chemical milieu', genetically determined, that sets some up for headache from certain meds, weather, stress, hormones, undersleeping, etc

TeriGuide 

Which class of preventive meds do you see the most success with?

Dr. L. Robbins 

Depakote and older antidepressants (Elavil, pamelor), and for migraine the beta blockers.. but side effects get in the way of all of these...

Jasmine 

My last neuro suggested Botox. Have any of your patients seen results?

Dr. L. Robbins 

I have done Botox in 430 pts...about 55 to 60%% of people are improved enough...it is not a miracle

Dr. L. Robbins 

It is safe in the short run, but we do not have studies for years on it (every 4 months for 10 or 20 years)

Jasmine 

thank you

Joyce 

beta blockers made me so much worse, is that because I also cluster?

Dr. L. Robbins 

Any class of med can, in susceptible individuals, make headaches worse...

Dr. L. Robbins 

I do not love beta blockers due to the side effects...

Jasmine 

I agree

Jasmine 

the dose makes the poison

kiddin 

What do you suggest when you preventative drugs haven't helped a lot, botox hasn't

Dr. L. Robbins 

There are certain 'end of the line choices...

kiddin 

what are the end of the line choices?

Dr. L. Robbins 

long-acting opioids, MAO inhibitors, frequent or daily triptans,2 or more preventives at a time,.. you need to be willing to accept the adverse side effects...

lesherb 

what long acting opiods?

lesherb 

What do you feel about 300 mgs 3xday, 150 mgs 1xday, .05mg synthroid 1xday, Vioxx as needed during my cycle, Ambien 10 mgs at bedtime. Axert 12.5 mg as needed...no more than 3 in a week

Dr. L. Robbins 

300 of what med?

lesherb 

sorry...neurontin

lesherb 

150 mgs Effexor XR

Jasmine 

Dr. Robbins, with all this talk of meds, how much do we have to worry about liver damage?

Dr. L. Robbins 

liver toxicity and kidney toxicity can occur with a lot of meds...we need to watch lab tests.

kiddin 

how often should workups be done and what kinds of blood work

Dr. L. Robbins 

It depends upon which, and how much, meds people are on... nsaids (Vioxx, Naproxen) and otc's need more monitoring, and meds like Depakote need closer watching

Donna 

I think the standing thought is that preventives just make the pain more tolerable and maybe shorter in duration for periods of time before you have to change your preventives. Do you see this to be true?

TeriGuide 

Donna, preventives have GREATLY reduced the frequency of my Migraines.

Donna 

Mine also, but I hear such negative feedback from so many other sufferers.

Dr. L. Robbins 

preventives work ok for the long-term in about 45%% of patients..

kiddin 

what do those of us do when the preven. Rx stop helping?

Dr. L. Robbins 

People often need to change preventives, or stop them for awhile.....sometimes long-acting opioids are a decent choice

kiddin 

like oxycontin

Dr. L. Robbins 

Oxycontin is a decent med, but it only lasts 4 to 7 hours, not the 12 that usually is stated

kiddin 

do you ever recommend drug holidays

Dr. L. Robbins 

We use a drug holiday (crummy term.. some holiday!) with Sansert, and in young people with daily meds.. I hate to commit adolescents to meds forever...

TeriGuide 

Would a severe Vitamin B12 deficiency have an effect on Migraine?

Dr. L. Robbins 

B12 is a nitrous oxide inhibitor, which is what we want for CDH...research has pointed out that nitrous oxide is crucial..

Dr. L. Robbins 

in Chronic Daily Headache.. in Europe they have a Vit B12 nasal spray, cause it is not well absorbed

Joyce 

how much b12

TeriGuide 

Hmmmmmmmm. Well, my primary just discovered my level to be exceedingly low. Maybe this B12 Nasal Gel Spray will help

Jasmine 

Teri, is that sold in the US?

