TREATMENT
Abortive Medications
Triptans, such as DHE, ergotamine, isometheptene (Midrin), rizatriptan (Maxalt), eletriptan (Relpax), sumatriptan (Imitrex), zolmitriptan (Zomig), and naratriptan (Amerge) bind to serotonin receptors, reducing pain by blocking TNC and reducing secondary sensitization. [8] They are highly effective with minimal side effects. However, they are highly addictive and cause rebound.
Prophylactic Approach
First line prophylactic approach is strict adherence to the “migraine diet.” David Buchholz, M.D., formerly of Johns Hopkins, in his Book, Heal Your Headache, [10] gives a comprehensive version of the diet. In short, it is recommended to quit all food triggers for three months, in order to rid the body of all metabolites. These foods include, in general, caffeine, chocolate, MSG, processed meats and fish, fermented dairy products, nuts, alcohol and vinegar, citrus fruits, dried fruits along with some other fruits, some vegetables, especially onions, yeast, and aspartame. The three major substances thought to be causative triggers are histamines, phenylethylamine, and tyramine.
If after three months, there is no clear difference, the patient will move onto prophylactic medications. If, however, there is significant help with the removal of trigger foods, the job is to add back foods, one at a time, to find out which food is the culprit.
Prophylactic medications - these may work for many people, but in my experience, there are many people they do not work for, or not for long. I ended up on 4 prophylactics at once. My hair fell out. I was severely constipated. One was an addictive benzo and the other had a severe withdrawal syndrome. Plus, though they got me out of bed, I still couldn't get out of the house. Give them a try, but keep in mind they are serious meds with serious side effects. As well, know that there is a natural alternative with absolutely no side effects, just a return to health.
According to Dr. Hain, the mechanisms of most of the prophylactic medications are not well understood, but they all work about 75% of the time and take weeks to months to work. According to Dr. Rauch’s Online Mass Eye and Ear Otology Clinic, a patient with migraine-associated vertigo will always need a vestibular suppressant to lead a full life free of symptoms. [9]
Dr. Hain categorizes prophylactic medications as follows: [8]
CSD blockers: Anticonvulsants
These probably raise the threshold for CSD and include the following:
topiramate (Topamax)
Topiramate is about 75% effective. The starting dose is 25 mg and the recommendation is to titrate as needed, in weekly 25 increments, up to 150 mg. Side effects include, but are not limited to, weight loss, hair loss, speech disturbance, difficulty in word-finding and tingling in the hands and feet. Toprimate is $1 a dose.
Other anticonvulsants used include: gabapentin (Neurontin), sodium valproate (Depakote) and levetiracetam (Keppra).
Mysterious mechanism agents: Beta blockers and L-channel calcium channel blockers
Beta blockers are 75% effective. The mechanism is unclear:
Any beta blocker will work: propranolol 60 LA, metoprolol 50 XL, or atenolol 50-100 mg a day. Side effects include fatigue, slow pulse and hypotension. It takes one month for them to work.
L-channel calcium channel blockers including:
Verapamil which is 75% effective. The mechanism is not well understood, although it possibly blocks TNC or possibly relates to the calcium channel gene. The therapeutic dose is 120-240 mg SR. It takes two weeks to work. The main side effect is constipation. If the patient is not constipated after two weeks, he/she may increase the dose.
Neurochemical modulators: Antidepressants
Venlafaxine (Effexor) is 80% effective. Mechanism is not very clear. Effexor is an SNRI and SSRI. It is very useful in managing the sensory amplifications seen in migraine. It is inexpensive. The starting dose is 12.5 mg, increasing slowly to a maximum of 75 mg. Side effects are minor. However, high doses have a difficult withdrawal syndrome.
Tricyclics – amitriptyline/nortriptyline. Dr. Hain calls these “messy agents.” They work as central antihistamines, and on norepinephrine and serotonin receptors. They accumulate in the body. A weight gain of 25 pounds is not unusual when using these medications.
Supplements
A handful of supplements are regularly taken by migraineurs. Riboflavin has been rigorously studied [11] and has demonstrated a reduction of migraine days and hours by 44%, although no reduction in intensity in headache.
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