Transformed Migraine There are times when a person with episodic migraines, meaning migraines that occur only a couple of times per month, will have a migraine headache that begins one day and may last for several days, weeks or even months without a day off. If there is nothing sinister, such as a tumor, increased intracranial pressure or infection in the mix, then it’s quite possible this could be a transformed migraine. Other terms such as Status Migrainosus have been used for particular painful attacks. Often by the time the headache is several days old, it becomes apparent that medications are not working or if they do it’s only for a short time. It will be tempting to try and find another acute pain medication or increase the dose. Most people will try but the effects are most often short lasting. Often there is overlap between transformed migraine and rebound headache. Indeed most patients with transformed migraine have an element of increased tolerance to medications. Perhaps the headache did not convert from occasional to daily because of medication overuse or rebound, but after several weeks of a non-stop migraine its likely that the very medications you are using to try and squash the pain are beginning to contribute to the problem. Here’s How I Approach Transformed Migraine Using Medications. - Stop all medications containing narcotics, barbiturates (like Fioricet), and caffeine. - Stop all caffeine use, all non-essential medications and supplements. If you are not already on one, we’ll start a daily preventative headache medication. Rarely I will start a second preventative medication for those on one already. If there is a possibility you have rebound headache or are developing olerance to pain medications then you should limit your use of pain medications to one or two days per week. - Examine your sleep hygiene and read this study. Sometimes naturally fixing your disturbed sleep pattern is enough to turn the headache around. - Often these treatments are sufficient. Though if not we can try Dihydroergotamine (DHE) which is a special headache medication often given intravenously. Outpatient Treatments Stop all pain medications except preventative medications then start 3-5 days of outpatient treatment in the outpatient infusion clinic with once a day IV DHE (Dihydroergotamine) 1 mg infused over 30 minutes. I often use a test dose of 0.5 mg the first day and if tolerated will give the remaining 0.5 mg. On successive days treatment I will use the full 1 mg dose if tolerated, otherwise we can use a smaller dose. I also often pretreat with either Compazine or Reglan about 20 minutes prior to the DHE. Sometimes I’ll offer trigger point injections in the neck or upper back and sometimes Lidocaine injections at the occipital nerve. Inpatient Treatments This is usually reserved for patients who we have been working with me for a week or more as an outpatient. Its generally a good idea to attempt outpatient treatment first. As an inpatient, I usually use DHE 3 mg IV infused slowly over 24 hours repeated for 3-5 days. All other pain medications except preventative medications will be stopped. If DHE is contraindicated, I’ll use IV Depacon (Valproic Acid) 500 mg every 8 hours for 3-5 days If the headache is not stopped by Day 5 or 6, then the hospitalization is terminated. For details on dosing see my section on Inpatient Treatment of Headache. I had one patient recently who did poorly on a vigorous inpatient medication routine. In fact, he continued to worsen in spite of the medications. So we stopped all medications and put him on a supervised water-only fast, drinking between 2-4 liters of water per day. By about 24-36 hours the headache was improving and by 48 hours he was headache free. While this is purely anecdotal evidence, most people can fast safely for a few days as long as they drink sufficient amounts of water. I do recommend checking with your physician before going on a fast. That’s basically it for medication treatments. I’ve have had no luck using narcotics or barbiturates in this type of intractable headache. In fact every time I’ve seen them used, the headache only gets worse. Steroids seem to be of limited usefulness. Lastly, I’ve used narcoleptics such as Olanzapine every 8 hours for 3-5 days with occasional success. Caution: In headaches that are resistant to multiple medications, there is considerable risk with experimentation with off-label, unproven medications. Transformed migraine almost invariably reverts back to occasional migraine at some point. Sometimes the prudent approach, once multiple medications have failed, is to fall back to the most benign medication or stop all medications. Each time we start a new medication, there is an increased risk of adverse side effects and a corresponding decreasing chance of success. Methods for Treating Transformed Migraine without Medications. Some of my patients have benefited greatly from a conservative approach, one that minimizes exposure to toxic medications and relies more on the innate healing abilities of the body. - Strict adherence to several sleep hygiene rules. Examine your sleep hygiene and read this study. - Stop all pain medications. Whether to continue or start preventative medications can be discussed. - Stop all caffeine, all non-essential medications and supplements. - Start a High Nutrient Elimination Diet. See my web page on diet and headaches, In healthy patients taking no other medications and with no medical contraindications, I may suggest a two day water-only fast prior to starting the elimination diet. During our office visit, I will give specific instructions on how to fast safely. - Trigger point injections for upper back and neck pain - Acupuncture two to three times the first week - Consider massage or chiropractor treatments. Ty a velcro headband or chilled face mask. - I can teach you a simple meditation technique which you can practice for 20 minutes twice a day. There are other non-medication approaches we can discuss if these are not helpful. Return to Headaches

Transformed Migraine

There are times when a person with episodic migraines, meaning migraines that occur only a couple of times per month, will have a migraine headache that begins one day and may last for several days, weeks or even months without a day off. If there is nothing sinister, such as a tumor, increased intracranial pressure or infection in the mix, then it’s quite possible this could be a transformed migraine. Other terms such as Status Migrainosus have been used for particular painful attacks.

