medication-overuse headache

5 June 2017

Why does Migraine become Chronic?

James Discoveries & Stats, Information, Tips 0

Why is it that some people start with the occasional migraine attack – and then months or years later they’re having an attack every other day – or worse? Is there some way to stop this from happening? Can it be reversed?

When Migraine becomes Chronic There have been some studies that point out “risk factors” for “chronification” of migraine. That doesn’t mean that the factor causes the attacks to become chronic necessarily. In fact, we really have very little understanding of what is happening, in spite of what you may have heard.

We do know that women tend to end up with chronic migraine more than men – however, it does affect everyone.

Some possible risk factors include:

GENETICS
Poor treatment (including ineffective medications, or using “too much” medication)
Depression
Physical trauma (brain injury)
Emotional/mental trauma (a history of abuse)
obesity
Sleep disorders (sleep apnea, snoring)

I shouted out genetics at the start there, because that may actually be the biggest key factor. In other words, no matter what the other risk factors may be, some people will get it, some won’t.

Medication overuse is a commonly cited factor. But it’s very tricky – is the medication causing more attacks (this does seem to happen), or is the patient taking more medication because of more attacks?

Either way, it’s important to get the best treatment available before your attacks start increasing, to avoid this outcome.

The other factors above are difficult, though providing treatment for each factor may help with migraine (counselling? diet?)

Chronification may also be a result of another underlying disease, which is why you need to talk to your doctor if you see your migraine attacks increasing. For example, idiopathic intracranial hypertension (IIH) is suprisingly common in chronic migraine patients. If there are no obvious IIH symptoms, it’s easy to write off the problem as chronic migraine (researchers in Italy expressed concern about this a couple of years ago).

Besides seeing your doctor as soon as possible, what else can you do if your migraine attacks are becoming chronic?

Obviously your doctor can help you with specific treatments and preventative medications. There may be medications that you’ve taken in the past that you now need to replace with something else to break the cycle. You may also find that you’re suffering from more than one type of headache.

Secondly, pay attention to the risk factors above. If you need treatment for depression, obesity, a sleep disorder – these should be treated along with the chronic migraine.

I appreciated Dr. William Young’s top recommendation in his talk at the World Migraine Summit. Recognizing the severe disability some people experience with chronic migraine and daily headache, he said this:

Just my personal take, recently I’ve become more and more convinced that movement is key and that patients whose migraines are so severe it hurts to move and then they stop, they have got to do something. They should walk a half an hour a day. If they can’t, they should walk 10 minutes three times a day. If they can’t do that, they should walk three minutes 10 times a day.

Yes, if you can’t do anything else, walk for three minutes 10 times a day. Even that may seem overwhelming, but I agree with Dr. Young that this is critical – get moving. Even if you start with three minutes the first day, and four the next.

Although we’re not sure of all the reasons why migraine becomes chronic, we do know that it’s common – 1-2% of the general population, and about 8% of patients with migraine. And we do know that it can be reversed – there is lots of hope for anyone with chronic migraine that you’ll experience major improvement with the right treatment.

For more information, see Chronic migraine: risk factors, mechanisms and treatment. and Migraine “Chronification”: What You Can Do (pdf file)

7 July 2016

Medication Overuse Headache: Overrated?

James Medications, News 6

Everybody is talking about medication overuse headache (MOH). There is a big push to cut down on drugs and to find alternatives. But is it possible that we’re over-emphasizing the problem?

At last month’s meeting of the American Headache Society in San Diego, organizers set up a discussion on the topic – is MOH actually a thing?

Ok, the thesis was “Medication Overuse Headache is a Proven Entity” – true, or false?

Taking opposite sides were Dr. Richard Lipton (“true”) and Dr. Ann Scher (“false”) (two experts who have actually worked together on a number of projects in the past).

The discussion is, of course, a lot more nuanced than that. Just what is MOH? What medications can cause MOH? How much of a certain drug is too much? Are there permanent consequences to MOH? Or is it easily resolved?

Medication Overuse Headache: How big is the problem? Dr. Scher brought up an important point. Common current advice is to limit abortive medication to 2x per week or less. Medications that should especially be avoided include opioids and butalbital combination medications. So the question is – How many are being harmed vs helped by this advice?

That is the bottom line, right? Whatever the details may be, is the current focus, the current common advice, actually helping patients?

For example, is it better to take a little too much (no, we’re not talking about multiple doses per day here), or to completely quit the medication?

Few would disagree that MOH exists in some form, but there is not equal evidence for every medication.

