Medication overuse (rebound) headache is a myth
Caffeine and opioid (narcotic) drugs, if taken regularly, are proven to worsen headaches. This will not come as a surprise to anyone drinking large amounts of coffee – skipping your morning cup will leave you with a headache. Taking too much Excedrin, Fioricet, or Percocet will also make you want to take these drugs more and more often and with diminishing relief. However, most neurologists and headache specialists believe that triptans (sumatriptan, rizatriptan, et al.) and NSAIDs (naproxen, ibuprofen, et al.) can also cause “medication overuse headaches”. This remains a belief, rather than a scientific fact and it leads to thousands of headache sufferers being unfairly accused of causing or worsening their own headaches. They are being denied a safe and effective treatment that could relieve their suffering and reduce disability. My most popular blog post that so far has elicited 247 comments, is one on the daily use of triptans.
Drs. Ann Scher of Uniformed Services University, Paul Rizzoli and Elizabeth Loder of Brigham and Women’s Hospital have just published an article in a leading neurology journal, Neurology, entitled, Medication overuse headache. An entrenched idea in need of scrutiny. Last year I described a debate on this topic between Dr. Scher and Dr. Richard Lipton of the Montefiore Headache Clinic at the meeting of the American Headache Society. The abstract of this new article can be easily understood by the lay public, so I am including its full text.
“It is a widely accepted idea that medications taken to relieve acute headache pain can paradoxically worsen headache if used too often. This type of secondary headache is referred to as medication overuse headache (MOH); previously used terms include rebound headache and drug-induced headache. In the absence of consensus about the duration of use, amount, and type of medication needed to cause MOH, the default position is conservative. A common recommendation is to limit treatment to no more than 10 or 15 days per month (depending on medication type) to prevent headache frequency progression. Medication withdrawal is often recommended as a first step in treatment of patients with very frequent headaches. Existing evidence, however, does not provide a strong basis for such causal claims about the relationship between medication use and frequent headache. Observational studies linking treatment patterns with headache frequency are by their nature confounded by indication. Medication withdrawal studies have mostly been uncontrolled and often have high dropout rates. Evaluation of this evidence suggests that only a minority of patients required to limit the use of symptomatic medication may benefit from treatment limitation. Similarly, only a minority of patients deemed to be overusing medications may benefit from withdrawal. These findings raise serious questions about the value of withholding or withdrawing symptom-relieving medications from people with frequent headaches solely to prevent or treat MOH. The benefits of doing so are smaller, and the harms larger, than currently recognized. The concept of MOH should be viewed with more skepticism. Until the evidence is better, we should avoid dogmatism about the use of symptomatic medication. Frequent use of symptom-relieving headache medications should be viewed more neutrally, as an indicator of poorly controlled headaches, and not invariably a cause.”
But this logic also apply to triptan nasal spray. I for one use Zomaltriptan. It’s actually a formulation known as Zomist manufactured by Cipla in India that I was able To buy at a huge discount. From the pharmacokinetics standpoint is there any issue in taking a double dose of Zomaltriptan nasal spray at the first sign of a headache. In my case I have a persistent headache throughout the entire day that sometimes gets worse and that is the time then I would take the double dose. My neurologist also told me to take you two Alleve which potentiates the triptan so I would probably take as well. What are your thoughts on using the double dose of the nasal spray as opposed to the regular pills for ODT in this manner?
I’ve had patients who bought various triptans, including sumatriptan, eletriptan and other while traveling in Europe. For example, a patient recently went on vacation to Italy and bought eletriptan (Relpax) for much less than it is sold for in the US. I would first check the availability and prices of specific triptans in each country because most European countries do not have all 7 triptans available for sale without a prescription.
Thank you. Yes, I know about Healthwarehouse. The issue is getting the Rx. I know that triptans are over-the-counter in the UK & EU and have seriously considered traveling to the UK to stock up. Have you heard of anyone doing this? Is this a crazy idea? I am desperate not to go back to having migraines 3x per week.
You can try to convince your doctor that you are doing much better on 1/2 tablet of naratriptan every night and show him a printout of my blog post. Hopefully, he will agree to give you a prescription for a large number of tablets of naratriptan. Your insurance is not likely to pay for that many, but you can buy 36 tablets for $55 at an online pharmacy HealthWarehouse (see https://www.goodrx.com/naratriptan?dosage=9-tablets-of-2.5mg&form=dose-pack&label_override=naratriptan&quantity=4), but your doctor has to send a prescription there.
Thank you for your help. I have been taking 1/2 tablet naratriptan every night for the past 5+ months and this has greatly increased my quality of life (versus restricting myself to a maximum of 9 doses of any triptan per month). My doctor says I will get MOH but my migraine days have gone dramatically down from ave 3x per week for many years to ave 1x per week for these last 5 months. I’m in a fairly small town and I doubt I can get an Rx for this many pills for much longer. Do you have any advice?
