Dr James Schaller
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  • Basics

    Thankfully most headaches are not serious even if very painful.

    Most severe headaches are migraine and the most common headaches that recur with severe pain.

    Every year, about 16% of women will have one or more migraines.

    2/3rds of migraine patients have migraines without flickering lights, numbness or some other sensory experience. If it is just simple pain, we call it a common migraine.

    Face pain headaches can be trigeminal headaches and eye headaches can be cluster headaches. Each has some unique treatments and causes.

    Migraines commonly are one sided, throb, worsen with activity, and sometimes have nausea and light/smell/noise sensitivity.

    Sometimes tension headaches or sinus headaches are actually migraines and vice versa.

    What Causes Them?

    We are not entirely sure. However, since different types of mechanisms in medications reduce them, there are probably different causes.

    Yet it is unlikely they are due to merely a spasm of a blood vessel. Causes may include decreased intracellular magnesium levels which typical basic blood testing cannot evaluate, inflammation of brain tissue, wiring abnormalities from the brain stem to the top of the head, routine pain control inhibition is impaired, and brain blood vessel changes.

    Simply, I do not know the cause of headaches. These are only ideas.

    When Do I Do More then Reach for The Tylenol or Motrin?

    First, if you use any medication or class or medication, like over the counter pain medications, more than 2 days a week for three weeks in the same month, see a neurologist. You will make the headache much worse by routine over the counter medication use.

    If you are having the "worst headache of you life" and it is new and very severe -- go to the emergency room -- it might be a bleed in the brain.

    If you have a headache with a persistent fever, unplanned weight loss, recent accident, other neurological problems or a history of cancer, have a prompt evaluation. It may be nothing, but an evaluation and brain scan will help rule out anything serious. Cat Scans are commonly used to evaluate for major findings and can often be done fast.

    What Can Make A Susceptible Person Get a Migraine?

    • Fasting over 4 hours
    • Drinking Alcohol
    • Synthetic Hormones
    • Caffeine use or suddenly stopping with causes withdrawal
    • Stress or sleep
    • Progesterone dominance before a period
    • Estrogen insufficiency in very thin girls during a period--the lack of fat estrogen can increase migraines
    • Fatigue
    • Exposure to lights, noise, pollution, perfume or noxious chemicals
    • Changes in weather or the "bariatric pressure" complaint
    • A head injury -- boxing, fall, car accident
    • Foods such as chocolate, aged cheeses, processed meats, fermented foods, aspartame, monosodium glutamate, citrus fruits, nuts, and others. If you take glutamine as a supplement some will become MSG.
  • I Am in Pain NOW! What Do I Do?s

    The longer the migraine is left untreated the harder it is to stop.

    Being calm may help.

    Stay in a dark and soothing room.

    Sleep may also help

    Drug Options:

    *Using an NSAID or Non-Steroidal anti-inflammatory Medication--Motrin, Tylenol, Naproxen, etc.

    *Combinations of Different Medications: Tylenol, Aspirin, Caffeine, codeine, oxycodeine, hydrocodone, Ergot medications, barbiturates and Ultram.

    *Triptans -- The first in the USA was Imitrex. If you fail one, another might work. Now there is at least 5-6 in the USA and can be taken many ways. Heart attacks are a very rare side effect.


    1. If you are nauseous you might consider taking some anti-nausea medications through your skin. A compounding pharmacist can let you know who in town writes for anti-nausea creams. Other articles on this Web site discus transdermal medications.
    2. DHE is a well-established treatment with modest success. It is given IV or under skin.
    3. Depokote or valproic acid can be given orally or IV. Weight gain is common if used daily for months.
    4. Toradol can also be given as a shot for rapid relief.
    5. Demerol also works rapidly as a shot and can also be given orally. Demerol cannot be used regularly because of a toxic metabolite, and because it will cause rebound if used more than 1 1/2 days a week.
  • The Danger of Rebound

    Most of the medications used for headaches can cause rebound. If you use triptans like Imitrex over 6 times per month or Tylenol over 2 days a week, you will get rebound -- a serious worsening of your baseline headache.

    If you are required to take a medication more than 2x a week, some will suggest you shift classes. You need a physician to teach you what is a different class drug -- many NSAIDS work the same way and you can get rebound.

  • One Way To Avoid Rebound and Yet Treat Pain

    Rather than wait for a migraine, consider prevention by regular medications.

    Prevention medications can take a full 3-4 months for a real trial.

    Options include: beta-blockers, calcium channel blockers, other special blood pressure medications, tricyclic antidepressants and anti-convulsants like Neurontin, Depokote or Topamax.

    All of these should be started very slowly since some can cause headaches if started too fast.

    Herbal Treatments might be of use, but are currently being debated.

    Botox Injections have some research to support them. Some practitioners give small numbers of injections and others are quite aggressive. I do not know which number or frequency is best.

    Other options include: relaxation training, biofeedback, cognitive-behavioral therapy and some patients report some help with neurofeedback -- a controversial modality which allows you to alter certain brain wave types. I will let you study this yourself.

    Currently Dr. Schaller has started a book on neuron repair and regeneration. Migraines are associated with inflammation and Dr. Schaller is looking at the dozens of chemicals involved in the inflammation and anti-inflammation system. Dr. Schaller hopes to find measurable specific laboratory abnormalities in this inflammation system, and then target these to treat resistant painful headaches.

    He also has created sublingual magnesium troches, which give sudden bursts of magnesium as another novel treatment, since magnesium at good doses decreases spasms and helps neurons. It is unclear how useful they are currently, but they do show promise.

    Just remember that the use of any medication for headache pain over 2x per week will cause rebound migraines, which means you are making the headaches worse. The triptan medications cannot even be taken this frequently. Please note that using Tylenol one day and Motrin two other days is really three days of medications that are too similar in mechanism.

    Some rotate classes of medications to abort severe migraines, but you need coaching from a physician to know what classes are truly different.

James Schaller, MD, MAR
Naples, Florida

Bank Towers, Tamiami Trail, Naples, FL
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