Call Us: 828.676.2551 or 828.676.2552 (f)
Treatments offered.
We practice patient-centered therapy.
One simple definition of patient-centered therapy is:
Care that considers patients’ cultural traditions, their personal preferences and values, their family situations,
One simple definition of patient-centered therapy is:
Care that considers patients’ cultural traditions, their personal preferences and values, their family situations,
and their lifestyles.
Learning about the choices available will help you get the most out of your visit.
Complementary and alternative medicine
Behavioral Medicine
Infusion Therapies
Interventional Therapies
Pain Management
Medications for headaches are classified as acute medicines (taken to treat headache symptoms after they have started) or preventive therapies. Acute therapies are further classified as migraine-specific or general pain relievers.
***Warning*** In general, acute headache therapies should not be taken more than 2 – 3 times/week – otherwise, “drug rebound” (or medication overuse headache) may develop. If you are taking acute medications daily or nearly every day, your medications may be causing your headaches! Please see Drug Rebound Headache (link) if this sounds like you.
For people with less frequent headaches, acute headache treatments work best if taken early on in the headache attack. Acute treatments include general pain medications and migraine-specific therapies.
The introduction of sumatriptan (Imitrex®) in 1993 revolutionized the treatment of migraine, and led to a dramatic improvement in the quality of life of millions of migraine sufferers around the world. Since then, many other triptans have been introduced. The triptans have some minor differences, but as a class they all work about the same.
Available triptans.
sumatriptan (Imitrex®) as pill, nose spray, injection,
and combined with naproxen (Treximet®)
rizatriptan (Maxalt®) – pill and rapid dissolving tablet
eletriptan (Relpax® - pill
zolmitriptan (Zomig®) – pill, spray
naratriptan (Amerge®) - pill
almotriptan (Axert®) - pill
frovatriptan (Frova®) - pill
Self-injections.
Dihydroergotamine (DHE).
DHE is an older compound that is possibly the most underutilized treatment for chronic or daily headache problems. It is available only as an injection or nose spray, but the injection is much more effective.
Ketorolac (Toradol®).
Ketorolac is the only non-steroidal anti-inflammatory drug (NSAID) that is available as an injection. When given intravenously (IV) in research studies, it is the most effective treatment to stop a migraine. Although ketorolac is not truly migraine-specific, we include it here because it has a special role in the treatment of migraine.
Many patients can successfully treat even their most severe headaches with a combination of DHE and ketorolac injected at home. Most patients who have migraine severe enough to need rescue therapy in an Emergency Room will be offered this effective therapy.
General pain medications for headache (migraine or tension-type headache)
· Non-steroidal anti-inflammatory drugs (NSAIDs) – this class includes ibuprofen (Motrin®, Advil® and others), naproxen (Naprosyn®, Aleve® and others), meloxicam (Mobic®, indomethacin (Indocin) and COX2 inhibitors such as celecoxib (Celebrex® and others)
o NSAIDs may be effective for milder migraine attacks, especially if taken early in the attack.
o NSAIDs may be combined with other migraine-specific drugs (see below) for longer-lasting effect
o Side effects of NSAIDs include stomach upset and fluid retention. Long-term use may cause ulcers, bleeding from the stomach, and kidney or liver problems.
· Acetaminophen (Tylenol ® and others) – Acetaminophen is better tolerated, but usually helpful only for milder headaches
· Opiates – These well known pain killers include Tylenol codeine®, hydrocodone (Vicodin® and others), oxycodone (Percodan®, Oxycontin®), morphine, methadone, and others. Opiates are commonly used to treat chronic pain disorders (chronic back pain, cancer pain, etc.) For headaches, opiates are usually avoided. Headache patients are prone to rebound worsening of pain following even a single dose of opiates. Many headache treatments lose effect when given to individuals who are used to taking opiates. Most headache patients improve when taken off opiates.
· Tramadol (Ultram®) – Tramadol is a relative of other opiates but has other properties that may offer some advantage in the treatment of headache. However, tramadol may also cause opiate-like dependence, and is not a first-line choice for headache treatment.
Preventive therapies.
There are many alternative therapies that have been promoted for the treatment of headache. The treatments with the most scientific basis are:
Natural supplements
Acupuncture
“Natural” Headache Herbs/Supplements
General comments about natural herbs and supplements:
These medicines are all used preventively, and may take 2 - 3 months for the effect to be seen. The advantage of this group of medicines is that they are very well-tolerated with few side effects and little in the way of drug interactions. The disadvantage is that they are often expensive, and may take a long time to help. The ones with the best evidence are listed below.
1. Petadolex (Butterbur root): Commonly used in Europe, This herb has been found to be effective in clinical trials, both in adults and children. The usual dose is 75 mg twice per day in adults and 50mg twice/day in children. Patients occasionally experience stomach upset or a bad taste. This product is not always found in health food stores, but may be ordered online.
2. Magnesium Oxide (or other chelated form): This has also been studied in adults and children, with variable results. We often offer IV infusions of magnesium which seem to be more effective. Usual dose of the supplement is 300mg twice/day. It's a good choice if you are having constipation as a side effect of medication, as magnesium tends to cause diarrhea.
3. Coenzyme Q-10 (COQ-10) has been suggested for many conditions, including coronary artery disease and progressive neurologic disorders, such as Parkinsons disease. The dose usually recommend for migraine prevention is 150mg twice/day.
4. Long Chain Fatty Acids (Omega-3 fatty acids): These compounds are often in the news, with studies suggesting they may be helpful for anxietyy and depression, as well as arthritis and heart disease.We usually recommend fish oil or Flaxseed oil, 1000 mg., 2 or 4 per day Look for the brands with the highest amounts (EPA / DHA) listed on the back.
5. Feverfew: There have been conflicting studies as to whether feverfew is helpful as a migraine preventive. Because feverfew can cause a mild increased tendency toward bleeding, and can interact with commonly used medicines (aspirin and anti-inflammatories) we don't often recommend it. It also should be discontinued 2 weeks prior to surgery and should not be used during pregnancy.
Acupuncture.
Acupuncture is difficult to study scientifically because of the need to give one group of patients "sham" acupuuncture. However, most studies of acupuncture as a headache preventive show benefit. The advantage is that it does not involve any medications, and may help provide a feeling of well-being in addition to headache relief. The disadvantage is time and cost. Most acupuncturists recommend a series of initial treatments and then ongoing maintenance treatments.
We do not provide acupuncture ourselves, but will discuss with you whether it is a reasonable treatment choice. In the Asheville area, there are two clinics that provide "community acupuncture" on a sliding scale fee, making them very affordable. These are:
(This is not an endorsement of either of these two clinics, but information provided for those seeking a low-cost option for acupuncture).
Latest Blog
Articles
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Articles by and about Morris Maizels available online
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Maizels M, McCarberg B. Antidepressants and Antiepileptic drugs for the treatment of chronic non-cancer pain. American Family Physician 2005
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Maizels M. The Patient with Daily Headaches. American Family Physician 2004.