questions about migraines and headaches in a live chat for the self-help community headbook.me.
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Dear Professor Göbel,
I (62) have suffered from migraines (1-3 times a week), various other aches and pains, and depression since my youth.
In a book about migraines, I read that 5-hydroxytryptophan (5-HTP) helps with migraines and has hardly any side effects. The same article mentioned the medicinal plant Griffonia simplifolia. My neurologist couldn't really help me. He told me that tryptophan (he didn't mention 5-HTP) cannot cross the blood-brain barrier.
I would be very grateful if you could tell me whether any of these substances (5-HTP, tryptophan, Griffonia) are effective, and if so, under what names they are available, what precautions should be taken when taking them, and whether taking them together with triptans could cause problems.Thank you so much,
Luzilla!-
Dear Luzilla,
5-Hydroxytryptophan is a precursor to serotonin. Serotonin is primarily stored in blood platelets. Serotonin levels measured in the blood are not indicative of the concentration and activity of serotonin in nerve cells. Previous studies have tested the effectiveness of 5-hydroxytryptophan in preventing migraines, but no effect was demonstrated. The same applies to the medicinal plant you mentioned. Today, there are many ways to actively prevent migraines, including numerous proven and scientifically validated medications. Therefore, there is no need to experiment with untested methods or options whose effectiveness has already been 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, and so far no cause has been found. I take Maxalt 10 times a month, but I have significantly more headache days.
What I find particularly puzzling, and what no one has been able to explain to me, is that every night, after about six hours of sleep, I wake up between 4 and 5 a.m. with a painful pressure in my forehead (headache above my eyes, usually on one side). If I get up, the pressure sometimes goes away within the next hour. If it doesn't, or if I don't get up, I get a migraine. Maxalt would help and allow me to sleep longer, but I know I can't take it for that purpose.What could be causing the nighttime ear infections (the ENT examination was unremarkable), and how else can I treat or prevent them?
My doctor can only suggest treatment with beta-blockers.-
Dear Tine,
Migraine is a distinct condition; it is the cause of the headache itself and does not require any other cause. Your observation could already be related to the development of medication overuse headaches. If you take Maxalt on 10 days a month, sensitization has already occurred, the pain-processing system is adjusting, the effect wears off overnight, and you are already experiencing medication overuse headaches. Try to develop preventative measures so that you have as few days as possible each month requiring acute medication.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
After switching from topiramate to amitriptyline (35 mg) for preventative medication, I did
n't feel any better for the first four weeks. Since resuming
light endurance exercise (swimming and running) 4-5 times a week,
I now only have a migraine attack (lasting over a day) about every 8-10 days.
How is this possible? I'm trying to identify a pattern so I can use it again during bad
spells. And: Would increasing the dosage further be advisable?Thank you in advance for your efforts.
Best regards,
Stefanie-
Dear Stefanie,
A new prophylactic medication should generally be evaluated over a period of at least 8 weeks. The key is to count the number of headache days and then assess any changes compared to the previous period. Amitriptyline typically only takes effect after about 4-6 weeks. Therefore, the observed change after the described period is not unusual. Combining medication with swimming and running has been shown to produce significantly better results, so your behavior also supports the medication's effectiveness. If well tolerated, increasing the dosage may be beneficial and further improve the medication's effectiveness.
Kind regards
, Hartmut Göbel
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Dear Professor Göbel,
I have been taking Saroten 50mg for about 5.5 years, which reduced the frequency and severity of my attacks (I suffer from migraines and tension headaches) and helped me a great deal. Because I gained a lot of weight, my family doctor advised me to try other medications. About 15 months ago, I was prescribed Metoprolol, then Venlafaxine, and currently Topiramate (2 x 50mg) in addition to Saroten. Unfortunately, none of these medications had a significant effect; in fact, the opposite was true. After discontinuing them, the positive effects of Saroten are no longer the same. I am now feeling increasingly worse, and my attacks are occurring at ever shorter intervals, even without any noticeable trigger, so I have to endure the headaches (due to medication overuse headache). Between attempts, I increased the Saroten dosage to 75mg, but this brought only minimal improvement. I now need to take my acute medication (Zolmitriptan) at 5mg instead of 2.5mg for several days in a row.
My questions are:
Could the reduced effectiveness of Saroten have been caused by the other medications?
Can the initially good effect of Saroten be restored?
What is the maximum dosage of Saroten I can take?
I've been experiencing nausea on and off daily for about six months. I've been taking Topiramate full-dose for about eight months now and have had various severe side effects. Could the nausea be related to the Topiramate?
What would you advise?Thank you for your time
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Dear Sabine,
If you suffer from both migraines and tension headaches, you need a medication that is effective preventively for both types of headaches. This is indeed the case with amitriptyline. Metoprolol, venlafaxine, and topiramate have no proven efficacy for tension headaches. However, your specific situation depends on which type of headache is predominant, whether you specifically want to achieve an effect on the migraines, and what the overall picture is. It's possible that you have experienced an increase in the frequency of attacks, require acute medication on more than 10 days a month, and have also developed another type of headache: medication-overuse headache. This further complicates treatment. It is now necessary to treat the medication-overuse headache first. Only then will the initial situation be restored, and a treatment plan for both migraines and tension headaches can be developed. Only then can the previous effectiveness of amitriptyline be regained. Solely administering Saroten will not solve the problem in the current situation, as the medication overuse headache must first be effectively treated. Continuing topiramate alone will most likely not solve the problem either.
Kind regards
, Hartmut Göbel-
My main problem is migraines. Because of the side effects, I would like to stop taking Topiramate. What do you think?
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Dear Sabine,
the nausea could be caused by Topamax, and if I were you, I would stop taking it.
Best regards,
Bettina
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Dear Professor
I was a patient of yours two years ago, and other neurologists have also diagnosed me with chronic migraine, which I've had for 12 years. Since I've already tried all the preventative medications (topiramate, valproic acid, beta-blockers, doxepin), I've been taking 25 mg of amitriptyline in the evenings for the past three months. Initially, I took 10 mg of amitriptyline, which was increased to 25 mg.
