The second case was a 43-year-old mother with mild fibromyalgia, subclinical anxiety, and a headache frequency of three to four times per week. During trials of other preventive drugs, she was prescribed clonazepam as a sleep aid. She returned a month later, stating that she had decided to take only the clonazepam and had experienced one headache in that time. At a three-month follow-up, she reported still having only one headache per month. “She’s not having the headaches that she’s been having, so we’re not just treating anxiety here. We’re treating migraine,” Dr. Maizels said.
In the third case, a 36-year-old woman had visited five major headache centers in the United States and remained refractory to all treatments other than narcotics. Initially, Dr. Maizels allowed the use of meperidine once a month when she first came in for a consult in 1999, but in the following year, she had increased the dosage to once a week. In the next few years, she was prescribed several different preventives, and the meperidine prescriptions were discontinued, but she continued to require frequent rescue treatment. When a trial of clonazepam was initiated in September 2006, she reported dramatic improvement at a return visit six weeks later, needing only one rescue treatment during that time. During the next year, she continued to take 1 to 2 mg of clonazepam along with eletriptan and hydrocodone. She lost about 75 pounds with diet and exercise and told Dr. Maizels, “I have my life back. I have not felt this well since I was 13.”
Less than 50% of patients tolerated clonazepam or had a strong positive response, but for a refractory headache population, a substantial proportion did tolerate it. Common symptoms among this group were anxiety, somatization, paresthesia, and dizziness. A commonly observed adverse effect of benzodiazepines is sedation, and one study in patients with chronic pain revealed a “downward spiral” in overall quality of life (eg, medical visits, domestic disability, depression) associated with benzodiazepine use, noted Dr. Maizels.
“I don’t want to suggest that this medicine is a panacea, and it certainly has its share of concerns,” said Dr. Maizels. He emphasized that clonazepam is not a proven therapy for migraine, and its potential hazards suggest limiting its use to clinicians who can adequately screen and monitor patients on this therapy. Yet, he noted, clonazepam is relatively benign and inexpensive if used cautiously. Also, compared with most other preventives, the clinical effect of clonazepam is rapid. “As soon as [patients] get to a target dose, it’s really dramatic,” said Dr. Maizels.
—Jessica Jannicelli