VoLUME
8, ISSUE 2
March
2003
March 11th Meeting:
“Talk It Over Night”
-
Bring your questions!
Michael Stein, MD, medical advisor and co-founder of the East Bay
Headache Support Group will lead us in a group discussion at the March 11th
meeting. Now’s your chance to ask
questions of a headache specialist without paying a dime.
Possible topics for
discussion include the different types of headaches, what causes or triggers
them, and what medications are currently available to either abort headaches or
to prevent them. And we’re all
curious to hear about new medications that may be coming down the pipeline, and
hoping that we’ll finally found the cure all.
We can also talk about the frustrations of living with frequent and/or
severe headaches, and learn from and support each other.
Family
and friends are welcome. The
meeting will be held in the Monterey Room, downstairs at John Muir Medical
Center, on Tuesday, March 11, from 7:30 to 9:00 p.m.
For
more information, call Leslie Davis at 925-685-8775.
NOTE:
Most of our meetings in 2003
will be held in the
Personal Profile
I would be in too much pain
to sleep. I found that I had to sit
with my head resting at a certain angle and keep very still to minimize the
throbbing pain.
I went to the Emergency Room
several times when these bad headaches first started. My head was x-ray’d. I
was found to
So, for many years to
follow, I just toughed out the headaches. Eventually,
though, they became more frequent—every month at the beginning
or end of my period—and I talked to my internist about them.
By this point, I was in my thirties and had found that the only time
My internist
prescribed a variety of different medications over the next few years.
I tried Ergotamine, hormones, Imitrex, and Fioricet.
About the only one that seemed to help me
much was Fioricet. At first, I was
very averse to taking medicine unless my headache was really bad.
But then I was told that I was waiting too long before taking my
medicine. So, I began taking the
medicine as soon as I was convinced a
This approach worked fairly
well for a long time. I started out
with 20 Fioricet pills per month and had no problems with running out.
As time passed, however, I found that instead of having headaches just at
the beginning or end of my period, I was getting them before, during and at the
end of my cycle. So, this meant
about 10 days in a row with headaches and frequent use of
Fioricet or Tylenol. I asked
for more medicine since I was often running out before the one-month window to
refill them. My monthly ration of
Fioricet was increased to 50 and I was told to take 2 no more than every 6
hours, and no more than 6 pills per day. Again,
this worked fine for quite some time, but eventually I realized that my
headaches were occurring almost all the time.
So, I talked again to my
internist and was referred to a neurologist who specializes in treating headache
patients. Right from the
beginning, the specialist told me Fioricet was not a good medication for
treating my type of headache. After
each visit, I would try to quit using it and rely instead on newer medicines to
abort migraines and/or preventive medicines prescribed by him to prevent them.
I was diligent about using a headache diary, tried very hard to eliminate
all possible migraine trigger foods (including caffeine), but ultimately, each
month I found myself relying on Fioricet or Tylenol since the preventives
didn’t “prevent” my headaches and the abortives were limited to only 6
pills per month. I also could not find any correlation between my diet and
migraines so I stopped restricting my diet.
The specialist continued to try to steer me away from Fioricet and I
sincerely tried to not take it. But,
most mornings I would wake up with a headache, and with two young kids and lots
of household and volunteer commitments, most days I would resort to taking
Fioricet again.
I tried taking some
preventive medications (Nortriptyline, Depakote and Amitryptiline) and an
abortive (Maxalt), but then would take Fioricet when they didn’t seem to work.
The specialist talked to me
about rebound headaches, but I didn’t really believe that I could be getting
them since I’d had headaches for so many years and they had gotten worse
gradually over time. I kept
thinking that I was just getting more headaches because my hormones were
changing as I aged, or something.
Finally, late last year, I
decided to really try hard NOT to take Fioricet. This was precipitated by the fact that my headaches were not
really getting much better; and I was feeling bad about having to tell the
neurologist that I’d again relied on Fioricet.
Plus, when I’d mentioned to my internist that I was running out of
pills before the month was up, she also said “REBOUND.” So, I tapered off Fioricet over a few days and then I went a
whole month without taking any Fioricet. I
was still taking Tylenol sometimes instead but I was still doing much better.
For occasional headaches that were more severe, I used Amerge which
helped, but since this was my first month without Fioricet, I ran out of
Amerge before I could refill my prescription.
So, after one month without Fioricet, I took it again because my headache
was just too bad and the Amerge was gone.
It didn’t take long for me
to get back into the same headache cycle again.
Those daily headaches were back but I was beginning to notice that I
could feel the difference from these headaches and the true (non-rebound)
migraine headaches I was getting. So,
once again I quit Fioricet and have cut way back on my Tylenol usage.
I am much, much, better. It’s
so strange after so many years to wake up and not have a headache.
My mind was just used to thinking “I just woke up.
How bad is my headache today and what should I take for it so it
doesn’t get worse?” Some days I
do have a headache still, but they are usually fairly minor and improve when I
either ignore them (and they get better as the day progresses), or I take
something (Amerge or Tylenol), which I try to limit to no more than twice per
week.
