What other preventive medicines are possibilities Dr. Robbins?

When we initially see a complicated headache patient, our list of possible medications take into account a number of factors, including all of the comorbidities: psychiatric, medical, and gastro-intentinal. It is helpful to note these other medicine possibilities in the chart since headache patients call often, as the meds may be ineffective or have side effects. We need to be able to easily switch meds. If you work with other physicians, they should be able to scan the chart and select another appropriate med.

With Heather, other preventive possibilities would be noted in her chart, as follows:

* Petadolex, an excellent evidence-based preventive (probably the most effective “natural” preventive; we do cycle off Petadolex periodically, due to carcinogenic concerns in animals).

* Lamotrigine, which may be helpful for her mild bipolar depression, although there is less evidence for helping the headaches.

* Verapamil, which may help the headache, and also the diarrhea with IBS.

* Gabapentin, which is safe, inexpensive, and easy to use; available as a longer-acting form, Gralise.

* Sodium valproate could help her bipolar depression, but weight gain is a drawback, and we would need to warn her about risks of pregnancy; because of the major concerns with the fetus, valproate is not usually used in young women.

* Oxcarbazepine, an anticonvulsant with more efficacy for her bipolar issues rather than headaches; available as a longer-acting preparation, Oxtellar XR.

*ARBs such as candesartan (Atacand) or losartan. These would avoid the weight gain of the beta blockers. Candesartan has been the most studied of this group.

* Muscle relaxants such as tizanidine (Zanaflex), cyclobenzaprine, etc.

It should be noted in Heather’s chart that lithium is a possibility, not for the headaches but for the bipolar issues. Lithium is underused, and many mildly bipolar patients state that they “finally feel normal” once lithium is given. In addition, the atypicals, such as quetiapine (Seroquel), or aripiprazole (Abilify) may be useful not only for Heather’s moods but for headaches as well.

Drugs that we want to avoid include the tricyclics (amitriptyline, nortriptyline, etc.) as they may exacerbate the bipolar illness and cause weight gain.

If Heather is on adequate mood stabilizing medication, we may be able to utilize antidepressants. The use of antidepressants in bipolar patients is still controversial. For some, they help the depression with no side effects but, in others, even a small dose will trigger hypomania. If Heather is on mood stabilizers, we may be able to add a small dose of a selective serotonin reuptake inhibitor or similar medication.

Beta blockers are also to be avoided, as we do not want to incur weight gain, and these may exacerbate Heather’s depression. If a patient’s headaches are improved but he or she gains 20 lbs and is always tired from the medicine, it is not the answer in the long run