My question is, is 25 mg sufficient as a preventative measure, or should the dose be increased? So far, I haven't noticed any difference in the frequency of attacks. Mucolytic cerebrospinal fluid (MSF) has been ruled out.Thank you very much,
Karin!-
Dear Karin,
25 mg of amitriptyline is generally considered the lower dose. If well tolerated and a stronger effect is desired, the dose can be increased to a medium dose of 50-75 mg. Some patients require doses up to 150 mg. The medication is absorbed very differently by each individual, so there is no standard dose, and the optimal dose must be determined on a case-by-case basis.
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). Currently, we're trying Cefaly and botulinum toxin. I received my first botulinum toxin injection two months ago. There hasn't been much change. How many treatments are typically given for this medication? Are there any alternatives?
Thank you in advance for your help.
Kind regards,
Konstanze-
Dear Konstanze,
Treatment of chronic migraine with botulinum toxin can improve with repeated applications. Typically, two or three cycles are attempted. However, if no effect is achieved, the treatment should be discontinued. It is crucial to understand that botulinum toxin alone cannot bring about change; significant behavioral adjustments are always necessary. Currently, there is no approved alternative to botulinum toxin in the field of medication for chronic migraine.
Kind regards
, Hartmut Göbel
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Dear Professor Göbel
, I was at the Kiel Pain Clinic last February and took a break from triptan medication, which I continued at home for another four weeks. After my discharge from the clinic, I was prescribed Mirtazapine 15mg, which I took for about six months. For acute treatment, I was given Relpax 40mg + Naproxen 500mg. The number of pain days decreased from 15-18 days before the break to about 8-10 days after. However, I still had the problem that my migraines always lasted up to 72 hours or longer. Therefore, Dr. Tomforde switched me to Naramig 2.5mg + Naproxen 500mg, and also to Arcoxia 90mg, since this triptan should last longer. It works well sometimes, except that Naramig doesn't work as quickly (which is still acceptable for me), and the headache returns more intensely on the third day. Can you suggest any other ways to reduce my recurring headaches? That would also further reduce the number of days I have pain. Unfortunately, I keep coming close to having 10 days of pain, and it's really getting me down!Greetings from Austria
Manfred
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Dear Manfred,
You already have a very effective treatment regimen. If this approach can keep migraine frequency below 10 days, an important goal has already been achieved. Further reduction of migraine days per month should now be pursued through intensified preventative measures. This applies to both behavioral and medication-related aspects. If well tolerated, the mirtazapine dosage could be increased. Alternatively, another medication could be added. However, this must be carefully considered in an individual consultation.
Kind regards
, Hartmut Göbel
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Dear Mr. Göbel,
My daily tension headaches have increasingly turned into migraines over the past few years, affecting almost all activities, leaving me feeling more and more restricted in my daily life. As a preventative measure, two weeks ago, after many years, I was switched from 150mg Venlafaxine to Cymbalta (30mg for one week, now 60mg) – still in combination with Stangyl 25mg.
Does your experience also suggest that this medication has a more pain-relieving effect and might have fewer side effects?
What trial period would you recommend?Greetings to Kiel!
kopflotte
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Dear Kopflotte,
The combination of medications you mentioned has proven effective in preventing tension-type headaches. However, it must be followed consistently. Whether venlafaxine or Cymbalta is more effective in an individual case can only be determined through observation. Generally, a period of at least three months should be allowed.
Kind regards
, Hartmut Göbel-
Thank you so much for your reply!
I forgot to ask afterwards whether I should now take my triptan even more cautiously (= less frequently).Greetings, kopflottegr
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Dear Kopflotte,
why shouldn't you be able to take a triptan for migraines?
Best regards,
Bettina
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Dear Prof. Göbel,
Besides chronic migraines and atypical facial pain, I suffer from severe, painful restless legs syndrome (RLS).
Because of this latter form of pain, and as an alternative to levodopa and dopamine agonists for my RLS, my doctor wants to prescribe an opiate.
Oxycodone has already proven effective in treating RLS in studies; my question is whether there are any other opiates available. It would also be important for me to know if there are any opiates with a favorable side effect profile regarding headaches.I am very much looking forward to hearing your expert advice and thank you very much for it.
Sincerely,Martina
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Dear Martina,
Restless legs syndrome is primarily treated with levodopa. If this is not sufficiently effective, opioids can be used. A specific opioid is not required. It is important to ensure that a sustained-release preparation is used. With a stable dose, no complications related to headaches should occur.
Kind regards
, Hartmut Göbel
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Good day Professor Göbel,
medical history:
Female, 48 years old, menstrual migraine for 13 years, until 3 years ago 1-2 attacks per month, alternating sides each time, then 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: V1 frontal foramen exit). The 5-day attack is usually interrupted for 6-18 hours and then switches sides. Acute therapy with triptans and naproxen. Prophylaxis: Mag. 600mg and vitamin B2 200mg daily.
1st question: Is the "other side" a new attack or a kind of recurring headache?
The pain days/attack frequency? Unfortunately, it has been around 13 days for the last few weeks, some of which have milder pain and some are tension headaches (which I haven't had since the onset of migraines). I also feel like everything is no longer connected to my cycle. I'm barely managing to stick to my 10/20 cycle. Naratriptan and naproxen help a lot. The prescribed prophylaxis with naproxen before my period is now impossible due to the total unpredictability of my bleeding (it sometimes stops for weeks or comes every two weeks).
Second question: Do you think I should try Topimarate, or do you have to have more than 15 days of pain before it's effective?
Third question: Can menstrual migraines change over time? My neurologist gave me great hope that the attacks would stop after menopause…
Thank you for your efforts,
Heike-
Dear Heike,
Without knowing your headache diary, and especially without knowing the regular frequency of headache days per month, the question isn't easy to answer. If a migraine attack lasts more than five days, it's called status migrainosus. This is treated differently than a primary migraine attack lasting a maximum of three days. It's particularly important not to repeatedly take painkillers despite their lack of effectiveness. This is the typical starting point for the development of medication-overuse headaches. In any case, it would be important to know if there are any headache-free periods at all. If there's only a break of six to eighteen hours, you might be suffering from daily headaches. In this case, simply taking a triptan and naproxen wouldn't be effective.