Dr. Alexander Mauskop, who kindly reported on this discussion for us (see The existence of medication overuse headache is debated), actually advocates the use of daily triptans for a few patients. Other doctors would be horrified by the thought.

The heart of the discussion really isn’t whether or not medication overuse headache actually exists. The question is – where is it really a problem, and how can it be treated? And the truth is, we have a long way to go before we’ll have good answers to these questions. It’s good to see the discussion moving forward.

8 January 2014

Question: If someone has Allodynia, can they take Imitrex?

James Information, Medications, Tips 0

The short answer is “yes”. But, of course, you didn’t come here for a short answer, did you? 🙂

Years ago, many doctors became concerned that triptans such as Imitrex (sumatriptan) would not work as well once the patient developed allodynia. (By the way, the allodynia here that we’re talking about is sensitivity/pain when the skin is touched – see My Hair Hurts! Migraine and Allodynia) In fact, it was soon repeated over and over that triptans need to be taken early in a migraine attack (for example before allodynia hits) in order to be most effective.

Now, taking medication earlier in the attack (as opposed to taking the same dose later in the attack) does seem to work better for a number of reasons. Quite simply, as migraine triggers more and more severe symptoms, you can end up with a vicious circle of pain that is very hard to stop.

However, the relationship between triptans and allodynia may not be so simple. For example, even if allodynia has already hit, if you take a triptan early in the attack it can still be effective (see Difference in Triptan Effect in Patients With Migraine and Early Allodynia)

Allodynia is something to be concerned about. Not only can it be uncomfortable or even disabling, it may be a predictor of chronic migraine. Plus, the frequent use of triptans can cause all kinds of problems, including medication-overuse headache.

So if someone has allodynia, can they take Imitrex? Yes, they can, but:

They should talk it over with a doctor who knows their symptoms and medical history.
It’s possible that another medication may work better for them, especially if allodynia is a major symptom.
If they are taking Imitrex or another triptan several days a month or more, they need to seriously look at other treatment options.
As with many migraine abortives, it’s still recommended that you try to take something early in the attack rather than several hours later. This applies whether you suffer from allodynia or not.

Take treatment seriously – it will help you avoid many more problems in future years.

6 January 2014

What is Triptan-Overuse Headache?

James Information, Medications, Treatments 2

Patient takes one or more meds containing a triptan 10+ days per month for 3+ months.
As more triptans are taken, headaches have increased to 10+ days per month.
Typically these attacks are not just headache but include other migraine symptoms.
Patients will have an underlying condition (a type of migraine) as well as the diagnosis of TOH.

Usually attacks decrease within 2 months after patient stops using triptans.

A patient taking triptans AND other abortives may be diagnosed with combination-analgesic-overuse headache, a condition which may be harder to treat.

Even if a patient technically doesn’t have TOH, they may still be taking too many triptans. Talk to a specialist who knows your medical history.

For more information:

13 December 2013

Painkillers – How Much is Too Much?

James Information, Medications 0

It’s easy to say “It’s just a headache – take a pill”. But what if you’re doing that over and over?

We hear over and over that overuse of medications is bad for us – and it is. Medication-overuse headache (MOH) is a serious issue.

So we don’t want to “overuse” medications – but how much is too much?

It’s a very controversial question. And it’s true that it will vary depending on your condition and medical history. Many doctors simply won’t give you an answer – they prefer to take things on a case by case basis, and evaluate how things are going as time goes by.

And they’re probably right.

The problem is, many people aren’t going to a doctor at all. Many are just relying on “painkillers” when there are better treatments available.

The International Headache Society has tried to classify MOH and give some suggestions regarding how much is too much. Generally, they’ve set the danger level at 10-15 days a month, depending on the medication. Medications such as triptans, opioids, and combination drugs should be taken less often than aspirin or ibuprofen, for example.

But the need to simplify once again means that certain people may be following the guidelines, and yet they’re still taking too much. For example, the person who takes a medication every day for a period of time, and then stops for a while. Or someone who’s taking something every other day. Some doctors will tell you that you should be concerned if you’re taking something more than 2-3 times a month.

If you are taking painkillers more than 2 or 3 times a month, at the very least you should be having a serious talk with your doctor. You do not want to see things get worse, and they could very easily. Tell your doctor what medication(s) you’re taking, how often, and what your symptoms are.

Some people may be able to take more medications than others – but once it goes beyond a very occasional dose, everyone should find a doctor who will listen and get some good advice. They should also do their own research. There are probably much better options for you that will be better for you.

Also see: How many headaches are too many in a week?