Migraines- Prevention

[Gabe H Coud]

Can anyone give any feedback on a fairly new injection proceedure called AIMOVIG ?

 

https://www.vejthani.com/2020/02/migraine/

 

Any thoughts appreciated even if different to the above 

 

Im in living hell last few days

 

thanks

[scubascuba3]

Can you describe your migraines and how frequent?

 

you can get clusters and then they disappear, you may be in the middle of one

Edited March 8, 2022 by scubascuba3

[Andre0720]

You could very well be ALLERGIC to Monosodium Glutamate, MSG.

Avoid it for some days, and if the migraine symptoms disappear, then you would need to check everything for MSG, starting with MAGGI sauce, then any soup, then any restaurant that uses Knorr as a food enhancer, or simply the MSG in white powder form.

I know of about 5 people who got rid of migraines with that.

Then I remember this lady who replied that she did not want to do that, because she wanted her food to taste better. I just said, well it is your choice to eat slightly better tasting food and then holding your head in your hands while waiting for some medication to take effect...

[Sheryl]

Have you already tried  the first line preventive drugs? (divalproex, topiramate, metoprolol, propranolol etc). These work for most people (not all) and will be vastly less expensive. (Aimvog will cost you in the vicinity of 20,000 baht a month).

 

How frequently do you get the migraines?

 

Do you have hypertension? (It is contraindicated if so).

 

Have you already tried Botox?

 

 

 

 

[Gabe H Coud]

i will attempt to answer all questions above

 

Im 60 this year and I have suffered from classical migraines for c.25 years that start with visual disturbances which are remarkably similar in pattern and length. My vision goes 'crazy' for almost same time (circa 40 mins) each time after which i get a bad headchache which can vary from a dull ache to excrutiating. Also feel sick and nauseous. Episodes last from 3 to 24 hours

 

I am aware they can come in clusters but ive never had so many is short time( 4 in 2.5 days)

 

over last 2 years i average around 14 migraines each year and in that time overall they werent too bad. But last few days have been horrendous!

 

MSG- i dont eat a lot of local food, probably 4 thai meals per week, will investigate. I never eat cheese chocolate Bananas sugary biscuits and ive even just given away 4 lovely avocados as apparently they can be a trigger(just who do you believe and where do you stop?!)

 

Meds- taken 20mg Propanolol/Betalol for 3 years, Depakine 500 every night for Migraine prevention and

Relpax(ellitriptan) on start of attack

 

During Mig attack i take 1 Ultracet(+ 1 paracetamol) it helps but slow to take effect

 

Aimovig- thanks Sheryl thought it would be pricey!

 

Botox not tried

 

Hypertension- No, BP normal

CT Brain scan normal

 

Attacks should be getting less frequent as i age but not the case

 

I feel i get more attacks in Thai(full time 3 yrs now) than i did in Uk......Heat?

 

Im aware of dehydration but we all slip sometimes

 

Im not overawed by my Neurologist Doc in Hua Hin, im sure hes a robot! Will see his colleague next time

 

One last point, i have reason to believe that i get more migraines at this time of year(March April) than any other??? Also  i didnt get a single attack for 6 whole months between Aug '20 and Feb 21.....very strange. Weather? Pressure changes? Jurys out on that theory

 

Thanks if anyone can help

 

 

 

 

 

 

 

[scubascuba3]

20 minutes ago, Gabe H Coud said:

i will attempt to answer all questions above

 

Im 60 this year and I have suffered from classical migraines for c.25 years that start with visual disturbances which are remarkably similar in pattern and length. My vision goes 'crazy' for almost same time (circa 40 mins) each time after which i get a bad headchache which can vary from a dull ache to excrutiating. Also feel sick and nauseous. Episodes last from 3 to 24 hours

 

I am aware they can come in clusters but ive never had so many is short time( 4 in 2.5 days)

 

over last 2 years i average around 14 migraines each year and in that time overall they werent too bad. But last few days have been horrendous!

 

MSG- i dont eat a lot of local food, probably 4 thai meals per week, will investigate. I never eat cheese chocolate Bananas sugary biscuits and ive even just given away 4 lovely avocados as apparently they can be a trigger(just who do you believe and where do you stop?!)

