Below you will find the contributions to the migraine and headache chat on February 16, 2015. Detailed information and all current topics on diagnosis and treatment can be found at headbook.me
It was written on February 16, 2015 at 1:56 pm
Dear Prof. Dr. Göbel,
I often wake up in the morning with a severe tension headache, accompanied by nausea and sweating. I've never taken a headache tablet because I'm afraid of an allergic reaction.
I have a penicillin allergy. I've heard that you shouldn't take headache tablets containing acetylsalicylic acid (ASA), which is found in many headache tablets. Is that true? For your information, I've been taking an antidepressant (Paroxetine) for 13 years due to my panic disorder/anxiety, 30 mg daily. I tolerate it very well. What about potential interactions with a headache tablet? I had abdominal surgery last year. I was given the painkiller Arcoxia, 60 mg, as pre-medication. Could I also take Arcoxia for my severe tension headaches? Or could you recommend another medication?
Kind regards,
Nicole
wrote on February 16, 2015 at 5:46 pm
Dear Nicole,
Before any treatment is recommended, you should first have a thorough examination to determine the specific types of headaches you experience. The timing and accompanying symptoms can also be consistent with migraine. In this case, it might be more effective to receive a specific migraine medication, such as a triptan, for treating attacks. A penicillin allergy does not necessarily preclude treatment with aspirin (ASA). There is no established link between these allergies. Similarly, there is no known interaction with paroxetine (Paroxetine). Arcoxia is an anti-inflammatory COX-2 inhibitor. This medication is typically used for chronic pain with inflammation, particularly in the joints. When used for acute headaches, its effects are usually delayed, and it may not provide sufficient immediate pain relief.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 4:34 pm
Dear Prof. Dr. Göbel,
I have basilar migraine, which is accompanied by severe neurological deficits.
This has happened quite often at work (nursing training) and recently also at school.
Many people were quite shocked.
How can we explain to them exactly what this is?
How can I best and most comfortably deal with these symptoms when I am away from home?
Thank you in advance.
Kind regards,
Laura
wrote on February 16, 2015 at 5:47 pm
Dear Laura,
Basilar migraine is a particularly severe form of migraine with aura. You should carry an emergency card with you that describes both the diagnosis and the symptoms. If a migraine occurs, you can show this card so that bystanders can be informed. You can also combine this emergency card with specific behavioral guidelines. For example, if you experience speech difficulties and cannot express what is happening, bystanders can get direct information from the card. Similarly, in the event of extreme fatigue or even loss of consciousness, bystanders can quickly determine what to do.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 5:23 pm
It's been almost two years since you diagnosed me with cluster headaches. I take 120 mg of Isoptin twice a day (I can't tolerate more due to circulatory problems), but the attacks aren't getting any less frequent.
My question is: what can I do to reduce the frequency of the attacks?
wrote on February 16, 2015 at 7:44 pm
Dear Elisabeth,
If the attacks do not improve with 2 x 120 mg Isoptin, a more effective preventative measure must be found. A combination with lithium or another preventative medication is possible. The type, duration, and severity of the attacks will determine which further treatment options are considered. Therefore, you should schedule a follow-up examination to adjust the treatment plan based on its effectiveness.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 11:52 am
Dear Professor Göbel,
I have been suffering from chronic migraines and severe headaches for a long time. I also have constant neck tension. In 2007, I was treated at the Kiel Pain Clinic.
For preventative purposes, I take Trevilor 75, Ergenyl Chrono 300, and Magn. Verla 300 three times a day.
Unfortunately, I can no longer distinguish between the different types of headaches. It always starts with neck pain and tension, then spreads across my temples and into my entire head. I experience it as just one continuous lump of pain. I can often only guess what kind of headache it is. Sometimes only Maxalt 10 mg helps, other times only Ibuhexal 800, or sometimes nothing at all. The phases of the headache vary greatly. I usually have pain for four days, almost every week. If I'm lucky, this period is somewhat shorter. In addition, I have very little mental resilience and am almost constantly tired.
Since I also developed headaches that were "somehow" different, I went to an orthopedist and received the following findings:
Steep posture of the cervical spine. Equivalent bone marrow edema in C6 and C7, more pronounced in C6 than C7, with irregular endplates. Faint line at T1 in C7 dorsally on the left. In this motion segment, there are also medial to bilateral recessed disc herniations on the left, presumably partially covered by bone, with narrowing of the anterior cerebrospinal fluid space without nerve root involvement. Main finding: In the C6/C7 segment, intervertebral osteochondrosis and a broad-based disc herniation with narrowing of the anterior cerebrospinal fluid space.
I am currently receiving intra-articular injections bilaterally at C5/C6 with barely noticeable relief.
