VoLUME 8, ISSUE 5  
september 2003

September 9th Meeting: Migraine Update and Overview

The East Bay Headache Support Group is pleased to have Michael J. Nelson, MD, as our guest speaker on September 9, to provide us with an overview of the migraine condition, and an update on the latest medical treatments.

Dr. Nelson is a neurologist in private practice at the Neurology Medical Group of Diablo Valley, with offices in Walnut Creek and Concord.  He has been a subinvestigator in many research studies, evaluating the effectiveness of new drugs in treating various neurological disorders. 

We will be meeting in the Ball Auditorium, downstairs at John Muir Medical Center, from 7:30 to 9:00 p.m. on Tuesday, September 9.  For more information, call 925-685-8775.

5th Annual  
Women’s Health Fair

 Visit the Women’s Health Fair presented by the Women’s Health Center, part of the John Muir/Mt. Diablo Health System. This FREE event will be held 2 days this year, Saturday and Sunday, October 18 and 19, from 11:00 a.m. to 4:00 p.m. at the Women’s Health Center and adjoining Grower’s Square Pavilion.  The address is 1656 North California Boulevard in downtown Walnut Creek. 

Stop in to say hello at the East Bay Headache Support Group booth, and then check out the other resources and businesses which offer services and products specific to women and their families. 

Leslie Griffith, award winning FOX 2 News Anchor, will speak at the opening ceremonies on Saturday at 11:00 a.m.

As a prelude to the Health Fair, the Women’s Health Center is presenting a series of FREE evening lectures by area experts on women’s health issues.  All lectures are held at the Women’s Health Center from 6:30-8:00 p.m.  Space is limited—Please call 925-941-7900, #3 for reservations.

Sept 9: Minimally Invasive Approaches to Hysterectomy, Robert Cole, MD, OB/Gyn

Sept 10:  Infertility Update 2003 — What’s New!  Stephen Weinstein, MD, OB/Gyn Infertility Specialist

Sept 17:  Menopause:  Debunking the Myths- Alternative Therapies vs HRT, Hope Rubin, PA, Women’s Health Specialist

Sept 24:  Headaches Through the Decades of a Woman’s Life— From Adolescence to Menopause,           Michael Stein, MD, Neurologist, East Bay Headache Support Group Advisor

Sept 25:  HRT:  The Good, the Bad and the Confusing!  Sondra Altman, MD, Gynecologist  

Oct 7:  Are You at Risk? Finding Out Your Real Risk for Breast Cancer, Angela Musial, MS, CGC Geneticist,

The Over-the-Counter Risk

They’re cheap, they’re easily accessible, and there are so many kinds to try.  Most of us have two or three brands in our medicine cabinets.  No doctor’s prescription needed and often quick relief.  They, of course, are over-the-counter (OTC) pain medications.  Close to 60% of migraine sufferers self-medicate with OTCs and it’s now a multi-billion dollar industry.

But while analgesics may seem safe, these quick fixes can actually pull you into the quicksand of rebound headache.  In fact, the overuse of analgesic medications is responsible for the majority of cases of chronic daily headache.  Short-term pain relief reached for too frequently and over an extended period of time can lead to a long-term headache.

Rebound headache has also been called medication-overuse headache, analgesic-induced headache, and refractory head-ache.  It describes a condition in which patients experience daily or almost-daily headache as a result of overusing pain relief medications, and who experience a delayed recovery after the medications are stopped.

The Problem May Be in Your Medicine Cabinet

While there are varying opinions as to which medications cause rebound, Dr. Tim Smith, Medical Director of Ryan Headache Center in Chesterfield, Missouri, believes that “just about any symptomatic medication for headache, if taken enough, can cause rebound.  We used to think that only certain medications did, but there are patients who can even rebound from triptans.”

In other words, any of the immediate headache relief medications—analgesics, barbiturates, ergots, triptans, and caffeine—if overused can lead to rebound.  The greatest problems seem to be associated with OTC caffeine-containing analgesics (even those marketed for migraine) and barbiturate-containing analgesics.

While rebound can develop more quickly with triptans than with OTC analgesics, overuse of triptans is rarer due to the higher costs and limits placed on their use by healthcare providers and insurance plans.  Anti-inflammatories are generally not associated with rebound, especially the longer-acting prescriptions.  However, even ibuprofen, plain acetaminophen and aspirin can be triggers.  “It does happen,” said Dr. Smith.  “I’ve seen it, but it’s not as likely.”

The current belief is that three or more doses of simple analgesics per day for five days or more per week can lead to rebound.  Sedatives, caffeine or triptans taken three or more days per week can cause the condition as can opioids or ergotamines taken two or more days per week.

Rebound is an insidious condition based on a cumulative effect.  It develops slowly, over weeks, months or years, and is rarely recognized by the person caught in the cycle, or even by their healthcare provider, who may be unaware that the patient is taking OTCs or even of the condition itself.

A Self-Perpetuating Problem

While the underlying pathology of rebound is still not completely understood, new scientific observations are helping unravel the mystery.  Research has shown that when an individual takes repeated doses of analgesics, which lower serotonin levels, the brain reacts by multiplying the number of serotonin receptors, especially the 5HT2 receptors.  These 5HT2 receptors are responsible for bringing on migraine. 

“In a nutshell,” said Dr. Smith, “when used in a repeated fashion over time, simple analgesics alter serotonin levels in the blood and brain, leading to a chain of events that cause a hyperalgesic state, meaning a high sensitivity to pain.”

