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Headache Management Case Report
Posted Dec 1998

(Many of these medications are not officially "approved" for headache. Only take medicine upon your physician's advice.)

Linda is a 43-year-old woman with frequent migraines and moderate intensity chronic daily headaches, increasing around her menstrual period. She has worsening headaches from stress, hormone changes, and exercise. Weather changes also bring on a migraine. Biofeedback/relaxation helps to a small degree, but she does not feel it is worth the effort. Acupuncture helped, but for a very short time only. Chiropractic relaxed her neck, but did not achieve any long-lasting help. Herbs, such as feverfew and ginger, and vitamins, such as the B-vitamins, were of no help.

She has severe nausea and vomiting, with long three-day migraine, almost every menstrual period. Linda's mom and daughter both have headaches. Her mom's headaches improved after menopause. Psychotherapy helped coping with the headaches very much, and helped issues in Linda's life, but did not help the headaches. Two previous medications, Elavil and Inderal, helped somewhat, but caused a great deal of weight gain and she could not take them. She was also very tired on these. She could not tolerate Stadol. Prozac and Zoloft did not help.

As far as abortive medications in the past, Fiorinal helped, but she ended up overusing it because of the daily headaches (on eight per day) and Fiorinal was stopped. Norgesic Forte irritated her stomach. Anti-inflammatories also upset her stomach. Midrin did not help. Compazine helped the nausea, but she was tired.

What to do now? At present, Linda is placed on Depakote, 250 mg. with dinner for five days, and then 500 mg., once with dinner, and we could go up on it to 500 mg. twice a day, or even higher. An average dose is 750 mg. per day. We give Linda Zofran for nausea, which is very expensive, approximately $16 or $17 per pill, but is also very effective (without any fatigue). Verapamil did not help, so we are not going to use this medication, although it is mild and safe. Imitrex is given to Linda, and the pills do help. She saves an Imitrex shot for severe menstrual migraine, which helps more. Norflex is a mild muscle relaxant and also helps the chronic daily headaches, and she takes one twice a day with an Aspirin-Free Excedrin. The occasional shot of Imitrex causes nausea and chest heaviness, but these side effects go away within 20 minutes and the headache then is 90% better.

Three months later: The daily headaches are better on Depakote, but the migraines seem just as frequent. The menstrual migraines are particularly severe, but Imitrex does help. However, they are lasting for three days and we give Linda cortisone, in the form of Decadron 4 mg., to take one every eight hours with food, three pills in a month only at most. We warn her about all of the side effects of cortisone as, of course, we warn everyone about the side effects of all of these medicines. We will consider Sansert, in low doses, around the menstrual period, or Bellergal, or even a hormonal approach, such as tamoxifen, or progesterone, or estrogen, but the menstrual migraines are always the most severe. They tend to be worse in the 30's and 40's are very debilitating. There are other medications for daily preventive medications, but avoiding GI upset and weight gain can be difficult, particularly with women in their 40's and 50's.