questions about migraines and headaches in a regular live chat for the self-help community headbook.me Below you will find the questions and answers from the last live chat
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Dear Professor Göbel,
I (62) have suffered from migraines (1-3 times a week), various other pains and depression since I was a teenager.
In a book about migraines I read that 5-hydroxytryptophan (5-HTP) helps against migraines and has hardly any side effects.
In the same article, the medicinal plant Griffonia simplifolia was mentioned. My neurologist couldn't really help me. He told me that tryptophan (he wasn't talking about 5 HTP) couldn't cross the brain barrier. I would be very grateful if you could tell me whether any of these active ingredients (5HTP, Tryptophan, Griffonia) are effective, as well as under what name they are available, what should be taken into account when taking them and whether they can be taken together with triptans can lead to problems.Thank you very much,
Lucilla-
Dear Lucilla,
5- Hydroxytryptophan is a precursor for serotonin. Serotonin is stored primarily in blood platelets. The serotonin levels that can be measured in the blood are not informative about the concentration and activities of serotonin in the nerve cells. The administration of 5-hydroxytryptophan has been tested in previous studies for its effectiveness in preventing migraines. No effect could be shown. The same applies to the medicinal plant you mentioned. Today there are many ways to actively prevent migraines. You can rely on many proven and scientifically proven active ingredients. So you don't have to carry out experiments yourself with untested options or with options for which effectiveness is already ruled out.
Kind regards
Hartmut Göbel
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Dear Mr. Göbel,
thank you very much for your support.I've had migraines for almost three years, a cause can't be found yet and I take Maxalt 10 times a month, but I have significantly more headache days.
What particularly surprises me and what no one has been able to explain to me yet is that every night, after about 6 hours of sleep, I wake up between 4 and 5 a.m. with a painful pressure in my forehead (headache above the eyes, usually on one side). When I get up, the pressure sometimes goes away over the next hour. If that doesn't work or I don't get up, I'll get a migraine. Maxalt would help and let me sleep longer, but I realize that I can't take it for that.What could be the cause of the clogging at night (the ENT report is normal) and how can I treat it differently or prevent it?
My doctor can only think of treatment with beta blockers.-
Dear Tine,
Migraine is an independent disease, it is the cause of the headache itself, it does not need any other cause. Your observation could already be related to the development of a headache due to medication overuse. If you take Maxalt 10 days a month, you will already be sensitized, the pain processing system will change, the effect will wear off overnight and you will already feel the headache from overusing the medication. Try to build up prevention so that you have as few acute medication days per month as possible.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
After changing prophylaxis from topiramate to amitriptyline (35 mg), I
initially didn't feel any better for the first four weeks.
After I started doing light endurance sports again 4-5 times a week (swimming and running),
I only have a migraine attack about every 8-10 days (over a day).
How can something like that be?
I'm trying to recognize a pattern so I can fall back on it in worse times. And: Does a further dosage make sense?Thank you in advance for your efforts.
Many greetings
Stefanie-
Dear Stefanie,
A new prophylaxis should generally be evaluated over a period of at least 8 weeks. The important thing is to count the number of headache days and then evaluate their change in relation to the time before. Amitriptyline usually only takes effect after about 4-6 weeks. In this respect, the change noticed after the period of time described is not unusual. Experience has shown that combining drug prevention with swimming and running shows significantly better results, so that the effect of the medication is supported by your behavior. If the dose is well tolerated, an increase in dosage can make sense and further improve the effect.
Kind regards
Hartmut Göbel
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Dear Professor Göbel,
I have been taking Saroten 50mg for about 5.5 years, which has reduced the frequency and severity of my attacks, which were very bad at the time (I suffer from migraines and tension headaches), and has helped me very well.
Since I had gained a lot of weight, my family doctor advised me to try other tablets. About 15 months ago, first metoprolol, then venlafaxine and currently topiramate (2x50mg) were added to the dosage in addition to Saroten. Unfortunately, none of the tablets had a resounding success, but rather the opposite was the case. After stopping, the good effect of Saroten is no longer as before. I'm feeling worse and worse now and my attacks come at ever shorter intervals without any noticeable triggers, so I have to endure the headache (due to MÜK). Between attempts I dosed Saroten up to 75mg, but this brought little improvement. I also now need my acute medication (zolmitriptan) in 5 mg instead of 2.5 mg, several days in a row. My questions would be:
Could the worsening of the effect of Saroten have been caused by the other tablets?
Can the originally good effects of saroten be “recovered”?
How high can I dose Saroten?
I've had nausea every day for about 6 months.
I have been taking topiramate “fully” for about 8 months now and have had various strong side effects. Could the nausea be due to the topiramate? What would be your advice?Thanks for your time
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Dear Sabine,
If you suffer from both migraines and tension headaches, you need an active ingredient that is effective in preventing both types of headaches. This actually applies to amitriptyline. Metoprolol, venlafaxine and topiramate have no proven effectiveness for tension headaches. However, it depends on which type of headache is in the foreground, whether you want to achieve a specific effect on the migraine and what the overall picture looks like. You may have actually experienced an increase in attack frequency, you require acute medication on more than 10 days a month and another headache, the medication overuse headache, has also occurred. This complicates the treatment even more. It is now necessary to first treat the medication overuse headache. Only then will the initial situation be present again and treatment must be developed for both the migraine and the tension headache. Then the previous effect of amitriptyline can be regained. Dosing Saroten alone to the current situation will not solve the problem, as the medication overuse headache must first be treated effectively. Continuing topiramate alone is unlikely to solve the problem.
Kind regards
Hartmut Göbel-
Migraines are my main concern. I would like to stop topiramate because of the side effects. What do you think?
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Dear Sabine,
the nausea can come from the Topamax and if I were you, I would stop taking it.
Kind regards,
Bettina
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Dear Mister Professor
I was treated by you two years ago and was diagnosed by other neurologists with chronic migraine, which has existed for 12 years.