 

Meds- taken 20mg Propanolol/Betalol for 3 years, Depakine 500 every night for Migraine prevention and

Relpax(ellitriptan) on start of attack

 

During Mig attack i take 1 Ultracet(+ 1 paracetamol) it helps but slow to take effect

 

Aimovig- thanks Sheryl thought it would be pricey!

 

Botox not tried

 

Hypertension- No, BP normal

CT Brain scan normal

 

Attacks should be getting less frequent as i age but not the case

 

I feel i get more attacks in Thai(full time 3 yrs now) than i did in Uk......Heat?

 

Im aware of dehydration but we all slip sometimes

 

Im not overawed by my Neurologist Doc in Hua Hin, im sure hes a robot! Will see his colleague next time

 

One last point, i have reason to believe that i get more migraines at this time of year(March April) than any other??? Also  i didnt get a single attack for 6 whole months between Aug '20 and Feb 21.....very strange. Weather? Pressure changes? Jurys out on that theory

 

Thanks if anyone can help

 

 

 

 

 

 

 

Interesting, my first migraine was 32 years ago, btw weather in particular low pressure is a trigger for me so when the weather gets stormy I'm more likely to have one. For me they have changed the last few years, sometimes no headache and aura pasts quicker, I don't take anything just live with it. i had a cluster a few months ago, very rare, last one 10 years ago.

 

I don't make a drama about it, I'm convinced it makes it worse so if I'm having a migraine I don't even tell anyone

Edited March 9, 2022 by scubascuba3

[Sheryl]

With 4 headaches now in 2 1/2 days you should see a neurologist to make sure something else is not going on.

 

I suggest you see one specializing in headaches at Siriraj Hosp (Thonburi)

 

Such as Prof. Niphon Poungvarin . Try contacting their private wing www

Siphhospital.com

 

Or  if he is not available then 

https://www.siphhospital.com/en/medical-services/doctor-biography?id=684

 

If you do end up needing Aimvog it will likely cost less there than at Vejthani (though still expensive) plus it is closer to Hua Hin

[Hummin]

4 hours ago, Sheryl said:

Have you already tried  the first line preventive drugs? (divalproex, topiramate, metoprolol, propranolol etc). These work for most people (not all) and will be vastly less expensive. (Aimvog will cost you in the vicinity of 20,000 baht a month).

 

How frequently do you get the migraines?

 

Do you have hypertension? (It is contraindicated if so).

 

Have you already tried Botox?

 

 

 

 

I have a x who used 5 HTP bought from iHerb and claim she got relieved from the worst attacks.

 

https://www.verywellhealth.com/5-htp-migraine-prevention-1718029

[1FinickyOne]

3 hours ago, Gabe H Coud said:

i get more migraines at this time of year(March April) than any other??

That also speaks to heat... I find it imperative to keep my body temperature in control and not to overheat... stay in a/c... cold showers.. 

 

the other thing is that as soon as I have the first vision of a symptom, I stop everything, get into a cool place and lay down, no activity at all and I take paracetamol 

 

As an older adult I have been able to keep them under control. I am retired and there is nothing that I have to do that would be more important than fending off a migraine...

 

Good luck to you... 

[Gabe H Coud]

1 hour ago, Sheryl said:

With 4 headaches now in 2 1/2 days you should see a neurologist to make sure something else is not going on.

 

I suggest you see one specializing in headaches at Siriraj Hosp (Thonburi)

 

Such as Prof. Niphon Poungvarin . Try contacting their private wing www

Siphhospital.com

 

Or  if he is not available then 

https://www.siphhospital.com/en/medical-services/doctor-biography?id=684

 

If you do end up needing Aimvog it will likely cost less there than at Vejthani (though still expensive) plus it is closer to Hua Hin

Saw Neurologist yest hence my comment re not much faith 

 

He just agreed with me that the obvious thing to do was to revert to the original dose of Depakine which I'd already implemented myself 

 

Thanks for the other names though, useful to have 

[Sheryl]

18 minutes ago, Gabe H Coud said:

Saw Neurologist yest hence my comment re not much faith 

 

He just agreed with me that the obvious thing to do was to revert to the original dose of Depakine which I'd already implemented myself 

 

Thanks for the other names though, useful to have 

I also do not think much of him.  Before just asusming that headaches nwo occurring more than once a day are just your usual migraines, you need  to rule out other causes like brain tumor.

