Medication overuse (rebound) headache (MOH) has been the subject of many studies and reports. Another review of this subject appeared in the latest issue of journal Pain by Italian neurologists. This review addressed possible causes, predisposing factors, and possible treatments. The list of possible drugs which can lead to overuse headaches included in this article includes every possible headache medicine. However, the authors do not mention that for some drugs there is more scientific evidence than for other. For example, only caffeine and opioid (narcotic) analgesics have been proven to cause MOH, while drugs such as aspirin may actually prevent the development of MOH. There is only anecdotal (case reports) evidence for triptans (sumatriptan, or Imitrex, rizatriptan, or Maxalt, and other). The authors suggest that both environmental and genetic factors may contribute to patient’s vulnerability to substance overuse, dependence, and withdrawal in MOH. They also think that psychological comorbidities such as depression, anxiety and poor pain coping abilities may contribute to chronification of headaches.
The authors report on different detox strategies, including the need for hospital admission for patients taking large doses of narcotics or barbiturates (such as butalbital, found in Fioricet, Fiorinal, Esgic). However, almost all patients seen at the New York Headache Center are successfully withdrawn on an out-patient basis. Many patients fear worsening of pain from medication withdrawal, but several treatments can make the process less painful. Botox injections, intravenous infusions of magnesium, topiramate (Topamax), gabapentin (Neurontin) and a short course of steroids are some of the most commonly used strategies. Elimination of dietary caffeine, regular aerobic exercise, biofeedback, and acupuncture are also very useful adjunctive therapies.
Many, but not all epilepsy drugs are also effective in preventing migraine headaches. For example, divalproex sodium (Depakote), topiramate (Topamax), and to a lesser degree gabapentin (Neurontin), pregabalin (Lyrica), and levetiracetam (Keppra) relieve migraine headaches, while other epilepsy drugs, such as phenytoin (Dilantin) and carbamazepine (Tegretol) do not. A report by Drs. Krusz at the annual meeting of the American Headache Society held last month suggests that a new epilepsy drug, lacosamide (Vimpat) may also be effective for the treatment of headaches. Dr. Krusz treated 22 patients with chronic migraines (patients who had more than 15 headache days each month) with this medication and discovered that on average the monthly number of headaches dropped from 21 to 13. Side effects, such as drowsiness, nausea, and cognitive impairment lead 4 patients to stop the drug. Despite very impressive results it is premature to declare lacosamide an effective headache treatment because the study was very small and not placebo-controlled.
Read MoreAspirin and similar anti-inflammatory drugs have been proven to be effective for many migraine sufferers. In a recent report 1,000 mg of aspirin was found to be as effective as 100 mg of sumatriptan (Imitrex) with fewer side effects. Cambia is a new prescription drug, which was recently approved by the FDA specifically for the treatment of migraine headaches. The active ingredient in this drug is diclofenac, which is also sold under Voltaren and Cataflam names. But unlike other forms of diclofenac, Cambia is a powder which patients are supposed to dissolve in a glass of water and drink it. Drinking a solution rather than swallowing a pill speeds absorption of the drug, which can make a difference for those migraine sufferers who need to catch their attacks early, or drugs don’t help. The drug has a “black box” warning, which cautions about possible cardiovascular side effects, as well as gastro-intestinal side effects, including bleeding and ulcers. The cardiovascular side effects of diclofenac are similar to those of Vioxx which was taken off the market. Other NSAIDs also carry risk of cardiovascular (and GI) side effects, but their risk is lower. The only NSAID without cardiovascular risks is aspirin. In fact it is used to prevent strokes and heart attacks. Aspirin is also the only drug which prevents the development of rebound headaches – worsening of headaches from frequent intake of a headache medicines or caffeine.