Since I have already tried all the medications for prevention (topiramate, valproic acid, beta blockers, doxepin), I have been taking amitriptiline 25 mg in the evenings for 3 months now. Initially I took 10mg of amitriptiline, which was increased to 25mg. My question now is, is 25 mg enough as a prophylactic, or should the dosage be even higher? Because so far I haven't noticed any difference in terms of the attacks. A muek is excluded.Thank you
Karin-
Dear Karin,
25 mg amitriptyline is usually considered the lower dosage. If the drug is well tolerated and a higher effect is desired, the dosage can be increased to medium doses of 50-75 mg. Some patients also require dosages up to 150 mg. The medication is absorbed very differently, so there is no standard dosage and you have to find out the optimal dosage individually.
Kind regards
Hartmut Göbel
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Dear Professor Göbel,
I have between 17 and 20 migraine days a month (I also have epilepsy and fibromyalgia). We are currently trying Cefaly and botulinum toxin. I received my first dose of botulinum toxin two months ago. Not much has changed. How many trials do you give this drug? Is there an alternative to this?
Thank you very much in advance for your help.
Kind regards
Konstanze-
Dear Constance,
The treatment of chronic migraine with botulinum toxin can achieve an improved effect with repeated use. As a rule, you try 2 or 3 cycles. However, if no effect is achieved, this treatment should be abandoned. It should always be noted that botulinum toxin alone cannot bring about a change, but that intensive behavioral adjustment is always necessary. In terms of medication, there is currently no approved alternative to botulinum toxin for chronic migraines.
Kind regards
Hartmut Göbel
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Dear Mr.
Prof. Göbel was in the Kiel pain clinic in February last year, where he took a break from taking the triptan, which I kept at home for another 4 weeks. After being discharged from the clinic, I was prescribed Mirtazapine 15 mg, took the tablets for about 6 months, for acute treatment I was given Relpax 40 mg + Naproxen 500 mg, the days of pain decreased from 15-18 days before the break to about 8-10 days after Medication break, but still had the problem that my migraines always lasted up to 72 hours or longer, so Dr. Tomforde on Naramig 2.5mg + Naproxen 500 or also on Arcoxia90mg since this triptan should last for a longer time, so far it sometimes works well. Except that the Naramig doesn't work as quickly (it's still OK for me) and the recurring headache comes back stronger on the third day. Can you offer me other options to reduce the recurring headaches, so that my days in pain would also be further reduced? Unfortunately, I keep revisiting the 10 days of pain and that puts a lot of strain on me!LG from Austria
Manfred
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Dear Manfred,
You already have a very well-versed treatment regimen. If this approach can keep the frequency of migraines below 10 days, an important goal has already been achieved. A further reduction in the number of migraine days per month should now be sought by intensifying prevention. This applies to both the behavioral area and the medication area. If tolerated well, mirtazapine could be increased. Alternatively, another medication could also be added. However, this must be carefully considered through individual advice.
Kind regards
Hartmut Göbel
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Dear Mr Göbel,
Over the last few years, my daily tension-type headaches have increasingly turned into migraines with almost all activities, so that I felt more and more restricted in everyday life.
So two weeks ago at Profilaxe, after many years of 150 mg of venlafaxine, I was switched to Cymbalta (1 week 30 mg, now 60 mg) - still together with Stangyl 25 mg. Does your experience also suggest that this medication has a more pain-relieving effect and could have fewer side effects?
How long do you suggest testing?Many greetings to Kiel
head fleet
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Dear Kopflotte,
The combination you mentioned has been proven to prevent tension-type headaches. However, it must be carried out consistently. Whether Venlafaxine or Cymbalta works better individually can only be determined by observation in individual cases. As a rule, you should allow a period of at least 3 months.
Kind regards
Hartmut Göbel-
Many thanks for the answer!
I forgot to ask if I could now take my triptan even more carefully (= less often).Greetings head fleet
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Dear Kopflotte,
why shouldn't you be able to take a triptan for migraines?
Kind regards,
Bettina
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Dear Prof. Göbel,
next to chron.
Migraines and atypical facial pain, I suffer from severe, painful restless leg syndrome. Because of the second form of pain mentioned and as an alternative to levodopa and dopamine agonists for RLS, my treating doctor wants to prescribe an opiate for me.
Oxycodone has already proven its effectiveness in the treatment of RLS in studies; My question to you is whether there are alternative opiates available. It would also be important for me to know whether there are any opiate preparations that have a favorable side effect profile with regard to headaches.I'm really looking forward to hearing your professional advice and thank you very much for it.
Best regardsMartina
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Dear Martina,
Restless legs syndrome would be treated primarily with levodopa. If this does not achieve sufficient effectiveness, opioids can also be used. A special opioid is not required. You should make sure that it is a sustained-release preparation. If the setting is fixed, no complications regarding headaches should arise.
Kind regards
Hartmut Göbel
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Hello Prof Göbel,
medical history:
Female, 48 years old, menstrual migraines for 13 years, until 3 years ago 1-2 attacks per month, each attack alternating, at that time tolerable with Thomapyrin.
For the past 3 years, some attacks have lasted up to 5 days and are very severe with vomiting, etc.!
(Main pain point exits V1 frontal foramen) The 5-day attack is usually interrupted for 6-18 hours and then changes sides. Accut therapy with triptan and naproxen. Prophylaxis: Mag.600mg and Vit B2 200mg daily. 1. Question: is the “other side” a new attack or a type of recurring headache?
The pain days/attack frequency??
Unfortunately, the last few weeks have been 13 days, some of which have been with milder pain and some of the tension headache type (I've never had them since the migraines started). I also have the feeling that everything no longer has any connection to my cycle. I can barely manage the 10/20 rule. Naratriptan and naproxen help well. The prescribed prophylaxis with naproxen before menstruation is now impossible due to the total unpredictability of the bleeding (it stops for weeks or occurs every 14 days). 2nd question: Do you think I should try topimarate or do I have to be in pain for over 15 days?