Often by the time the headache is several days old, it becomes apparent that medications are not working or if they do it’s only for a short time. It will be tempting to try and find another acute pain medication or increase the dose. Most people will try but the effects are most often short lasting.

Often there is overlap between transformed migraine and rebound headache. Indeed most patients with transformed migraine have an element of increased tolerance to medications. Perhaps the headache did not convert from occasional to daily because of medication overuse or rebound, but after several weeks of a non-stop migraine its likely that the very medications you are using to try and squash the pain are beginning to contribute to the problem.

Here’s How I Approach Transformed Migraine Using Medications.

- Stop all medications containing narcotics, barbiturates (like Fioricet), and caffeine.

- Stop all caffeine use, all non-essential medications and supplements.

-If you are not already on one, we’ll start a daily preventative headache medication. Rarely I will start a second preventative medication for those on one already.
-If there is a possibility you have rebound headache or are developing olerance to pain medications then you should limit your use of pain medications to one or two days per week.

- Examine your sleep hygiene and read this study. Sometimes naturally fixing your disturbed sleep pattern is enough to turn the headache around.

- Often these treatments are sufficient. Though if not we can try Dihydroergotamine (DHE) which is a special headache medication often given intravenously.

Outpatient Treatments

Stop all pain medications except preventative medications then start 3-5 days of outpatient treatment in the outpatient infusion clinic with once a day IV DHE (Dihydroergotamine) 1 mg infused over 30 minutes. I often use a test dose of 0.5 mg the first day and if tolerated will give the remaining 0.5 mg. On successive days treatment I will use the full 1 mg dose if tolerated, otherwise we can use a smaller dose. I also often pretreat with either Compazine or Reglan about 20 minutes prior to the DHE.

Sometimes I’ll offer trigger point injections in the neck or upper back and sometimes Lidocaine injections at the occipital nerve.

Inpatient Treatments

This is usually reserved for patients who we have been working with me for a week or more as an outpatient. Its generally a good idea to attempt outpatient treatment first.

As an inpatient, I usually use DHE 3 mg IV infused slowly over 24 hours repeated for 3-5 days. All other pain medications except preventative medications will be stopped.

If DHE is contraindicated, I’ll use IV Depacon (Valproic Acid) 500 mg every 8 hours for 3-5 days

If the headache is not stopped by Day 5 or 6, then the hospitalization is terminated.

For details on dosing see my section on Inpatient Treatment of Headache.

I had one patient recently who did poorly on a vigorous inpatient medication routine. In fact, he continued to worsen in spite of the medications. So we stopped all medications and put him on a supervised water-only fast, drinking between 2-4 liters of water per day. By about 24-36 hours the headache was improving and by 48 hours he was headache free. While this is purely anecdotal evidence, most people can fast safely for a few days as long as they drink sufficient amounts of water. I do recommend checking with your physician before going on a fast.

That’s basically it for medication treatments. I’ve have had no luck using narcotics or barbiturates in this type of intractable headache. In fact every time I’ve seen them used, the headache only gets worse. Steroids seem to be of limited usefulness. Lastly, I’ve used narcoleptics such as Olanzapine every 8 hours for 3-5 days with occasional success.

Caution: In headaches that are resistant to multiple medications, there is considerable risk with experimentation with off-label, unproven medications. Transformed migraine almost invariably reverts back to occasional migraine at some point. Sometimes the prudent approach, once multiple medications have failed, is to fall back to the most benign medication or stop all medications. Each time we start a new medication, there is an increased risk of adverse side effects and a corresponding decreasing chance of success.

Methods for Treating Transformed Migraine without Medications.

Some of my patients have benefited greatly from a conservative approach, one that minimizes exposure to toxic medications and relies more on the innate healing abilities of the body.

- Strict adherence to several sleep hygiene rules. Examine your sleep hygiene and read this study.

- Stop all pain medications. Whether to continue or start preventative medications can be discussed.

- Stop all caffeine, all non-essential medications and supplements.

- Start a High Nutrient Elimination Diet. See my web page on diet and headaches, In healthy patients taking no other medications and with no medical contraindications, I may suggest a two day water-only fast prior to starting the elimination diet. During our office visit, I will give specific instructions on how to fast safely.

- Trigger point injections for upper back and neck pain

- Acupuncture two to three times the first week

- Consider massage or chiropractor treatments. Ty a velcro headband or chilled face mask.

- I can teach you a simple meditation technique which you can practice for 20 minutes twice a day.

There are other non-medication approaches we can discuss if these are not helpful.

Return to Headaches