Chlorpromazine (Thorazine) belongs to the phenothiazine family, which includes prochlorperazine (Compazine) and promethazine (Phenergan), drugs used to treat nausea and vomiting. These drugs can relieve not only the accompanying nausea, but the migraine headache as well. The Australian & New Zealand Association of Neurologists recommends chlorpromazine as one of the drugs for the treatment of moderate to severe migraine in an emergency setting.

Chlorpromazine is approved for the treatment of schizophrenia, severe mania and also for nausea, vomiting, severe hiccups, and other conditions. Chlorpromazine is considered to be a stronger antiemetic (anti-nausea) drug than prochlorperazine and promethazine, but it can have more side effects. Side effects include dizziness, drowsiness, but the most unpleasant side effect is severe restlessness and involuntary movements. Some patients describe it as wanting to crawl out of their skin. This side effect usually can be relieved by diphenhydramine (Benadryl). Prolonged use of phenothiazines can lead to persistent involuntary movements, which are extremely unpleasant and do not go away after the medicine is stopped. Higher incidence of side effects is why chlorpromazine should be used for nausea only if milder drugs such as ondansetron (Zofran), metoclopramide (Reglan) and prochlorperazine (Compazine) do not help.

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Medical marijuana (MM) is now legal in 30 states. Most states approve its use for specific medical conditions and severe pain and nausea, which are symptoms of migraine, are usually on the list.

I’ve been prescribing MM since it was legalized in the State of NY four years ago. My estimate is that one out of three patients find it useful. Some take it daily for the prevention of migraine attacks, but the majority use it as needed, whenever an attack occurs. MM sometimes relieves all of the symptoms of migraine, but sometimes only pain or only nausea. Some patients find that it helps them to go to sleep and when they wake up, the headache is gone. A few patients have told me that they take it regularly for insomnia and that it often works better than prescription drugs, such as zolpidem (Ambien) and does not cause side effects. The calming effect of MM is also useful when dealing with a very upsetting and debilitating condition such as migraine.

Most states require an analysis of the amount of active ingredients in every MM product by an independent laboratory. The two main ingredients are tetrahydrocannabinol (THC) and cannabidiol (CBD). This is one of the advantages of going the legal route – you know that the product will be the same each time you buy it. However, my patients have told me that they prever products from one or another dispensary even when using products with the same concentration of THC and CBD. This can be explained by the fact that all MM products contain other supposedly inactive ingredients, which in fact may also have various positive or negative effects.

CBD oil made from hemp is legal to buy without a doctor’s prescription and is available for purchase online. For many it works well by itself to relieve pain, nausea, and inflammation. THC is responsible for the sedating and calming effect. However, even a small amount of THC often makes CBD more effective. Raphael Mechoulam, a Hebrew University professor who discovered THC, calls this the entourage effect.

Many patients take low THC/high CBD products during the day to avoid euphoric and cognitive effects, while at night they might take a high THC/low CD combination.

For faster onset of actionvaping MM is optimal, while for the prevention, taking a pill or a tincture can be more convenient. These are the three types of products that are approved in NY.

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Almost everyone has an occasional pain in the upper back and shoulders, often caused by prolonged sitting in front of a computer or just by stress. The pain is due to muscle spasm and keeping those muscles in good shape helps prevent this problem. It also helps to be aware of your body through regular meditation practice or Awareness Through Movement method developed by an Israeli physicist Moshe Feldenkrais. I’ve posted Feldenkrais exercise videos for neck pain here and here. Most people are shocked at the immediate improvement in the range of movements they notice even after the first set of exercises.

