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Suggest Treatment For Severe Migraine
Question: Dear Dr,
A severe migraine case in a 19y/o girl, multiple daily recurrence, resistant to any therapeutic approach up to this point (Dipyrone, Ibuprophen, Topiramate, Eletriptan, Lornoxicam, Verapamil, Amitryptiline, Diclofenac).
Beta blockers do not apply (asthma).
Grateful thanks in advance
XXXX
A severe migraine case in a 19y/o girl, multiple daily recurrence, resistant to any therapeutic approach up to this point (Dipyrone, Ibuprophen, Topiramate, Eletriptan, Lornoxicam, Verapamil, Amitryptiline, Diclofenac).
Beta blockers do not apply (asthma).
Grateful thanks in advance
XXXX
Brief Answer:
Wish the answer were so easy--
Detailed Answer:
Good morning Doctor. My name is Dr. Dariush Saghafi. I am a neurologist and headache/facial pain sub-specialist. Since it appears you are a physician as well, I am going to tilt the discussion towards a colleague's point of appreciation.
In my headache clinic that I've been directing through the XXXXXXX VA Medical Center since 2003 the cornerstone to any successful treatment in a difficult case like this is to get the most detailed history possible from the patient. Fortunately, in her case she is only 19 years old (i.e. her history of headaches is at least less than 20 years in duration-- as opposed to some of my patients whose history often span 40+ years).
Therefore, I always get the index attack if possible and try and build a story of how the headaches evolved over time. Of course, this depends upon the reliability and interest in the patient to come forward with details. In the case of patients who are in complex social situations where psychological, physical, or sexual abuse may be factors sometimes these take a little more time or work to get from them...but obviously, these are things to consider when dealing in young people who appear to be almost refractory to all reasonable attempts and are still having debilitating and chronic headaches. So that's one facet of this case that would be important to ferret out.
As a corollary to the above one thing we deal with at the VA (perhaps more than in the civilian population) is the concept of poor sleep hygiene which could be due to multiple comorbid meidcal issues (unlikely in your patient's case) or due to PTSD issues from military experience, nightmares and other parasomnias, etc. Sometimes detecting things such as sleep apnea and narcolepsy becomes very important as these are clear and present risk factor in over 30% of my population who suffers from chronic headaches.
Also, I am sensitive to the menstrual history in women and how it intermixes with her headache history; is she also on contraceptives or not, does she have PCOS and details such as that as well as what the OTC usage history is like. In a 19 year old excessive OTC medication use is a bit unusual but nevertheless can and does happen. We need to keep in mind the definitions of Medication Overuse Headache (MOH) or what we used to call Analgesic Rebound headaches which is the use of abortive medication for more than 10 days per month. In other words, if she uses any more than 10 days of abortive medication per month the chances of her suffering from a background of MOH is high. So then, comes the task of detoxification before re-implementation of any abortives back to start the process again. Protocols have been published on the detoxification process using bridging high dose steroids (even infusions) while dovetailing other abortives and tapering others down. In my experience none of those regimens have ever been universally successful and the best approach to this day has simply been a total and complete cessation of the offending drug or drugs, a washout period of no less than 15-22 days, and then, reimplementation.
It is also critical to get a full description of all the patient's headaches in the form of a diary and to instruct them to not only keep track of the SEVERE headaches but also the "minor" or "less important" headaches. Often time patients think that a diary is only for the most outrageously painful or debilitating headaches which gives the physician a false sense of actual frequency as well as TYPE of headache the person has since it is usually the case in chronic headaches that there are at least 2 different headache types at work (migraine + tension type) etc.
Family history is very important as well as the history of what anybody in the family with similar headaches has used with success. Familial headache syndromes are now known to be due to channelopathies, mostly calcium and so medications may be chosen that address this sort of problem based upon likely inheritance patterns if they exist.
The other aspect of the patient's history I always elicit from them when it appears they are refractory to treatment is to get an EXACT treatment regimen for each and every medication to which they claim NO RESPONSE or poor response (i.e. doses tried, timing of those doses, why stopped, etc.) Also, I review all side effects which they state limited or terminated their use of any medication. Many times people's interpretation of a side effect or allergic response is incorrect or the side effect was more likely due to a medication to medication interaction that can be fixed as opposed to a strict bodily reaction which makes it completely useful.
