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Migraine prophylaxis


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Best migraine prophylaxis for a young female (27) who has failed on sumatriptans? Has had negative ct/MRI. Failed on beta blockers, neurontjn, depakote.

 

Topamax worked ok, but she stopped it when she got pregnant. (Shes no longer pregnant). Also her BP already runs low 100's/60's

 

Read jmj's post about Atacand. Has anyone had experience with this?!

 

Thank you.

 

 

Let food be thy medicine

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  • 2 months later...

Yes, in our neurology practice we even start people off on amitriptyline. Many of our patients have comorbid depression and while we never reach a dose high enough to have true antidepressant properties, sometimes it does help mood and sleep which also helps the headaches. I've never used Atacand, so can't speak on that. 

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Zonisamide has a lower side effect profile than topiramate and works nearly as well.  That is just one of many thoughts.

 

 

1{demonstrated by personal experience and one study ((Headache 2011;51:287-291) Zonisamide for Migraine Prophylaxis in Topiramate-Intolerant

Patients: An Observational Studyhead_1842 287..291
Veronica Villani, MD; Alessandro Ciuffoli, MD; Luca Prosperini, MD; Giuliano Sette, MD, PhD} 
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Topic related, but not specific to the OP's patient...

 

What do you know/feel about riboflavin (B2) for migraine prophylaxis?

 

I had a patient in the ED the other day very resistant to initiate any sort of migraine prophylaxis. (The classic "I just don't don't like to take medications because they're unnatural"). After episodic symptomatic treatment, I got a neuro consult in the ED (one of the perks of working in a large teaching hospital...specialists at your fingertips woohoo) mostly because this patient had been lost to follow up to neuro despite many ED visits for her migraines.

 

The neuro's rec for this patient with resistance to start a prophylactic med (but not necessarily against a "vitamin supplementation"? Riboflavin 400mg daily. I don't ever really recall learning about this utilization, but I've since stumbled upon a few papers suggesting it is good at decreasing frequency, but not severity of migraines. Minimal side effects, too. 

 

Thoughts? Anyone else use this? JMJ??

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a lot of good info in here on non-rx management of migraines to include discussion of riboflavin, magnesium, etc. ( written by our own Mike Jones!):
http://www.amazon.com/Why-Your-HeadAches-Research-Explained/dp/1412077419/ref=sr_1_fkmr3_1?s=books&ie=UTF8&qid=1387093616&sr=1-1-fkmr3&keywords=why+my+headaches+jones

 

his other book A Kernel in the pod is also excellent and should be required reading for every PA student.

http://www.amazon.com/Kernel-Pod-Pa-C-Michael-Jones/dp/1401054293/ref=sr_1_1?s=books&ie=UTF8&qid=1387094348&sr=1-1

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How do you (or would you) treat a patient who is in active alcohol dependence with history of migraine?  The patient it on amitriptyline (for sleep, at 25 mg qhs altho she self medicates to 75 m gqhs), sumatriptan which she will take 2x a day and calls for refills every three days, is on tramadol and flexeril for her fibromyalgia, and gabapentin and 800mg ibuprofen, prn for low back pain.

 

My answer if this:  Stop treating.  She is getting rebound headaches for failing to follow directions on how to take her medicine, is actively drinking so the alcohol is making things worse and the cocktail of alcohol and all those meds could be horrible.

 

The riboflavin, magnesium and a multi-vit might be the safest for this patient.  All efforts to get the patient into treatment has failed.

 

I have stopped writing any prescriptions for her and want to stop ALL medications until she is sober but she calls and tries to come in for her medication review (but doesn't make it).   If I am not there she sometimes gets another provider to give her refills.   Any suggestions?

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  • 3 weeks later...

Mike, does the trans-cranial stim work for common migraine without aura? I get far fewer migraines than I used to but lately interested in manipulation techniques like these as an osteopathic physician (almost!)

Also, any risk of inducing seizures with this? My sis-in-law is a Hodgkins survivor who has done well generally but does have a low seizure threshold after multiple rounds of chemo and she does get common migraine as well.

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Mike, does the trans-cranial stim work for common migraine without aura? I get far fewer migraines than I used to but lately interested in manipulation techniques like these as an osteopathic physician (almost!)

Also, any risk of inducing seizures with this? My sis-in-law is a Hodgkins survivor who has done well generally but does have a low seizure threshold after multiple rounds of chemo and she does get common migraine as well.

No seizures induced during trials so I think that is unlikely but I don't know if they study it with epileptics.  I wouldn't be surprised if the same technology could abort a seizure if it was caught early enough, somewhat like the VNS magnet activating a electrical charge from the stimulator.  It can induce a migraine aura in a non-migraine patient, which is what happened to a friend of mine who participated in the early trials as a "normal."  Regarding migraine without aura, that is a complex question.  The reason is, some in the headache research community believe that migraine with and without aura are the same only for those without aura, the electrical storm (spreading cortical depression) is so mild that there are no clinical manifestations.  However, to get this to work, you have to intervene in the headache before the pain cycle begins. So, if you have migraine without aura but have a clue when a headache is starting (other prodrome features) theoretically, it could work.  I will mention again that this is the ONLY non-drug treatment for migraine in the world that has been proven effective in placebo-controlled trials.

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Very interacting. Thanks Mike...I would have liked to try it this morning--first migraine in weeks lol. Thankfully my old faithful rizatriptan is helping.

I do use a sub occipital release tool from Amazon (look up DaVinci tool) which is based on a simple osteopathic technique which puts gentle pressure on the C1 nerve roots until the spasm releases. It helps but not as good as a skilled osteopath's hands. Hard to do on yourself though (I've tried!) hence the tool. Wondered if you knew about this and might find it useful for your patients. Sorry I can't attach the link at the moment.

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Very interacting. Thanks Mike...I would have liked to try it this morning--first migraine in weeks lol. Thankfully my old faithful rizatriptan is helping.

I do use a sub occipital release tool from Amazon (look up DaVinci tool) which is based on a simple osteopathic technique which puts gentle pressure on the C1 nerve roots until the spasm releases. It helps but not as good as a skilled osteopath's hands. Hard to do on yourself though (I've tried!) hence the tool. Wondered if you knew about this and might find it useful for your patients. Sorry I can't attach the link at the moment.

You can just send the link to the placebo-controlled study that was published in a good peer-review journal and I would love to read about it.

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  • 4 years later...

Hi,

A migraine is a chronic neurological condition with episodic.The first-line therapies for migraine prophylaxis in adults include propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate.According to me, the total daily dose of topiramate for prophylaxis of a migraine is 100 mg a day administered 2 divided doses.

Thanks!!
.

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