Guidance for Referring Providers

 General Headache Instructions: 

1.) Maintain a headache diary; learn to identify and avoid triggers. Migraine Buddy is one of several free smart phone apps that can help with this.

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2.) Limit use of acute treatments (over-the-counter medications, triptans, etc.) to no more than two days per week or 10 days per month to prevent medication overuse headache (rebound headache). 

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3.) Follow a regular schedule (including weekends and holidays) for the next six weeks:

​Get seven hours of sleep at night. Practice good sleep hygiene. If you can't get to sleep after 15-30 minutes, get up out of bed and do something quiet like reading until tired. No phone or TV in bed. Music is OK.

• ​Don't skip meals. Eat breakfast, lunch and dinner.

• Some patients try an elimination diet, avoiding some of the following food triggers. Keep in mind, these have weak evidence as triggers:

  • Caffeine in coffee, chocolate, tea, cola/pop/soda. Some daily caffeine is OK as long as you keep it consistent. Large fluctuations in caffeine use can worsen headaches.

  • Foods containing nitrates (deli meat, ham, bacon, sausage, hot dogs)

  • Alcohol (wines containing sulfites are big culprits)

  • Tyramine (aged cheese; can only have American cheese, cottage cheese, Velveeta and fresh mozzarella. Most pizza uses aged mozzarella)

  • MSG (Chinese/Hispanic foods, Doritos, all flavored chips and ramen noodles)

  • NutraSweet and artificial sweeteners

•  Minimize stress.

•  Exercise 30 minutes per day. Weight loss has been proven to reduce migraine episode frequency in overweight/obese patients with migraine.

• Keep well hydrated and drink six to eight glasses of water per day.

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4.) Initiate non-pharmacologic measures at the earliest onset of your headache.

• Rest and quiet in a cool, dark environment.

• Relax and reduce stress. Meditation apps (Calm, Headspace, etc.) can be helpful.

• Cold compress to head (place a dry washcloth to forehead, cover with a blue freezer packet and use a headband to press the freezer packet across the forehead and temples).

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5.) Don't wait! Take the maximum allowable dosage of prescribed medication at the very earliest sign of headache.

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6.) Compliance: Take prescribed medication regularly as directed and at the first sign of a headache.

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7.) Communicate: MyChart me when problems arise, especially if your headaches change, increase in frequency/severity or become associated with neurological symptoms (weakness, numbness, slurred speech, etc.).

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8.) Headache/pain management therapies: Consider various complementary methods, including medication, behavioral therapy, psychological counseling, biofeedback, massage therapy, acupuncture and other modalities. Such measures may reduce the need for medications. Counseling for pain management, where patients learn to function and ignore/minimize their pain, seems to work very well.

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9.) Recommend changing family's attention and focus away from patient's headaches. Instead, emphasize daily activities. If the first question of the day is 'How are your headaches/Do you have a headache today?', then patient will constantly think about headaches, thus making them worse. The goal is to re-direct attention away from headaches, toward daily activities and other distractions.

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10.) It's important to try to attend work or school even with a headache. Missing work and school doesn't help improve headaches. At our practice, we don't fill out disability paperwork for headaches, although we're willing to fill out FMLA paperwork. If you have FMLA paperwork to fill out, either bring it to your appointment or contact me via MyChart. If you bring it to clinic on a day other than your appointment, or fax it in, you will be charged a form fee. 

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11.) Get the COVID-19 vaccine/booster if you haven't already. The COVID-19 infection worsens headaches and migraine attacks. 

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Avoiding Medication Overuse Headache and Rebound Headache:

Based on current research, the types of medications and their frequency of use that converts a previously episodic headache (particularly migraine) into a chronic daily headache (any headache occurring 15 or more days per month for at least four hours per day) are: 

• Over-the-counter medications, NSAIDs and combination analgesics: 

  • More than two days per week, or more than 10 days per month.

  • These include medications such as acetaminophen (Tylenol), naproxen (Aleve), ibuprofen (Advil, Motrin), acetaminophen/caffeine (Excedrin), acetaminophen/dichloralphenazone/isometheptene (Midrin), aspirin (OK to continue if taking for medical reasons), cold remedies and sleep-promoting agents, among others.

• Triptans: 

  • More than two days per week, or more than 10 days per month. 