A recurrent headache is defined as one in which the initial medication reduces the headache, but the headache then returns after this improvement. Accurate classification can only be determined using a headache diary and knowledge of the precise course of the headache. Similarly, whether this is a new attack can only be clarified by understanding the subsequent course of the headaches.
I've only just read that you apparently have headaches almost every other day. It's likely that you're also experiencing medication-overuse headache, even if you're still adhering to the 10-20 rule. Some patients develop sensitization after only 8 or 9 days a month. A diagnostic medication break could clarify the situation in your case. Following that, we could consider how to proceed with preventative measures. It's unlikely that topiramate will change the course of your headaches without a systematic medication break. Unfortunately, waiting for menopause isn't a good option. In 50% of cases, the attacks remain the same, in 25% they worsen, and in another 25% they improve. On average, therefore, no change is to be expected.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
I would like to hear your opinion today on the assessments of the psychosomatic component of migraines by the two doctors Rüdiger Dahlke and Oliver Sacks. I have read both authors' books with great interest, and I can identify with some things, such as the triggering function of emotional stress. However, I feel that R. Dahlke doesn't take my neurological condition seriously and relegates me to the "psychological corner." How significant do you estimate the "psychological component" of migraines to be?
Thank you very much for your time and best regards,
Hanni21-
Dear Hanni,
Oliver Sacks was a neurologist who provided very precise descriptions of migraine auras, the headache phase, and the underlying mechanisms. Many of his findings are based on empirical research. The brain mediates perception, cognition, and emotions. Headaches originate 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. They deal with topics such as laws of fate and principles of life. Worldviews and opinions form the basis for these themes. These cannot be scientifically verified and are therefore not supported by scientific evidence.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
I have an average of about 20 headache days per month, and I take 50 mg of topiramate as a preventative measure.
I had to reduce the dose from 75 mg to 50 mg due to the severe side effects (I don't notice any
difference in effectiveness between 75 mg and 50 mg).For the past month, I've had a new problem: the acute medications are no longer working. I follow the 10/20 rule and take
acute medication on 4-6 days per month. However, lately it's impossible to stop a migraine, even if I
take, for example, 2 x 100 mg of sumatriptan + 500 mg of Novalgin. The effect is either minimal or nonexistent. 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. Reading information I've found suggests my symptoms are similar to medication overuse headache (MOH), although I don't overuse medication.
I've already tried amitriptyline, duloxetine, and topiramate as preventative medications. Nothing helps, or rather, the effect wears off very quickly.Why aren't the emergency medications working? What could be the cause?
Thank you so much for your reply!!
Lora.-
Dear Lora,
You have described the course of the illness very well. Topiramate generally 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 nonexistent. In this situation, it is not advisable to take the medication again during an attack. It will not work on the second attempt either. This is precisely the situation you are describing. However, if one proceeds as you have described, the consequence will be that the medication is taken for 3, 4, 5, or even more days without sufficient effect. This is already the typical path to medication-overuse headache. Therefore, a replacement medication must be found that can effectively relieve the headache. If it then recurs as a headache, you can take this medication again; it should then be effective. It does not seem to work with the current prophylaxis. Therefore, a different preventative measure should be found. It's possible that you've already developed a sensitivity to the medication, and medication-overuse headache may have become a significant factor. The preventative measures you've mentioned so far need to be re-evaluated regarding dosage and duration. Only then can it be determined whether they are truly ineffective. Therefore, a new preventative strategy is necessary; a medication break should be considered beforehand, as you must thoroughly understand and adhere to the guidelines for acute medication use.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
I would like to revisit my question from our last chat, as your answer, while very informative, unfortunately didn't address my specific question. This question concerned the administration of a sustained-release opioid due to increased pain sensitivity following a migraine attack. I'm including the question and answer here again and would appreciate your advice regarding my situation.
Dear Prof. Göbel,
Thank you so much for the opportunity to ask you another question.
I have been suffering from a complex pain syndrome for several years (chronic migraine, neuropathic pain in the area of the second branch of the trigeminal nerve, tension-type headaches). After migraine attacks that last for several days and barely respond to triptans or other pain medications (microscopic cephalalgia has been ruled out), my head is extremely sensitive to pain, and the intensity of the other types of headaches that occur immediately after the migraine is significantly increased. This rather severe pain then often becomes a trigger for the next migraine attack.
I take amitriptyline as migraine prophylaxis; I have tried other prophylactic medications (e.g., beta-blockers, topiramate, Botox, and related recommendations) over the years, so further optimization of my migraine prophylaxis is not possible. I consistently adhere to recommended behavioral measures (e.g., relaxation techniques).
My pain specialist suggests trying to alleviate the non-migraine pain by taking a sustained-release opioid daily, so that it no longer triggers migraines. Lyrica, gabapentin, and carbamazepine have not reduced this pain.
My question is whether sustained-release opioids could be helpful in this case, especially during the pain-sensitive phase immediately following a migraine, to improve my overall situation.Thank you for your efforts and best regards to the entire team.
MarleneHartmut Göbel, January 11, 2016 at 6:00 PM
Dear Marlene,The use of extended-release opioids for migraine prophylaxis is not supported by scientific studies. No effect is to be expected. In my view, this would essentially only result in side effects of the opioid, without any therapeutic benefit. In individual cases, there are very aggressive forms of migraine that respond very poorly or not at all to standard preventive measures. In such situations, inpatient pain therapy should be considered. Various existing treatment methods can be further optimized and combined for this purpose.
Kind regards
, Hartmut GöbelThank you for your understanding regarding my repeated request.
Warm greetings to Kiel!
