Here is a list of things you should bring to your initial appointment.
A list of every medication you are using currently (whether it’s for headaches or not).
A list of all medications you’ve used in the past (whether for headaches or not).
Copies of any brain imaging studies you’ve ever had of your head: MRIs, CT scans.
Any neurological reports or other doctor’s reports related to your headaches. When you leave one health provider, ask for all reports and notes related to your treatment. It’s your legal right to have them—and you don’t have to pay to have them photocopied.
A completed MIDAS scale (see Ch. 7), which measure how serious your migraine disability is.
A list of anyone else in your family who suffers from headaches, when they began getting headaches and when they ended, what triggered their headaches, and what treatments worked for them.
What drugs, if any, you are allergic to.
Your risk factors for such health problems as heart disease and high blood pressure—before your first visit, find out if anyone in your family suffered from these conditions.
The name, address, and phone number of your primary care provider. Your headache specialist will want to get in touch with him or her to share information, and you’ll get better care as a result.
You may want to bring someone along with you to the appointment who knows your headache history and has witnessed you during a migraine attack—a partner, spouse, parent, or friend. I always find information from them very helpful because others often notice symptoms or patterns of your migraine that you’ve missed.
And—very important—you should bring a headache diary or journal.
The Headache Diary. A month before your first appointment with the doctor, start keeping a detailed headache diary.
This diary is invaluable in diagnosing and treating you. My “gold-star” patients are those who show up with a meticulously kept headache diary because it gives me such a clear picture of what their headaches are like. It helps me make a correct diagnosis very quickly—and prescribe the best treatment.
At the First Visit. Your first appointment is your opportunity to get to know the doctor and see if you are a good fit for an ongoing relationship. For that reason, most of your visit should be spent with the doctor herself rather than an assistant. A nurse or physician’s assistant may review a medical history with you, take your blood pressure, and weigh you, but after that, the doctor should step in.
During the first visit, the doctor should take a comprehensive medical history of all your health issues. Make sure you reveal every health problem you’ve ever had, even if you think they are unrelated to headaches.
You should receive a complete neurological exam, which should be performed by the doctor, not the nurse or another assistant. You probably won’t need to undress for this exam. The doctor will use a light to look into your eyes, and ask you to walk around the exam room so your gait can be checked. Your reflexes and strength will also be checked. These are tests of your cranial nerves, your motor and sensory systems, and your coordination, all essential parts of your neurological system, which help us see whether there are any abnormalities that need attention.
An MRI or CT scan is not always part of a headache diagnosis, but may sometimes be necessary. Sometimes a doctor will order a blood test, which can be helpful in diagnosing some neurological conditions. If there’s a possibility that you may have a seizure disorder, your doctor may order an EEG. He should explain clearly any tests he does order—what they are for, and why he wants them.
An important part of an initial migraine visit is the opportunity for you to tell your migraine story. The doctor should give you undivided attention while you talk about your migraine, what it feels like, and how it affects your life. You should also describe your lifestyle, general health and well-being, and any other questions or concerns you may have. I always ask patients to describe their headaches in their own words. Their descriptions are often very vivid—“it feels like a hot poker going through my left eye,” or “my face feels hot and then I throw up and fall asleep”—and can be extremely helpful in making a diagnosis.
Be sure to tell your doctor if your headaches are new or different, if the symptoms have changed, and if they’ve gotten worse.
Questions to Ask the Doctor. I allow time in this first appointment to ask patients if they have any questions they want to ask me. They may have specific questions about migraine, or they may have questions about my philosophy of treatment. Some questions you may want to ask your doctor:
What should I do if I get a really bad headache—should I call your office or the ER?
What kind of emergency facilities do you have?
Can I get in to see you immediately if I’m in really bad shape with a headache?
What are the side effects of the drugs you are prescribing?
Please explain the benefits of any nondrug treatments you are recommending.
How can I get in touch with you for questions I may have later? Can I talk to your nurse? Can I email you? (Every patient should have a reliable way to get in touch with her headache doctor, whether it’s through the nurse or via email.)
You should leave this first visit with a few things in hand, including:
A diagnosis of your headache, in most cases—especially if you did your homework and provided your doctor with the information we describe above.
Referrals, as needed, to other specialists such as a nutritionist or psychiatrist.
An exercise plan. As you know, exercise is an essential component to staying migraine free. I give my patients a recommended plan I think they can follow, based on the kinds of activities they enjoy.
An emergency room form (see below).
Contact information for getting in touch with the doctor and staff.