As an example, Topamax is labeled by the manufacturer as having a limit of 200mg. daily maximum. I have more than 1 patient in my clinic who use upwards of 800mg. daily and 1 who we put on 1200 mg. in 4 divided doses for migraine prophylaxis. In other words, manufacturer upper limits are numbers that are useful guides when talking about general population statistics but in some cases are entirely meaningless when dealing with individual patients.
Finally, but NOT NECESSARILY LEAST IMPORTANT, is the concept of NON-PHARMACOLOGICAL strategies and approaches. Does this patient have other modalities available to her to treat her chronic headaches which have shown efficacy such as relaxation therapy, acupuncture, biofeedback, SOOTHEAWAY device (www.sootheaway.com), yoga, Tai Chi, aromatherapy. Of course, none thse complementary or alternative medical approaches can be said to work in the vast majority of patients but they represent options in those who have "tried every medication known to man" as so many say to me.
There are also occipital trigger point injections and BOTOX injections which I also employ in appropriate patients.
And so the above concepts and ideas reflect an overview if you will as to my approach which I believe results in a high yield of success both in new as well as complex and refractory patients with headaches and facial pain.
Now, in your patient I have a couple of questions. Your first statement you say she has migraine and you describe "multiple daily recurrence." Migraine headaches do not typically recur on a daily basis but other types of headaches such as clusters, trigeminal autonomic cephalgic, and of course tension type can recur during the course of a day. Therefore, my question would be on the semiology of these headaches if they are recurrent throughout the day since perhaps, we are dealing with something other than migraine. Has she tried any of the other available triptans such as sumatriptan in injectable form? Also, what is your timing of the triptan medications? A very elegant investigation in the timing of triptans was done a number of years ago where it was shown that if we tell patients to take their medication "as soon as possible" which is the usual instruction that it may be TOO EARLY and in that setting it is possible that the full dosing effect of the medication is lost.
What this study showed was that if giving triptans the first dose should be delayed by 20-30 minutes until after either symptoms of aura or the headache itself (if no aura) have initiated. That's when the first dose should be administered. Also, the 2nd dose of the triptan should be given 60-90 minutes following the first dose (not the recommended 2 hrs....way too long). There is also a limite of 2 doses of any triptan in 24 hrs. and 4 doses in 7 days otherwise, the patient will possibly fall into MOH and become refractory to the triptan.
I hope this information has provided you some further direction and insight into how to approach your patient and I am happy to continue discussing things with you to try and narrow down the scope of what other methods or modalities may be helpful for her if you wish. Just send me some more information back about her history, evolution, and other things I've mentioned regarding some of the medications you've already tried.
If you would like a HEADACHE LOG that I use for my patients to keep track of their headaches and symptoms I am happy to forward one to you. Simply give me your email address and I will send it to your attention. I can't emphasize HOW IMPORTANT THE HEADACHE LOG is in my clinic. I often "yell"...very nicely of course, at my patients who forget their logs at home...or tell me the dog ate it or some other reason that they couldn't do them. I tell them that without their input and cooperation at smoking out the details I need on that log that the prospect of my being able to do anything better than the other 50 physicians they've been seeing who randomly choose potions off their shelves is poor to nonexistent. I am usually successful at convincing the majority to get involved in this somewhat tedious activity but worthwhile all the same.
If this information has been useful to you would you please do me the great favor of a bit of written feedback and provide a STAR RATING as that helps me know how well I met your needs. Also, if you have no further questions or comments then, CLOSING THE QUERY will also be appreciated. Otherwise, I look forward to answering another question for you soon.
Please consider sending me other questions specifically to my attention by using the DIRECT QUERY function of this website by going to my personal page at:
http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474
This query required 60 minutes of physician specific time to review, research, and document in final draft format for envoy.
Cheers!
Wish the answer were so easy--
Detailed Answer:
Good morning Doctor. My name is Dr. Dariush Saghafi. I am a neurologist and headache/facial pain sub-specialist. Since it appears you are a physician as well, I am going to tilt the discussion towards a colleague's point of appreciation.