It’s great to be so much
better. The television show
“20/20” had a special on rebound headaches in December 2002. It basically said that all medicines that one takes for
headaches (be it aspirin, Tylenol, triptan drugs, Fioricet, etc.) have been
found to cause rebound headaches when taken more than twice a week.
So, the very medicines I felt I had to take to make it through the day,
were, in fact, making me worse. One
of the people interviewed on the show had been having daily headaches for 20
years. He had been taking Excedrin every day, and now, without
Excedrin, he is fine.
I hope that quitting my
frequent use of medications finally allows me to manage my headaches, and that
they will hopefully be less severe and more infrequent.
At the very least, my experience leads me to believe that if, like me,
you have found yourself taking more medicine and having more headaches, if you
are finding that you are nervous because you can’t refill your prescription
for another week and you don’t know if you can stretch out your remaining
medicine that long, or if you are watching the clock to see if the 6 hours are
up so you can take more medicine, you should talk to your doctor and ask if
he/she thinks you too may be suffering from rebound headaches.
Triptan-Induced
The 1988 International
Headache Society (IHS) diagnostic criteria characterize the condition (formerly
known as “drug-induced headache”) as a nearly constant dull head pain that
typically arises after several months or years of overuse of analgesics and
ergots. With the rising popularity
of triptans, however, clinicians have observed a similar but clinically distinct
form of MOH that results from overuse of this class of drugs.
As opposed to the low-grade headache common with other painkillers,
reports of triptan overuse describe a new daily migraine-like headache or an
increase in the frequency of primary migraine attacks.
96 Confirmed MOH Cases
In a new study from Germany,
V. Limmroth, MD, and colleagues from the University Hospital of Essen compared
the features of triptan-induced MOH with those of other medication-caused
headaches.1 They
enrolled 98 patients with MOH, defined as those with more than 10 headache days
per month and intake of any type of acute headache drug for more than 10 days
per month. The researchers excluded
symptomatic headaches through clinical examination, ultrasound, CT scans, or MRI.
Patients whose headaches did not improve one month after withdrawal from
medication also were excluded from the study.
A neurologist interviewed
patients regarding their history of primary headache, their development of MOH
(including drugs, intake frequency, dosages, etc.), and the clinical features of
their MOH. Using this information,
the investigators calculated key statistics such as mean duration of overuse
before onset, average intake frequency, and mean monthly dosage associated with
MOH. They also noted the specific
clinical features accompanying overuse of each class of drug.
Of the 96 patients who
completed the study, 46 (48%) overused analgesics, 12 (13%) overused ergots, and
38 (39%) overused triptans. The
mean duration of overuse before onset was 4.8 years for analgesics, 2.7 years
for ergots, and 1.7 years for triptans. With
very few exceptions, patients who overused analgesics and ergots exhibited the
classic daily tension-type headache that has been well described in the
literature. By contrast, patients
who overused triptans displayed a variety of symptoms: 40% showed an increase in frequency of their primary migraine
attacks, 26% developed a new migraine-like daily headache, and 34% displayed a
daily tension-type headache.
Frequent Triptan Trigger?
An important finding is that
triptan-induced MOH seems to be rising with the increased popularity of these
drugs. “The overuse of triptans
outnumbered the overuse of ergots by a large margin, which is a clear difference
from the results of previous studies,” noted Limmroth, et al.
“This may reflect [the fact] that despite high costs, triptans have
become widely used [and overused], and suggests that triptans are to become the
most important group of drugs causing MOH.”
Triptans induced MOH sooner
and at a lower dosage than the other drugs.
Intake as low as a single dose every third day might be enough to trigger
MOH, the researchers suggested. In
addition, MOH was found in patients taking four types of triptan, indicating
that all triptan formulations may cause MOH.
As they recognize the
increasing likelihood of triptan-induced headache, clinicians also should be
aware of its differing characteristics. “This
study suggests that the pharmacologic and clinical presentation of triptan-induced
MOH is different from that induced by other acute headache drugs such as ergots
and analgesics,”
According to Silberstein and
Welch, the new IHS criteria for MOH describe medication overuse as an
aggravating factor in headache but do not specify the type of headache produced.
Broadly speaking, the elements of the condition, as described in the
revised criteria, include headaches more than 15 days/month and a minimum
medication intake of 2 or more days per week (depending on the substance) for
more than a month. (Table 1 shows
specific criteria associated with each class
To confirm an MOH diagnosis, say Silberstein and Welch, “the only therapeutic maneuver that should be allowed is withdrawal of the medication.”
References
1. Limmroth V, et al. Features
of medication overuse headache following overuse of different acute headache
drugs. Neurology 2002;
2. Silberstein SD, Welch KMA.
Painkiller headache. Neurology
2002;59:972-974.
Excerpted
from the December 2002 issue of Topics in Pain Management.