Brief Answer:
Variety of reasons for medication to not work

Detailed Answer:
Thank you for your question. I've read the response by my colleague and understand some of the additional information about your headache and as a headache specialist and neurologist would like to make the following comments.

Medications don't cure headaches universally probably a variety of reasons. Please keep in mind that headache treatments are different from something as straight forward as strep throat which virtually responds in every human being by them penicillin. That's probably one of the few examples in medicine where one specific treatment for a human ailment works predictably, consistently, and completely.

Everything else in medicine is highly dependent upon the INDIVIDUAL PATIENT and their body chemistry, the accuracy of the diagnosis, the severity of the problem, and then, a thousand other factors having to do with other conditions the patient that may interfere with the co-existent diagnosis which may change the person's response to the "usual" medication, their diet and how food can affect medications that are prescribed, the compliance of the patient (how precise and good they are about sticking to the exact instructions on how to take the medication). When you have to take those factors into consideration and "GUESS" the best drug to take for something like a headache then, unfortunately, doctors (even headache specialists) could very well be WRONG more times than they are RIGHT on the very first try. I hope that makes sense and explains potentially a little bit of why your amitriptyline "does not seem to be working."

As an aside, whenever I choose to use the class of medication of TRICYCLIC ANTIDEPRESSANT which is what amitriptyline is....I almost always first choose NORTRIPTYLINE (Brand Name Pamelor). My patients almost universally have a better tolerance to that drug in terms of side effects compared to amitriptyline. It also allows me to titrate the medication to higher doses before getting really intolerable side effects compared to amitriptyline which could start giving people trouble all the way as low as 10 or 20 mg.

So now that you understand a bit on why a first choice of drug may not work based upon an individual's chemistry and reduced response potential let me offer some other possibilities:

1. Medication may be underdosed. Typically amitriptyline is increased slowly from 10mg. on a weekly basis and given at bedtime (once daily) up to a maximum ceiling of 50mg. On occasion I will push past the 50mg. mark in a patient depending upon what their headache log is showing. You say for example that the amitriptyline is NOT WORKING at all....but if you in fact, have gotten to the usual ceiling dose of 50mg. is is possible that the drug may be working "somewhat?" but that you simply don't notice its benefit because of the fact that in actuality what you're really looking for is "complete relief?" Anything short of that would be an assumption that the drug is not working at all.....but if there were any small bit of improvement I might consider pushing the dose a bit higher into the 60+ range.

2. Interactions with other medications?

3. Type of headache may better merit another prophylactic agent such as a calcium channel blocker which I have always found helpful in a good number of my patients who have some sort of intracranial pathology. In your case even though you don't have an actual ruptured brain aneurysm the fact of the matter is you do have a stent which means you've had a neurosurgical or at least an invasive radiological procedure involving brain structures. This means that other types of repetitive pains generated through the trigeminal nerve may be more response to medications such as INDOMETHACIN and not anything through the TRICYCLIC CLASS.

4. I would try and see a headache specialist because there are even other options that could be better than the standard TCA class of drugs we use for standard migraine types of headaches.

5, There is another problem I notice right away and that is you are taking much too much Advil. At twice daily you are in a high risk category of what we call MEDICATION OVERUSE HEADACHE and this means that by virtue of taking that much of an abortive medication there may be an actual INCREASED PRODUCTION of headaches making it more difficult for the amitriptyline to work. I would highly recommend you reduce the amount of daily Advil. Recommendations to avoid MOH state that less than 15 doses of such medications should be taken. At twice daily you're going to be taking at least 60 doses monthly.

I have some patients who have sung the praises of Hawthorn root but there are no good controlled scientific studies to validate its effectiveness. So long as there are no significant consequences I cannot see where it can be harmful to try it for a short period of time.

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Brief Answer:
Higher risk of stroke in migraine WITH AURA patients

Detailed Answer:
Thank you for your return response and clarifications. In terms of stroke risks getting MIGRAINE types of headaches under control WITH AURA.....not migraines WITHOUT aura or really any other type of primary headache is associated with increased risk of stroke. It sounds that in your case your headaches are secondary to the procedure of the stenting. You've not said anything about visual or other aura before, during, or after your headache (which seems to be constant and not episodic as migraine headaches are themselves) therefore, I don't believe that your risk for stroke is elevated in this case simply based upon the fact that you are having chronic daily headaches.