3. Question: Can menstrual migraines change over time?
My neurologist gave me great hope that there would be no attacks after the menopause... Thank you for your efforts,
Heike-
Dear Heike,
Without knowing the headache calendar and especially without knowing the regular frequency of headache days per month, the question cannot be answered easily. If a migraine attack occurs over 5 days, it is known as status migraine. This is treated differently than a primary migraine attack lasting a maximum of 3 days. The most important thing is not to keep taking a painkiller despite its lack of effectiveness. This is the typical starting point for the development of a medication overuse headache. In any case, it would be important to know whether headache-free periods still exist. If there is a break of just 6-18 hours, you could be suffering from daily headaches. Simply taking a triptan and naproxen would not be effective here.
A recurrent headache is defined as the primary medication used to reduce the headache and then the headache returning after this improvement. The exact classification can only be made with the headache calendar and knowledge of the exact course. The question of whether this is a new attack can only be clarified if you know how the headache will progress.
I'm only now reading that you obviously have a headache almost every other day. You are probably also experiencing medication overuse headaches, even if you still follow the 10-20 rule. There are patients in whom sensitization occurs as early as 8 or 9 days a month. In your case, a diagnostic medication break would provide clarification. Afterwards, it could be considered how further prevention should take place. Topiramate is unlikely to alter the course without a systematic drug break. Unfortunately, waiting for menopause is not a good prospect. At 50% the attacks stay the same, at 25% they get worse, at another 25% they improve. On average, no change is to be expected.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
Today I would like to hear your opinion on the assessments of the psychosomatic component of migraines by the two doctors Rüdiger Dahlke and Oliver Sacks.
I read both authors' books with great interest, with some things, such as: B. I can identify with the trigger function of emotional stress. But I especially feel that R. Dahlke did not take my neurological illness seriously and put it in the “psycho corner”. How high do you estimate the “psychological contribution” is to migraines? Thank you for your effort and kind regards
Hanni21-
Dear Hanni,
Oliver Sacks was a neurologist and made very precise descriptions of migraine aurora, the headache phase and the underlying mechanisms. Many of his results result from empirical studies. The brain mediates knowledge, cognitions and feelings. Headaches arise in the central nervous system and can be influenced both positively and negatively by these brain functions. Rüdiger Dahlke's books focus on illness as a symbol. This is about topics such as the laws of fate and life principles. World views and opinions are the basis for this. These cannot be scientifically verified and are therefore not scientifically proven.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
I have an average of around 20 headache days per month and take topiramate 50 mg as prophylaxis.
I had to reduce from 75 mg to 50 mg because of the strong side effects (I don't notice any
difference in the effect whether 75 or 50 mg).I've had a new problem for a month: the acute medications no longer help.
I follow the 10/20 rule and take acute medications 4-6 days per month.
However, recently it has been impossible to stop migraines, even if I take, for example, 2x Sumatriptan 100 mg + Novalgin 500 mg. The effect is either minimal or non-existent. The migraine fluctuates between moderate – severe – very severe – moderate for up to 5 days.From March 1st to 13th I was only relatively headache-free for 3 days.
When I read information, my symptoms are similar to MÜK, even though I don't overuse medication. As prophylaxis I already have: Amitriptyline, Duloxetine, Topiramate. Nothing helps and the effect wears off very quickly.Why don't the acute medications work? What could that be?
Thank you very much for your answer!!
Lora.-
Dear Lora,
You described the process very well. Topiramate usually does not change the frequency of attacks, but can often only reduce the intensity of individual attacks. The acute medication you are using does not seem to be working sufficiently. You write that the effect is either minimal or non-existent. In this situation, it does not make sense to take the medication again in the event of an attack. It will then not work even when repeated. This is exactly the situation you are describing. However, if you proceed as you have described, the consequence will be that you will take the medication for 3, 4, 5 or even more days without sufficient effect. This is already the typical path to medication overuse headache. A replacement medication must therefore be found that can, if possible, effectively stop the headache. If it then occurs again as a recurring headache, you can take this medication again and it will then be effective. It doesn't seem to work with the current prophylaxis. Another prevention should therefore be found. There may already be sensitization and the medication overuse headache has already taken over a larger proportion. The previous prevention measures you mentioned need to be re-evaluated in terms of dosage and duration. Only then can it be clarified whether there is actually no effect. It is therefore necessary to establish a new preventive measure; a medication break should first be considered; after all, you must know and implement the rules for acute medication exactly.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
I would like to contact you again today with my question from the last chat, as your answer was very informative but unfortunately did not answer my actual question. This referred to the administration of a sustained-release opioid due to increased pain sensitivity after surviving a migraine attack. I'm pasting the relevant question and answer here again and would be happy if you could give me some advice for the situation described.
Dear Prof. Göbel,
Thank you very much for the opportunity to ask you a question again.
I have been suffering from complex pain syndrome (chronic migraines, neuropathic pain in the area of the 2nd trigeminal branch, tension-type headaches) for several years.
After migraine attacks that last for several days and hardly respond to triptans or other pain medications (muk is ruled out), there is increased sensitivity to pain in the head and the intensity of the pain of other types of headaches that recur immediately after the migraine is significantly increased. This quite severe pain then often becomes a new trigger for the next migraine attack. I take amitriptyline as migraine prophylaxis;
I have tried other prophylaxis (e.g. beta blockers, topiramate, Botox and corresponding recommendations) over the years, so further optimization of migraine prophylaxis is impossible. I consistently adhere to recommended behavioral measures (e.g. relaxation procedures). My pain therapist suggests trying to alleviate the migraine headaches by taking a daily sustained-release opioid so that they can no longer become a migraine trigger.
Taking Lyrica, gabapentin and carbamazepine did not reduce the pain. My question to you would now be whether sustained-release opioids could be helpful in this case, especially in the pain-sensitive phase immediately after the migraine, in order to improve my overall situation.Thank you for your effort and best wishes to the entire team.
MarleneHartmut Göbel January 11, 2016 at 6:00 p.m.
Dear Marlene,The use of sustained-release opioids for migraine prophylaxis cannot be proven by scientific studies. No effect is expected. In my opinion, this would essentially only result in side effects from the opioid, but there would be no effect. In individual cases, there are very aggressive forms of migraine that respond only with great difficulty or not at all to standard preventive measures. Inpatient pain therapy should be considered in this situation. A wide variety of therapeutic methods, even if they are already known, can be optimized and used in combination.