I feel quite helpless in this situation, especially since I have the feeling that the respective doctor has essentially already given up on me.
Are the medications sufficient and appropriate in my case?
Would it perhaps be more sensible to consult other doctors or consider inpatient treatment at a clinic?
Can you recommend a pain center near Berlin?
Is there anything I can do differently myself?
Many thanks for your attention.
Hugs
wrote on February 16, 2015 at 6:30 pm
Dear cuddles,
You describe a very complex course of illness. I cannot discuss it in detail here. However, it is clear that you require further intensive treatment, possibly even inpatient care. You should consult a specialized facility that can treat the various pain conditions using an interdisciplinary approach. If necessary, they will recommend inpatient treatment. You can find outpatient treatment centers on our website: https://schmerzklinik.de .
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 11:56 am
Do you have any findings on non-invasive neurostimulation technology (vagal nerve stimulation)?
Have any successes been achieved?
Thank you for your reply
Konstanze
wrote on February 16, 2015 at 6:31 pm
Dear Konstanze,
Regarding the treatment of migraines and other conditions, there are a number of so-called uncontrolled case reports. Controlled studies comparing this treatment to other treatment methods have not yet been published. Its effectiveness has not been sufficiently proven, and the procedure is not approved; health insurance companies do not reimburse it.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 11:58 am
Dear Prof. Göbel,
Thank you so much for taking the time to answer our questions again today.
I have had migraines for 29 years and have been taking only triptans to treat attacks for the last 17 years because they are the only reliably effective acute medication for me.
Due to a lack of effective preventative measures, I have been suffering from medication overuse headache (MOH) for 10 months. Hormonal fluctuations are my strongest trigger, and three consecutive days of triptan use are enough for me to experience MOH.
I recently made two unsuccessful attempts to take a break from medication. The first was
as an inpatient with four days of cortisone, the second as an outpatient with 16 days of cortisone. On the 18th day, I resumed taking a triptan. Unfortunately, this break wasn't enough either. On top of that, the prolonged high-dose cortisone use caused a thrombosis in my lower leg, which is now being treated with the anticoagulant Xarelto (2 x 15mg daily) and compression stockings.
Fortunately, I will be going to the pain clinic in March for another break from medication.
Even the two cortisone-assisted breaks were difficult and very anxiety-ridden for me. Because of the thrombosis, I can't have cortisone again. But a break without this support seems unimaginable. The fear of the anticipated pain is simply overwhelming. Due to the long medication overuse headache (MOH) and the unsuccessful breaks, I'm not getting any rest; I'm mentally exhausted, and my pain tolerance is practically nonexistent because I lack the necessary energy. At the same time, my pain sensitivity seems to have become enormously heightened.
Now to my question: Are there ways to adjust my medication during breaks so that I can sleep as much as possible despite the extreme pain? Would magnesium infusion be an option? Vomex and Melperon don't work for me at all.
Thank you very much in advance for your reply!
Northern Lights
wrote on February 16, 2015 at 6:33 pm
Dear Northern Lights,
Based on your description, you should not attempt another medication break on your own before your hospital stay. The complications you described can indeed occur. Furthermore, if the medication break proves ineffective, it becomes increasingly difficult to achieve a successful treatment outcome. During your inpatient treatment, you will receive support and guidance throughout the process. For severe medication-related headaches, you will, of course, be offered all possible treatment options to alleviate and manage them. This is generally very successful.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 11:59 am
Dear Prof. Göbel,
In one of our recent chats, you wrote: "Anything that helps with acute, primary headache attacks can also perpetuate medication-overuse headaches."
How does this apply to non-orally administered medications, such as lidocaine injections into trigger points in the neck, or the use of peppermint oil or Versatis patches (which I was prescribed for atypical facial pain)?
Do these medications also count towards the "10-day rule" for painkiller use?
Thank you for your reply and best regards to Kiel.
Peter
wrote on February 16, 2015 at 6:35 pm
Dear Peter,
Lidocaine injections into trigger points or the application of peppermint oil do not cause medication overuse. Peppermint oil is actually a special exception; it can relieve pain without causing central sensitization in the sense of medication overuse headache. However, injections with local anesthetics should not be used long-term and should only be used for a short, clearly defined period.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:01 pm
Dear Prof. Göbel,
Thank you so much for giving me the opportunity to ask you a question that has been on my mind for a long time.
For several years now, I've been experiencing daily pain due to chronic migraines, tension headaches, and atypical facial pain. Unfortunately, no acute medications (including triptans and opioids) are effective for any of the pain types. There are no medication errors, such as insufficient dosage or taking the medication too late, nor is there any risk of medication overdose.
The following possible reasons for the ineffectiveness of medications have been mentioned in the Headbook and in the medical literature
:
excessively rapid metabolism in the liver;
the receptors responsible for drug absorption have ceased functioning due to the constant pain.