 

You also need (assuming other pathologies are  ruled out) a neurologist who specifically specializes in headaches. You will not find this in Hua Hin. Sirirj and Thonburi Hospitals would be the closest source

 

I would certainly try Botox if I were you before going on to more expensive treatments.

[Speedo1968]

Florescent lighting can affect vision ( the flickering you don't see with your eyes but your mind does. )
I used to get extreme migraines and used a self injector pen ( can't remember name Epipen ? worked quick ).
Did a lot of flying and sometimes had to use on plane or at airport medical centre.
For some unknown reason my migraines stopped having had them for about 40 years, now mid 70s.
One injection by doctor emergency call out at 2am in England worked well but some 6 hours later had body seizure whilst driving car.
Good luck in finding something that works for you.

[Gabe H Coud]

On 3/9/2022 at 5:18 PM, Sheryl said:

I also do not think much of him.  Before just asusming that headaches nwo occurring more than once a day are just your usual migraines, you need  to rule out other causes like brain tumor.

 

You also need (assuming other pathologies are  ruled out) a neurologist who specifically specializes in headaches. You will not find this in Hua Hin. Sirirj and Thonburi Hospitals would be the closest source

 

I would certainly try Botox if I were you before going on to more expensive treatments.

CT brain scan 2 years ago normal

will investigate Botox

thanks Sheryl

Edited March 10, 2022 by Gabe H Coud

[impulse]

I hate to be Captain Obvious, because most migraine sufferers know of the caffeine connection.  I suffered from migraines for 30+ years.  Consulted many doctors during that time, with many treatments tried.  I'd be debilitated for entire days, complete with vomiting.  Lost 4 or 5 days a month to migraines until I started working and just had to suffer through them at the office.  Not once do I recall a doctor suggesting a caffeine connection.

 

When I got my caffeine intake stable, they pretty much disappeared.  In 7+ years living in Thailand, I had a total of 3 bad migraines.  I didn't give up caffeine, but I made sure I consumed a pretty consistent amount every day.  I even bought NoDoz tablets for those days when I couldn't get coffee working in the field.

In fairness, I did my suffering and got my relief before many of the current treatments were even available- and doctors had pretty much nothing to offer.  Starting in the 60's, through the 90's.  And it may be sheer coincidence that the migraines quit when I started paying attention to my caffeine intake.  But I don't think it's coincidence that many migraine remedies contain caffeine.

Edited March 10, 2022 by impulse

[Sheryl]

10 hours ago, Gabe H Coud said:

CT brain scan 2 years ago normal

will investigate Botox

thanks Sheryl

Two years ago you were not having more than 1 migraine a day as you apparently are now.

 

 

[Gabe H Coud]

1 hour ago, Sheryl said:

Two years ago you were not having more than 1 migraine a day as you apparently are now.

 

 

no, as per my long note above i *average* 14 per annum/ approx 1 per 4 weeks

yes i had 4 in 3 days but that was a cluster

it is wrong to conclude i have more than 1 per day 

that said if things continue i will seek another scan 

thanks

 

ps a quick study on botox suggests i dont have enough attacks to 'qualify'

recommended for those who have 15 bad headaches a month of which 8 are certainly migraines 

i suppose it depends which Doctor you talk to

[Gabe H Coud]

10 hours ago, impulse said:

I hate to be Captain Obvious, because most migraine sufferers know of the caffeine connection.  I suffered from migraines for 30+ years.  Consulted many doctors during that time, with many treatments tried.  I'd be debilitated for entire days, complete with vomiting.  Lost 4 or 5 days a month to migraines until I started working and just had to suffer through them at the office.  Not once do I recall a doctor suggesting a caffeine connection.

 

When I got my caffeine intake stable, they pretty much disappeared.  In 7+ years living in Thailand, I had a total of 3 bad migraines.  I didn't give up caffeine, but I made sure I consumed a pretty consistent amount every day.  I even bought NoDoz tablets for those days when I couldn't get coffee working in the field.

In fairness, I did my suffering and got my relief before many of the current treatments were even available- and doctors had pretty much nothing to offer.  Starting in the 60's, through the 90's.  And it may be sheer coincidence that the migraines quit when I started paying attention to my caffeine intake.  But I don't think it's coincidence that many migraine remedies contain caffeine.

