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Conari Press, an imprint of Red Wheel/Weiser, LLC  is the publisher of Sharron's book, Migraine: Identify Your Triggers, Break your Dependence on Medication, Take Back Your Life -  An Integrative Self-Care Plan for Wellness," released June, 2013. Follow Sharron on Twitter @murraysharron, and her page Sharron Murray, MS, RN on Facebook, for tips to help you battle your migraines and achieve wellness.

 

Tuesday
Sep172013

Migraine: Three Ways to Avoid Medication Overuse Headaches

Migraine, a largely inherited (genetic) neurological disease with clinical manifestations known as migraine attacks, affects the lives of millions of people worldwide (37-38 million in the United States). For many of us, the majority women, the relentless headache, a phase of the attack, can be excruciating and accompanied by debilitating bouts of nausea and vomiting.

Because our attacks often increase in frequency and severity during the very busiest years of our lives (twenties to fifties) when we are balancing our jobs, family responsibilities, and social obligations, we may inadvertently (often due to gaps in knowledge, poor response, and lack of effectiveness) overuse acute medications (over the counter or prescription) to abort attacks and manage pain, while we attempt to maintain the roles we juggle and keep up with the demands we face. This, as I found out, can lead to medication overuse headaches (MOHs), previously known as rebound headaches.

We should also be aware that we may develop MOHs because of a delay in diagnosis, or a misdiagnosis. For example, in the case of misdiagnosis, because of common symptoms like nasal and sinus congestion, clear nasal discharge and watery eyes, migraine may be misdiagnosed as "sinus" headache and the wrong treatment may be selected.

The International Classification of Headache Disorders, Third Edition  (ICHD-3) defines MOH as headache attributed to overuse of one or more medications. Diagnosis is coded according to the specific medication(s) overused. For example, triptan-overuse headache, simple analgesic -overuse headache, opioid- overuse headache and combination -analgesic overuse headache.

ICHD-3  describes MOH as "Medication-overuse headache is an interaction between a therapeutic agent used excessively and a susceptible patient". It goes on to say that about half of the people with headache on 15 or more days per month for more than 3 months, fit the diagnosis for medication-overuse headache (p. 122). Drugs implicated include:  

  • opioids = to or >10 days per month,
  • combination analgesics that contain opioids, barbiturates, and/or caffeine = to or >10 days per month,
  • simple analgesics including acetaminophen, acetylsalicylic acid, and non-steroidal anti-inflammatory drugs (NSAIDs) = to or >15 days per month, 
  • abortive drugs like ergots, and triptans. = to or >10 days per month, and 
  • multiple drugs for acute or symptomatic treatment of headache (we may not be able to give an adequate account of names or quantities) on 10 or > days per month for > 3 months.

We need to know that medication overuse (regular use on 10 or 15 days per month, for more than 3 months, depending on the medication) is considered to be a risk factor for the progression of episodic to chronic migraine. Episodic migraine (EM) refers to migraine attacks that occur with less than 15 headache days/month. Chronic migraine (CM) refers to attacks that occur with headache (tension-type-like and/or migraine-like) days more than 15 days/month for a period greater than three months, with features of migraine equal to or >8 days per month.

"Clinical evidence shows that the majority of patients with this disorder improve after discontinuation of the overused medication, as does their responsiveness to preventive treatment" (p. 122). 

In my case, unaware of the chance of MOHs, as I took more and more Imitrex to treat my attacks, I progressed to CM, with headaches every day of the month for a number of years. If you think you may be experiencing MOHs, here are some suggestions I have to help you break the cycle of overuse, prevent the progression of episodic to chronic migraine, and improve the quality of your life:

  • First, to avoid medication overuse do not exceed your recommended dose, or take the medication more often than your doctor, or the label on the container, has recommended. If a medication is not working for you, ask your doctor to switch you to one that might be more effective. If you are not on a preventive medication, ask your doctor about one. 
  • Second, if the route of administration is not working for you, ask your doctor to switch you to another one. For example, if you cannot keep the pills you swallow down, a sublingual form, nasal spray, injection, or rectal suppository may be more beneficial.
  • Third, if the frequency and severity of your migraine attacks persist no matter what, or how much, medication you ingest, you might want to do what I did when I found I couldn't keep taking Imitrex to manage my attacks and maintain the hectic lifestyle I loved: consider incorporating acupuncture or one of the other integrative therapies like biofeedback, behavioral modification (cognitive behavioral therapy), meditation, mind-body exercises such as tai chi and yoga, and/or energy healing techniques like Reike and healing touch into your treatment plan. 

These therapies can help balance our nervous systems, stabilize our serotonin levels, increase our endorphins, and thus decrease the frequency and severity of our migraine attacks. As well, because these therapies permit our bodies to relax, facilitate digestion, and allow our energy and blood to circulate freely, they can enhance the effect of the medication we take, and reduce the amount we require.    

Keep in mind, we need to have an accurate diagnosis for our headaches; our doctors should be aware of any integrative therapies or treatments we incorporate into our treatment plans, including herbs and supplements; and, we should never discontinue, or wean ourselves off, any medication without our doctors' consent. 

Keeping a daily diary is a good way to help our doctors diagnose and manage both chronic migraine and medication overuse headaches.

Reference:

International Headache Society (2018). "The International Classification of Headache Disorders" (3rd Edition). Cephalalgia. Vol. 38(1) 1-211.

Sharron Murray MS, RN is an author and coauthor CaMEO Study, "Life With Migraine". Currently, Sharron is active in the migraine community as a writer, advocate, American Migraine Foundation Partner, moderator for the American Migraine Foundation "Move Against Migraine" Facebook Group, and member of the National Headache Foundation Patient Leadership Council. 

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN 

This article is not intended as a substitute for medical advice. If you have any specific concerns about your health or nutrition, please consult a qualified health care professional.

Updated February, 2019

Copyright September, 2013 Sharron E. Murray

 

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  • Response
    These are few ways to avoid over medication to get rid of the headache. It is the dangerous if the humans are engrossed and indulged in headache of the over medication. It is the interesting tip for the smoothness and healthy living.

Reader Comments (2)

Hi Sharron,

Great write up about avoiding medication overuse headache! May I add to your recommendation to not exceed the label or your doctor's direction. Many of the medications which can cause medication overuse headache are available over-the-counter in pharmacies. Pharmacists and pharmacy assistants should trained to discourage people from using pain relievers on more than 10 days a month to treat headaches. This would go a long way to help prevent medication overuse headache.

I would be interested to hear your thoughts.

Kind regards,
Phil Spyrou (B. Pharm)

May 22, 2015 | Unregistered CommenterPhil Spyrou

Hi Phil,

Pharmacists are certainly in a position to help us keep track of the amount of medication we are taking for headaches associated with a migraine attack or other headache disorders. As well, they can encourage us to see our doctors for an accurate diagnosis of our headache disorder and, in the case of migraine, a prescription for a preventive medication should it be appropriate. What we really need to decrease medication overuse headaches associated with migraine is effective migraine-specific acute medications (analgesics and abortives) and preventives. Thank you for your comment. Much appreciated.

June 4, 2015 | Registered CommenterSharron E. Murray

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