Can you confirm any of these statements, or do you have another explanation for the lack of effectiveness of the medications?
My most important question, however, is whether, regardless of optimizing preventative measures, there is a way to identify the underlying cause and then address it.
Thank you so much for your reply and all the best to you and your team.
Kind regards, Marlene
wrote on February 16, 2015 at 6:37 pm
Dear Marlene,
Indeed, in very rare individual cases, there are patients for whom acute medications are ineffective or insufficiently effective. Nature is highly diverse; the body has different receptors and metabolic processes. The reasons you mentioned can certainly apply in individual cases. However, there are various ways to optimize the effectiveness of medications in attack therapy. These include, in particular, specific preventative measures through behavior and medication. Often, effectiveness can also be achieved by selecting the appropriate acute medication and how it is administered. Therefore, there are usually always ways to achieve a successful treatment outcome.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:01 pm
Hello Prof. Dr. Göbel,
A few months ago, in consultation with my anesthesiologist/pain specialist, I stopped taking topiramate (50mg in the morning and 50mg in the evening). I discontinued it very slowly, as prescribed. For the first two weeks after stopping completely, I felt fine. But then things took a turn for the worse. I had 16 days straight of the most horrific migraine attacks imaginable. The pain and accompanying symptoms were so severe that I barely knew how I would get through it. The triptans offered little relief, and by the end, I was so physically and mentally exhausted that I was completely broken. My anesthesiologist couldn't explain this severe reaction. But after 16 days, I restarted topiramate because my family doctor strongly advised me to, and the migraines, including the accompanying symptoms, subsided dramatically. I gradually began to feel better again. I now take a dose of 25mg in the morning and 25mg in the evening. I'm currently managing well and only need to take triptans 2-3 times a month. Why did I react so strongly? I followed the tapering plan strictly, reducing the dose by one week each time. Now I'm terrified of trying again, if it even makes sense. My pain specialist says that since I've been taking topiramate for so long, it might be necessary to stop after two years. I don't think that's a good idea. I can't go through that again. Do you really always have to stop topiramate after a certain period, even though it helps so much?
Thank you so much for your advice.
wrote on February 16, 2015 at 6:47 pm
Dear Ivitho,
The prolonged migraine episode after discontinuing topiramate is not necessarily related to the discontinuation itself. Many other factors could be responsible. Similarly, the rather sudden improvement after resuming treatment may not be due to the reintroduction of topiramate. In any migraine episode, prolonged, severe attacks can occur completely unexpectedly—a so-called status migrainosus, which is unresponsive to any medication and seems to persist. However, there always comes a time when these attacks subside on their own. Therefore, you don't need to worry that discontinuing topiramate will inevitably trigger recurring migraines in the manner you just experienced.
On the other hand, there's no specific reason to discontinue topiramate after a certain period. Topiramate is generally a long-term medication that can be used for years, if not decades. If you feel safer with a lower dose, there's generally no reason not to continue using it long-term. You can then very carefully reduce the dose further over a longer period, and you'll find that, under certain circumstances, your condition doesn't necessarily worsen. There are many reasons to continue a well-tolerated preventative medication if it gives the patient the confidence of being protected from migraine attacks.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:02 pm
Dear Prof. Göbel,
I suffer from tension headaches and chronic migraines and would like to hear your opinion on whether a constantly elevated heart rate could be the cause of my frequent headaches or perhaps even worsen them.
My blood pressure is normal, or sometimes even low, and my resting heart rate averages around 100.
I've read the following as a possible explanation for the assumption that an elevated heart rate causes or intensifies the headaches: If the heart beats slower, the pain impulses are also "sent" more slowly.
Since I cannot take beta-blockers due to serious side effects, it would be very important for me to know if there is any connection at all between heart rate and headaches.
Thank you so much for your reply, Martina
wrote on February 16, 2015 at 6:38 pm
Dear Martina,
There isn't necessarily a direct link between heart rate and headaches. Only an extremely slow or very fast heart rate can worsen a headache. A resting heart rate of 100 is not unusual. It's unlikely that changes in heart rate affect headaches.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:04 pm
Dear Prof. Göbel,
For several years I have suffered from chronic migraines and tension-type headaches. During this time, I have increasingly had difficulty lying flat, so that now I can only lie or sleep with my upper body significantly elevated (almost in a sitting position). Lying flatter significantly intensifies the pain (intense pressure).
I happened to read in your book that cluster headache patients also experience increased pain when lying down, due to inflammation of the venous blood vessels and the impaired venous drainage in this position.
Could this also apply to chronic migraines, and would aspirin (100 mg) as a blood thinner be helpful in this case? If not, what other possible reasons could be causing these difficulties?
