Question: Excruciating headaches after change from prednisone to methotrexate?
Answer:
Full Question:
My husband, age 75, suffered a bout of severe
dehydration last July, as a result of an attempt to wean him off prednisone and
supplant his therapy with methotrexate for recurring Polymyalgia Rheumatica. His
dose of methotrexate was 10 mg. weekly -- he had only taken 2 weeks' worth, a
total of 20 mg., when he suffered constant nausea, 15-lb. weight loss, and
severe dehydration, resulting in an overnight hospital stay in which 8.0 liters
of fluids were administered over the course of 24 hours. Shortly after, he began
having excruciating headaches. To date, he has been seen by an ENT specialist, a
neurologist, a rheumatologist, a neurologist-ophthalmologist, in addition to his
regular internist. He has had three CT scans performed, 2 of the sinuses, and
one of the brain, all with negative results. In addition, there has been an MRI
of the brain, again with negative results. He has also endured a left temporal
artery biopsy in the quest for evidence of Temporal arteritis, and when that
proved negative, he was subjected to bilateral carotid artery doppler. That exam
showed less than 40% occlusion in both carotids, which was interpreted as
non-eventful. Based upon all the negative findings, the neurologist, who was the
last physician seen in this chain of events, diagnosed the headaches as
tension-related, because there was nothing else obviously wrong. Prescribed
Elavil, 25 mg. daily, for a month, followed by 50 mg. daily beginning the second
month. No improvement was seen, so the regular internist discontinued the drug.
My husband is extremely intolerant to many medications, so he has been taking 2
Fiorinal tabs (sans codeine) every 6 to 8 hours as needed to control the pain,
and has only yesterday been referred for Physical Therapy in an attempt to
provide some relief to these so-called "tension" headaches. My husband has had
recurring PMR since 1996, and has been on prednisone therapy at different times
since then. He is currently on a "weaning" process from a 20 mg./day dose to his
current level of 13 mg./day. That frequent reliance on prednisone, along with
the serious dehydration episode from the methotrexate trial, are the only
significant features in his health picture. He has no heart problems or
diabetes, and has never had -- he has been a healthy individual until the PMR
episodes began, but he does not have any significant abnormal findings at this
time. Except for the excruciating headaches which never leave. Do you have any
ideas? Mary Anne.
Answer:
Dear Mary Anne;
Obviously, diagnosing and treating in this column are not appropriate. The headaches may have several bases: the prednisone may be a culprit of sorts; Fiorinal may also lead to an intractable headache we call analgesic rebound headache (or medication overuse headache). PMR may also be associated with headaches. Hard to know who's on first. My strongest suggestion is to seek out a headache specialist in your area; most neurologists are not. Hopefully they could coordinate with the rheumatologist.
Good luck,
John Claude Krusz
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Published November 27, 2005