Your homework plan—your doctor may want more information from you for the next visit, including continuing to keep your headache diary. This is how we determine whether the treatment plan is working.
A scheduled follow-up appointment.
Contact information for a headache support group, if your doctor knows of one, or other headache resources to help you.
A treatment plan, in writing. At the Women’s Headache Center, I use a form for treatment plans that includes the diagnosis and a preventive plan, abortive plan, and rescue plan. It includes prescriptions for medications, and a written list of alternative treatments for this patient, such as biofeedback or acupuncture.
For example, Nancy is a forty-five-year-old freelance writer who leads a hectic life, with a teenage son and a very busy career. She prides herself on exercising at least three times a week but realizes she’s slipped in her dedication in recent months. She’s in excellent health except for her migraines. She gets them three to four times a month and they’re absolutely crippling, a 10 out of 10 on the pain scale. She doesn’t get aura, but her migraine disability, according to the MIDAS scale, is a 22. Nancy gets migraines when she doesn’t eat enough or eats processed food, and when she’s stressed out. I ask Nancy what she does for fun, and she looks flummoxed. “I used to go to a lot of live music shows but I find myself working all the time now,” she says. “I guess I’ve become a workaholic.”
When Nancy leaves my office after her first visit, she takes along a piece of paper I’ve filled out and signed. It looks like this:
Written Treatment Plan for Nancy from Dr. Bernstein
My Diagnosis: Frequent migraine without aura.
My Abortive Plan: Maxalt (prescriptive drug) 10 milligram tongue melt; take one at first sign of migraine, another four hours later if needed.
My Preventive Plan: No preventive drugs. Exercise half an hour a day at least. Drink eight glasses of water a day. Eat healthy, high-fiber, high-protein foods every four to six hours to keep blood-sugar levels even.
My Rescue Plan: 600 milligrams of Ibuprofen plus a caffeine drink.
Things I Need to Do:
> Keep a food journal to make sure that I’m keeping my glycemic levels even by eating enough high-protein, high-fiber foods.
Keep an exercise journal to make sure I’m exercising at least half an hour a day.
People I Need to Talk to About My Migraine Plan: My husband. My favorite co-worker (to explain why I’m sometimes in the bathroom throwing up). My son, so he’ll understand migraine and won’t worry unnecessarily about me.
Misc.: Take more time for myself. Go to a rock concert.
A Critical Tool—the Emergency Room Form. At this first appointment, I provide my patients with a signed form for use at those times when, despite our best efforts otherwise, they end up in the emergency room There is a copy of this form in the appendix, which you may want to ask your doctor to fill out. My patients who arrive at the ER with this form signed by me say there is a world of difference in how they are treated.
The Follow-up Appointment. I typically ask new patients to come in again one to three months later for a follow-up appointment. The return visit is important in determining whether their treatment plan is working. They fill out the MIDAS scale again (see Ch. 7) to see whether their headaches are getting better. If not, we may give the plan a little longer or we may decide to change it right away.
Sometimes a patient has to try several different approaches before getting better. Those who choose medicine may find that one drug doesn’t work and so I’ll prescribe a different one, or a combination. Then we’ll need to monitor whether the new drugs are helping. Some patients don’t want medicine at first but change their minds if complementary treatments aren’t working. Some patients seek my guidance on adjusting their diets or lifestyles in our quest to get them healthy. There are many ways to tweak the plan, and I’m happy to work with them in doing so.
Many of my patients hit upon their ideal treatment plan very quickly. Maybe they need simply to exercise more, get eight hours of sleep a night, and take a triptan whenever they feel a migraine coming. Other patients take more time. It may require a number of regular appointments—every month or so, say—before you start to see improvement. At any subsequent appointment, be sure to tell your physician about any changes in your lifestyle, headache, or general health.
CHAPTER 9
Medicines That Work
“It never occurred to me that there might be medicines for migraine. No doctor ever offered them to me. Then I saw on TV that some football player had a migraine in the middle of the Super Bowl, and he took some medicine and went back into the game and won it. And I thought, ‘I have to have that drug, whatever he’s taking!’”
—Maddy, 41, home-schooling mom
For the first time in history, there are medications that can actually end a migraine attack in more than 80 percent of migraine patients. Prior to 1992, most migraine patients were treated with painkillers, including very powerful ones that could be addictive. There weren’t many other good options, and these painkillers didn’t always work. You could end up with a drug habit—and still have a terrible headache.
One kind of new migraine-halting drugs, called triptans, are considered a miracle treatment by many patients and doctors. Yet a minority of migraineurs have tried them because many people don’t know what they are or what they do.