Thank you for your reply and best regards to you and your entire team. Tina
wrote on February 16, 2015 at 6:49 pm
Dear Tina,
Migraine sufferers typically feel better when lying as flat as possible. For other types of headaches, elevating the upper body can improve the pain. This applies to cluster headaches and headaches associated with increased intracranial pressure. Headaches caused by arterial hypertension can also be alleviated by elevating the upper body while lying down. Therefore, you should undergo a thorough examination to determine if any of these conditions apply.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:08 pm
Dear Prof. Göbel,
I would like to ask you another question today.
In our chat last November, you advised me to include occasional doses of Tizanidine in the "10-dose rule" as a precaution.
However, you stated that this rule does not apply to Orthodon.
My question is: what is the difference between these medications that necessitates this different approach?
Thanks for your answer.
wrote on February 16, 2015 at 6:50 pm
Dear Tobi,
A definitive statement cannot be made for either tizanidine or Ortoton. Ortoton contains the active ingredient methocarbamol. It is a centrally acting muscle relaxant, very poorly researched, and causes a general depression of the central nervous system. Studies on its long-term effects and use in headaches are not available. For this reason, it cannot be said with certainty whether medication overuse headache will develop. The same applies to tizanidine. Therefore, as a precaution, the "10-day rule" should be applied to both medications.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:10 pm
Dear Prof. Göbel,
Following a medication break at your clinic, I am now strictly adhering to the 20/10 rule. In the event of a migraine, I initially take naproxen plus sumatriptan 100 mg. So far, this has always worked quickly and reliably. Towards the end of an attack, I now only take ibuprofen to avoid having to terminate the migraine with sumatriptan. Lately, I have the feeling that sumatriptan isn't working as quickly, sometimes not at all. Can I try a different triptan to "quickly end" an attack? Which one would you recommend? I took Maxalt a few years ago, but I found sumatriptan to be more reliable and had fewer side effects.
Thank you very much for your help!
wrote on February 16, 2015 at 6:51 pm
Dear Jedida,
It is indeed sometimes the response to a triptan to change. In such cases, it's worth considering whether a so-called triptan rotation, meaning switching to a different triptan, might achieve better efficacy. Triptans with rapid onset include rizatriptan, almotriptan, zolmitriptan, and eletriptan. However, individual cases may vary, so it's always necessary to try each one to determine its effectiveness.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:10 pm
Dear Prof. Dr. Göbel,
In your current book from 2014 (“Successfully against headaches and migraines”) you write on page 266:
“The company pregnancy registry has not yet revealed a significantly increased risk of birth defects when sumatriptan is used in the first trimester, based on over 1000 pregnancies (as of January 2013). For the other triptans, the data (…) is insufficient. However, until sufficient experience is available, triptans must not be used during pregnancy.”
Does the last sentence refer to all triptans, or is sumatriptan 100 excluded?
(Last autumn I was pregnant until the 11th week of pregnancy; during this time I unfortunately had very frequent and very severe migraines; in consultation with my neurologist and gynecologist I also sometimes took Sumatriptan 100 – “of course” with no good feeling – since Vomex often didn't help or I was, for example, driving alone and couldn't take Vomex because of the resulting fatigue.)
Thank you so much for your reply!
Susisonne
wrote on February 16, 2015 at 6:53 pm
Dear Morgenfrisch,
Sumatriptan was the first triptan, and therefore there is a long history of experience with its use during pregnancy. In summary, the data show that taking sumatriptan during pregnancy does not significantly increase the risk. Similarly extensive long-term experience with the other triptans is not yet available. Therefore, their use during pregnancy cannot be recommended. Nevertheless, women do occasionally become pregnant while taking various triptans; pregnancy registries are being maintained, and more detailed information will be available over time.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:19 pm
Dear Dr. Göbel,
The current issue of migraine magazine mentions the new VITOS therapy device from Cerbotec, which was presented at the pain congress last October!
What are your thoughts on it? Would it be worthwhile to try this device? After all, there was a study conducted by the University Hospital of Munich Großhadern!
So far, all preventative medications have failed for me, and a year ago I saw you in Kiel, which did me a world of good! Currently, my attacks are increasing again.
I haven't yet been prescribed
Would this device be an option? What are your thoughts on it?
Thank you very much for your reply and for taking the time for us!
Warm regards,
Tessa
wrote on February 16, 2015 at 7:06 pm
Dear Tessa,
The study you described was conducted on a very small group of patients. A general conclusion is not possible, and I am not aware of any study that has been able to replicate the results. The manufacturer offers a 30-day free trial of the device. The press release states that if it proves ineffective after this period, it can be returned without incurring any costs. From this perspective, it seems reasonable to try this procedure. If you meet the criteria for chronic migraine, treatment with botulinum toxin A is also a therapeutic option that can be considered.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:25 pm
Dear Professor Göbel,
I have two questions today concerning my current headache situation.