Marlene
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Dear Marlene,
In my previous reply, I advised against taking a sustained-release opioid to reduce pain sensitivity after a migraine attack. This still stands. There is no evidence that an opioid reduces sensitivity to migraine headaches. You wrote that you were advised to alleviate non-migraine pain by taking a sustained-release opioid daily so that it wouldn't trigger migraines. This won't work. At the same time, you wrote that Lyrica, Gabapentin, and Carbamazepine didn't reduce this pain. That wasn't to be expected, as none of these substances are effective for migraine prevention. Please consult the Headbook for information on medication-based migraine prevention, paying particular attention to the behavioral measures. Based on this, you can assess the likelihood of success.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
I have been suffering from increasingly frequent and severe migraines and tension headaches for about five years. Currently, I am taking 10 mg of amitriptyline as a preventative measure (for about four weeks now; my neurologist says I should stay at this dosage).
Several doctors and physiotherapists have diagnosed severe tension in my neck and back, as well as a blockage at C2.
In addition, I am experiencing back pain more and more frequently, especially in the evenings and after prolonged sitting (lots of work on my laptop, studying). I also have temporomandibular joint (TMJ) problems (clicking, pain, restricted movement), and my dentist diagnosed me with TMD (temporomandibular joint disorder).Could there be a connection between neck/back problems, TMJ disorder, and migraines?
I also have a quick question about the medication: Can I combine zolmitriptan or rizatriptan with ibuprofen 600 or naproxen, respectively? If so, what dosage of naproxen should I take?
And what do you think about high-dose magnesium intake (600 mg per day)?
Thank you for your time and best regards!
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Dear Lisa,
Migraine is a distinct condition resulting from a genetically determined function of the nervous system. Tension in the back is not the cause of migraines. However, it can be a consequence of migraines due to sensitization and activation of defensive reflexes. Prolonged sitting, lack of exercise, stress, and tension are behaviors that can trigger migraine attacks and simultaneously cause back pain. Jaw clenching and grinding are also caused by neural activity in the central nervous system. They are not the cause of migraines but can be a consequence of the resulting sensitization.
Zolmitriptan can be combined with an NSAID such as ibuprofen or naproxen. Typically, 500 mg of naproxen is used. The aim is to reduce the occurrence of recurrent headaches. Administering 300 mg of magnesium twice daily has proven effective in migraine prevention.
Kind regards
, Hartmut Göbel
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Dear Prof. Dr. Göbel,
First of all, thank you so much for this wonderful chat function!
I'm 26 and have had migraines for as long as I can remember. Until recently, I had about 1-3 attacks per week. For the past three weeks, I've been suffering from a constant headache that almost every day develops into a moderate migraine. Medication overuse headache (MOH) has been ruled out, as I've been able to endure most attacks and only took about 3-4 Tristane tablets per month. I have an appointment at the West German Headache Center in two weeks.
Are you aware of any cases where episodic migraine has suddenly transitioned into a constant headache with almost daily migraine attacks?
What advice can you give me in this regard?Thank you in advance for your time and best regards
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Dear Gritzner,
Migraine can progress slowly and chronically, with an increasing frequency of headache days per month. However, relatively rapid and abrupt changes in the course of migraine can also occur. A previously episodic course with only a few days per month can very quickly, within 1-2 months, transform into chronic migraine with headache days on more than 15 days per month. In such cases, intensive preventative measures through behavioral changes and, if necessary, medication, as well as specific attack therapy, are essential.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
I've been taking Petadolex for six weeks now, at the dosage you recommended.
After initially experiencing about 8 to 15 migraine days a year, I've now had a reduction in migraines – meaning I haven't had a migraine for two weeks. (Of course, I'm having my liver function checked.)Since January 2016, I have taken a maximum of 10 naratripts, also after studying your book. Before that, I had taken sumatriptan for many years, which allowed me to control my migraines most of the time. Before I had to take more than 10 triptans, I could sometimes endure the pain.
My question is: If the attacks remain so infrequent, should I endure the migraine attacks for a certain period of time in order to truly wean myself off the triptans?
Or would this be a pointless endeavor that would only cause me pain?Thank you very much for your reply and your excellent work in the area of head pain.
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Dear Giotto,
In individual cases, a temporary, short break from medication can be effective. This is especially true if you're consistently close to the 10-day limit. However, if you're in the "green zone" with only 2 to 6 migraine days per month, it makes no sense to endure the migraine. On the contrary, it's better to treat migraine attacks as effectively as possible to prevent further sensitization and avoid the risk of migraine complications.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
According to the diagnosis at your clinic, I have migraine without aura, as well as secondary headache after carotid dissection.
I am currently undergoing a more extensive diagnostic process for relapsing polychondritis. Apparently, this disease cannot be ruled out even if, as in my case, there are no positive test results from laboratory examinations so far.
Alternatively, a 'Red Ear Syndrome' is also a possibility, which would most likely be associated with headaches and facial pain. Since it's not clearly defined as a disease and is also extremely rare, I haven't yet found any real support in determining which of the two conditions I actually have.
I have read the relevant case reports/scientific literature on 'Red Ear Syndrome'. However, that doesn't help me either.
The distinction between the two diagnoses is important to me, since the medication for ‘relapsing polychondritis’ is very intensive, whereas for ‘Red Ear Syndrome’ it probably follows more general headache prophylaxis recommendations.
Do you believe that Dr. Heinze could be of assistance to me in this regard during an outpatient appointment, or can you otherwise give me advice regarding possible further diagnostic procedures for 'Red Ear Syndrome'?
Thank you
happinessofearth
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Dear Luck of the Earth,
Relapsing polychondritis is an autoimmune disease in which the body attacks and potentially destroys cartilage tissue. There are no reliable laboratory tests for this disease. The diagnosis is made clinically. Red ear syndrome, on the other hand, is a pain disorder. The ear becomes red and a burning pain occurs. The attacks can last from seconds to hours, but most often occur between 30 minutes and one hour. The attacks can occur daily, with a frequency of approximately 20 per day to just a few attacks per year. This syndrome is thought to belong to the group of trigeminal autonomic cephalalgias, similar to cluster headaches. It is very rare. Only about 100 cases are described in the literature. Treatment can only be experimental, as there are no scientific studies on therapy. Generally, treatment approaches similar to those for migraine, tension-type headache, and cluster headache are chosen. This headache disorder is also diagnosed by an experienced clinician; there are no laboratory tests for it. I am confident that Dr. Heinze will be able to assist you with this matter at your next appointment.