Read MoreMedication overuse headaches are usually treated by withdrawing the offending drug (usually Excedrin, Fioricet or narcotics, such as codeine, Vicodin and Percocet) or dietary caffeine. About half of the people who stop taking these drugs improve, while the other half does not. A recent study by Dr. Andrew Hershey and his colleagues at the University of Cincinnati suggests that by doing genomic analysis of the blood we may be able to predict who is going to improve by withdrawing overused medication and who is not. This does not mean that the latter group is going to be left to suffer. However, this test could save a major effort that is involved in getting someone off medications. Instead these patients can be maintained on their medication while other preventive treatments are tried. These treatments can include biofeedback, magnesium infusions, Botox injections, prophylactic drugs, acupuncture, CoQ10, butterbur, and other treatments.
Read MoreSevere migraines are often accompanied by nausea and vomiting, making oral medications ineffective. Sumatriptan (Imitrex) and Zomig (zolmitriptan) are available in a nasal spray and Imitrex also as an injection (a needleless injection, Sumavel was launched recently). Nasal spray is not well absorbed and does not work well for many (in my experience, Zomig spray is somewhat better than Imitrex). Injections work fast, but are painful (even the needleless injection hurts) and expensive. Another way to get medicine into the body is rectally. Rectal suppositories are absorbed very quickly and more consistently than nasal sprays. Europeans are much more receptive to this route of administration than the Americans. A group of Italian researchers compared the effect of a suppository containing 25 mg of sumatriptan with a 50 mg tablet. The suppository was slightly more effective than the tablet. Imitrex suppositories are not available, but so called compounding pharmacies can prepare a suppository of any medication, if doctor writes an order. With Imitrex going generic, the price should be more affordable.
There are two other products in development (not yet available), which will bypass oral route – a sumatriptan skin patch and an inhaler of dihydroergotamine (Levadex). The patch is somewhat large and may be awkward to use, while the inhaler is much more promising. Inhaling a drug into the lungs provides very fast onset of action, faster than subcutaneous injection of Imitrex. According to the published data the efficacy of Levadex is very good with few side effects.
Read MoreOccipital nerve blocks can stop a migraine attack when other treatments fail. This is a relatively simple procedure (although not many physicians are trained in it), and it consists of an injection of lidocaine or a similar local anesthetic drug into an area at the back of the head on one or both sides. There are two branches of the nerve – greater and lesser occipital nerves and I usually inject both. The block can help even if the headache is not strictly localized to the back of the head. In some people headache returns after a few hours, once the effect of the local anesthetic wears off. However, a recent study presented at the American Academy of Neurology suggested that up to 60% of patients with an acute migraine may respond without return of the headache. Adding steroid medication to the local anesthetic does not seem to improve outcome. However, occipital nerve block with steroid medication (Depo-Medrol, Celestone, and other) is effective in aborting cluster headaches.
Obviously, occipital nerve block is not practical or necessary treatment for people who respond to oral or self-injected medications, but if these treatments fail such a block is an excellent option. However, even if other treatments fail, we usually start office treatment of severe migraines with intravenous magnesium, which is more effective than any other treatment in those 50% of patients who are magnesium deficient.
Read MoreReview of 16 published scientific articles on the efficacy of naproxen sodium as a treatment of acute migraine indicates that it is effective in the treatment of moderate to severe migraines. Naproxen sodium, 500 mg (2 tablets of Aleve) provided some relief after 2 hours to 45% of patients, complete pain relief to 17% and complete relief after 24 hours to 11%. Aspirin, 1,000 mg (2 extra-strength tablets) has been shown to do better, providing 52%, 27% and 24% of relief, respectively. Both naproxen sodium and aspirin relieve all of the migraine symptoms, including pain, nausea, sensitivity to light and noise.
