Brief Answer:
Inadequate regimen of Ativan and Fioricet

Detailed Answer:
Good morning and I'm sorry to see that your wife's regimen of medications is not working for her headaches. As a Headache Neurologist myself I always begin treating patients by explaining how to document their symptoms of headaches (including different types of aura, actual pain of the head, the numeric scales that are conventionally used, etc). I then, have the patient go through a careful history as to when their headaches first began and how they evolved throughout time....which in your wife's case may be since childhood or from her late teens or 20's through time. It's even possible that when a woman hits the menopause that her migraines go away for a period of time...years perhaps....but then, come back as severe as they ever were.....that's a common problem. Whatever the history for this person...we extract it to the fullest degree possible. Next, and in conjunction with a log of symptoms that they keep from 30-60 days which they are carefully documenting along with any and all medications they are taking to alleviate the symptoms we go back and look at the collection of information and decide WHAT KIND OF HEADACHE is being dealt with...often times and I think it is altogether possible in your wife's case....there are at least 2 headaches such as migraine PLUS tension type. This is very common. We call these mixed headaches. In your wife's case where she seems to be only given Fioricet as an acute abortive she has a high likelihood of suffering from something called MEDICATION OVERUSE HEADACHE (MOH). Please look this up to see how your wife's detailed symptoms correlate with this entity and the risk that people are at when all they take are abortives. In my practice I do not prescribe Fioricet since it does not get the mechanism of any type of CHRONIC HEADACHE in any measurably sustainable way and most times ends up being overused or even abused by patients who start taking more than recommended amounts and fall into a downward spiraling cycle. Ativan is not a headache medication and so we won't really discuss its role except in the sense that we know that STRESS is the #1 trigger for all forms of headaches.

After identifying the type(s) of headaches that the patient suffers we look at ALL MEDICATIONS they've tried in the past as well as their dosages. It is often the case that patients who are not being well controlled by their own measure refer to the doctor that the last prescription really didn't work for them and the doctor without doing much more investigation changes the patient to another agent and after a month or so...changes to something else....and we're off to the races.

Both patient and doctor fall into the belief that NOTHING works and that EVERYTHING'S been tried. Nothing's further from the truth in that aspect since it is almost always the case that at least several agents that have been tried along the way were not prescribed entirely properly with respect to HOW they should be taken nor were the doses used to their maximum limits before deciding that a change was necessary. So in my patients, often times we will actually go back and revisit the medications they've tried and this time with the aid of the HEADACHE LOG start carefully documenting symptoms, doses and timing of medications, as well as responses. A careful analysis of the log by the headache doctor may actually reveal IMPROVEMENT in the patient WITHOUT HAVING necessarily ERADICATED THE HEADACHE. Remember, a migraine headache is not just PAIN....but it's everything else that disable a person such as nausea, vomiting, photo, phono, and osmophobias, phosphenes, scotomas, inability to concentrate, etc. The actual PAIN end of it may only last a fraction of the time that the patient is DOWN.....that's why education is crucial with headache patients who've been "tried on everything."

One other aspect of the HEADACHE LOG that I should mention which is very important is when we document and look for POTENTIAL TRIGGER items, activities, or situations which place your wife in the path of imminent headaches. I'm not just referring to foods and beverages since those are the most obvious but virtually anything and everything INCLUDING PSYCHOLOGICAL STRESSORS are considered candidates to start a person down the cascade that leads to the migraine.

Interventions aside from medications must also be tried and discussed which can have a huge impact on patients who have chronic headaches. There are more and more devices starting to pop up which are FDA approved for migraine headaches but one that most of my patients have really said works well for them to calm their acute headaches down when they come on...even without medication necessarily is something called a THERMAZONE device. This is not a device (obviously) that can prophylax headaches but boy do people love this thing!

http://therma-zone.com/product/3
http://therma-zone.com/migraine--headache

As far as prophylactic agents are concerned there are as many out there as the day is long and again, I can't emphasize how in my practice I rarely have had to go outside a small number before finding something that works well for those patients who do their due diligence and fill out their charts. I typically start with PROPRANOLOL and then, move to NORTRIPTYLINE, TOPAMAX, OR ZONEGRAN. If these agents don't work well and I know the patient truly has migraine headaches then, my next move may be to consider calcium channel blockers such as diltiazem and AED's such as phenytoin, carbamazepine, or oxcarbazepine, and valproic acid.

I can tell you that I also tend to recommend riboflavin (Vitamin B2) in addition to other prescription drugs.

If patients are still not responding to HEALTHY doses of these medications then, I begin evaluating them for potential magnesium replacement therapy which can either be in oral or in a more potent and expedient way IV form. These types of options should really be managed by headache specialists in my opinion since they are not overly published as options to primary doctors or internists.

BOTOX injections for chronic migraine headaches in addition to good abortive options which include triptans and/or ergotamine based treatments have shown very good results in at least 80% of my migraine patient population and the effect can last from 10-14 weeks in most cases. There are other more aggressive forms of therapy including sphenopalatine ganglion blocks which can be done traditionally with needles that access nerve bundles that lie behind the eye or more recently using an FDA approved device which is needleless and accesses the area through the upper nasal passages using a catheter technique.

If I've adequately answered your questions could you do me a huge favor by CLOSING THE QUERY and being sure to include some fine words of feedback along with a 5 STAR rating if you feel my suggestions have helped? Again, many thanks for posing your questions and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 45 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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