5 years ago my UK Doc told me to avoid caffeine at all costs( and i do, i drink decaff tea only, no coffee, and caffeine free sprite)

 

My Thai Neuro Doc confirmed this week that some caffeine is good(hence Caffergot as you say )

 

again, who do you believe?!

 

 

 

 

[Sheryl]

2 hours ago, Gabe H Coud said:

5 years ago my UK Doc told me to avoid caffeine at all costs( and i do, i drink decaff tea only, no coffee, and caffeine free sprite)

 

My Thai Neuro Doc confirmed this week that some caffeine is good(hence Caffergot as you say )

 

again, who do you believe?!

 

 

 

 

For caffeine (as well as other triggers) it is highly individual - believe your own experience

 

Long ago when I used to get migraines, low blood sugar (often triggered by eating foods with high glycemic index on empty stomach, or skipping means) was a key trigger. But that was me. Everyone is different.

[NancyL]

Topamax (topiramate) did the trick for me.  

[EricTh]

On 3/9/2022 at 6:27 AM, Andre0720 said:

You could very well be ALLERGIC to Monosodium Glutamate, MSG.

Avoid it for some days, and if the migraine symptoms disappear, then you would need to check everything for MSG, starting with MAGGI sauce, then any soup, then any restaurant that uses Knorr as a food enhancer, or simply the MSG in white powder form.

I know of about 5 people who got rid of migraines with that.

Then I remember this lady who replied that she did not want to do that, because she wanted her food to taste better. I just said, well it is your choice to eat slightly better tasting food and then holding your head in your hands while waiting for some medication to take effect...

 

Thai people put MSG in all their food, I always ask them not to put MSG.

 

I used to have headaches for no reasons for many decades, the useless doctors just gave paracetamol to me which doesn't solve the root cause.

 

Then I read about MSG causing headaches and I stopped taking it, I now no longer have headaches.

 

There are lots of causes for migraines and it's usually related to allergies to either food or smoke from cigarettes

Edited March 11, 2022 by EricTh

[scubascuba3]

59 minutes ago, EricTh said:

the useless doctors just gave paracetamol to me which doesn't solve the root cause.

 

I'm surprised paracetamol helps anyone with a migraine

[EricTh]

9 minutes ago, scubascuba3 said:

I'm surprised paracetamol helps anyone with a migraine

 

I said headaches and not migraine. 

 

For migraine, they will usually prescribe another medicine that dilates the blood, (can't remember the name but something to do with caffeine)

 

One of the causes of headaches is MSG (if we don't have high blood pressure).

 

Whenever I ask Thai people not to put MSG, I get a weird look from them. They always say  MSG is 'aroi' so why am I not taking it?

 

Migraines can also be caused by allergies like second-hand smoke.

 

Edited March 11, 2022 by EricTh

[ThailandRyan]

Relpax is the medication for migraines which my GF takes when she has one of her migraines that incapacitates her.  The medication along with earplugs and sitting in darkness takes care of the issue in about 1 hour, but she then sleeps for at least two.

https://www.relpax.com/

[scubascuba3]

Last two days I've had migraines, must be something in the air, i continued as normal, once the aura passed that was it, no pain

[Nojohndoe]

On 3/9/2022 at 12:15 PM, Gabe H Coud said:

i will attempt to answer all questions above

 

Im 60 this year and I have suffered from classical migraines for c.25 years that start with visual disturbances which are remarkably similar in pattern and length. My vision goes 'crazy' for almost same time (circa 40 mins) each time after which i get a bad headchache which can vary from a dull ache to excrutiating. Also feel sick and nauseous. Episodes last from 3 to 24 hours

 

I am aware they can come in clusters but ive never had so many is short time( 4 in 2.5 days)

 

over last 2 years i average around 14 migraines each year and in that time overall they werent too bad. But last few days have been horrendous!

 

MSG- i dont eat a lot of local food, probably 4 thai meals per week, will investigate. I never eat cheese chocolate Bananas sugary biscuits and ive even just given away 4 lovely avocados as apparently they can be a trigger(just who do you believe and where do you stop?!)

 

Meds- taken 20mg Propanolol/Betalol for 3 years, Depakine 500 every night for Migraine prevention and

Relpax(ellitriptan) on start of attack

 

During Mig attack i take 1 Ultracet(+ 1 paracetamol) it helps but slow to take effect

 

Aimovig- thanks Sheryl thought it would be pricey!