I don't understand the logic of restricting your activity levels on the basis of the stenting and procedures....in fact, in my opinion, that sort of thinking is rather old school and since we're not talking about any Major Surgical incisions that still need healing, stitches that could be loosened by the physical force of dancing, or other exercise activity, etc. then, if you were my patient I would trying to encourage you to get out there and cut a rug as soon as possible.....if you are feeling up to it.....if you YOURSELF don't feel up to it...then, that's a different matter and I would be happy to wait for you to feel better....but I don't think that there should be an automatic mandate of any sort barring activity from what you're describing....people get even more major brain surgery itself and can get back to normal activities in short order...it just depends on the person and how they feel I believe.

I agree with you that these are unlikely to be migraine headaches by description. The actual definition of a migraine headache is an EPISODIC event that lasts a minimum 4 hrs. and a maximum of 72 hrs. Pain is intense, usually one sided and is accompanied by at least 2 out of the following 4 symptoms: Nausea, vomiting, photo and/or phonophobia which refer to light and sound sensitivity that many people have with these types of headaches. These headaches do not qualify for these criteria therefore, I do not think they are migraine. I further believe that if you could find your way back to some more normal physical and social activities you were used to doing before this procedure that you could in fact ACCELERATE the healing process....by staying out of things....you only serve to prolong convalescence which only favors the state of chronic pain and with the amount of Advil you're taking....CHRONIC DAILY HEADACHES.

I believe that the feeling you have in your head...or headaches if we should put a more common name on them....is very possibly the unfortunate consequence of the surgical procedures/manipulations that have taken place in order to get that stent placed as well perhaps as any chronic type of pain/irritation/damage that may have occurred to any brain structure as a result of being squeezed/compressed or otherwise compromised by the presence of the aneurysm before it was found. These headaches or these chronic pain then, would be an entity which we would HOPE would subside on their own and with the aid of proper medication treatments but there is not way to predict with certainty if or when they may completely subside.

It is very much like predicting when the pain from a fractured arm or leg is destined to go away. We hope that as healing continues and the person becomes more XXXXXXX and active that their skeletal structure adjusts and bounces back without any pain or discomfort......BUT we realize and recognize that people exist who are always left with residual pain symptoms..the severity of which varies from one patient to another.

I think if you stay the course with BEST MEDICAL and/or other treatments with appropriate and WITHOUT EXCESSIVE use of analgesics and get back to activities and social activities that you would be giving yourself the very best chance at a full recovery. BTW, I recommend being very careful with the RECOMMENDED doses of Advil. Manufacturer's ideas of acceptable doses are quite different from headache specialists who typically do not like to see patients taking more than 2-4 tablets of any OTC medication for a chronic headache.

You should consider non-pharmacological alternatives. A very good example of something that my patients have found absolutely a XXXXXXX to use for headaches of all varieties and chronicities is called a THERMAZONE device. You can find it on the internet. It is an FDA approved device not just for headaches but for other pains and headache patients I've prescribed it for just love this machine. Problem with it? Most insurances will not cover its cost but you can always run it past your own insurance carrier and see what they say. And there are other alternative forms of dealing with headaches such as breathing techniques, relaxation therapies, biofeedback, acupuncture, and other holistic/alternative forms of dealing with headaches...of which you also brought up the use of Hawthorne Root.

BTW, I do NOT RECOMMEND and in fact, actively counsel patients NOT TO engage in chiropractic manipulation of the cervical spine when it comes to treating headaches. These are dangerous maneuvers, are not curative in the least though some people report short term relief, and place patients at great risk for consequences which increase with age.....strokes can occur from that sort of intervention and they can be devastating. That is one alternative intervention I am clearly against.

Everything else in my opinion is fair play to try if you've done other things that don't seem to work. Keep "drugs" though to a minimum.....I believe those are the least likely to help in the long run as opposed to physical and other stimulatory activities that can help your brain start to REFOCUS on making other things important as they were before the stent.....as opposed to thinking about the pain. Make sense?

If I've adequately answered your questions could you do me a huge favor by CLOSING THE QUERY and being sure to include some fine words of feedback along with a 5 STAR rating if you feel my answers/suggestions have helped? Again, many thanks for posing your questions and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 88 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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