Kind regards
Hartmut GöbelThank you for your understanding of my repeated concerns.
Kind regards to Kiel
Marlene
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Dear Marlene,
In my answer at the time, I advised you against administering a sustained-release opioid to reduce pain sensitivity after a migraine attack. This also applies today. There is no evidence that an opioid reduces susceptibility to migraine headaches. You write that you were advised to alleviate the non-migraine pain by taking a sustained-release opioid daily so that it can no longer become a migraine trigger. It will not work. At the same time, you write that the administration of Lyrica, gabapentin and carbamazepine did not reduce the pain in relation to this pain. This was not to be expected; none of these substances are effective in preventing migraines. Please find out more about the options for migraine prevention with medication in the Headbook and pay particular attention to the behavioral measures. Based on this, you have the probability of effectiveness.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
I have been suffering from increasing migraines and tension headaches (intensity and frequency) for about 5 years.
I'm currently taking amitriptyline 10 mg for prophylaxis (for about 4 weeks, according to the neurologist I should stay at this dosage). Various doctors/physiotherapists have found massive tension in the neck/back area and a blockage in C2.
I also have back pain more and more often, especially in the evenings and after sitting for a long time (a lot of work on the laptop, studying). In addition, there are jaw joint problems (clicking, pain, restricted movement), and the dentist diagnosed TMD.Can there be a connection between neck/back problems, CMD and migraines?
I also have a quick question about medication: Can I combine Zolmitriptan or Rizatriptan with ibuprofen 600 or naproxen? In what dosage should naproxen be taken, if possible?
And what do you think about taking high doses of magnesium (600 mg per day)?
Thank you for your time and best regards!
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Dear Lisa,
Migraine is an independent disease and is caused by a genetically predetermined functioning of the nervous system. Tension in the back area is not the cause of migraines. However, they can be a consequence of migraines due to sensitization and activation of defensive reflexes. Sitting for long periods of time, lack of exercise, stress and tension are behaviors that can cause migraine attacks and at the same time back pain. Jaw clenching and grinding are also caused by nervous activity in the central nervous system. They are not the cause of migraines, but can be the result of the resulting sensitization.
Zolmitriptan can be combined with a so-called NSAID such as ibuprofen or naproxen. Typically 500 mg of naproxen is used. The aim is to reduce the occurrence of recurring headaches. The administration of magnesium 2×300 mg per day has proven effective in preventing migraines.
Kind regards
Hartmut Göbel
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Dear Prof. Dr. Göbel,
First of all, thank you for this wonderful chat function!
I'm 26 and have had migraines for as long as I can remember.
Until recently, around 1-3 attacks per week. For 3 weeks I have been suffering from a constant headache that turns into a moderate migraine almost every day. A MÜK is ruled out because I endured most of the attacks and only took about 3-4 Tristane per month. I have an appointment at the West German Headache Center in two weeks. Do you know of cases in which an episodic migraine suddenly turned into a permanent headache with almost daily migraine attacks?
What can you advise me about this?Thank you in advance for your time and best regards
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Dear Gritzner,
Migraine can slowly progress chronically with an increasing frequency of headache days per month. However, abrupt changes in the course of the migraine can also occur relatively quickly. What was previously an episodic course with only a few days per month can very quickly turn into a chronic migraine with headaches on more than 15 days per month within 1-2 months. What is necessary is very intensive prevention through behavior and, if necessary, medication as well as specific attack therapy.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
I have been taking Petadolex for 6 weeks, dosage according to your recommendation.
Now, after originally about 8 to 15 days of migraines, there has been a reduction, meaning no migraines for 2 weeks. (I will of course have my liver values checked)I have been taking a maximum of 10 Naratriptat since January 2016, also after studying your book, and previously took Sumatriptan for many years, with which I was mostly able to successfully combat migraines. Before I had to take over 10 triptans, I could sometimes endure the pain.
My question: If the attacks remain so minor, should I endure the migraine attacks for a certain period of time in order to really get away from the triptans?
Or would this be a pointless endeavor that would only cause me pain?Thank you for your answer and your excellent services in the head pain area.
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Dear Giotto,
In individual cases, a short, temporary medication break may be effective. This is especially true if you are always close to the 10-day limit. However, if you are in the “green” zone with only 2 to 6 migraine days per month, it makes no sense to endure the migraines. On the contrary, it is better to stop the migraine attacks as effectively as possible so that further sensitization cannot occur and you do not risk complications of the migraine.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
According to your clinic's diagnosis, I have migraines without aura, as well as secondary headaches after carotid dissection.
I am currently undergoing a more complex diagnosis of 'relapsing polychondritis'. Apparently this disease cannot be ruled out, even if, as in my case, there have been no positive laboratory results so far.
Alternatively, there is also 'Red Ear Syndrome' which would most likely be attributed to headaches and facial pain. Since it is not clearly defined as an illness and is extremely rare, I have not yet found any real support when it comes to the question of which of the two illnesses I have.
The corresponding case reports/scientific. I have read literature on 'Red Ear Syndrome'. But that doesn't help me either.
The distinction between the two diagnoses is important to me because the medication for 'relapsing polychondritis' is very severe, whereas for 'Red Ear Syndrome' it probably follows general headache prophylaxis recommendations.
Do you believe that Dr. Could Heinze be helpful to me in this regard at an outpatient appointment or can you give me any other advice regarding possible further diagnostics of 'Red Ear Syndrome'?
Thank you
lucky earth
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Dear lucky earth,
Relapsing polychondritis is an autoimmune disease in which the body attacks and possibly destroys cartilage tissue in the body. There are no proven laboratory tests for this condition. The diagnosis is made clinically. Red Ear Syndrome, on the other hand, is a pain disorder. The ear becomes red and there is a burning pain. The attacks can last from seconds to hours, most often occurring between 30 minutes and an hour. The attacks can occur daily, the frequency is around 20 per day to a few attacks per year. It is assumed that this syndrome, like cluster headaches, is one of the so-called trigemino-autonomous forms of headache. The frequency is very rare. Only about 100 cases are described in the literature. The treatment can only be experimental as there are no scientific studies on therapy. As a rule, therapeutic approaches similar to migraines, tension-type headaches and cluster headaches are chosen. This type of headache is also diagnosed by an experienced clinician; there are no laboratory tests for it. I am convinced that Dr. Heinze will be there to help you at your next appointment.