Dr. Smith noted that people who don’t have migraine and take analgesics for such conditions as chronic back pain or arthritis don’t get rebound.  “With migraine you already have a defective serotonin system and the central nervous system is already susceptible.  The process of taking analgesics further changes the central nervous system function and worsens the pain.”

Rebound, then, is a self-perpetuating condition.  Over time, the headache patient develops a tolerance to the offending analgesic and so she/he increases the dose.  This alters the serotonin balance even more and the headaches return.  The patient ups the dose once again and the cycle continues.

“My record holder was a woman who was taking 35 OTC tablets per day,” said Dr. Smith.  “The amount she took grew progressively over years, but by the time I saw her nothing was working for her headaches and she was miserable.”

High doses of analgesics can have other ramifications.  Gastric irritation (heart burn, stomach aches), sleep disturbance from caffeine, and mood changes (possibly due to serotonin changes) are the most common.  Dr. Smith added that there are hidden effects as well.  Some analgesics taken over time can be injurtious to the kidneys and the liver, while aspirin thins the blood and puts patients at risk for bleeding ulcers.

Of course, nobody develops rebound on purpose.  “They’re just trying to get through their day,” said Dr. Smith.

How to Know if It’s Rebound

As the condition worsens, patients often start taking pain medications in an anticipatory fashion, say before going to work.  Some will even set their alarm clocks for the middle of the night in order to take another dose so they won’t wake up with a headache.  If you’ve reached this point, it’s a fairly clear indication that your solution is in fact your problem.

 “If a patient is taking medications more than two times per week for more than three months,” Dr. Smith said, “they’re probably already in trouble.”

Since there’s no blood test for rebound, the diagnosis can actually only be made in retrospect, once a patient has withdrawn from the offending medication(s) and relief is obtained.  But there are other clues.

Often the sufferer has a history of migraine.  Over time, migraine symptoms such as nausea and noise and light sensitivity diminish and headache of a duller nature become more frequent.  Preventive medications do not have any effect on patients with rebound and stopping the medications for a few days does not resolve the problem—in fact, it often temporarily makes the headache worse (hence the term “rebound”).

Once the condition is established, the pain medication does not need to be taken daily.  At that point, rebound headaches will continue if the drug is taken as infrequently as once a week or even, in some cases, once a month.

Breaking the Cycle

Here’s the kicker—without complete discontinuation of the offending medication(s), rebound headache is almost impossible to get rid of, but it takes up to three months for serotonin levels in the brain to normalize and rebound head-ache to resolve.  “Three months is a stiff sentence for someone dependent on these medications,” admitted Dr. Smith.

Treating rebound takes time and patience.  Patients must completely avoid using analgesics not only for headaches but other painful conditions.  Some patients are able to use the “cold turkey” approach, but others may need bridging or transition programs, which use medications to lessen the blow.  About half of rebounders will notice an increase in the intensity of their headaches for one to two weeks.  Because those first two weeks are always the hardest, that’s the most important time for healthcare providers to be involved.

“Studies show that patients who make nonpharmacologic changes, as well as taking preventives, do better with the detox,” said Dr. Smith.  These nonpharmacological approaches include biofeedback to lower stress levels, regular sleep, and healthy eating.

Dr. Smith noted that after breaking the cycle, patients feel like they’re coming out of a fog.  “A cloud has been lifted; they look brighter.”

About 75% of patients who go through withdrawal will revert back to an intermittent pattern of headaches that are more treatable.  However, one third will start taking OTCs intermittently and end up back in a rebound pattern.

The message is, once you get detoxed, don’t go back.  Better yet, don’t get started in the first place.

Having seen so many patients suffering from rebound headaches, headaches specialists know how important it is to get the message out about the condition in order to stop rebound before it starts.  “This is the biggest problem we face,” said Dr. Smith.  “Not enough people know about this.  Patients don’t pay attention to the warnings on the label and doctors often give their blessings.  We need to educate doctors to be looking for this.  This thing is real.” 

WHEN IS IT OK TO TAKE OVER-THE-COUNTER MEDICATIONS?

Acetaminophen, aspirin, ibuprofen, and aspirin/acetaminophen/caffeine combination products have all been shown to be more effective than placebo at reducing moderate to severe migraine pain within two hours.  So, “If a patient gets a good response from them, then that’s #1,” says Dr. Smith.

The general rule of thumb is don’t take analgesics more than two times per week.  If you are, that’s a warning sign.

According to Richard Wenzel, pharmacist at the Inpatient Headache Unit at St. Joseph’s Hospital in Chicago, whose article “Over-the-counter medications for acute migraine attacks” was in the April edition of Pharmacotherapy, “Patients who experience disability during the predominance of their attacks are poor candidates for OTC exclusive therapy and should seek a physician’s help for migraine-specific medications.”

Since the majority of migraine sufferers experience disability—defined as an inability to perform routine job, school, and/or household activities, and/or the need for bedrest—OTC therapy is usually inadequate.  Wenzel notes that for migraine sufferers who experience disability during fewer than half of their migraine attacks and/or vomiting in fewer than 20% of attacks, sole use of OTCs may be a viable treatment option.

The best candidates for OTC use are those with tension-type headache characteristics—a constant, dull ache on both sides of the head, mild to moderate in intensity, possibly accompanied by sensitivity to either lights or noise, but not both. 

Wenzel counsels patients to treat a minimum of three attacks with a new OTC.  If the drug doesn’t work in at least two out of three attempts, try a new one.  If two or more OTCs have been tried without success, speak to a physician or headache specialist. 

By Lesley Reed

Excerpted from the May/June 2003 issue of NHF HeadLines, a bimonthly publication of the National Headache Foundation.  On the Internet at www.headaches.org