“I have a bad head almost daily. I use painkillers to keep going at work but really the tablets just take the edge off the pain. I’ve tried every other possible drug and diet but nothing works. This is not like the infrequent migraines I used to get when I was younger”

What is it?

Some people find that their migraine gets more and more frequent. The natural thing to do is to take more migraine tablets. People with migraine know that early treatment of an attack, works better than late treatment. It’s easy to take medication “just in case”.

It’s a very odd thing about migraine, which doesn’t happen with other types of head pain such as cluster headache: the more you take a short term or rescue treatment for migraine, the more it tends to come back after the medication wears off.

How much medication is too much?

The official definition requires three months of head pain at least as often as not, with 15 doses a month of ordinary painkillers like aspirin, paracetamol, or ibuprofen; 10 doses a month of triptans, opiates, or combination drugs (e.g. paracetamol and codeine).

The surprising thing is that you only have to take paracetamol once every other day, or a triptan every third day, to get medication overuse headache, if you also have migraine.

Pattern of use is important. Short term high usage can be OK; the steady drip drip drip of painkillers or triptans over many months is not.

Which medications cause it?

Most people with medication overuse headache are taking combination drugs, particularly paracetamol/codeine combinations. But any drug used in the short term to abort migraine, can cause medication overuse headache. Some drugs such as naproxen, diclofenac and indometacin can cause medication overuse headache when used as and when required;  but the same drugs taken absolutely regularly three times a day, can be helpful for medication overuse headache.

How easy is it to put right?

The simple answer is just to stop the overused medications. This is easier said than done. It is reasonable to have time off sick, and to ask for help or support from family and friends, while doing this. The graph shows what happened to a large group for patients in the 1980s that stopped using frequent painkillers.

medication overuse

Source: Schuman E. Another Comment on “Drug Induced Refractory Headache”. Headache: 2008;48(8):1242

 

The first group (marked as triangles) carried on with their acute rescue medications and didn’t improve much over 12 weeks.

The second group (squares) abandoned their acute rescue medications. There was transient worsening but they were “past the hump” after 3 or 4 weeks and then gradually improved.

The third group not only quit their acute rescue medications, but also started a regular preventative. They were past the same “hump” of transient worsening in a couple of weeks.

Should another drug be added?

Some experts used to think that adding in other drugs, in the case of medication overuse headache, was a waste of time. Recent studies of topiramate and Botox show a modest benefit from starting these treatments, in addition to continuing frequent acute rescue medications. But these benefits are relatively small and the strong consensus is that medication overuse needs to be addressed before other treatments work well.

If you think you may be able to cope without starting another drug, then it may be best to avoid one, as all drugs can have side effects.

Many experts think that adding the painkiller naproxen, taken absolutely regularly 250 mg or 375 mg three times daily after meals, makes stopping acute rescue drugs a little less difficult. The main side effect of these drugs is acid indigestion. Normally this needs be taken for no more than three months. Nausea or vomiting can be treated with domperidone (Motilium) 20 mg three times daily before meals. Alternatively, drugs like amitripyiline, topiramate, or Botox could be used. A short course of oral steroids, or a greater occipital nerve block, can also be considered.

How do drugs make migraine worse?

An attack of migraine eventually goes away with no treatment. The brain has natural mechanisms that make this happen. The more you help the brain, by using medication to do this, the less well the brain manages this on its own, without medication. It takes a few or several weeks for those mechanisms to recover.

Should I cut out medication suddenly?

Sudden abrupt cessation works best for most people. It’s tough for the first couple of weeks.

Gradual cessation can seem gentler, and can be effective. The first problem is difficulty establishing exactly how often you take medication, to give a starting point from which to work down.  Most people don’t like taking medication, so take the minimum that can to keep going; so what’s the point in taking less than the minimum? Also, phasing out these drugs gradually can just prolong the agony.

So, how many painkillers can I take?

Some experts think that, once you have a problem with frequent migraine or headache, and over-frequent medication, there has to be a period of zero acute rescue medication. Others believe that as long as you’re below the threshold of 10-15 doses a month, all is well; but if that doesn’t work for you, try absolutely zero acute medication.

What next?

After two months of addressing medication overuse, ideally with no short term drugs at all, there are three possible headache outcomes.

Firstly, zero headache. This obviously requires no treatment.

Secondly, occasional migraine or headache. This requires careful targeting of acute rescue, with the right drugs taken at the right time. This usually means aspirin 900mg or ibuprofen 600mg,  dissolved in water and accompanied by domperidone 20mg tablets; alternatively or additionally, a triptan. Avoid drugs that are sold as combinations, and particularly avoid opiates such as codeine. It is best to avoid paracetamol too as this is a quite a weak drug for migraine, compared with aspirin.

Thirdly, frequent migraine or headache. This needs to be treated with regular planned medication, and careful occasional use of acute rescue drugs. Regular drugs that have been ineffective during medication overuse may become effective thereafter.

Medication overuse headache tends to happen to people with bad migraine so there is a high risk of it recurring. It is therefore important to avoid this, with careful attention to lifestyle triggers, restricted use of rescue remedies, and reconsideration of the use, dose and nature of regular planned medication.

Triptan overuse

When the only overused medication is a triptan, people usually settle more rapidly after cessation, than with other acute drugs. This is because triptans have a more specific action on migraine, than painkillers. People who overuse only triptans, and not painkillers, often settle in about a week after complete cessation. It is possible that Frovatriptan, which lasts in the body almost ten times longer than other triptans, may be the least bad triptan to overuse.

Bottom line

Infrequent migraine or headache can be treated with occasional carefully targeted medications.

Frequent migraine should be treated with a medication taken absolutely regularly, or with no medication.

 

 

This information is provided as a general guide only and is not a comprehensive overview of prescribing information. If you have any queries or concerns about your headaches or medications please discuss them with your GP or a doctor at the National Migraine Centre.