Dr. L. Robbins 

....I do use B12 injections here and there, but usually large doses of tablets...1000 or 1500mcg daily

TeriGuide 

I don't think this one is the one being used in Europe. It's Nascobal.

Jasmine 

thanks

Dr. L. Robbins 

truly low B12 is usually pernicious anemia, and your gi system needs to be assessed....

TeriGuide 

My doc is blaming gi system. I had the surgery for GERD

Dr. L. Robbins 

no, the nasal gel is different than the Europe one..

Joyce 

I have gerd as well,,, are we seeing a pattern

TeriGuide 

That's what I thought. Saw the Cephalalgia piece on that European spray.

Joyce 

I take 100mg Topamax BID and 160 mg Calan TID and still have migraine or cluster most every day. I take no OTC's I limit pain meds to less than twice a week for the rebound issue. I use oxygen and phenergan as needed. But my doctor wants me to try lithium for my clusters and that scares me....

lesherb 

what is the typical dosage of anticonvulsants compared to the dosage of these same meds used for migraine prevention?

snuggelbear 

Are there any preventives or abortives that are safe to use during pregnancy??? Or while trying to get pregnant?

Dr. L. Robbins 

during preg, we try and avoid dailies.. but if absolutely necessary, certain antidepressants can be used, or beta or calcium blockers.. but we try and avoid during the first tri...

snuggelbear 

so what about while trying to get pregnant?

Dr. L. Robbins 

we use all the meds trying, but if it is possible that you are pregnant (missed period or late, etc) we stick to tylenol/caffeine, aspirin free excedrin), and pain meds (certain narcotics) and occasionally anti-nausea meds are used during preg. We need to avoid most daily meds, and avoid triptans.

snuggelbear 

like tylenol 2 or 3

snuggelbear 

like Diclectin for anti-nausea

Dr. L. Robbins 

yes, tyl 2 or 3 or Vicodin or Darvocet

Dr. L. Robbins 

occasional metoclopramide or (expensive- Zofran for nausea.

snuggelbear 

I don't believe Darvecet is one I have seen in Canada

Dr. L. Robbins 

Zofran is the only one that does not cause tiredness..

snuggelbear 

Zofran though is mostly for Cancer pts

Dr. L. Robbins 

Darvocet is propoxyphene

snuggelbear 

ok that we have

Dr. L. Robbins 

Zofran is also used for migraine nausea (or any nausea)...

Donna 

Zofran in the oral disintegrating form is great.

snuggelbear 

I work as a pharmacy tech and am trying to battle the everyday migs again without taking to much because I want to get pregnant. I tapered off of Topamax which I had great luck with thank you

Jasmine 

Dr. Robbins, how long until patients are screened...this way each individual can be treated as needed? Hope that makes sense.

Dr. L. Robbins 

screened for what??

Jasmine 

for whatever...I thought I heard on the news that scientists are working towards individualized health care

Jasmine 

instead of placing people in a box

Jasmine 

I long for the day when a doctor can diagnose me w/o running through a 1,000 questions. Let the tests speak for me, so the proper treatment can begin. Instead of all this trial and error, let's take every med out there, type of health care. I know, I'm dreaming ;)

Dr. L. Robbins 

got to go, thanks a lot, it was fun...

kiddin 

thanks

Jasmine 

Thank you so much Dr. Robbins

TeriGuide 

Thank YOU, Dr. Robbins.

snuggelbear 

Thank You !!!!

Jasmine 

have a great night all

Joyce 

thank you great food for thought.....

Barblovesroses 

Thank you so much for being with us and sharing your time and thoughts

Donna 

Thank you!!

Dr. L. Robbins 

I would be happy to come back anytime, Teri.. you do a terrific job...

lesherb 

This was great. I'd love to have all the time in the world to pick his brain! It was very thoughtful of him to use his free time to come here. Please tell him how much I appreciated it. Happy Thanksgiving. This is one of the things I am thankful for this year....people who understand. Good night all.