Kind regards
Hartmut Göbel
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Dear Dr. Göbel,
According to the diagnosis made in your company in 2010, I have:
1. Migraine without aura, ICD-10 G34.0
2. Episodic tension-type headache, ICD-10 G44.2
3. Status migraenosus, ICD-10 G 43.2I have been suffering from migraines for 30 years and later also from... as stated above.
Now I've tried a lot of things, including medicinal protaxes.
Do you think an examination of the cerebrospinal fluid, i.e. a lumbar puncture, would provide new information?
Thank you very much for your efforts
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Dear Issey,
The diagnoses you listed are primary forms of headache. They are independent diseases and do not require any other cause. They are the disease itself. Examining the cerebrospinal fluid through a lumbar puncture would not provide any new information.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
I have had migraines since I was a child, and they became more frequent and chronic 12 years ago.
Initially, a tension headache was incorrectly diagnosed, which was unsuccessfully tried to treat with Nortrilen, Katadolon, Mydocalm and Amitriptilyn. After being diagnosed with chronic migraines, I tried the following medications: – Beta blockers (metoprolol)
– Amitriptilyn
– Topiramate
– Valproate
– Flunarizine
– various triptans
– Naproxen
– Ibuprofen
– ParacetamolI'm currently taking:
Morning:
- 100 mg Metoprolol
- 10 mg Paroxat
Evening:
- 50 mg Doxepin
- 100 mg MetoprololIn addition to the medication, I have already been to the Tutzing pain clinic and the Königstein migraine clinic.
These (current) medications are the only ones mentioned that have a reasonably good effect, so I only have a few severe attacks, but I am never completely pain-free.
But I still notice that the migraine can break out at any time if there is visual overstimulation, which is my main migraine trigger. Reading is never possible for me; half a page of a book would be enough to trigger a seizure, no matter how relaxed I was. I can usually switch off other triggers (cold wind, sweets, not drinking enough, acidic fruit). The attack often occurs overnight. Stress doesn't play a role for me, that was confirmed to me in both clinics.In general, I respond very poorly to medication; acutely only an Imigran injection sometimes helps, everything else has no effect.
Unfortunately, this also means that my body always “gets used to” medication very quickly and then no longer responds well to it. That's why I always have to take a break from metoprolol after a year, as my condition then rapidly worsens (currently I have migraines on about half of all days and on the other days I only manage to reduce eye strain, an attack to prevent). In recent years I have been able to stop the deterioration phase with - a shaman's stay in Peru and an ayahuasca treatment over several days, to which I responded very well
- a stay in Königstein
- the Cefaly device
(every year)
and thus prevent it that I get daily attacks during this time.
The Cefaly device continues to work very well, but no longer has the effect it had a year ago, when I was able to use it to intercept and prevent seizures. Here too, a certain amount of getting used to has set in. I also tried Cerbomed as part of a study (Grosshadern Clinic), but it was too weak. Botox had no effect at all on me, nor did acupuncture.Now I'm a bit at a loss as to what I could do this year to take a break from metoprolol. Is there another medication or other treatment option that I haven't tried yet? What can you recommend to me?
Many thanks for your help!
Christof-
Dear Christophe,
Migraine is a neurological disease and the underlying mechanisms are now well known. A series of all possible treatment options, the effects of which have not been proven and some of which come from unconventional areas, is not productive. It is important to use the proven basic principles of migraine therapy. This has the greatest probability of an effect. I ask you to read up on this in the individual Headbook groups.
Kind regards
Hartmut Göbel-
Dear Prof. Göbel,
Apart from the stay in Peru, which was admittedly a somewhat “act of desperation”, all steps were carried out with a migraine expert (Dr. Mühlbauer or Dr. Brand). It's not a series of cases, it's just that medications that weren't effective were discarded. Which treatment options are you criticizing exactly?
I know the background to migraines very well; I have been dealing with them intensively for 10 years.
I also know that I am not a “standard patient” and that the fact that migraines are triggered by visual overload and stress is not a factor is very unusual. I'm looking for help all the more because most doctors are overwhelmed by my medical history. As you can see, I've already tried everything.Do you have any recommendations as to what else I could try? I went into this chat with very high hopes because I really don't know what to do right now.
I would really be VERY grateful for a specific tip!
Kind regards,
Christophe-
Dear Christof,
as the chats become more and more frequent and the number of questions increases significantly, it is no longer possible to answer follow-up questions due to time constraints. All questions asked here can also be answered via Headbook, which is why Prof. Göbel refers to them. Please also take advantage of this community's useful opportunity for many members! In addition, individual questions cannot be answered without a personal examination.Another tip from me, the ineffective procedures include the following, which you could perhaps avoid in the future: trips to Peru, Cerbumed and acupuncture.
Kind regards,
Bettina
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Dear Professor Göbel,
I would like to know what you think of Cefaly!
Do you see opportunities or risks in this? Neither Profilaxe nor vagus nerve stimulation with GammaCore has helped me.
Thank you very much
Robert-
Dear Robert,
Cefaly is a special form of neuromodulation. There is data for the preventive effect on episodic migraine. It is a very simple and ultimately cost-effective process. Therefore, in my opinion there is nothing wrong with using it; studies indicate a certain effect. To date, there is no convincing data for the effectiveness of vagal stimulation with GammaCore; the possibility that the device cannot simply be recharged repeatedly is a purely business approach with no comprehensible basis for me.
Kind regards
Hartmut Göbel
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Dear Prof. Dr. Göbel, unfortunately my application to come to you was rejected. I should report back in 3 months. I really hope it works. I have migraines every 2 days and suffer a lot.