 

Botox not tried

 

Hypertension- No, BP normal

CT Brain scan normal

 

Attacks should be getting less frequent as i age but not the case

 

I feel i get more attacks in Thai(full time 3 yrs now) than i did in Uk......Heat?

 

Im aware of dehydration but we all slip sometimes

 

Im not overawed by my Neurologist Doc in Hua Hin, im sure hes a robot! Will see his colleague next time

 

One last point, i have reason to believe that i get more migraines at this time of year(March April) than any other??? Also  i didnt get a single attack for 6 whole months between Aug '20 and Feb 21.....very strange. Weather? Pressure changes? Jurys out on that theory

 

Thanks if anyone can help

 

 

 

 

 

 

 

I used to suffer cluster headaches from about  age 30 which came in unpredictably. There is a distinction between "classic " migraine " and cluster "headache" but which the intensity of I would understand is relative to the opinion of sufferer . But an alternative  name for clusters is "Suicide headache" which for more than one has been the route taken to escape the pain that medical science says the brain can not feel ! The  medics may be  correct but as a sufferer I could argue differently  at those moments of intensity.

Once diagnosed the  brief moment of relief derived from expectations that the wonders of modern medicine would relegate the problem to  history was short lived. Concoctions of ergot and  caffiene rarely made an impact and when woken in the night by yet another rising of the  devilish pain that could and did occur more than once in a night in addition to those in the  daytime it left a sense of a vague zombie like functionality. Even when a cluster ceased to  produce it's  torture  there was a "post  sufferance" that kept  a lingering  preparative  fear in thought. Add to that the dire warning  about  not  resorting to said  medication  beyond a certain amount. Refer to ergot poisoning if at all interested!

Doctors would  nod sympathetically in recognition of educated knowledge of symptoms but it was only after 12 years I came across a Doctor who was a fellow sufferer . He too was living in hope of the Medicinal Holy Grail to combat the problem. And  eventually it did in the form of Sumatriptan !

Initially in oral tablet form but  soon after in an injectible  similar to  insulin shots.

For  me a life  changer for those times clusters surfaced. The almost instant reduction of severity and duration was an incredible relief from the trepidation of not knowing either the intensity or long term duration of a cluster  might be. In fact (for me) what had been becoming a rise  in intensity and frequency of clusters and cluster episodes rapidly decreased . Interestingly the incidence  also is said to  decrease with age and becomes rare after the age of 60. I had my last cluster at age 62  . It  was short and a little different in effect and duration. To this day I keep medication at hand but despite the fact the "use  by" date is  long gone  I would  use it  !

I just realized I should have  mentioned at the start  that "Classic  Migraine" and "Cluster Headache" are  generally gender  related.  Females tend get the long term intense headache with aversion to light  type thing that can last days. Males are more prone to the "Cluster  Headache" presentation that in pain terms is generally considered  greater and more debillitating in intensity while  in effect  than the longer lasting insidious  "Classic" migraine.

Interesting  the  medications now in use are generally effective  for  both  forms but not always.

I should not be but  can not help be cynically amused when I  hear someone with a hangover headache who declares  relief from using paracetamol for their "Migraine" !

If they knew the difference they would be proud of the hangover !

I am aware there are now generics and alternatives to the  medication I  mentioned.

In reference to the  quest for triggering factors? Very very interesting the suggestion of weather systems etc and atmospheric pressure. I  can attest to the fact that while not necessarily initiating a  cluster that driving a vehicle over rapid changes in road elevation, buildups to thunderstorms  and

aircraft departures were a common feature of onset once a cluster started.

 

 

 

 

 

[Nojohndoe]

24 minutes ago, scubascuba3 said:

I'm surprised paracetamol helps anyone with a migraine

If  actually definable as "migraine" it does not  (usually)

[scubascuba3]

7 minutes ago, Nojohndoe said:

 Very very interesting the suggestion of weather systems etc and atmospheric pressure. I  can attest to the fact that while not necessarily initiating a  cluster that driving a vehicle over rapid changes in road elevation, buildups to thunderstorms  and

aircraft departures were a common feature of onset once a cluster started.