Read MoreAnxiety and depression occur in migraine patients 2 to 3 times more often than in those without headaches. The opposite is also true, those with anxiety and depression are more likely to develop migraines. Certain antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor), venlafaxine (Effexor), and duloxetine (Cymbalta) have been shown to help prevent headaches. However, when an antidepressant (or any other drug) is being tested for the prevention of headaches, patients with depression and anxiety are usually excluded. This is done to clearly establish if a drug works to prevent headaches directly, rather than indirectly through relieving anxiety and depression. There have been no studies of drugs to treat people who have both conditions. A report by Dr. Morris Meizels published in the current issue of Headache presents cases of three patients with severe migraines and anxiety who did not respond to the usual preventive medications. They did respond very well when he prescribed clonazepam (Klonopin), which is a tranquilizer in the family of benzodiazepines. Diazepam (Valium) and alprazolam (Xanax) are two other well-known members of that family, but they all have somewhat different clinical properties. Dr. Meizels stresses the fact that these drugs are potentially addictive and habituating and should be used in carefully selected patients and under close supervision.
Read MoreOccipital nerve stimulation has been under investigation for the treatment of difficult to treat migraine headaches for the past several years with promising results. A recent study at the Mayo Clinic in
It is very exciting to finally have two published studies (PREEMPT 1 and PREEMPT 2) which provide definitive proof that Botox is effective for chronic migraine headaches. More than 15 years ago a plastic surgeon in California, Bill Binder reported that many of his patients treated with Botox for wrinkles found relief from headaches. Everyone was very skeptical, but having many patients who failed every other treatment and having learned that Botox is very safe if used properly, I decided to try it. To my great surprise Botox worked exceptionally well. My most dramatic experience was in a 76-year-old woman who suffered from daily headaches for 60 years. She had failed a long list of medications, nerve blocks, acupuncture and other treatments. After the first Botox treatment, for the first time in 60 years she went for three months without a single headache. Her neurologist came to my office to learn the technique I developed and has been using Botox in his practice ever since. More than 200 doctors from around the world came to our Center to learn how to use Botox for headaches. They were all searching for new treatments for their desperate patients. At the same time most of the medical community had remained very skeptical and dismissive of this approach. They could not believe that Botox could help headaches and wanted to see double-blind, placebo-controlled trials before using it in their patients. Well, now they have it, but over the past 15 years many of their patients could have benefited from this safe and effective treatment. Yes, we do need proof that any new treatment works, but when this treatment is safe and there are no better alternative, it is appropriate to try it before definitive proof is available. We hope that these two studies will lead to the FDA approval of Botox for the treatment of chronic migraines before the end of 2010, which will make it easier for patients to obtain insurance reimbursement.
Read MoreSome headaches, usually migraines, do not respond to the usual over-the-counter and even prescription headache medications. Once it is clear that there is no serious underlying cause, such as an aneurysm, several injectable medications can be given in an emergency room (during office hours at the New York Headache Center we also give injections in the office). These medicines may include intravenous injections of: magnesium sulfate (which is not a medication, but a mineral), sumatriptan (Imitrex, which can be self-injected by patients at home), ketorolac (or it is also called Toradol, which is a drug in the aspirin family), dexamethasone (Decadron, a steroid drug, which can help pain of almost any type, but cannot be given for long periods of time), prochlorperazine (or Compazine, which is a nausea medication but can help pain as well), valproate sodium (Depacon), and several other drugs.
Read MoreThere are several effective preventive medications for migraine headaches, however they are prescribed to only a small number of people who could benefit from them. A study by Dr. Richard Lipton in the journal Cephalagia and his colleagues discovered that only 13% of migraine sufferers are taking preventive medications, but those who do have significantly less disability than those who don’t. Among possible reasons, doctors who don’t realize how disabling migraines are, patients how think that medications are dangerous or will cause side effects. Cost does not seem to be a factor because all patients in this study had insurance and most of these medications are inexpensive. Patients are often reluctant to take medications, but would rather find and remove the cause. Unfortunately, in most cases migraine is a genetic disorder and true cure is not possible. However, for most migraine sufferers it is possible to find and remove triggers which make headaches worse. If this is not sufficient, magnesium, CoQ10, other supplements, biofeedback, Botox injections, and regular exercise can provide relief without drugs. If all this still does not provide relief, medications, such as anti-depressants, epilepsy drugs, and high blood pressure drugs can be very effective and improve the quality of life.
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