Here's my question:
I'm currently trying 50 mg of Metroprolol, unfortunately there's no more in it due to infectious asthma and low blood pressure, you should take at least 100 mg.
Question: Can I take Flunarizine 5 or 10 mg in the evening or does it not fit with the Metroprolol?
How should I dose the flunarizine exactly and for how much?
Why can you only take it for 6 months?
If it would help me, can't I take it longer? If I get depression from it, can't you just add Doxepin so that you don't get depression?How far is the vaccination for migraines? Can you try it if you are hospitalized?
Thank you very much for your chat, you don't feel so alone with the pain.
Best regards
Be quiet, Bettina
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Dear Bettina,
In principle, you should initially only carry out prevention with a single substance and dose it out. If metoprolol is not well tolerated, you should change the medication and use another substance. It would therefore make more sense to switch completely to flunarizine and then dose it off until it becomes effective or intolerance occurs. As a rule, 5 to 10 mg is used per day or every other day. This must also be decided individually on a case-by-case basis. Flunarizine can also be given for longer than 6 months. However, it is initially used for a period of 6 months to evaluate its effectiveness. If the migraine attacks are significantly reduced, you should consider discontinuing the medication; in many cases the effectiveness can be maintained without having to continue taking the medication. If depression occurs during treatment with flunarizine, you should consider discontinuing it and choosing a different medication. Here too, it would be better to initially switch to Doxepin, which you mentioned.
The prevention of migraines with antibodies is still being clinically tested. Its use is likely to be expected in 3 or 4 years as part of routine therapy.
Kind regards
Hartmut Göbel
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Dear Prof. Dr.
Göbel, another question: With the Metroprolol 50, the migraines were better for the first 14 days, but I now had a Strovac vaccination for my frequent bladder infections and since the vaccination it has been very bad again. I have had migraines almost every day for the past 2 weeks I think it's because of the vaccination. I was supposed to get 2 more injections, but now I don't dare to do it anymore. I'm afraid that the migraines will get worse for months, although I had it better under control with the metoprolol. But not since the vaccination. Should I get the second and third vaccination or not? There are 6 strains coli bacteria and enterococci etc.Best regards
Bettina
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Dear Bettina,
please discuss this with your treating doctor. In my opinion, it cannot be assumed that the vaccination is the cause of a change in migraines.
Kind regards
Hartmut Göbel
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Dear Professor Dr. Göbel,
Thank you very much for the option of live chat!
I was an inpatient at the Kiel Pain Clinic in February 2014. According to your doctors and also my neurologist, I have now “gone through” pretty much all of the prophylactic medications. My current prophylaxis consists of 12 mg candesartan (I can no longer tolerate any higher because of my low blood pressure), 50 mg doxepin and 5 mg fluoxetine. I also receive Botox every three months. I've been taking fluoxetine since October, it was an idea from my neurologist. Unfortunately, the problem is that it gives me anxiety, extreme sadness, sleep problems and night sweats (which no one can explain because it should actually have the opposite effect). However, it has had a very positive effect on migraines, which for the first time (in contrast to all previous prophylactic medications) have also been greatly reduced in frequency. It's now a vicious circle, the more fluoxetine I take, the better the migraine is, but the worse I feel otherwise. And vice versa. I have therefore already had 3 attempts to sell the drug, each time ending up in a very bad status migraenosus, which could only be interrupted with cortisone or, last time, not even with that, but only with higher doses of fluoxetine. The situation (migraines every day) only improved when fluoxetine was taken again or the dosage was increased). I can't explain this, but I don't know what to do either - since stopping it never worked, but I also can't take any medication that causes me depression (the depressive symptoms always disappeared when I stopped!) . The only time I've ever felt this "depressed" was while taking triptans (which cause the same feeling, but much weaker). How can this be explained medically - especially with regard to serotonin, which obviously plays a major role in all these medications and migraines? What would be your advice? The suffering is unimaginable at the moment.Second quick question: What do you think about correcting the Atlas misalignment in relation to migraines?
Thanks alot!
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Dear sunflower,
In my opinion it is not very likely that the anxiety states you describe are caused by the fluoxetine. Since, as you write, it has a good effect on migraines, I would be reluctant to make a change because of the very limited treatment options you describe. During a migraine attack, pronounced emotional changes with mood reduction as well as anxiety and panic attacks can occur, and very intense neuropsychological changes can occur. From this point of view, stabilization of the severe migraine should be considered.
Correcting an atlas misalignment has no proven effect on migraines.
Kind regards
Hartmut Göbel
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Dear Prof Göbel,
my neurologist keeps telling me that migraines can only occur in the digestive organs.
I haven't had a headache since I was 70 years old.
Is migraine prophylaxis even appropriate or does it damage the stomach?
The nausea with bladder cramps always lasts for several days, during which I lie down.
On these days, leg cramps occur, which levodopa helps.
Since I am disabled, I don't have many options to change doctors.
That's why I would be grateful for some advice.-
Dear Margit,
Migraines can also manifest as abdominal pain, abdominal cramps, diarrhea and other abdominal symptoms. However, due to the limited information available, it is not possible to decide whether you have this type of migraine. However, it would be worth considering suspending migraine prevention for a while. You could then evaluate whether this is effective at all and whether it needs to be continued and whether the course can be changed as a result.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
I am 52 years old and have around 10 migraine days per month. If an attack begins and I start with triptans (Allegro, Formigran), then it usually lasts 3-5 days, although I have the impression that the triptans maintain the migraine attack (almost like an addict who gets withdrawal symptoms (= recurrence of the migraine attack). Migraine) as soon as the drug is broken down. Ibuprofen does nothing to shorten the duration of the attack. If you manage (rarely!) to get the migraine under control with just Voltaren and Metamizole on the first day, then you can usually rest.A neurologist recommended dihydroergotamine nasal spray to me to avoid recurring headaches, which the spray usually does. The spray is no longer approved in Germany and must be purchased from France.
How many times a month can I safely take the dihydroergotamine spray?
You recently mentioned (January 12, 2016) in the program “Migraine, a widespread disease” (SWR 2014) in a patient with hemiplegia that the risk of stroke is increased with triptans.