In my headache clinic that I've been directing through the XXXXXXX VA Medical Center since 2003 the cornerstone to any successful treatment in a difficult case like this is to get the most detailed history possible from the patient. Fortunately, in her case she is only 19 years old (i.e. her history of headaches is at least less than 20 years in duration-- as opposed to some of my patients whose history often span 40+ years).
Therefore, I always get the index attack if possible and try and build a story of how the headaches evolved over time. Of course, this depends upon the reliability and interest in the patient to come forward with details. In the case of patients who are in complex social situations where psychological, physical, or sexual abuse may be factors sometimes these take a little more time or work to get from them...but obviously, these are things to consider when dealing in young people who appear to be almost refractory to all reasonable attempts and are still having debilitating and chronic headaches. So that's one facet of this case that would be important to ferret out.
As a corollary to the above one thing we deal with at the VA (perhaps more than in the civilian population) is the concept of poor sleep hygiene which could be due to multiple comorbid meidcal issues (unlikely in your patient's case) or due to PTSD issues from military experience, nightmares and other parasomnias, etc. Sometimes detecting things such as sleep apnea and narcolepsy becomes very important as these are clear and present risk factor in over 30% of my population who suffers from chronic headaches.
Also, I am sensitive to the menstrual history in women and how it intermixes with her headache history; is she also on contraceptives or not, does she have PCOS and details such as that as well as what the OTC usage history is like. In a 19 year old excessive OTC medication use is a bit unusual but nevertheless can and does happen. We need to keep in mind the definitions of Medication Overuse Headache (MOH) or what we used to call Analgesic Rebound headaches which is the use of abortive medication for more than 10 days per month. In other words, if she uses any more than 10 days of abortive medication per month the chances of her suffering from a background of MOH is high. So then, comes the task of detoxification before re-implementation of any abortives back to start the process again. Protocols have been published on the detoxification process using bridging high dose steroids (even infusions) while dovetailing other abortives and tapering others down. In my experience none of those regimens have ever been universally successful and the best approach to this day has simply been a total and complete cessation of the offending drug or drugs, a washout period of no less than 15-22 days, and then, reimplementation.
It is also critical to get a full description of all the patient's headaches in the form of a diary and to instruct them to not only keep track of the SEVERE headaches but also the "minor" or "less important" headaches. Often time patients think that a diary is only for the most outrageously painful or debilitating headaches which gives the physician a false sense of actual frequency as well as TYPE of headache the person has since it is usually the case in chronic headaches that there are at least 2 different headache types at work (migraine + tension type) etc.
Family history is very important as well as the history of what anybody in the family with similar headaches has used with success. Familial headache syndromes are now known to be due to channelopathies, mostly calcium and so medications may be chosen that address this sort of problem based upon likely inheritance patterns if they exist.
The other aspect of the patient's history I always elicit from them when it appears they are refractory to treatment is to get an EXACT treatment regimen for each and every medication to which they claim NO RESPONSE or poor response (i.e. doses tried, timing of those doses, why stopped, etc.) Also, I review all side effects which they state limited or terminated their use of any medication. Many times people's interpretation of a side effect or allergic response is incorrect or the side effect was more likely due to a medication to medication interaction that can be fixed as opposed to a strict bodily reaction which makes it completely useful.
As an example, Topamax is labeled by the manufacturer as having a limit of 200mg. daily maximum. I have more than 1 patient in my clinic who use upwards of 800mg. daily and 1 who we put on 1200 mg. in 4 divided doses for migraine prophylaxis. In other words, manufacturer upper limits are numbers that are useful guides when talking about general population statistics but in some cases are entirely meaningless when dealing with individual patients.
Finally, but NOT NECESSARILY LEAST IMPORTANT, is the concept of NON-PHARMACOLOGICAL strategies and approaches. Does this patient have other modalities available to her to treat her chronic headaches which have shown efficacy such as relaxation therapy, acupuncture, biofeedback, SOOTHEAWAY device (www.sootheaway.com), yoga, Tai Chi, aromatherapy. Of course, none thse complementary or alternative medical approaches can be said to work in the vast majority of patients but they represent options in those who have "tried every medication known to man" as so many say to me.
There are also occipital trigger point injections and BOTOX injections which I also employ in appropriate patients.