- Can one simply say that if triptans work wonderfully and antidepressants don't help at all, the diagnosis is migraine?
- Does a headache that occurs unusually frequently and at the same time (daily around 9 pm +/- 1 hour) point in a particular diagnostic direction?
Thank you for your answers
wrote on February 16, 2015 at 7:07 pm
Dear Harry,
Thank you for the precise question. Generally speaking, one cannot draw a specific diagnosis based solely on the effectiveness of triptans or the lack thereof of antidepressants. The diagnosis of "migraine" is determined by the headache phenotype, the way in which the headache symptoms manifest. There are migraine attacks that are unaffected by triptans, while others respond even to placebos.
Headaches that occur at specific times can point in a particular diagnostic direction. One example is the so-called "sleep-related headache," which arises during sleep. Cluster headache attacks can also occur at specific times in a fixed rhythm. This also applies to medication overuse headaches, which, with a certain medication regimen, occur at a specific time when the medication's effects wear off. Overall, there are many possibilities. However, in each individual case, it is always necessary to carefully examine which other characteristics of the headaches are present in order to arrive at a diagnosis. Furthermore, various examinations must also be carried out.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:27 pm
Hello Professor Dr. Göbel,
I generally have my migraines very well under control. I treat them with topiramate (2 x 50 mg) and, for acute attacks, with Allegro. The frequency of attacks fluctuates seasonally between two and eight per month (the latter being a peak period) and has remained relatively consistent for years. Around four attacks are typical.
The switch to Allegro occurred approximately three years ago, after sumatriptan and novratriptan showed no effect or only very slow relief. An interim trial with sumatriptan also demonstrated that it sometimes took ten to twelve hours for any slight effect to occur. In some cases, the medication provided no improvement at all.
Lately, the attacks have become more aggressive. That is, the pain is more intense, and the Allegro medication is working less effectively and with a longer delay. Is the body getting used to this?
My concern is that this medication will once again lose its effectiveness, as was the case with the two mentioned above. If so, is this normal, and should one expect to have to change medications every few years because they simply stop working?
Thank you for your reply and best regards
, T. Bauer
wrote on February 16, 2015 at 7:09 pm
Dear Xandrian,
In long-term migraine treatment, especially with very aggressive attacks, it can happen that after a certain period the migraine no longer responds as well to a specific triptan. In such cases, switching to a different triptan, a practice known as triptan rotation, should be considered. Adjusting preventative measures can also be done to restore the triptan's effectiveness. Combining the triptan with, for example, an anti-nausea medication and an anti-inflammatory pain reliever can also be considered. Often, the issue is not so much a decrease in the medication's effectiveness, but rather the increasing chronicity and aggressiveness of the migraine attacks themselves.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 7:33 pm
Good evening!
Thank you very much for the detailed answer.
Greetings from Bayreuth
wrote on February 16, 2015 at 12:38 pm
Dear Prof. Göbel,
I've often read that a ketogenic diet can alleviate migraines and headaches.
The idea is that brain cells can be supplied with ketones after an adaptation phase. Simply reducing carbohydrates (avoiding bread, pasta, and rice) provided little relief. However, the amount of carbohydrates I consumed through fruits and vegetables was too high to induce ketosis.
Would it be advisable, in your opinion, to further reduce carbohydrate intake?
I have suffered from migraines, tension headaches, and medication overuse headache (MOH) for many years (currently taking painkillers and/or triptans daily). I was referred to your clinic in October and am looking for a way to bridge the time until my admission, as I wake up at night due to the pain and have to take medication again.
Thank you for your reply and best regards from Saxony.
Phylli
wrote on February 16, 2015 at 7:14 pm
Dear Phylli,
There is no scientific evidence that any type of diet or specific nutritional approach can improve migraines. This is especially true for the ketogenic diet. According to scientific findings, reducing carbohydrates is detrimental to migraines. The nervous system requires a sufficient carbohydrate supply to be able to convert the necessary energy in the nerve cells.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 12:38 pm
Dear Prof. Dr. Göbel,
I received my second Botox injection on Monday, February 9th, 2015. Since Tuesday, I've still been having problems with my neck – I can't move my head downwards or sideways without pain. Starting Wednesday, I also had another severe migraine attack that lasted two days and completely incapacitated me. Is the neck pain still within the normal range after a week, and should I expect a) this type of migraine attack to recur after each injection, and b) the neck problems to continue as well?