I have no other vascular risk factors (normal blood pressure, LDL below 140 mg/dl, non-smoker, no family history of CHD, no diabetes). Can you estimate how much my risk of stroke is increased when taking triptans?Is it higher with dihydroergotamine?
I really appreciate you taking the time to answer such important questions for us in this chat.
Thank you very much, best regards,
Islay-
Dear Islay,
A medication can never be taken without hesitation. This is particularly true for dihydroergotamine spray. The program you mentioned is about a patient who continued to be treated with triptans despite having a stroke. Triptans must not be used if cardiovascular diseases such as a heart attack or stroke have previously occurred. It is therefore necessary to have regular follow-up examinations with a doctor if you suffer from migraines and use triptans. According to current knowledge, the risk of stroke per se is not increased with triptans.
I am not aware of any relevant studies for dihydroergotamine. However, unlike triptans, it does not work selectively, but rather throughout the body. Therefore, side effects on the vascular system are more likely.
Kind regards
Hartmut Göbel
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I, 49, was in Kiel in 2014.
Severe migraines. MÜK. Depressive phases. Since then it has been stopped prophylactically with Beloc Zok mite 47.5 mg (1 1/2 in the morning, 1 in the evening) and venlafaxine 37.5 mg (112.5 mg in the morning). For acute treatment Ascotop 5 mg and naproxen. After half a year of improvement. Attack-free phases of 2-3 weeks :-) The attacks have been increasing again since the beginning of the year. Despite beta blockers, blood pressure was usually 140/92-95 (this was also the case before Beloc, but much higher in the clinic). Overall, I have become calmer, which is good for me. I attribute this primarily to venlafaxine. However, as before with MÜK, I often feel dizzy again, i.e. dizziness and dizziness, so that I have trouble concentrating and I tend to avoid driving. My question: How long is migraine prophylaxis taken? Forever? In intervals with breaks lasting several months? Does it make sense to continue taking beta blockers (ACE inhibitors are not possible, I react to this with an extreme, persistent dry cough; weight gain of 8 kg due to beta blockers)? Without prophylaxis, I would be afraid of a repeat of the attacks like in Kiel. My neurologist helps me and has also implemented the clinic's treatment plan, but in my 20 years of medical odyssey I have only met really good migraine specialists in Kiel. And: During a severe attack that had lasted a whole week, my doctor gave me intravenous aspirin to stop the attack. Unfortunately it didn't help at all. Are there special migraine medications to stop intravenous attacks?-
Dear Binchen,
Migraine prophylaxis should be taken for as long as necessary. This can be seen primarily in how many migraine days there are per month and whether the acute medication is sufficiently effective. If the migraine is very aggressive and you have more than 7 migraine days per month, which are difficult to treat with acute medication, long-term migraine prophylaxis may be necessary, in individual cases even for decades. Breaks of several months may be possible if there is a temporary significant improvement and you want to try to avoid it. Based on your descriptions, I think continuing a beta blocker is worth considering. Aspirin can be given intravenously as a replacement medication for migraine attacks that are otherwise resistant to treatment. It is important that 1 g is administered. The effect can be improved by adding an anti-nausea drug such as metoclopramide to the infusion. For severe, treatment-resistant migraine attacks, there are also other special options that can be given in an emergency situation. These include, for example, Novaminsulfone, Prednisolone and others.
Kind regards
Hartmut Göbel
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Dear Prof. Dr. Göbel,
This is my first time in headbook. I have to apologize for not using the salutation in my already posted comment. I'll make up for it here :-)
Thanks so much
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All right, dear Binchen, Prof. Göbel saw it.
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Dear Professor Göbel,
I have a general question regarding opioids, which were also prescribed to me in Kiel.
Are opioids weight dependent? So does it make a difference when it comes to dosage whether a patient weighs 50kg or 100kg? Furthermore, with the long-term administration of 2x 200 mg Tramabeta long, I unfortunately still reach my pain threshold, which is unbearable (chronic tension headache, NPDH, migraines, but especially the NDPH pain). I had previously been given stronger opioids for battery therapy, which had an effect (Targin). However, I don't want to take such strong opioids, even though they have made a normal life possible again. Is there a slightly stronger extended-release opioid than tramadol that my neurologist can prescribe for me?Thank you in advance for your tireless work. There are no words to express how valuable your commitment is.
Kind regards,
Erik-
Dear Erik,
The administration of opioids can depend on body weight. What is much more important, however, is how severe the pain intensity is and how the patient metabolizes the medication. If you are currently using 2×200 mg of Tramal in a sustained release form and do not yet have sufficient effect, a further dose increase up to 2×300 mg is possible. There are also medications that can be added to the opioid as a so-called comedication to improve the effect. These include, for example, amitriptyline, pregabalin and others.
Kind regards
Hartmut Göbel
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Dear Professor Göbel, I am 58 years old and have had migraines for 40 years.
So far I've got it somewhat under control thanks to the triptans, but the attacks have been increasing since December, so my neurologist now wants to start taking beta blockers. But I have low blood pressure. Can I even take the BB? I am a teacher and need my mental skills in front of the class. Are they restricted by the BB? A second question: I have always taken Maxalt, but after 24 hours I need the second and then a third. This quickly adds up to 10 (danger MÜK) Is there a triptan that lasts longer so I don't need as many? Thank you for your reply.
Kind regards,
Birgit Bose-
Dear Ms. Bose,
If beta blockers are dosed slowly, they can also be used for low blood pressure. As a teacher, mental abilities in front of the class are generally not impaired by beta blockers. Beta blockers are considered first-choice medications because they are generally very well tolerated and have a good effect. However, there are patients who do not respond adequately to it or cannot tolerate it. Then there are numerous other therapy options. Maxalt has a very quick effect, but the special thing is that it wears off quickly and then a so-called recurring headache occurs. If the frequency of intake is significantly less than 10 days per month, this is not a problem. Longer-acting triptans include Relpax, Allegro or Almogran. You don't count the tablets per month, but rather the days of intake per month. It is therefore better to treat effectively in one day, even using 2 tablets, and then not need any medication the next day.