Kind regards
, Hartmut Göbel
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Dear Dr. Göbel,
According to the diagnosis prepared at your facility in 2010, I have:
1. Migraine without aura, ICD-10 G34.0
2. Episodic tension-type headache, ICD-10 G44.2
3. Status migrainosus, ICD-10 G43.2I have suffered from migraines for 30 years and later also from... as stated above.
I've already tried many things, including preventative medication.
Do you think an examination of the cerebrospinal fluid, i.e., a lumbar puncture, would provide any new information?
Thank you very much for your efforts
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Dear Issey,
The diagnoses you listed are primary headache disorders. They are independent conditions and do not require any other cause. They are the condition itself. Examining the cerebrospinal fluid via lumbar puncture would not provide any new information.
Kind regards
, Hartmut Göbel
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Dear Prof. Göbel,
I have had migraines since childhood, which became significantly more frequent 12 years ago and then chronic. Initially, I was mistakenly diagnosed with tension headaches, which were unsuccessfully treated with Nortrilen, Katadolon, Mydocalm, and Amitriptyline. After the diagnosis of "chronic migraine," I tried the following medications:
– Beta-blocker (Metoprolol)
– Amitriptyline
– Topiramate
– Valproate
– Flunarizine
– Various triptans
– Naproxen
– Ibuprofen
– ParacetamolCurrently I am taking:
Morning:
– 100 mg Metoprolol
– 10 mg Paroxetine
Evening:
– 50 mg Doxepin
– 100 mg MetoprololIn addition to medication, I have already had stays at the pain clinic in Tutzing and the migraine clinic in Königstein.
These (current) medications are the only ones mentioned that have a reasonably good effect, so I only have a few severe attacks, but I'm never completely pain-free. However, I still notice that the migraine can erupt at any time if there's 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 an attack, no matter how relaxed I am.
I can usually eliminate other triggers (cold wind, sweets, not drinking enough water, acidic fruit). Often, though, the attack comes on overnight. Stress doesn't play a role for me; this was confirmed in both clinics.Generally, I respond very poorly to medication; in acute cases, only an Imigran injection sometimes helps, everything else is ineffective. Unfortunately, this also means that my body quickly becomes "accustomed" to medication and then no longer responds well to it. Therefore, I always have to take a break from Metoprolol after a year, as my condition deteriorates rapidly (currently, I have migraines about half the day, and on the other days, I can only prevent an attack by reducing eye strain). In recent years, I've been able to counteract the worsening phase with
: a shamanic retreat in Peru and several days of ayahuasca treatment, to which I responded very well
; a stay in Königstein
; and the Cefaly device
(each a year apart)
, thus preventing daily attacks during those periods. While the Cefaly device still works very well, it no longer has the same effect it did a year ago when I could use it to prevent and stop attacks. Here too, a certain habituation effect set in.
I also tried Cerbomed as part of a study (at the Großhadern Clinic), but it was too weak. Botox had no effect on me at all, nor did acupuncture.I'm now a bit unsure what I could do this year to take a break from metoprolol. Is there another medication or treatment option I haven't tried yet? What can you recommend?
Thank you so much for your help!
Christof-
Dear Christof,
Migraine is a neurological disorder, and its underlying mechanisms are now well understood. Simply stringing together all possible treatment options, some of which are unproven and even unconventional, is counterproductive. It is crucial to apply the established principles of migraine therapy. This offers the greatest likelihood of success. I encourage you to familiarize yourself with this topic in the individual groups on Headbook.
Kind regards
, Hartmut Göbel-
Dear Prof. Göbel,
Apart from the trip to Peru, which admittedly was a somewhat desperate measure, all steps were carried out with a migraine specialist (Dr. Mühlbauer or Dr. Brand). It wasn't a random sequence of treatments, but rather a process of discarding ineffective medications. Which specific treatment options are you criticizing?
I know the underlying causes of migraines very well; I've been studying them intensively for 10 years. I also know that I'm not a "standard patient" and that the fact that my migraines are triggered by visual overload and stress plays no role is very unusual.
That's why I'm seeking help so much, since most doctors are overwhelmed by my medical history. As you can see, I've already tried everything.Do you have any suggestions for what else I could try? I went into this chat with very high hopes because I'm really at a loss right now.
I would be extremely grateful for a specific tip!
Kind regards,
Christof-
Dear Christof,
as the chats are becoming increasingly frequent and the number of questions is growing significantly, answering follow-up questions is no longer possible due to time constraints. All questions asked here can also be answered via Headbook, which is why Prof. Göbel refers you to it. Please also take advantage of this community resource, which is useful for many members! Furthermore, individual questions cannot be answered without a personal examination.One more tip from me: the following are among the ineffective methods that one could perhaps do without in the future: trips to Peru, Cerbumed and acupuncture.
Kind regards,
Bettina
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Dear Professor Göbel,
I would like to know your opinion of Cefaly! Do you see any opportunities or risks in it?
No preventative treatment has helped me so far, not even vagus nerve stimulation with GammaCore.
Thank you very much,
Robert-
Dear Robert,
Cefaly is a specific form of neuromodulation. There is data supporting its preventative effect in episodic migraines. It is a very simple and ultimately cost-effective procedure. Therefore, in my view, there is no reason not to use it; studies suggest a certain degree of effectiveness. For vagus nerve stimulation with GammaCore, there is still no convincing data on its efficacy, and the fact that the device cannot be easily recharged is a purely business-driven approach without any justifiable basis, in my opinion.
Kind regards
, Hartmut Göbel
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Dear Professor Dr. Göbel, unfortunately my application to see you was rejected. I'm supposed to contact you again in three months. I really hope it works out. I have migraines every other day and am suffering terribly.
Here's my question:
I'm currently trying 50 mg of metoprolol, but unfortunately, I can't take more due to my asthma and low blood pressure. I know the minimum recommended dose is 100 mg.
Can I take 5 or 10 mg of flunarizine in the evenings in addition to the metoprolol, or is that incompatible with it?