Thank you for your reply!
wrote on February 16, 2015 at 7:15 pm
Dear Lulu,
Muscle pain after botulinum toxin treatment is the most common side effect. It can be explained by the fact that pain-mediating substances, previously trapped within the overactive muscle fibers, are released into the muscle during relaxation, causing the muscular pain. This phenomenon typically lasts about 10 to 14 days, after which these substances are broken down and the effects of the botulinum toxin begin. Generally, the occurrence of muscle pain, similar to a feeling of muscle soreness, is a positive sign and indicates that the treatment is taking effect.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 1:10 pm
Good afternoon, Dr. Göbel!
I have suffered from migraines and tension headaches for over thirty years, and recently also from medication overuse headache. Therefore, I sought treatment at your clinic and am more than satisfied with the treatment, your competent and friendly team of doctors, and your effective approach!
I've been back home from your clinic for a week now and have successfully continued my pain medication break. I'm more than happy to be free of medication overuse headache.
Now my question:
I was prescribed 50 mg of trimipramine at your clinic after doxepin made me extremely tired and caused severe circulatory problems. I tolerate trimipramine better in that respect, but since then I've been suffering from terrible nightmares almost every night. Therefore, I reduced the dosage to 25 mg for the last three nights. Now I'm sleeping better again. I'd like to know if the lower dose of 25 mg will be sufficient for pain relief, or if I should try to gradually increase the dose back up to 50 mg. Or would switching to a different antidepressant be advisable, and if so, which one would you recommend?
Thank you in advance and best regards from Berlin, Ingrid
wrote on February 16, 2015 at 7:18 pm
Dear Catingrid,
Thank you very much for your comment and your explanation. I sincerely hope that your condition will continue to stabilize. Very often, significant adjustment problems occur during a medication break, especially in the first 10 to 14 days. Many patients mistake the symptoms during a medication break for side effects of the newly prescribed medication. It is sometimes very difficult to explain that the problems associated with a medication break often arise from the overuse of acute medications beforehand, and not from the accompanying therapy or the new preventative therapy.
The severe circulatory problems may not have been caused by trimipramine; in fact, they are typical during a medication break. Nevertheless, switching medications can improve the situation. Often, only side effects are experienced in the first few days and weeks after starting a new preventative medication, with the effects only becoming apparent over the long term. This frequently leads to misunderstandings. Nightmares and sleep disturbances are also typical side effects of a medication break. It can be assumed that these will improve over time, and normal sleep patterns without nightmares will return. Generally, frequent changes in preventative medication should be avoided, as this often negates the effectiveness and makes it impossible to reliably assess its efficacy. A dosage of 25 mg is sufficient if consistently maintained for 3 to 6 months. However, this must always be clarified on a case-by-case basis. It is better to use a lower dosage than to be unable to tolerate a higher dosage and then discontinue it prematurely.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 7:29 pm
Thank you so much for your enlightening explanations, Mr. Göbel. I can/will now continue with the trimipramine with peace of mind.
wrote on February 16, 2015 at 1:14 pm
Dear Dr. Göbel,
I have two questions for you:
Before and during a migraine attack, I develop inflamed areas under my scalp that are sensitive and painful. These areas spread and then harden into a raised bump, like a pimple, painful and slightly reddish. When I scratch them, like a skin pimple, a little blood comes out. Then it subsides. It's very unpleasant, inflamed, and feels like there's a foreign body in it. So far, I've only read about this in Oliver Sacks' writings. Is there anything to alleviate this, besides ice? My
migraines often occur with changes in the weather; is there any way to reduce or cure this weather sensitivity?
I currently have up to six migraine attacks a day and can't tolerate any preventative medication. I take naratriptan.
Thank you very much
wrote on February 16, 2015 at 7:23 pm
Dear Alice,
Your description is very unusual and cannot be classified without a direct examination. I am not familiar with Oliver Sacks' description; I would be grateful if you could send me the exact reference. Migraines associated with weather changes can be alleviated through behavioral measures as well as preventive medication.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 1:21 pm
Dear Professor Göbel,
Is there a connection between sudden hearing loss or the risk of experiencing it and migraines?
I had sudden hearing loss years ago (during my period, followed by a migraine), and for the past two days, I've had a muffled feeling in my right ear (reminding me of the hearing loss). I'm currently menstruating, and a migraine is coming on!
Are you aware of anything related to this?
My sister and brother have also had sudden hearing loss in the past!
I'm not under any stress at the moment, so that can be ruled out as a cause.
Thank you for your willingness to answer questions from us headbookers.
I am incredibly grateful for this forum!
