Dr. Robbins recently had an article published in the journal Practical Pain Management: Chronic Headache Recognizing Triggers.

The article was titled Chronic Headache Management: Outpatient Strategies. Here is a section of the article, dealing with triggers…

One of the primary things pain practitioners can do for their patients with headache is educate them about triggers. Certain triggers cannot be controlled, but when a patient has a headache every time the weather changes, or the first day of every menstrual period, clinicians can prescribe medication to be taken the day or night before as a preventive.

The top triggers tend to be stress (daily hassles), menses, and weather. When they occur simultaneously, patients get the worst, most prolonged migraines. Of course, missing meals, under- or over-sleeping, bright lights, and certain foods also contribute, but the role of foods tends to be overemphasized.

Many books concentrate on diet and foods, but these are low on the list of important triggers. Caffeine, however, is a major trigger. We need to limit the patient’s intake, although the limit varies from person to person. Some people can consume 800 mg of caffeine a day and not have rebound headaches or withdrawal. Other people get headaches from a small amount of caffeine in their diet.

Caffeine is an adjunct for pain relief because in small amounts it helps enhance the effect of analgesics. But, patients should be advised to watch out for the specialty coffeehouse effect. For example, Starbucks coffee has approximately 23 mg of caffeine per ounce. In an oversized cup of Starbucks, a patient can ingest 400 mg of caffeine (twice the daily maximum recommended), or more. Most home-brewed coffees have manageable doses. For example, Folgers or Hills Brothers brewed coffees have about 150 mg per cup, whereas instant coffee has half that amount. Tea, if it has caffeine, will generally have 30 to 60 mg per cup. Cola drinks have 40 t0 60 mg and Mountain Dew has a little more. The new energy drinks may have 200 mg in 12 ounces. Patients should be advised to watch for accumulated caffeine from these sources and OTC medications. Each tablet of the acetaminophen-caffeine combination analgesic has 65 mg of caffeine, whereas the aspirin-caffeine combination product has 33 mg. I attempt to limit a patient’s daily caffeine intake to 150 mg. with 200 mg as the maximum.

Practical Pain Management
March 2015

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