What is the correct dosage of flunarizine, and for how long?
Why is it only allowed to be taken for six months? If it helps me, couldn't I take it longer?
If I develop depression from it, couldn't I simply add doxepin to prevent that?How far along is the migraine vaccine? Can one try it if one is admitted to your hospital?
Thank you so much for your chat; it makes one feel less alone with the pain.
Best regards
Leis Bettina
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Dear Bettina,
Generally, preventative treatment should always begin with a single medication, and the dosage should be gradually reduced. If metoprolol is not well tolerated, the medication should be changed to a different substance. It would therefore be more sensible to switch completely to flunarizine and then gradually reduce the dosage until effectiveness or intolerance is observed. The usual dosage is 5 to 10 mg per day or every other day. This, too, must be decided individually in each case. Flunarizine can be administered for longer than six months. However, it is typically used for an initial period of six months to assess its effectiveness. If migraine attacks are significantly reduced during this time, discontinuation can be considered; in many cases, effectiveness can be maintained without continuing the medication. If depression occurs during treatment with flunarizine, discontinuation should be considered, and a different medication should be chosen. Here, too, it would initially be better to switch to doxepin, which you mentioned.
Antibody-based migraine prevention is still undergoing clinical trials. It is likely that it will be used as part of routine therapy in 3 or 4 years.
Kind regards
, Hartmut Göbel
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Dear Professor Dr. Göbel, I have another question: My migraines were better for the first 14 days with Metoprolol 50, but I recently had a Strovac vaccination for my frequent bladder infections, and since the vaccination, they've gotten much worse again. I've had migraines almost every day for the past two weeks. I think it's from the vaccination, and I was supposed to get two more injections, but now I'm afraid to get them. I'm worried that my migraines will be worse again for months. I had them much better under control with Metoprolol, but not since the vaccination.
Should I get the second and third vaccinations or not? They contain six strains of E. coli and enterococci, etc.Best regards
Bettina
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Dear Bettina,
Please discuss this with your doctor. In my opinion, it is unlikely that the vaccination is the cause of any change in migraines.
Kind regards
, Hartmut Göbel
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Dear Professor Dr. Göbel,
Thank you so much for the opportunity to chat live!
I was an inpatient at the Kiel Pain Clinic in February 2014. According to your doctors and my neurologist, I've now tried pretty much every preventative medication. My current preventative regimen consists of 12 mg of candesartan (I couldn't tolerate a higher dose due to my low blood pressure), 50 mg of doxepin, and 5 mg of fluoxetine. I also receive Botox injections every three months. I've been taking fluoxetine since October; it was suggested by my neurologist. Unfortunately, the problem is that it causes me anxiety, extreme sadness, sleep problems, and night sweats (which no one can explain, since it should actually have the opposite effect). However, it has had a very positive effect on my migraines, which, for the first time (unlike with all the previous preventative medications), have also been significantly reduced in frequency. It's a vicious cycle now: the more fluoxetine I take, the better my migraines are, but the worse I feel otherwise. And vice versa. I've already tried to stop taking it three times, and each time I ended up in a very severe migraine attack, which could only be stopped with cortisone, or, the last time, not even with that, but only with higher doses of fluoxetine. The situation (daily migraines) only ever improved when I started taking fluoxetine again or increased the dose. I can't explain this, but I don't know what to do – since stopping it has never worked, but I also can't take any medication that causes depression (because the depressive symptoms always disappeared when I stopped taking it!). The only times I've felt this "depressed" so far were while taking triptans (which cause the same feeling, but much less intensely). How can this be explained medically – especially with regard to serotonin, which obviously plays a major role in all these medications and in migraines? What would you advise me to do? The suffering I'm currently experiencing is unimaginable.Second short question: What do you think about correcting the atlas misalignment in relation to migraines?
Thanks alot!
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Dear Sunflower,
From my perspective, it is not very likely that the anxiety you described is caused by the fluoxetine. Since, as you write, it has a good effect on your migraines, I would be hesitant to change it, given the very limited treatment options you described. During a migraine attack, pronounced emotional changes with mood swings, as well as anxiety and panic attacks, can occur; very intense neuropsychological changes are also possible. From this perspective, stabilizing 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 Professor Göbel,
my neurologist keeps telling me that migraines can indeed originate solely in the digestive system.
I haven't had a headache since I turned 70.
Is migraine prophylaxis even appropriate at this point, or would it be more likely to damage my stomach?
The nausea and bladder spasms always last several days, during which I'm bedridden.
On these days, I also experience leg cramps, which levodopa helps with.
Since I have difficulty walking, I don't have many options for changing doctors.
Therefore, I would be grateful for your advice.-
Dear Margit,
Migraines can also manifest as abdominal pain, cramps, diarrhea, and other abdominal symptoms. However, due to the limited information provided, it's impossible to determine whether you have this subtype of migraine. It would be worth considering temporarily suspending your migraine prophylaxis. You could then assess whether it's effective and whether it needs to be continued, and whether this might alter the course of your migraines.
Kind regards
, Hartmut Göbel
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Dear Professor Göbel,
I am 52 years old and have about 10 migraine days per month. When an attack starts and I begin taking triptans (Allegro, Formigran), it usually lasts 3-5 days. I have the impression that the triptans prolong the migraine attack (almost like an addict experiencing withdrawal symptoms – i.e., a recurrence of the migraine) as soon as the drug is metabolized. Ibuprofen does nothing to shorten the duration of the attack. If I manage (rarely!) to control the migraine on the first day using only Voltaren and metamizole, then it usually subsides.A neurologist recommended dihydroergotamine nasal spray to prevent recurrent headaches, which it usually does. The spray is no longer approved in Germany and must be obtained from France.
How often per month can I safely use the dihydroergotamine spray?
You recently mentioned (January 12, 2016) in the program "Migraine: A Common Ailment" (SWR 2014) that the risk of stroke is increased with triptans in the case of a patient with hemiplegia. I otherwise have no vascular risk factors (normal blood pressure, LDL below 140 mg/dl, non-smoker, no family history of coronary artery disease, no diabetes).
