specialists.
Deeper neck (cervical) injections may help some patients
with RCM, particularly when the neck is involved. For
those with neck and “back of the head” pain, these injections should be considered. These include steroid epidural
injections, and “facet” nerve blocks which are performed
by a pain specialist on an outpatient basis. Although generally safe, these injections carry slightly more risk than the
superficial injections, and are costly.
Miscellaneous Medication Approaches
Monoamine oxidase inhibitors (MAOI) are powerful antidepressants that may be effective for refractory headaches.
For those with moderate or severe depression, the MAOIs
may be beneficial.
Weight gain and insomnia are common side effects.
With traditional MAOI, such as phenelzine (Nardil), the
low-tyramine diet must be followed, and certain medications may not be used concurrently. At this time, MAOIs
are probably underutilized. There is a milder MAOI patch
available, Selegline (Ensam)r, with less side effects.
Stimulants (methylphenidate or mixed amphetamine
salts) may help pain as well as some comorbidities (fatigue,
weight, attention). For some patients, these agents greatly
enhance quality of life. Fatigue is commonly encountered
in headache patients, and stimulants may help offset the
fatigue. Stimulants are primarily used for ADHD, which is
a common condition. Many patients with RCM struggle
with their weight, and the stimulants help weight loss (at
least for a period of time).
Methylergonovine (Methergine) is a medication used
following childbirth and is occasionally helpful for headaches. Methylergonovine is usually dosed 2 to 3 times
daily. However, a number of medication interactions have
been reported. Cost and availability have been issues.
Memantine (Namenda XR) is a drug used for memory
problems (Alzheimer’s syndrome). Memantine is fairly safe
16
and well-tolerated. Memantine (used in the XR form, once
per day) is effective for some headache patients with very
few drug interactions.
Muscle relaxants are occasionally effective for RCM. The
non-addicting agents are preferred, such as lioresal (Baclofen), cyclobenzaprine (Flexeril), or tizanidine (Zanaflex). Although generally safe, associated fatigue may limit
their use. For those with insomnia, using a muscle relaxant
at night may help both sleep and headache.
Conclusion
HeadW ise ®
|
Volume 4, Issue 2 • 2014
For many chronic headache sufferers, the “usual” approaches are not effective. It is important to utilize nonmedication approaches while minimizing medicine. This
article presents various treatment approaches for patients
who have been unsuccessful with the standard headache
therapies. Hopefully, in the near future, more effective
therapies for pain will be avail