And so the above concepts and ideas reflect an overview if you will as to my approach which I believe results in a high yield of success both in new as well as complex and refractory patients with headaches and facial pain.
Now, in your patient I have a couple of questions. Your first statement you say she has migraine and you describe "multiple daily recurrence." Migraine headaches do not typically recur on a daily basis but other types of headaches such as clusters, trigeminal autonomic cephalgic, and of course tension type can recur during the course of a day. Therefore, my question would be on the semiology of these headaches if they are recurrent throughout the day since perhaps, we are dealing with something other than migraine. Has she tried any of the other available triptans such as sumatriptan in injectable form? Also, what is your timing of the triptan medications? A very elegant investigation in the timing of triptans was done a number of years ago where it was shown that if we tell patients to take their medication "as soon as possible" which is the usual instruction that it may be TOO EARLY and in that setting it is possible that the full dosing effect of the medication is lost.
What this study showed was that if giving triptans the first dose should be delayed by 20-30 minutes until after either symptoms of aura or the headache itself (if no aura) have initiated. That's when the first dose should be administered. Also, the 2nd dose of the triptan should be given 60-90 minutes following the first dose (not the recommended 2 hrs....way too long). There is also a limite of 2 doses of any triptan in 24 hrs. and 4 doses in 7 days otherwise, the patient will possibly fall into MOH and become refractory to the triptan.
I hope this information has provided you some further direction and insight into how to approach your patient and I am happy to continue discussing things with you to try and narrow down the scope of what other methods or modalities may be helpful for her if you wish. Just send me some more information back about her history, evolution, and other things I've mentioned regarding some of the medications you've already tried.
If you would like a HEADACHE LOG that I use for my patients to keep track of their headaches and symptoms I am happy to forward one to you. Simply give me your email address and I will send it to your attention. I can't emphasize HOW IMPORTANT THE HEADACHE LOG is in my clinic. I often "yell"...very nicely of course, at my patients who forget their logs at home...or tell me the dog ate it or some other reason that they couldn't do them. I tell them that without their input and cooperation at smoking out the details I need on that log that the prospect of my being able to do anything better than the other 50 physicians they've been seeing who randomly choose potions off their shelves is poor to nonexistent. I am usually successful at convincing the majority to get involved in this somewhat tedious activity but worthwhile all the same.
If this information has been useful to you would you please do me the great favor of a bit of written feedback and provide a STAR RATING as that helps me know how well I met your needs. Also, if you have no further questions or comments then, CLOSING THE QUERY will also be appreciated. Otherwise, I look forward to answering another question for you soon.
Please consider sending me other questions specifically to my attention by using the DIRECT QUERY function of this website by going to my personal page at:
http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474
This query required 60 minutes of physician specific time to review, research, and document in final draft format for envoy.
Cheers!
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Dear Dr. Saghafi,
Grateful thanks for your long an detailed consideration of my case!
I am aware of the paramount importance of both the completeness of anamnestic data and an as accurate observation of the clinical picture as possible, for a most individualized approach to a specific case. Therefore I would be enormously grateful to you for sharing with me your Headache Log form to be completed for a few days of close observation (as well as a brief anamnestic enquiry form you might consider useful) before our next step of blessed cooperation. Please kindly inform about the concrete way I could use your website for further dialogue and financial balance of your efforts. My Email: YYYY@YYYY
Respectfully yours,
XXXX
Grateful thanks for your long an detailed consideration of my case!
I am aware of the paramount importance of both the completeness of anamnestic data and an as accurate observation of the clinical picture as possible, for a most individualized approach to a specific case. Therefore I would be enormously grateful to you for sharing with me your Headache Log form to be completed for a few days of close observation (as well as a brief anamnestic enquiry form you might consider useful) before our next step of blessed cooperation. Please kindly inform about the concrete way I could use your website for further dialogue and financial balance of your efforts. My Email: YYYY@YYYY
Respectfully yours,
XXXX
Brief Answer:
Headache Log will be sent with pleasure
Detailed Answer:
My apologies for the delay in getting back to you. I will be gladly forwarding a copy of the headache log to your attention which is my design and which we use in the Headache clinic at the XXXXXXX VA Hospital to gather data on headache patients. The typical minimum duration we recommend is a 30 day query which gives plenty of time for a patient to "get the hang of things" as well as be able to recognize the different types of headaches and the different symptoms that each headache may in fact carry. It also gives a better chance for enough potential trigger items in the diet and/or environment to be expressed so that we may be able to identify the common denominator between different headaches and then, work to get rid of them.