Can you estimate by how much my risk of stroke is increased with triptans?Is it higher under dihydroergotamine?
I really appreciate you taking the time to answer such important questions in this chat. Thank you very much,
best regards,
Islay-
Dear Islay,
No medication can ever be taken without careful consideration. This is especially true for dihydroergotamine spray. The program you mentioned concerns a patient who continued to be treated with triptans despite having suffered a stroke. Triptans must not be used if cardiovascular diseases such as a heart attack or stroke have occurred previously. Therefore, it is also necessary to have regular check-ups with a doctor if you suffer from migraines and use triptans. According to current knowledge, the risk of stroke is not inherently increased by triptans.
I am not aware of any studies on dihydroergotamine. However, unlike triptans, it does not act selectively, but rather throughout the entire body. Therefore, side effects on the vascular system are more likely.
Kind regards
, Hartmut Göbel
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I'm 49 and was in Kiel in 2014. I suffered from severe migraines, medication overuse headache (MOH), and depressive episodes. Since then, I've been on prophylactic medication with Beloc Zok mite 47.5 mg (1.5 tablets in the morning, 1 in the evening) and Venlafaxine 37.5 mg (112.5 mg in the morning). For acute treatment, I take Ascotop 5 mg and Naproxen. After six months, I experienced improvement, with attack-free periods of 2-3 weeks. :-) Since the beginning of this year, the attacks have become more frequent again. Despite the beta-blockers, my blood pressure is usually around 140/92-95 (it was the same before Beloc, but much higher in the hospital). Overall, I've become calmer, which is good for me. I attribute this primarily to the Venlafaxine. However, as with the previous MOH, I'm also experiencing dizziness more often—a feeling of unsteadiness and lightheadedness—making it difficult to concentrate, and I tend to avoid driving. My question: How long is migraine prophylaxis taken? Forever? In intervals with breaks of several months? Does it make sense to continue taking beta-blockers (ACE inhibitors are not an option, as I react to them with an extremely persistent, irritating cough; beta-blockers have caused me to gain 8 kg)? Without prophylaxis, I would be afraid of another spate of attacks like the one in Kiel. My neurologist is helping me and has implemented the clinic's treatment plan, but in about 20 years of doctor visits, I have only encountered truly good migraine specialists in Kiel.
Furthermore, during a severe attack that lasted a whole week, my doctor administered intravenous aspirin to stop it. Unfortunately, it didn't help at all. Are there specific migraine medications for intravenous attack control?-
Dear Binchen,
Migraine prophylaxis should be taken for as long as necessary. This is primarily determined by the number of migraine days per month and whether acute medication is sufficiently effective. If the migraine is very aggressive and there are more than seven migraine days per month that are also difficult to treat with acute medication, migraine prophylaxis may be necessary long-term, in some cases even for decades. Breaks of several months are possible if there is a temporary significant improvement and one wishes to try discontinuing the medication. Based on your description, continuing a beta-blocker seems worth considering. As an alternative medication for otherwise treatment-resistant migraine attacks, aspirin can be administered intravenously. It is important to administer 1 gram. The effect can be improved by adding an anti-nausea medication such as metoclopramide to the infusion. For severe, treatment-resistant migraine attacks, there are also other specific options that can be administered in emergency situations. These include, for example, metamizole, prednisolone, and others.
Kind regards
, Hartmut Göbel
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Dear Professor Dr. Göbel,
This is my first time using Headbook. I apologize for not using a salutation in my previous comment. I'm rectifying that now :-)
Thanks so much
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Okay, dear Binchen, Professor Göbel has seen it.
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Dear Professor Göbel,
I have a general question regarding opioids, which were also prescribed to me in Kiel. Are opioid dosages weight-dependent? Does it make a difference to the dosage whether a patient weighs 50 kg or 100 kg?
Furthermore, with the continuous administration of 2 x 200 mg Tramabeta long-acting tablets, I unfortunately still reach my pain threshold, which is unbearable (chronic tension headache, NPDH, migraine, but especially the NPDH pain). I have previously been prescribed stronger opioids for acute treatment, which were effective (Targin). However, I don't want to take such strong opioids, even though they allowed me to lead a normal life again. Is there a slightly stronger, extended-release opioid than Tramadol that my neurologist could prescribe?Thank you in advance for your tireless work. Words cannot express the immense value of your dedication.
Best regards,
Erik-
Dear Erik,
The dosage of opioids can depend on body weight. However, the intensity of the pain and how the patient metabolizes the medication are much more important. If you are currently taking 2 x 200 mg of extended-release Tramadol and are not yet experiencing sufficient relief, the dose can be increased to 2 x 300 mg. There are also medications that can be added to the opioid as so-called comedication to improve its effectiveness. 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 suffered from migraines for 40 years. Until now, I've managed them reasonably well with triptans, but since December the attacks have become more frequent, so my neurologist wants to start me on beta blockers. However, I have low blood pressure. Am I even allowed to take beta blockers? I'm a teacher and need to be mentally alert in front of the class. Will the beta blockers impair my ability to do so? I have a second question: I've always taken Maxalt, but after 24 hours I need a second dose, and then a third. This quickly adds up to 10 doses (risk of medication overuse headache). Is there a triptan that lasts longer, so I might not need so many?
Thank you very much for your reply.
Best regards,
Birgit Bose-
Dear Mrs. Bose,
If beta-blockers are started at a slow, steady dose, they can also be used in cases of low blood pressure. Mental abilities while teaching are generally not impaired by beta-blockers. Beta-blockers are considered first-line medications because they are usually very well tolerated and effective. However, some patients do not respond adequately or cannot tolerate them. In such cases, numerous other treatment options are available. Maxalt has a very rapid effect, but its characteristic is that its effects also wear off quickly, leading to a so-called rebound headache. This is not a problem if the frequency of use is significantly less than 10 days per month. Longer-acting triptans include Relpax, Allegro, and Almogran. The number of days taken per month is not counted, not the number of tablets. It is therefore better to treat effectively on one day, even with two tablets, and then not need any medication the following day.