As I mentioned in this post, MOH from triptans is rare. I start with sumatriptan (Imitrex) because it is the cheapest triptan, but if it does not work well enough or causes side effects, I prescribe rizatriptan (Maxalt), naratriptan (Amerge), and all other triptans. Patients with MTHFR mutation often need to take B complex vitamins, including folic acid, vitamins B12 (cyanocobalamine), B6 (pyridoxine), and B2 (riboflavin). There is some evidence that taking these vitamins can help migraines as well.
Over the past 5 months I’ve been getting migraines almost every day. Usually I get about 10 or 14 migraines a month. My doctor the other day said I need to see a neurologist because it could be MOH. All the migraines fit my usual triggers. Plus, I have the MTHFR C677T mutation. I do not want to go through withdrawals! My doctor switched me over to Maxalt instead of Imitrex. Took the Maxalt yesterday, no migraine today! The fear of MOH put me into a bipolar state. I have fibromyalgia and multiple chemical sensitivity all of which add to the migraine problem. Any thoughts?
No, 1/2 tablet is very unlikely to cause medication overuse headaches.
Thank you Dr. Mauskop. My headaches seem to be getting worse these days. I’ve stopped drinking coffee a few years ago but I usually have one coke at lunch time. Could a daily 1/2 tablet of prontalgine cause MOH? (I haven’t been able to find information on the daily amounts of caffeine + codeine that could lead to MOH. I know it is best to avoid them but NSAIDs don’t help + hurt my stomach).
Thank you very much for your help.
Yes, estrogen withdrawal can definitely worsen migraines. 1/2 a tablet of prontalgine taken on 15 days a month is not likely to cause MOH, unless you also drink a 2 cups or more of coffee every day.
Thank you for your insights, it’s a relief to read that some doctors have a different approach to MOH. I live in France, where neurologists and GPs follow this “blaming patients” approach.
I’ve had episodic migraines since I was around 20 years old. These worsened over the past 7 years an taking triptans has greatly improved my quality of life (my migraines were as frequent before starting them). I also take Prontalgine (which contains 400mg Paracetamol, 50mg caffeine and 20mg codeine). I haven’t used it more than 15 days/month (2 tablets) and have reduced my intakes to 1/2 a tablet (which often works with no need to double the dose except for strong migraines).
I had to go off my birthcontrol pill 2 months ago (I had already tried stopping it a few times, each time going through the same symptoms: constant headache and pounding pressure on my forehead, a bit different from my usual migraines). Each time, these headaches develop a few days after stopping B/C (I also had similar headaches whilst pregnant with twins). This time I didn’t resume taking my B/C pill (upon advice from my obgyn), but I’ve taken an average of 1/2 Relpax (20mg) and 1/2 Prontalgine every other day (+ sometimes doubled the dose for stronger migraines).
I also take 15 drops of amytriptyline, which doesn’t seem to help very much (+ not a big fan of its side effects). I tried betabloquants but I am hypotensive so not the best option. Botox isn’t covered in France and the new anti-cgrp drugs are not on the market yet (+ it is unclear whether they will be covered).
My questions are: have you ever seen this type of withdrawal symptom from going off the B/C pill? do you think this dose of Prontalgine might cause MOH? If so, what could I do to be able to function (I’m a translator and this has a terrible impact on my work)?
Many thanks and greetings from France.
This the first time I hear about a doctor telling the patient that Botox is not going to work if she takes Relpax or another triptan. Even patients who take triptans every day can have an excellent response to Botox. If the second round of Botox does not work, trying Aimovig or Ajovy is a good idea. Some of my patients need both Botox injections and Aimovig because each treatment may provide 40-50% relief, while together they can result in an almost complete elimination of headaches. Unfortunately, many insurers refuse to pay for two expensive treatments, so we often continue with Botox and try to get patient a free trial of Aimovig, Ajovy, or Emgality – the latest CGRP monoclonal antibody. We always continue triptans with Aimovig and its cousins, which have no interaction with any other drugs.
I have been on triptains for over 20 years, before that it was a variety of medications, ergots, and the list goes on. What my question is, I am up in Vermont and started my second round of Botox shots and have been told that I cannot take Relpax or any triptain because it would not allow the botox to work, as you have seen with other patients, not taking what I call a miracle drug that gave me back my life to wait and see if the Botox would even work is disturbing. Is that correct, the Botox can not work if triptains are being taken? I would appreciate any help, I was trying to get thru Botox to be able to try Amovig, and again, can you take Amovig while taking Relpax?
Yes! I fluctuate monthly & altho I limit my triptans due to how many times my Dr’s have mentioned MOH, I’ve kept a diary since 2012 & swear I have never had MOH!
Thank you. Very helpful, and mirrors my own experience. I think it’s much easier for some doctors to blame the patient than admit that there is still a lot about migraine that is not fully understood, and that control can be difficult despite everyone’s best efforts.