I recently had a tight knot in one of my shoulders which did not go away after 90 minutes of hot yoga. Lying on the floor at the end of the yoga session I did a 5-minute Feldenkrais exercise which made the knot melt away. In this video I demonstrate this exercise that relaxes tight muscles and stops shoulder and upper back pain. Instead of watching the video you can follow these written instructions:

Lie down on your back with a thin pillow or a soft pad under your head. Spend a minute paying attention to spots where your head, shoulders, back, arms and legs touch the ground. Then, bend your knees and keep your feet flat on the floor. Stretch your arms in front of you and put your palms together with your arms forming a tall triangle. Keep your eyes on the thumbs and slowly lift the right shoulder off the ground with your head rolling to the left. Press down the left foot to make the movement easier. Keep the shoulder lift small to avoid straining and time it with exhalation. Repeat this shoulder lift and head turn five times while maintaining the gaze on the thumbs. Then, do another five of these movements in exactly the same way, except now move your eyes from the thumbs as far as you can in the opposite direction from the head roll. It may be difficult at first because your head may want to move with the eyes. When you come back to the midline, your eyes return to the thumbs. Put your arms and legs down and again spend a minute noticing the areas of pressure where various parts of your body touch the floor. Now, repeat the same two sets of 5 movements to the left side and then rest for a minute to feel your body contact the floor.
Try to maintain regular slow breathing throughout this exercise.

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Candesartan (Atacand) is a blood pressure medication in the class of ACE receptor blockers (ARBs), none of which are approved for the treatment of migraines. Because they are available in a cheap generic form no pharmaceutical company will spend hundreds of millions of dollars on large trials required for the official FDA approval. This does not mean that unapproved drugs are ineffective, it’s just the evidence is weaker because it is based on small trials. Unfortunately, only four oral drugs are FDA-approved for the prevention of migraines – two beta blockers and two epilepsy drugs (Botox and Aimovig or erenumab are injectable). So most of the preventive drugs we prescribe are “off label”, that is they lack FDA approval.

Candesartan was first shown to work for the prevention of migraine headaches in a 60-patients Norwegian trial published in JAMA in 2003. This was a double-blind crossover trial, which means that half of the patients were first placed on a placebo and then switched to candesartan and the second group started on candesartan and then were switched to placebo. This trial showed that when compared to placebo, 16 mg of candesartan resulted in a very significant reduction in mean number of days with headache, hours with headache, days with migraine, hours with migraine, headache severity index, level of disability, and days of sick leave. Candesartan was very well tolerated – there was no difference in side effects in patients taking the drug and those taking the placebo.

In another trial, the researchers compared candesartan to placebo as well as to propranolol, which is an FDA-approved blood pressure drug for the prevention of migraines. This trial in 72 migraine sufferers compared 16 mg of candesartan with placebo and with 160 mg of propranolol. Candesartan and propranolol were equally effective in reducing migraine days per month and both were significantly more effective than placebo.

One advantage of candesartan over propranolol and other beta blockers is that it does not lower heart rate, which can make exercise difficult. Both can cause fatigue and dizziness due to the lowering of blood pressure, but the weight gain and depression occasionally seen with propranolol does not happen with candesartan. On the other hand, propranolol can sometimes help reduce anxiety.

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The New York Headache Center participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg of butterbur is effective in the prevention of migraine headaches when compared to placebo. The results were published in Neurology and the American Academy of Neurology endorsed the use of butterbur for the prevention of migraine headaches. Because butterbur is highly toxic to the liver and can cause cancer we were very happy to have a highly purified product manufactured in Germany (sold as Petadolex), where it had to pass strict safety studies. However, Germany does not allow butterbur to be sold there because the manufacturer changed its purification process and did not repeat all of the required safety studies. Butterbur is still made in Germany and is sold in the US, but our FDA does not regulate herbal products and does not require the extensive safety tests that are required in Germany.

The manufacturer of Petadolex brand of butterbur sent me an email saying that the FDA conducted an inspection of their manufacturing plant in Germany. However, my concerns about butterbur have not been addressed. Here is my email response to the manufacturer:
“Thank you for this additional information. It is good to see that the FDA conducted a “comprehensive inspection” of the manufacturing facility in Germany. However, my concerns about the safety of Petadolex are not due to possible deficiencies in manufacturing, but are related to the extraction process. As far as I know, this is why German and UK governments still do not allow the sale of Petadolex and this is why I do not recommend Petadolex to my patients. I am also concerned that because Petadolex is fairly expensive, many patients will decide to buy a cheaper brand of butterbur, which can be truly dangerous. Once Petadolex is cleared for sale in Germany I will be happy to resume recommending it to my migraine patients”.