Kind regards
, Hartmut Göbel
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Dear Professor Dr. Göbel,
thank you for being there!
I can't get my average number of painkiller-related days below six. Acute therapy with triptans always works well to very well. However, I'm afraid of medication overuse headache (MOH).
My neurologist is considering prophylaxis.
I would be very grateful for your opinion.
I am 54, a non-smoker, athletic, and still at a normal weight.
Beta-blockers: I have rather low blood pressure;
weight gain?
Antidepressants: I fear weight gain,
as I have a diagnosed anxiety disorder. Perhaps they would be ideal during depressive phases? Two birds with one stone?
Which antidepressant causes the least weight gain?
Topiramate: Does it exacerbate anxiety disorders?
Is that correct? Apparently, it has strong side effects?Thank you so much for your assessment of my situation.
Perhaps no preventative treatment is needed after all?
Best regards from Austria,
Biggie-
Dear Biggie,
Six days a month using painkillers puts you in a good position. It's not always helpful to fight windmills. If, due to specific genetic predisposition, you experience a migraine frequency of six days a month and the attacks are well-controlled with a triptan, there's no reason not to take it in stride. If your situation is stable, the risk of medication overuse headache (MOH) is very low. In this case, prophylaxis with medication is not strictly necessary. However, if you have a co-occurring anxiety disorder with depressive episodes and an antidepressant would be needed anyway, this step would be doubly beneficial. Topiramate should not be used in this situation, as it can exacerbate depression and anxiety.
Kind regards
, Hartmut Göbel
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What would you recommend to someone who has had CPR for years and whose prophylaxis isn't working? She's a woman who doesn't smoke, drink, or use drugs. Her prophylaxis includes lithium, Vera, and oxygen. When would you recommend surgery, and if so, which type and where? She
has 8-10 attacks with fainting spells.-
Dear Selina,
Given the course of your symptoms as you described, you should urgently consult a cluster headache specialist center to have your situation assessed 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 years old, male) have been diagnosed with migraine, which I can confirm from my own experience of years (2-4 times per month). For the past four months, however, I have also been suffering from almost daily pain very similar to migraine, but perceived with varying intensity: consistently a dull, left-sided neck pain radiating to my eye, sometimes accompanied by sensitivity to noise. I am currently 100% unable to work. A head MRI is pending.
After reading your book and building my own knowledge, I am very dissatisfied with my neurologist. Furthermore, I am uncertain about my current diagnosis: chronic migraine or episodic migraine combined with chronic tension-type headache. I am struggling to complete the checkboxes on the Kiel Headache Questionnaire when analyzing the almost daily and debilitating neck pain I've been experiencing for the past four months.
1)
Do you have any recommendations for well-qualified neurologists, pain clinics, psychiatrists, psychologists, or multimodal behavioral therapies in Switzerland that specialize in primary headaches? I am also looking for holistic treatment for my neurological condition(s); does this exist at a professional level in Switzerland?2)
Somehow I have the feeling that my dissatisfaction and lack of motivation at work, which I've experienced over months and years, is now reflected in what seems to be chronic migraines. Do you know any other male pain patients who don't have financial security through a partner? How did these patients escape the rat race? The fear of financial insecurity certainly doesn't make coping with the pain any easier…-
Dear Svensson,
You can find information on the website of the Swiss Headache Society and ask regional pain therapists for advice. 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 Professor Dr. Göbel,
thank you so much for your dedication in every respect. I have already been to your clinic twice, and it is so important for me to have this point of contact.Regarding my question: I am female, 32 years old, have had migraines since the age of 5, chronic migraines for about five years, recurrent depression, and have had one-night stands for two years. Currently, I am taking 25mg of amitriptyline for prophylaxis (this dosage was prescribed at the pain clinic in Kiel due to my desire to have children).
Unfortunately, my desire to have children has not yet been fulfilled. A blood test at my gynecologist's office revealed that I have an estrogen deficiency. If I want to have children, this should be treated with hormone therapy. Such treatment with estrogen failed about ten years ago. After each estrogen injection, I experienced severe migraines.
Is there anything that can be done to improve the situation? Is there any way to prevent the migraines from worsening? I currently have about 15 days of pain per month (with about six days of triptan use). Any worsening would be disastrous.
Thank you! It's wonderful that there are people like you.
Best regards,
Lenchen
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Dear Lenchen,
Estrogen therapy doesn't necessarily worsen migraine symptoms. If it did 10 years ago, it doesn't mean it will happen again now. Ultimately, a case-by-case assessment is necessary, weighing the benefits against the risks and potential benefits. Since you currently have comprehensive migraine prevention, including neuromodulation, there's a better chance your migraines will remain stable despite fertility treatment.
Kind regards
, Hartmut Göbel
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The comment section has been closed
March 14, 2016 at 12:10 PM – Edit
Dear Mr. Göbel,
Thank you so much for the opportunity to have a live chat with you here!
What constitutes a good mindset that allows one to live well with and manage headaches? I think that one's perspective on things can make a big difference, especially for the better. Do you have any specific suggestions?
I've had chronic tension-type headaches for almost four years, and my current therapy consists of endurance sports and progressive muscle relaxation according to Jacobson. Initially, I thought the headaches would disappear after a year or two. However, for the past two years, I've been increasingly losing faith in a headache-free life, although I haven't given up hope and am continuing with the therapy.
Warm regards,
Robert
March 14, 2016 at 6:19 PM – Edit
Dear Robert,
Chronic tension-type headaches generally cannot be eliminated with simple measures, and often not quickly. They wouldn't be called "chronic tension-type headaches" if they could be resolved quickly. One must therefore be prepared to deal with the issue for an extended period. On the other hand, there are many ways to actively counteract headaches. These include knowledge, information, understanding how headaches are maintained and can become chronic, implementing preventative behaviors, and knowing how to use medication correctly. Very often, this can reduce headaches and sometimes even eliminate them completely. However, how long this takes is uncertain. There is no alternative to actively engaging with the topic and doing everything possible to reduce headaches. This knowledge can be found in the Headbook groups, where further resources are also listed.
Kind regards
, Hartmut Göbel