Janet, a single 35 year-old teacher in Atlanta, Georgia writes:
“I’ve had headaches all of my life, or at least as long as I can remember. Not a day goes by that I don’t have some sort of headache. Not a week goes by that I don’t spend a day or more lying in bed with a cold rag on my forehead, trying not to vomit. Headaches are a way of life for me, and I’ve learned to live with them. I’ve been on every migraine medication there is, but nothing has worked. The only relief I get is from Lortab. I don’t like the way it makes me feel, but at least I can function. My doctor will only prescribe 30 Lortab pills a month. I’ve tried to explain to him that sometimes I have to take 3 or 4 pills in one day, and 30 is not enough, but he refuses to prescribe more. Why won’t he give me more medication? I am NOT a drug addict, although he makes me feel like one.”
The Doctor's Reply
Janet has an all too common problem. She has chronic migraine, but none of the therapies typically prescribed to prevent or suppress chronic migraine have been effective for her, and nothing has helped other than Lortab (a combination of an opioid, hydrocodone, and acetaminophen). She’s right; as with the great majority of patients like her, Janet is not a drug addict. Instead, she’s struggling to escape the grip of her migraine.
Despite the advances that have been made in migraine therapeutics, the grim reality is that, like Janet, many patients with chronic migraine either cannot tolerate those therapies or simply do not respond. When Janet found a medication intended for “symptomatic” (acute) migraine treatment that helped temporarily reduce her head pain, she understandably wanted more. Given more medication, such patients often fall into a pattern of symptomatic medication overuse. It’s estimated that 50% or more of patients with chronic migraine overuse symptomatic medication.
Medication overuse headache is popularly known as rebound headache. In using this term patients often are mistaking the early recurrence of an incompletely treated acute migraine headache for the slow and sneaky worsening of a headache disorder that may occur with chronic symptomatic medication overuse.
The medications implicated in causing medication overuse headache range from the “simple” analgesics such as acetaminophen to much more potent drugs such as the opiates (eg, codeine) and opioids (e.g.s, hydrocodone, oxycodone). Because it is so readily available and can be quite effective in treating acute migraine headache if taken early, Excedrin or its generic equivalent is one of the most commonly overused symptomatic medications.
Current theory is that use of a simple analgesic 15 or more days per month for 3 or more consecutive months will produce medication overuse headache and that use of an opiate, opioid or butalbital (a shortacting barbiturate found in compound medications such as Fioricet, Esgic or their generic equivalents) will do the same after 10 or more days of use for 3 or more months. Some investigators have warned that even less frequent use of symptomatic medication may increase the chance of the migraineur with episodic migraine eventually developing chronic migraine. And even worse, preliminary research has demonstrated that baseline overuse of an opiate, opioid or butalbital significantly decreases the chance that a patient with chronic migraine will respond positively to topiramate or serial BotoxA injection therapy.
Perhaps for now it’s best for Janet to restrict her use of opioids and try as an alternative an acute/symptomatic medication less likely to reduce the effectiveness of topiramate or BotoxA. Given that she may require a course of prevention therapy and that these two therapies and Aimovig currently are the leading evidence-based treatments for use in suppressing chronic migraine, it only makes sense to give her the best chance she can have for a positive response.