Love and best wishes,
Eva
wrote on February 16, 2015 at 7:24 pm
Dear Evken,
A link between tinnitus, sudden hearing loss, and migraine is known. For this reason, migraine should be taken seriously and treated effectively; in particular, adequate preventative measures should be implemented.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 1:23 pm
Dear Professor Göbel,
I had Botox treatment in October 2014. My migraine attacks decreased significantly. Unfortunately, triptans (Ascotop 5mg nasal spray or Sumatriptan 100mg) no longer helped during the last few attacks. Is this a known side effect after Botox treatment?
My pain pattern has also changed (headaches now start at the back of the head).
Thank you in advance and best regards to Kiel, Ilona
wrote on February 16, 2015 at 7:25 pm
Dear Ilona,
Botulinum toxin does not negatively affect the efficacy of triptans. It can happen that a triptan, despite initially being effective for a while, is no longer sufficiently effective. Generally speaking, at best only 8 to 9 out of 10 treated attacks will respond. Therefore, one should not be discouraged by a lack of effectiveness. It is possible that the headache pattern may change as a result of treatment with botulinum toxin.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 1:58 pm
Dear Prof. Göbel,
Since triptans are contraindicated for basilar migraine, what medications do you suggest for acute attacks? For headaches? For severe vertigo/dizziness? And for prevention?
Why is there so little information about basilar migraine on your website, for example? This type of migraine is not uncommon. Since I posted some of my own experiences with basilar migraine on my website, I've received many emails from other people who received this diagnosis after a long and frustrating search for answers. They were also very distressed by the lack of information available about this type of migraine and by the fact that doctors (general practitioners and even neurologists) don't really know much about it and prescribe triptans, which can trigger strokes because they constrict blood vessels.
Best regards from Petra
wrote on February 16, 2015 at 7:27 pm
Dear Petra,
Triptans should not be taken for basilar migraine, or as we now call it, migraine with brainstem aura. This is because the basilar artery supplies vital regions in the brainstem. This artery is not paired, meaning there is no right or left basilar artery like other arteries in the cerebrum. For safety reasons, triptans are therefore not recommended for basilar migraine. Non-vasoactive medications are an option, such as non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, or naproxen. Alternatively, metamizole or diclofenac can be used.
I describe the treatment of basilar artery migraine both on our website and in my books and publications. Compared to many other forms of migraine, basilar migraine is a rare subtype. However, considering the large number of people affected by migraine in general, basilar migraine is certainly not uncommon. It is therefore important to emphasize the need for greater awareness and information.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 2:15 pm
Dear Prof. Göbel,
Thank you so much for taking the time to help us pain patients.
Can NDPH cause headaches without nausea after 20 years, or nausea without vomiting? Eating has no effect on the nausea.
If so, how is it treated?
Medications taken so far without success: Iberogast, Ranitidine, Domperidone, Pantoprazole, various probiotics, Doxepin. Dimenhydrinate does relieve the nausea, but causes excessive fatigue.
All examinations by the gastroenterologist were normal. There are no food intolerances. An endoscopy and colonoscopy were performed about two years ago. A biopsy was not performed because the stomach and intestines appeared normal.
A two-month discontinuation of the medication (opioid) was also unsuccessful. About a month ago, in consultation with my new gastroenterologist, Tilidin retard was replaced with DHC retard. This stopped the persistent diarrhea. I can eat everything again without abdominal or intestinal pain. The nausea has barely improved. Unfortunately, DHC doesn't work as well against my pain as Tilidin.
Thank you very much for your reply.
Thomas
wrote on February 16, 2015 at 7:38 pm
Dear Thomas,
The newly occurring daily headache (NDPH) follows a course similar to chronic tension-type headache. Nausea and vomiting are not typical symptoms. Treatment with opioids should be avoided. Generally, a treatment approach similar to that for chronic tension-type headache is most likely to be effective. However, this type of headache is very persistent, often chronic, and difficult to treat. Based on your description, the exact course of treatment cannot be definitively determined. It is possible, however, that the frequent use of opioid analgesics has caused medication-overuse headache. I would suggest that you consult a specialized headache clinic again to have the problem diagnosed and treated there.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 4:18 pm
Dear Professor Dr. Göbel,
thank you so much in advance for your kind efforts in answering all our questions.
My chronic migraines have been particularly severe in recent weeks. As an additional symptom, I've developed intense sensory disturbances in my temples and around my eyes. Could these disturbances be related to the migraines, or is the cause perhaps something else? Since they have also caused very unpleasant pain, I'm wondering if there's any way to treat them.
Kind regards!
Claudia-Sibylle
wrote on February 16, 2015 at 7:40 pm
Dear Claudia-Sibylle,
Pronounced sensory disturbances, such as hypersensitivity or muscle pain in the temples and around the eyes, can accompany chronic migraine. Effective preventative measures are crucial. Unfortunately, treatment options for chronic migraine are limited. Medications are generally not sustainably effective for episodic migraine; otherwise, it wouldn't develop into chronic migraine. If you haven't yet undergone treatment with botulinum toxin, this could be considered.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 4:57 pm
Dear Dr. Göbel,
In the program "Die Ernährungsdocs" (The Nutrition Docs), it was claimed that migraine sufferers should avoid/limit carbohydrates. Is this true based on your experience/knowledge?
