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Dr. Andrew Rynne

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Suggest treatment for chronic migraine that is causing sleeplessness

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Dr. Manisha Gopal

Psychiatrist

Practicing since :2005

Answered : 947 Questions

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Posted on Wed, 27 Aug 2014 in Sleep Disorders
Question: Hi

I am not able to sleep properly. It has been a long time. I have chronic migraine problem XXXXXXX to which I will not be able to sleep..I do not get sleep only. I will wake frequently during night and again getting sleep becomes difficult. In mornings, I will feel as if I have not slept at all and I wake up with bad headache (I suspect it's because of lack of sleep). Could you tell me what should I do about it?

XXXXXXX
doctor
Answered by Dr. Manisha Gopal 58 minutes later
Brief Answer:
take zolpidem 5-10mg for sleep & try oxcarbazepine

Detailed Answer:
Hello,
You have given a good detail of your problem and about the meds you have had and currently taking (with proper mentioning of side effects you are facing). All this is helpful to move ahead in managment.

1. From your history of headache coming or increasing after sleep and from the history of pain in neck/back..I think you should get an X Ray neck AP and Lateral view to rule out cervical spondylosis. It is a must.
If found positive- neck exercises and certain other measures will help you a lot.

2. you have chronic migrain- In such cases there are several triggering factors which can bring about an episode- Like: cervical spondylisis, travelling, remaining hungry for long hours, or peri menstrual, visual problems, certain food items. Many of these can be avoided and attacks can be prevented. So, also get eye sight test and wear specks if you have a number.

3. There is a protocol which should be followed on getting an attack of migraine. One should take the pain killer within 5-10min of starting of pain. Trying to avoid taking meds soon or thinking of toleraring will only make it worse and the drug will not help later. Take it as soon as you realize that it is starting.

4. I have seen that patients whose pain dosent go away with naxdom 500mg SOS basis, have good response with rizatryptan 5-10mg. You may try it once and see.

5. There are several patients who have no respinse to oral meds, in such cases- injectables are helpful in aborting the attack and breaking the cycle of migraine. Inj. Diclofenac 75mg with metocloperamide is very helpful.

6. You can practice deep breathing technique to calm your nerves- this is good in reducing the intensity & number of attacks.

7. Pain in face and other areas can accompany migraine headache. Even there can be pain in ears/ burning sensation. There can be asosciated swelling of such areas. Donot worry, all these are simple and harmless neurological sequelae of migraine. I have seen excellent response in such cases with oxcarbamazepine. There is no associated weight hain with this drug unlike other .

8. Get TSH , Sr. B12 and Vit. D levels. Correcting them help a lot in resistant migraine cases.

Donot loose hope. There are many drugs and options still present which can be tried successfully in your case.

Hope the reply is helpful. Please feel free to ask more questions for clarification.

Dr. Manisha Gopal
MD Neuropsychiatry
Above answer was peer-reviewed by : Dr. Bhagyalaxmi Nalaparaju
doctor
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Follow up: Dr. Manisha Gopal 2 hours later
Hello Doc

Thanks a lot for your quick response! Below are my comments/questions:

1. From your history of headache coming or increasing after sleep and from the history of pain in neck/back..I think you should get an X Ray neck AP and Lateral view to rule out cervical spondylosis. It is a must.
If found positive- neck exercises and certain other measures will help you a lot.

Akanksha: Ma'am, as I have been on different treatments for migraine since 2012, I have got my X ray done, and doctor said, everything is fine. Moreover for past 2-3 months I am not using pillow, which has decreased my neck pain to a large extent.

2. you have chronic migrain- In such cases there are several triggering factors which can bring about an episode- Like: cervical spondylisis, travelling, remaining hungry for long hours, or peri menstrual, visual problems, certain food items. Many of these can be avoided and attacks can be prevented. So, also get eye sight test and wear specks if you have a number.

Akanksha: I am aware about migraine triggers, but as we can't avoid it all every time but only can assign reasons when headache starts, this is happening with me every time. I do not travel much, my office is around 3 kms from my house. I do carry biscuits, fruits all the time. Fried items are a trigger for me, so I do not take them. Eye sight, I do get it checked on regular intervals (as I get blurred vision many times, during migraine attacks), but it has been constant for past 13-14 years.

3. There is a protocol which should be followed on getting an attack of migraine. One should take the pain killer within 5-10min of starting of pain. Trying to avoid taking meds soon or thinking of toleraring will only make it worse and the drug will not help later. Take it as soon as you realize that it is starting.

Akanksha: Ma'am, right now I am on medication for migraine:
1.Betacap TR 40 1tab daily in morning ( Start if Pulse Rate is more than 60 per minute) daily
2.Pregabaline Sustained/extended release tab (SR/ER) 75 mg at 9 pm daily
3.Naxdom 500mg 1tab for pain (max 2 tab a day )
4.Suminat or Sumitrex 50 mg on aggrevation of pain,can be repeated
after 3hrs.
These medicines, I am taking regularly since 1st May 2014. But nothing has been changed much since then too.