 

 

 

 

 

The day i realised mine were weather induced was when a colleague and i started getting an aura at the exact split second, thunder, rain was coming

[Speedo1968]

23 hours ago, scubascuba3 said:

The day i realised mine were weather induced was when a colleague and i started getting an aura at the exact split second, thunder, rain was coming

High body electric can respond to weather, I also used to get it when sandstorms were approaching when I was working in Saudi, Kuwait and any desert conditions.    I have shorted out car battery when touching car during sandstorm.     Likewise with rain storms and lightening.

 

I can't wear clothes other than cotton due to body electric, perhaps the original OP could consider wearing cotton clothes.

I can't touch a persons hand when standing on a carpet, my daughters and I had this problem.

[scubascuba3]

8 hours ago, Speedo1968 said:

High body electric can respond to weather, I also used to get it when sandstorms were approaching when I was working in Saudi, Kuwait and any desert conditions.    I have shorted out car battery when touching car during sandstorm.     Likewise with rain storms and lightening.

 

I can't wear clothes other than cotton due to body electric, perhaps the original OP could consider wearing cotton clothes.

I can't touch a persons hand when standing on a carpet, my daughters and I had this problem.

Interesting, I've noticed a bit like that, even phone button selects sometimes with just being near it, not to your level though

[Gabe H Coud]

On 3/11/2022 at 8:02 PM, Nojohndoe said:

I used to suffer cluster headaches from about  age 30 which came in unpredictably. There is a distinction between "classic " migraine " and cluster "headache" but which the intensity of I would understand is relative to the opinion of sufferer . But an alternative  name for clusters is "Suicide headache" which for more than one has been the route taken to escape the pain that medical science says the brain can not feel ! The  medics may be  correct but as a sufferer I could argue differently  at those moments of intensity.

Once diagnosed the  brief moment of relief derived from expectations that the wonders of modern medicine would relegate the problem to  history was short lived. Concoctions of ergot and  caffiene rarely made an impact and when woken in the night by yet another rising of the  devilish pain that could and did occur more than once in a night in addition to those in the  daytime it left a sense of a vague zombie like functionality. Even when a cluster ceased to  produce it's  torture  there was a "post  sufferance" that kept  a lingering  preparative  fear in thought. Add to that the dire warning  about  not  resorting to said  medication  beyond a certain amount. Refer to ergot poisoning if at all interested!

Doctors would  nod sympathetically in recognition of educated knowledge of symptoms but it was only after 12 years I came across a Doctor who was a fellow sufferer . He too was living in hope of the Medicinal Holy Grail to combat the problem. And  eventually it did in the form of Sumatriptan !

Initially in oral tablet form but  soon after in an injectible  similar to  insulin shots.

For  me a life  changer for those times clusters surfaced. The almost instant reduction of severity and duration was an incredible relief from the trepidation of not knowing either the intensity or long term duration of a cluster  might be. In fact (for me) what had been becoming a rise  in intensity and frequency of clusters and cluster episodes rapidly decreased . Interestingly the incidence  also is said to  decrease with age and becomes rare after the age of 60. I had my last cluster at age 62  . It  was short and a little different in effect and duration. To this day I keep medication at hand but despite the fact the "use  by" date is  long gone  I would  use it  !

I just realized I should have  mentioned at the start  that "Classic  Migraine" and "Cluster Headache" are  generally gender  related.  Females tend get the long term intense headache with aversion to light  type thing that can last days. Males are more prone to the "Cluster  Headache" presentation that in pain terms is generally considered  greater and more debillitating in intensity while  in effect  than the longer lasting insidious  "Classic" migraine.

Interesting  the  medications now in use are generally effective  for  both  forms but not always.

I should not be but  can not help be cynically amused when I  hear someone with a hangover headache who declares  relief from using paracetamol for their "Migraine" !

If they knew the difference they would be proud of the hangover !

I am aware there are now generics and alternatives to the  medication I  mentioned.

In reference to the  quest for triggering factors? Very very interesting the suggestion of weather systems etc and atmospheric pressure. I  can attest to the fact that while not necessarily initiating a  cluster that driving a vehicle over rapid changes in road elevation, buildups to thunderstorms  and

aircraft departures were a common feature of onset once a cluster started.

 

 

 

 

 

for record i take paracetamol for migraine but only in conjunction with Tramadol(Ultracet in Thailand)

 

yes, i wouldnt bother without the Tramadol combo