Thank you for your desire to support my efforts. The best way we can collaborate together in this regard is to direct future questions to me as DIRECT QUERIES and to specify that they should be in the field of Neurology.
You or your patient can do both of those things at: http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474
I will be sending you the headache log within the next 6-10 hrs. since it will have to wait until I can access the hospital server where the log is stored.
Allow me to verify that your email for this file to be sent is YYYY@YYYY ?
Thank you.
Cheers!
Headache Log will be sent with pleasure
Detailed Answer:
My apologies for the delay in getting back to you. I will be gladly forwarding a copy of the headache log to your attention which is my design and which we use in the Headache clinic at the XXXXXXX VA Hospital to gather data on headache patients. The typical minimum duration we recommend is a 30 day query which gives plenty of time for a patient to "get the hang of things" as well as be able to recognize the different types of headaches and the different symptoms that each headache may in fact carry. It also gives a better chance for enough potential trigger items in the diet and/or environment to be expressed so that we may be able to identify the common denominator between different headaches and then, work to get rid of them.
Thank you for your desire to support my efforts. The best way we can collaborate together in this regard is to direct future questions to me as DIRECT QUERIES and to specify that they should be in the field of Neurology.
You or your patient can do both of those things at: http://doctor.healthcaremagic.com/doctors/dr-dariush-saghafi/68474
I will be sending you the headache log within the next 6-10 hrs. since it will have to wait until I can access the hospital server where the log is stored.
Allow me to verify that your email for this file to be sent is YYYY@YYYY ?
Thank you.
Cheers!
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Thank you so much for your kindness!
Yes, the Email you've mentioned is accurate.
In the site you've suggested, there is a field labeled "Ask a neurologist" - which seems to lead not specifically to you. I am unable to see any field "Direct Queries". Is the one I've found the correct one? If not, please kindly assist me toward the right field for our correspondence.
As the follow-up period you request would be 30 days, please advise how to compensate your current efforts without "closing the case" by such compensation.
I am not too familiar with the way the "HealthcareMagic" works :-)
Sincerely yours,
Dr. Klein
Yes, the Email you've mentioned is accurate.
In the site you've suggested, there is a field labeled "Ask a neurologist" - which seems to lead not specifically to you. I am unable to see any field "Direct Queries". Is the one I've found the correct one? If not, please kindly assist me toward the right field for our correspondence.
As the follow-up period you request would be 30 days, please advise how to compensate your current efforts without "closing the case" by such compensation.
I am not too familiar with the way the "HealthcareMagic" works :-)
Sincerely yours,
Dr. Klein
Brief Answer:
Her is the link that will take you directly
Detailed Answer:
Thanks so much for writing back. Here is the link that takes you directly to the dialog box that will get questions directly to my attention:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
If you use the original link I gave you it takes you to my basic home page and if you'll look right underneath my picture there is a big ORANGE link that says something like ASK ME A QUESTION. Don't worry...I missed it myself....even though it's big....I think the color ORANGE doesn't stand out and my eye (as yours) was drawn to the big dialog box on the opposite side of the page that said ASK A DOCTOR because of the BIG BLUE BOX and the picture of that guy whose picture is 3x the size of mine laughing!
But now you have the link that will take you directly to a dialog box which will be directed to my attention. Headache diary on the way.
Her is the link that will take you directly
Detailed Answer:
Thanks so much for writing back. Here is the link that takes you directly to the dialog box that will get questions directly to my attention:
http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474
If you use the original link I gave you it takes you to my basic home page and if you'll look right underneath my picture there is a big ORANGE link that says something like ASK ME A QUESTION. Don't worry...I missed it myself....even though it's big....I think the color ORANGE doesn't stand out and my eye (as yours) was drawn to the big dialog box on the opposite side of the page that said ASK A DOCTOR because of the BIG BLUE BOX and the picture of that guy whose picture is 3x the size of mine laughing!
But now you have the link that will take you directly to a dialog box which will be directed to my attention. Headache diary on the way.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Answered by
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