4. I have seen that patients whose pain dosent go away with naxdom 500mg SOS basis, have good response with rizatryptan 5-10mg. You may try it once and see.

Akanksha: Ma'am, I will try this medicine as well. I have tried Paracetamol 1g too, which worked with me only once or twice but now no effects.

5. There are several patients who have no respinse to oral meds, in such cases- injectables are helpful in aborting the attack and breaking the cycle of migraine. Inj. Diclofenac 75mg with metocloperamide is very helpful.

Akanksha: Ma'am, what do you suggest in my case?

6. You can practice deep breathing technique to calm your nerves- this is good in reducing the intensity & number of attacks.

Akanksha: Ma'am, I do practice paranayam 3-4 days in a week for 30-40 mins.

7. Pain in face and other areas can accompany migraine headache. Even there can be pain in ears/ burning sensation. There can be asosciated swelling of such areas. Donot worry, all these are simple and harmless neurological sequelae of migraine. I have seen excellent response in such cases with oxcarbamazepine. There is no associated weight hain with this drug unlike other .

8. Get TSH , Sr. B12 and Vit. D levels. Correcting them help a lot in resistant migraine cases.

Akanksha: Ma'am, I got my Thyroid levels checked 2 times, recent in late 2012, but my thyoid levels were normal.

Please answer my queries, while considering my latest added information.

Also please let me know, if medicines suggested by you for sleep and migraine can be taken on regular basis, if not then what should be the dosage. Also for buying these medicines, I think I will need prescription.

Thanks & Regards,
XXXXXXX
doctor
Answered by Dr. Manisha Gopal 24 hours later
Brief Answer:
prothiaden + oxcarbazepine along with JPMR

Detailed Answer:
Hello XXXXXXX

I will try to maintain the reply in same sequence which we had previously so that they are easy to understand.

1. If avoiding pillow helped in the intensity and episodes of head ache- I would suggest that neck exercises will help you a lot. Its not possible to teach them correctly here but you can easily get them on web.
These should be done 3-4 times a day for 5 minutes each.

2. You have had eye test which doent reveal any problmes- this is good.

And blurred vision during attacks are commonly seen in patients of severe migraine- but these are harmless and have full recovery afterwards.

3 +4+5 . Propanolol is fine, but I usually prefer it in divided doses- 10mg in morning and and again in afternoon. This prevents episodes of dizziness and anxiety due to low BP which propanolol is notorious to cause (espically in females). Pregabalin is usually given for neuropathic pain and migraine has a vascular origin.
So, I think your doctor has prescribed it for sleep.
Naxdom is almost the first choice SOS pain killer in migraine attacks & in next step I try rizatryptan 5-10mg.
I usually tend to avoid using suminat due to its side effects. You can try rizatryptan next time when you feel the need.
Finally, 1/100 patinet dosent have good relief even with rizaptryptan - then I prefer injectable pain killers. So, you may follow this protocol and see if it helps you.


6. Its good to know that you are trying a holistic approach for managing your problem and not just depending on meds solely. I think that you must learn JPMR- an excellent relaxation exercise (available on net) . It is a 40-45min procedure..but one can do this in steps and sometimes even 10-15 min. are good enough to show response. Some of my patients have had appreciable results in form of decrease in the frequency and intensity of episodes of pain. This exercise is very helpful in sleep as well- as it calmes your nerves. So, please see if you can learn it.

7. If I had been treating someone like you, I would have tried dosulepin (prothiaden) 25-100mg daily at night time ( as a regular medicine, preffrably at night. Maximumcdose an.be 225mg. This is an old drug suitable for migraineous headaches and has sleep inducing properties as well - so, would take care of sleep). Along with this I would add oxcarbazepine - 150mg and increase it upto 300-600mg daily. This will not only reduce the pain episodes but also take care of neurological sequelae associated with migraine. This is taken in divided doses usually, with maximum part at night time.
It will be helpful to add ranitidine 150mg (in mornibg empty stomach) to help in acidity/ bloating/gastritis symptoms for initial few days.

Please get Vit B12 & D levels done & treat them if found low.

I think both dosulepin and oxcarbazepine will help your sleep adequately, but if not then you may take zolpidem 5-10mg at night for some days. Im hopeful that when you will practice JPMR and take the meds- sleep will definitely become fine.

Try to do jogging or brisk walk for 15-20min daily. This will increase endorphins and reduce the headache episodes.

Add more salad (3-4 servings) in daily diet. Include one bowl of any sprouted pulse or bean daily.
Walnuts (1-2 daily) is helpful in barin functioning.

Hope the reply is helpful for you. Ask more queries of there are any doubts.

Wish you good luck and speedy recovery.
Dr. Manisha Gopal
MD Neuropsychiatry
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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