Some of the above text is from my previous posts a few years ago, but I still do not routinely recommend butterbur. If a patient expresses an interest in it and if other herbal treatments and supplements fail, I will provide directions for its use and will emphasise the importance of not substituting Petadolex for a cheaper brand.

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Caffeine can be considered a drug since it is available in a pure form in tablets and injections. It is also included in medications, such as Excedrin, Fioricet, and Fiorinal. It is considered to be an analgesic adjuvant, meaning that it enhances the effect of other pain medicines, such as aspirin and acetaminophen, but it has been shown to relieve tension-type headaches by itself as well. However, there are no studies showing that caffeine alone taken by mouth relieves migraine headaches. It does enhance the effect of acetaminophen and aspirin in Excedrin and this combination has been proven to relieve mild and moderately severe migraines.

In a pilot open-label study of intravenous infusion of 60 mg of caffeine citrate for an acute migraine showed significant relief within an hour of infusion. The study was published in 2015 in the Journal of Caffeine Research (who knew such a journal existed).

Besides caffeine, Fioricet, Fiorinal, and Esgic contain either acetaminophen or aspirin and butalbital, which is a barbiturate. Barbiturates are used for epilepsy, anesthesia, and in the past had been used for insomnia. However, they are addictive and they are no longer widely used. However, butalbital’s use in headache products stubbornly persists despite its addictive nature and lack of proof that it relieves migraines. These products can cause not only addiction, but also medication overuse headaches, most likely due to their caffeine content.

Caffeine can cause headaches directly, but much more often the headache is due to caffeine withdrawal when it is consumed for long periods of time in large amounts. Caffeine withdrawal headaches have been proven to occur in a double-blind withdrawal study. Most people who drink a lot of coffee know this from their personal experience – skipping the morning cup or not drinking coffee on days of fasting leads to a bad headache, which is usually a migraine. Sometimes caffeine withdrawal headaches are not obvious. Someone who drinks two cups of coffee and two caffeinated sodas daily may not realize that their daily headaches are caffeine-related. They just take Excedrin, which provides temporary relief, but adds fuel to the fire.

Children who drink too much caffeinated sodas can also develop daily headaches, which are relieved by gradually reducing and then stopping caffeine intake.

Some people develop tolerance to caffeine, which means that the stimulating effect lasts shorter and shorter periods of time and such individuals have to drink more and more coffee to maintain its effect. This ends up in needing 10 cups of coffee or 10-20 tablets of Excedrin daily. My record-holder was a patient who was taking about 25-30 tablets of Fioricet daily and had to be hospitalized for detoxification.

The bottom line with caffeine is that it helps when used occasionally and worsens headaches when taken more than a few times a week.

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Boswellia serrata is not a drug, but a plant, but I am including herbal products as well if a serious scientific journal has published articles on it. Most of the available information on Boswellia is in mentioned in my previous post. I would only add that of all herbal products, Boswellia is the first one I recommend because it is very safe and I continue to see many patients who respond well to it. My preferred brands of Boswellia are Nature’s Way and Pure Encapsulations, although Nature’s Way is cheaper.

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Jan Mundo, who is a Somatic and Headache Coach, and Bodyworker just wrote a book, The Headache Healer’s Handbook, which was published by the New World Library. I’ve known Jan and her wonderful work with headache patients for many years and was happy to write a foreword to her very readable and useful book. Here is the foreword:

Headaches afflict close to half of the US population with 40 million suffering from migraines, which can be very disabling. Many books have been written for the general public, including two of my own, but Jan Mundo’s Headache Healer’s Handbook brings a unique perspective to this problem.
When I treat patients in the office, they are usually reassured by the fact that I am also a migraine sufferer and so it is with Jan’s book – she knows first-hand what it feels like to have a migraine. More importantly, she has discovered ways to relieve her own attacks and those of other countless migraineurs.
Like Jan, I am a big proponent of non-drug treatments and this is what she details in her book. I also like her hands-on approach, both literally and figuratively. Psychologists have proven that active treatments, where people are doing things to improve their condition, are much more effective than passive treatments, such as massage, chiropractic, and acupuncture, where things are done to them. This leads to the transfer of external locus of control to internal locus of control or in other words, a shift from a passive and helpless victim of external circumstances, to being an active participant in the events with a significant degree of control.
Jan begins with the basics – identifying your type of headache and finding possible triggers that make headaches worse. She does recommend at least one visit to the doctor to confirm the diagnosis. This is important not because a brain tumor or an aneurysm is likely to be found since those are very rare, but a routine blood test could detect magnesium or thyroid deficiency, anemia, or another medical problem that could be contributing to headaches.
Once your diagnosis is confirmed, with Jan’s help you can take an inventory of your diet, sleeping habits, your physical environment, and posture, and try to find triggers, which can be corrected. Then Jan recommends breathing exercises which to me had echoes of the Feldenkrais method – becoming aware of how you breathe and improve not only your breathing, but also the movements of your chest, spine, and the rest of your body.
In the chapter, Being still: Mindfulness and Headaches Jan describes another powerful tool in combating not only headaches, but many other physical and mental ailments. Yes, everyone is talking about the proven benefits of meditation, but it is surprising how few people actually practice it.
Posture, Ergonomics, and Sleep is followed by a chapter on physical exercise, which is proven to not only be good for you, but to specifically reduce the frequency and the severity of headaches.
A large portion of the book is devoted to the Mundo method, Jan’s unique hands-on therapy, which she has developed to treat her own headaches and which has helped many sufferers she has worked with. The healing power of touch is scientifically proven to dramatically improve outcomes in premature babies and without a doubt, can be also harnessed to relieve a variety of headache conditions. Just follow Jan’s advice and watch your headaches go away.

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Baclofen (Lioresal) is one of several muscle relaxants that have been tested for the treatment of migraine headaches. The testing was not very rigorous – baclofen was subjected only to one open label trial. The trial done by an Israeli neurologist, Dr. Rachel Hering-Hanit involved 54 patients. After a 4-week baseline assessment period, patients were given baclofen for 12 weeks. The drug was given three times a day with the dose ranging from 15 to 40 mg.

What was impressive about this study is that not only 86% of patients improved by at least 50%, but also that 51 out of 54 patients completed the study. It is very likely that many would have dropped out if the treatment was ineffective or had a high rate of side effects. Only 3 patients dropped out because of side effects.

Dr. Hering-Hanit also tested baclofen in 9 cluster headache sufferers with six improving within a week on doses ranging from of 15 to 30 mg.

The main side effect of this drug is drowsiness. Some patients may not need to take it three times a day – one nightly dose may suffice. I start with 10 mg nightly and gradually increase the dose. However, another muscle relaxant, tizanidine has been shown to relieve chronic migraine in double-blind studies and I tend to use it much more frequently than baclofen. Tizanidine has the same main side effect – sedation.

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Butalbital, a short-acting barbiturate, is one of the three ingredients in headache drugs such as Fioricet, Fiorinal, Esgic and their generic equivalents. Fiorinal and Fioricet derive their name from the Montefiore Headache Clinic, where they were developed over 60 years ago. In those days extensive clinical trials were not required by the FDA and they were approved without much testing. The approval was and still is only for the treatment of tension-type headaches. They have never been shown to be effective for migraines, although this is what they are mostly used for. Fioricet and Esgic contain butalbital, caffeine, and acetaminophen, while in Fiorinal acetaminophen is replaced with aspirin.

