Treating so-called medication overuse headache
If you are “overusing” acute migraine medications, preventive migraine treatments still work very well. This was the conclusion of a study that was just published in the journal of the American Academy of Neurology, Neurology.
The concept of medication overuse headache (MOH) has remained controversial. The majority of headache specialists believe in its existence. And that is what it is, a belief. There are correlational studies showing that those who take acute migraine drugs tend to have them more often as time goes on. This obviously does not mean that the drug is responsible for the increase in frequency. It is more likely that people take drugs more often because their headaches have gotten worse. There is proof for the existence of MOH only for two drugs – caffeine and opioid (narcotic) pain drugs. Triptans and NSAIDs have no such proof and in my 30 years of experience, they rarely cause MOH.
The daily use of triptans is the topic of my most popular post in the 15 years of writing this blog. It received about 400 comments. Many people commented how relieved they are that taking triptans daily can be safe and effective. They often lament that they can’t get their doctors to prescribe a sufficient quantity of pills.
I am not suggesting that taking triptans daily is the first or second option. It is always better to try Botox and non-drug approaches. Taking a triptan daily, however, is probably safer than taking FRA-approved epilepsy drugs such as topiramate (Topamax) or divalproex (Depakote), or even an antidepressant.
The article in Neurology describes a large study with over 700 participants who were “overusing” acute migraine medications. Half of them were taken off these drugs and started on preventive therapies and the other half were given preventive therapies without stopping acute drugs. Both groups did equally well. This goes against the old dogma that preventive therapies will be ineffective if the daily abortive drugs are not stopped first. The most common preventive treatments in this study were topiramate, Botox, and amitriptyline (Elavil).
Yes, I have occasionally seen an increase in the frequency of cluster attacks with frequent use of sumatriptan injections. The attacks become less frequent when sumatriptan is stopped. The big question is what to do in place of sumatriptan. At times oxygen can help. Also, injections of dihydroergotamine provide longer-lasting relief than sumatriptan without a rebound phenomenon. And we try all the preventive treatments – Emgality, verapamil, lithium, Botox, occipital nerve blocks, etc.
Thank you for this, I’ve been struggling a lot with the guilt/shame associated with taking Sumatriptan when I have a bad migraine.
More recently I’ve developed cluster headaches, and in that community (especially clusterheads) there is a strong belief that Sumatriptan has a similar overuse effect. Many folks there claim they consistently get worse headaches later and/or it extends their cluster headache cycle.
Do you have a point of view on this? I’m curious if you think it’s the same false attribution as in the migraine community you’re writing focuses on.
Thank you, Dr. Mauskop, for continuing to share your belief that triptans rarely cause MOH. I spent the first few years of my chronic migraine journey living in constant fear of taking too many triptans and causing MOH. The result was that I under-treated my headaches and lost many precious days of work and family life because I could hardly get out of bed. Once I got a new doctor who said it was okay to take triptans as often as I needed them (14-20 days/month), my quality of life improved dramatically. Now that I am on two preventive therapies (Emgality and Nurtec), I rarely need triptans more than 6-8 times per month.