In a radio program about migraines, it was said that 2-3 attacks a month is a lot!
Is that correct? Would prophylaxis with beta-blockers be indicated then? I would be happy with so few attacks! Thank you for your reply.
wrote on February 16, 2015 at 7:43 pm
Dear Trumpet,
The statements in the program were somewhat misleading. On the one hand, it was advised to limit carbohydrate intake, while on the other hand, it was recommended to increase the consumption of vegetables and similar foods. The confusion likely stemmed from the fact that there are different types of carbohydrates. In nerve cells, carbohydrates are converted into energy. During normal functioning, the brain uses only carbohydrates for energy metabolism. Therefore, every brain, especially the brain of migraine sufferers, depends on an adequate supply of carbohydrates.
When it comes to nutrition, it's important to consume whole-grain carbohydrates. These are found, for example, in potatoes, rice, baked goods, whole-grain bread, muesli, oatmeal, and whole-wheat pasta. However, low-quality carbohydrates such as hazelnut spread, jam, sweets, milk chocolate, and gummy bears should be avoided. This wasn't clearly explained in the program, and several viewers noticed the misunderstanding.
Two to three migraine attacks a month can be a lot if each attack lasts three days or longer. That quickly adds up to nine to twelve days. However, if these attacks respond to migraine medication within 30 minutes, for example, the migraine is relatively harmless and easily managed. Always keep in mind that media reports tend to oversimplify things and don't apply to every individual case. Today's two- to three-minute news segments simply don't have the space to meet the information needs of migraine patients and their demand for detailed information.
The use of prophylactic medication also depends entirely on the course and characteristics of each attack, as well as its duration. If you experience two to three severe migraine attacks, for example, with severe brainstem auras and persistent vomiting, lasting three days, this may more than justify intensive preventative measures. However, if you have the same number of attacks and can manage them with two aspirin tablets, the situation is completely different.
Kind regards
, Hartmut Göbel
wrote on February 16, 2015 at 5:28 pm
Dear Professor Göbel,
Thank you so much for this opportunity to ask you questions.
I have a question about acute treatment:
For years, I took 500 mg of paracetamol with my triptan as an enhancer. It worked well in combination, but the effect didn't last very long. So, in a 72-hour attack, I sometimes needed six paracetamol tablets, and since I have chronic migraines, that adds up to a lot of paracetamol.
They therefore advised me at the pain clinic to take Arcoxia 60mg instead (I can't tolerate naproxen). I've also tried all the triptans – none of them work as well in combination with Arcoxia as they do with paracetamol.
But I stuck with Arcoxia because you said it doesn't damage the liver like paracetamol.
My neurologist, however, sees things differently than you. He advises me to take paracetamol again, because while it can damage the liver, Arcoxia can damage the heart. The risk is equally high with both, and since paracetamol is more effective, I should take it again.
I wanted to consult with you again because I greatly value your expertise and you expressed your opinion very clearly.
Thank you very much and have a lovely evening!
Zuckerschaukel
wrote on February 16, 2015 at 7:50 pm
Dear Sugar Swing,
The specific approach depends largely on how many days you need to take the medication as you described. If this occurs once or twice a month, this approach could be considered. However, based on your description and the mention of chronic migraine, it seems likely that this happens much more frequently. It's also possible that you're exceeding the 10-day rule, and this type of medication use could lead to the development of medication-overuse headache.
The primary goal should be to achieve optimal efficacy using the triptan alone. Switching to a different triptan can be considered. Increasing the single triptan dose is also possible. For example, zolmitriptan is available in 2.5 mg and 5 mg tablets. The medication Relpax can also be used in both 40 mg and 80 mg doses. While only the 40 mg tablet is approved in Germany, an 80 mg tablet is also available in other countries, such as Switzerland.
Ideally, the primary goal should be to optimize the effect through monotherapy, i.e., by administering a single medication. Only if this is not possible should combined treatment be considered. Personally, I would try to avoid the regular intake of high doses of paracetamol. Every medication can have side effects; Arcoxia, too, can indeed be problematic for those with high blood pressure or heart conditions. Therefore, the need for additional medication always depends on the individual case. Finally, it should be noted that adjusting preventive therapy can further enhance the effectiveness of monotherapy.
Arcoxia has the advantage of being better tolerated by the stomach when used for longer periods. Overall, there are many options that need to be individually tailored.
Kind regards
, Hartmut Göbel