  • These include sumatriptan (Imitrex), sumatriptan/naproxen (Treximet), rizatriptan (Maxalt), almotriptan (Axert), zolmitriptan (Zomig), eletriptan (Relpax), naratriptan (Amerge), frovatriptan (Frova).

• Opiates/Opioids (Narcotics):

  • Zero days or more per month. Some research suggests that even infrequent use of these medications makes migraine-specific medications such as triptans and NSAIDs less effective.

  • These include any narcotics such as acetaminophen/hydrocodone (Vicodin), acetaminophen/oxycodone (Percocet), acetaminophen/propoxyhene (Darvocet), acetaminophen/codeine (Tylenol #3, #4), tramadol (Ultram), acetaminophen/tramadol (Ultracet), oxycodone (OxyContin), hydromorphone (Dilaudid), fentanyl, butorphanol (Stadol), morphine or any form of a morphine derivative. We don't prescribe narcotics under any circumstances at this practice.

• Butalbital-containing medications: 

  • Ten or more days per month. These are typically the worst offenders.

  • These include acetaminophen/butalbital/caffeine (Fioricet, Esgic) acetaminophen/butalbital/caffeine/codeine (Fioricet with codeine), aspirin/butalbital/caffeine (Fiorinal), aspirin/butalbital/caffeine/codeine (Fiorinal with codeine).

 

​Supplements That Show Potential for Migraine Prevention:

• Magnesium: Magnesium oxide or citrate (400-600 mg daily with food) has a relaxant effect on smooth muscles such as blood vessels. We often give intravenous magnesium to patients who come into the emergency department for a migraine attack because it helps to break the migraine episode. Three trials found 40-90% average headache reduction when used as a preventative. Magnesium also demonstrated the benefit in menstrual-related migraine. Magnesium is part of the messenger system in the serotonin cascade and is a good muscle relaxant. It's also useful for constipation, which can be a side effect of other medications used to treat migraine attacks. Good sources of magnesium include nuts, whole grains, and tomatoes. There's controversy over whether this is safe in pregnancy, although it's been used safely in oral form for decades in pregnancy.

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• Coenzyme Q10: This is present in almost all cells in the body and is a critical component for the conversion of energy. Recent studies have shown that a nutritional supplement of CoQ10 can reduce the frequency of migraine attacks by improving the energy production of cells as with riboflavin. Doses of 300-400 mg daily have been shown to be effective. This medication is NOT safe if you're taking warfarin (Coumadin). There is uncertain safety in pregnancy. 

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• Riboflavin (Vitamin B2): 400 mg daily. This vitamin assists nerve cells in the production of ATP, a principal energy-storing molecule. It's necessary for many chemical reactions in the body. There has been a randomized, placebo-controlled clinical trial using 400 mg per day, which suggested that migraine episode frequency can be decreased. The supplement is found in bread, cereal, milk, meat, and poultry. Most Americans get more riboflavin than the recommended daily allowance, however riboflavin deficiency isn't necessary for the supplements to help prevent headache. This supplement is safe in pregnancy.

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• Melatonin: Has shown to decrease headache intensity and duration. It's widely used as a sleep aid. Sleep is nature's way of dealing with migraine attack. A dose of 3 mg is recommended to start for headaches including migraine and cluster headache. Higher doses up to 15 mg have been reviewed for use in cluster headache and have been used. The rationale behind using melatonin for cluster is that many theories regarding the cause of cluster headache center around the disruption of the normal circadian rhythm. This helps restore the normal circadian rhythm. It should be taken at least two hours before bedtime.

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• Ginger: Ginger has a small amount of anti-histamine and anti-inflammatory action that may help headaches. It's primarily used for nausea and may aid in the absorption of other medications.

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• Essential oils: Lavender and peppermint can be helpful.

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• Vitamin D: People who live in the Midwest or places without much sun should take 1000-2000 units per day of vitamin D in the winter months. You may need more than this; have your primary care physician check levels periodically. There have been two randomized, controlled clinical trials showing benefit for vitamin D supplementation in migraine. 

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• Marijuana/CBD: Medical marijuana and CBD oil have anecdotal evidence in migraine. There aren't large, randomized, controlled clinical trials for this yet. 

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• Grape seed extract: There's some evidence in animal models that this may be beneficial in migraine. My headache medicine colleagues typically recommend 300 mg daily, this is available on Amazon. We have used the Healthy Origins brand. Given the lack of evidence of safety in pregnancy, this is NOT recommended in pregnancy.