Kind regards
Hartmut Göbel
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Dear Professor Dr. Göbel,
thank you for existing!
!!! My average painkiller days cannot be brought below 6. Acute therapy with triptans always works well to very well. But I'm afraid of MÜK.
Neurologist is considering prophylaxis.
Kindly ask for your opinion.
I'm 54, NR, sporty, still of normal weight.
Beta blockers: I have rather low BP,
increase?
Antidepressants: Fear of increasing weight
because I have a diagnosed anxiety disorder in depressive phases. Would it be ideal??
two birds with one stone?? Which AD causes the least increase?
Topiramate: increases anxiety disorder ??
correct? ??supposedly strong side effects?Thank you very much for assessing my situation.
Maybe no prophylaxis at all?
? LG from Austria
Biggie-
Dear Biggie,
with 6 painkiller days per month you are in the “green” zone. It doesn't always help to fight against windmills. If, due to the special genetic prerequisites, there is a migraine frequency of 6 days a month and the attacks can be easily treated with a triptan, there is no reason why you should not take it easy. If the situation is stable, the risk of MOC is very low. Prophylaxis in this situation with medication is not absolutely necessary. However, if there is an anxiety disorder with depressive phases as a comorbidity and an antidepressant would be necessary anyway, this step would make doubly sense. Topiramate should not be used in this situation as it can increase depression and anxiety.
Kind regards
Hartmut Göbel
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What would you recommend to someone who has had CD for years and the prophylaxis is not working?
is a woman, doesn't smoke, doesn't drink and doesn't use drugs, prophylaxis lithium, vera and oxygen, at what point would you recommend the operation and if so, which one and where I had 8-10 attacks with tipping over-
Dear Selina,
If the course you describe occurs, you should urgently go to a cluster headache competence center and have the situation clarified individually. There is no general answer to your question.
Kind regards
Hartmut Göbel
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Dear Prof. Göbel,
According to your Kiel headache questionnaire, I (31-year-old, male) confirmed 100% migraines, which I have been able to confirm from my own experience for years (2-4 times per month). For the past 4 months I have also been suffering from almost daily pain, which is very similar to migraines, but is perceived in varying pain intensity: always left-sided & dull neck pain up to the eye, sometimes with sensitivity to noise. I am currently 100% unable to work. Head MRI is still being done.
After studying your book and building up my own knowledge, I am very dissatisfied with my neurologists. I'm also unsure about the current diagnosis: chronic migraine or episodic migraine combined with chronic tension-type headache. I'm having trouble checking the boxes in the Kiel headache questionnaire when analyzing the almost daily and debilitating neck pain for 4 months.
1)
Do you have any recommendations for well-qualified neurologists, pain institutions, psychiatrists, psychologists or multi-modal behavioral therapies in Switzerland who specialize in primary headaches? I am also looking for holistic treatment for my neurological illness(es), does this exist at a professional level in Switzerland?2)
Somehow I have the feeling that my dissatisfaction and lack of motivation at work over months and years is now reflected in a chronified migraine. Do you know similar male pain patients who do not have a life support from a partner? How did such patients get off the hamster wheel? Existential fear doesn't make dealing with the pain any easier...-
Dear Svensson,
You can find out more on the homepage of the Swiss Headache Society and ask regional pain therapists for information. If a life situation is very stressful, you should seek individual advice and try to change it.
Kind regards
Hartmut Göbel
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Dear Prof. Dr.
Göbel, thank you very much for your commitment in every respect. I have been to your clinic twice and it is so important for me to have this point of contact.To my question: I am female, 32 years old, have had migraines since I was 5 years old, chronic migraines for about five years, recurrent depression, ONS for two years. I am currently taking 25 mg amitriptyline for prophylaxis (was discontinued in the Kiel pain clinic due to the desire to have children).
Unfortunately, the desire to have children has not (yet) turned into a success. A blood test by my gynecologist revealed that I have an estrogen deficiency. If I want to have children, this should be treated with hormones. Such treatment with estrogen failed about ten years ago. After every dose of estrogen I reacted with severe migraines.
Can something be done “better” in such a case? Is there a way to prevent migraines from getting worse? I currently have about 15 pain days a month (about six triptan days). Any deterioration would be fatal.
Thanks! It's great that there are people like you.
Best regards,
Lenchen
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Dear Lenchen,
Estrogen treatment does not necessarily make migraines worse. If this was the case 10 years ago, it doesn't mean that it will happen now. Ultimately, it must be individually considered what should be achieved, with what effort and with what risk. Since you currently have very comprehensive migraine prevention including neuromodulation, there is a better chance that the migraines will remain stable despite fertility treatment.
Kind regards
Hartmut Göbel
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March 14, 2016 at 12:10 pm - Edit
Dear Mr Göbel,
Thank you for the opportunity to chat live with you here!
What is a good inner attitude so that you can live and deal well with your headaches? I think that your own perspective on things can change a lot. And above all, towards the positive. Do you have any specific suggestions for this?
I have had chronic tension-type headaches for almost 4 years and my therapy currently consists of endurance sports and progressive muscle relaxation according to Jacobsen. At first I thought the headaches wouldn't be there after a year or two. But for the last 2 years I have been losing more and more faith in a headache-free life, although I haven't given up hope yet and am continuing to pursue therapy.
Best regards,
Robert
March 14, 2016 at 6:19 p.m. – Edit
Dear Robert,
Chronic tension-type headaches usually cannot be eliminated through simple measures and often not quickly. It wouldn't be called "chronic tension-type headache" if it were to be temporary. You actually have to be prepared to be confronted with the topic in the long term. On the other hand, there are many ways to actively counteract the headache. Knowledge, information, understanding how the headache is maintained and can become chronic, implementing behavioral measures to prevent it, and knowing how to use medication correctly are all part of this. Very often this can reduce the headache and often eliminate it completely. However, how long this will take remains to be seen. There is no other way than to deal with the issue with commitment and do everything to make the headaches less. The knowledge about this can be found in the headbook groups, where additional sources are also given.
Kind regards
Hartmut Göbel