Triptans are not painkillers per se. They don’t mask migraine pain or reduce your ability to feel it. Instead, they interrupt the neurochemical reaction of a migraine attack before the pain gets too far along, usually halting the migraine altogether. Unlike painkillers, triptans are not addictive (although you can develop a rebound headache if you use too many). They truly have revolutionized migraine treatment. I’ll talk more about them later in this chapter, but for now, know that triptans have changed the lives of many migraineurs.
However, taking medication is a personal choice, and I respect your decision. If you hate drugs of any sort, are considering becoming pregnant, take a lot of other medications, or would prefer to rely on nondrug treatments, then migraine meds may not be for you. But I want you to make an informed decision about taking medication or not, especially since triptans and some other drugs are so successful at treating migraine.
A Variety of Migraine Medications
Triptans are often an excellent option because they are so effective and safe for most people, but many other drugs are available. Some have fallen out of general use since the arrival of triptans, although some doctors still prescribe them. Other drugs are good choices if your migraines don’t respond to triptans or you can’t take them and you need a more aggressive treatment plan.
With migraine drugs, every person is different: in which drugs work for you, whether you need more than one drug, and how long the drugs continue to work. That’s why you need to work with your doctor to create a customized medication plan. Don’t assume that a migraine drug that works for your friend will be right for you. And please don’t share your migraine drugs with someone else, no matter how much pain he or she is in! You could endanger his or her health. Never give a child any medication without a physician’s approval. Children metabolize medications differently than adults, which is why there is a separate FDA approval for drugs for kids.
Always let your doctor know about every drug you are taking, prescription and over the counter. This is extremely important for your safety.
Prevent, Abort, Rescue—the Three Types of Drugs
My three-part approach to fighting back against migraines is to Prevent, Abort, and Rescue, and there are medicines that correspond to each of these stages. Triptans are abortive drugs, designed to stop a migraine once it’s started. Preventive drugs stop migraines from arising in the first place, and rescue drugs are for those times when, despite your best efforts, you end up with a full-blown migraine and need pain relief.
Some people have all three types of drugs in their migraine arsenal. They take a daily preventive drug, use an abortive drug if the preventive doesn’t work, and have rescue drugs on hand in case the abortive failed. Finding the right drug or drug combination for you may take time, and you may have to adjust your plan if your migraine stops responding to it.
The easiest patients for me to work with are those who haven’t yet tried any drugs. We can develop a well-considered plan on what might work for them, and tweak it over time. The hardest patients are those who’ve been treated by a number of different doctors with a number of different medications. These patients often say that none of the drugs helped, and it’s difficult to determine whether they gave the drug a fair shot at working. One patient, for example, had tried a smorgasbord of medications but couldn’t remember the dosage or how long she was on them. Some will try something for two days and then quit, which isn’t really giving the drug enough of a chance.
Preventive Drugs
While the triptans are an excellent choice for halting migraine attacks, they aren’t effective enough for some migraineurs who get a lot of headaches or very severe headaches. For these people, it’s better to try to prevent headaches from coming on in the first place.
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Important Points on Migraine Meds
Take the medication as prescribed. If you don’t follow the directions, you reduce the chances that it will work for you, or you might end up with more serious problems.
Don’t stop taking the medication without talking to your doctor, unless you are having a serious reaction to it or side effects that are really bothering you. In any event, let your doctor know immediately.
Do not increase the dosage if the medicine stops working. Taking more than the prescribed amount could result in health problems, including a rebound headache that will be very difficult to treat. If your medicine is no longer effective, see your doctor.
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A preventive drug is a medication that you take every day, with the goal of preventing your migraines from ever starting up. You may be a candidate for a prevention drug if your migraines are frequent, disabling, or not responsive to an abortive medicine.
; Preventive drugs:
Only work if you take them every day
Won’t work if you take them once a headache has begun.
Preventive drugs can reduce the number of migraines by 50 to 80 percent in almost half the people who try them. They also reduce the severity of the pain and how long it lasts, according to a study commissioned by the National Headache Foundation.
Frequency—If your migraines come more than four times a month, you are a candidate for preventive drugs.
Disability—If your migraines aren’t that frequent but are so severe that they knock you out for days, you may want to consider a preventive drug. Tools like the MIDAS scale (see Ch. 7) can help you figure out how disabled you are by migraines. If you rank as “moderate to severe” on the MIDAS scale, you may want to think about a preventive drug.
Nonresponsive—If your migraine does not respond to abortive medications that halt an attack in progress, you may want to consider a preventive drug.
The Migraine Brain Page 18