Neurologists have a strong dislike of this drug, although general practitioners tend to like it because they are very familiar with it. The dislike comes from the fact that butalbital is addictive and caffeine can make headaches worse. I’ve seen patients who openly admitted that they often take Fiorinal to relieve anxiety and many become physically dependent and addicted to it. My most memorable patient was one who took 20 to 30 tablets every day. I had to hospitalize her for detoxification. In patients who take more than 5-6 tablets a day sudden discontinuation can lead to an epileptic seizure. We usual switch patients to a long-acting barbiturate, phenobarbital, which is easier to stop. Withdrawal from caffeine worsens headaches, for which sumatriptan tablets or injections can help. Botox injections and other preventive migraine drugs can also make the withdrawal process less painful.

I should mention that I do have a very small number of patients for whom I prescribe these drugs for occasional use, but these exceptions confirm the rule – Fioricet and Fiorinal are ineffective for the vast majority of migraine sufferers and can lead to worsening of migraines and addiction.

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Headaches that occur during sexual activity tend to elicit fear and embarrassment. Embarrassment is why most people are not aware that this is a fairly common condition – you would not share your experience at a party. The fear is justified – a rupture of an aneurysm in the brain is a deadly condition with 40% of patients dying before they reach the hospital. Fortunately, even though the pain is excruciating, in the vast majority of cases, the pain of an orgasmic headache is brief and the cause is benign.

Sex-induced headaches are three times more common in men. In 80% of people the pain is sudden, occurs at the time of the orgasm, and lasts 30 minutes to a couple of hours. In the remaining 20%, the pain builds up gradually during sex before the orgasm and often does not reach a crescendo if the sexual activity is aborted.

These headaches tend to be common during sex with the usual partner or less often with masturbation. Anecdotally, aneurysm rupture is more likely to occur during an extramarital affair – due to the divine punishment, or more likely, greater excitement and higher elevation of blood pressure than what would occur with the spouse.

This post was prompted by a recent patient who developed an orgasmic headache during masturbation for the first time at the age of 60. The headache had occurred the day before and had completely resolved by the following day. However, with the first orgasmic headache we usually tend to get an urgent CT scan (the CT scan is better at detecting fresh blood than the MRI) because a small leak from an aneurysm could be the underlying cause of a brief headache. My index of suspicion was low because his neurological examination was normal and he’s had some headaches in the past. But the age of onset was a bit late and aneurysms tend to enlarge with age. We both were reassured by a normal CT scan.

Orgasmic headaches can be recurrent and the pain is so severe that some patients are afraid to have sex. Sometimes the solution is simple – take 400 mg of ibuprofen or naproxen an hour before having sex. If this strategy works, after a few times of taking medicine the headaches may not return. If an over-the-counter medication does not work, a prescription migraine drug, such as sumatriptan (Imitrex) can help. Regular exercise can be helpful in preventing these headaches for people who are out of shape.

In older individuals, a common cause of sex-induced headaches is the cervical spine and neck muscles. These headache are usually not as intense. Another patient of mine, a woman in her late 60s stopped having headaches after I suggested changing her position during sex. Strengthening neck muscles, general conditioning, and taking ibuprofen can also help.

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Anxiety is one of the conditions comorbid with migraines – if you have migraines you are 2-3 times more likely to suffer from anxiety as well. The relationship is bidirectional, meaning that if you have anxiety, you are more likely to develop migraines. Antidepressants are proven to relieve anxiety even in the absence of depression and they are a better long-term solution than anxiety drugs such as diazepam (Valium) or alprazolam (Xanax) because they are not addictive and do not lose their efficacy over time. A unique drug that is used only for anxiety and not depression and does not cause addiction, is buspirone (Buspar).

Several studies suggest that buspirone is effective for the treatment of migraines. In a 74-patient randomized, prospective, parallel group, double-blind, placebo-controlled study (the most rigorous type of study) headache frequency showed a 43% reduction in the buspirone-treated group, but only a 10% reduction in the placebo group. This effect was independent of the presence or absence of anxiety. Similarly, antidepressants prevent migraines even if the patient is not depressed.

Buspirone has a favorable side effect profile and it does not cause withdrawal symptoms, which is often a problem with other anxiety drugs and to a lesser extent, antidepressants.

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