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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
Apr222014

Effective use of medications for migraine relief -5 Ways to overcome unmet needs and improve our treatment outcomes

 

"Half of the modern drugs could well be thrown out of the window, except that the birds might eat them." -Martin Henry Fischer

In the throes of a violent migraine attack, we all want a drug that will eradicate our pain. Unfortunately, for many of us, such a drug does not exist. In an effort to relieve our pain, we plow through unpleasant side effects of our medications, may exceed the recommended dose of one or more of the drugs we take, accidentally take too much of a drug, or take a medication more often than we should and end up with medication overuse headaches (MOHs). We become vulnerable to anything, or anyone, that offers to put an end to our agony in the name of a "cure" and, in our frustration, may feel like tossing the lot of our medications out the window.

In an important step toward reducing barriers to our care and improving treatment outcomes, a recent study examined  unmet treatment needs among persons with episodic migraine (Lipton, Buse, et al, 2013). Results showed the three most common unmet needs were:

  • moderate or severe headache-related disability,
  • treatment dissatisfaction related to efficacy (effectiveness), safety and overall satisfaction of a comprehensive list of acute and preventive medications, and
  • excessive opiods and/or barbiturate use or probable dependence.

To help us overcome these unmet needs and achieve optimal therapy, this article adapts physician guidelines for successful migraine management (American Headache Society, PDF), as patient-centered strategies. Let's take a look:

1. Establish a partnership with our physicians:

  • The role of our physicians is to help us understand the nature and mechanism of migraine disease and the non-pharmacological and pharmacological options that are available for treatment. In other words, our doctors are guides to help us make wise choices for our migraine treatment programs, including how they fit into our overall health.
  • Our role as patients is to reach the best possible decision about choices for treatment through an educated discussion with our doctor. This should involve an evaluation of our lifestyle, as well as attitudes and beliefs about taking medication (side effects), herbs , and supplements .

 2. Educate ourselves:

  • To facilitate an educated discussion, ask questions and encourage a dialogue with our physicians.
  • Listen to the answers with an open mind.  For example, you may want a medication your doctor denies out of concern for your overall health, or that the medication may harm you. In my case, the best thing a doctor ever did for me was tell me he wouldn't refill my Imitrex prescription for 18 pills a month.
  • If you are confused about the information your doctor relays, ask for clarification. Knowledge gives us a feeling of empowerment and helps us actively participate in our management program. In the same example, this stunning news came in a visit to a new doctor. When I asked for clarification, he told me I had MOHs (known as rebound at that time) and we would have to explore other ways to manage my attacks.

3. Work with our physicians to set realistic goals

  • While being completely pain-free might not be an option, decreasing the severity of pain and frequency of attacks is achievable.
  • Given our individual situations, identify ways to reduce the frequency of our attacks and limit the negative effects of migraine on our daily lives. In my case, my doctor and I decided that I needed to be more diligent about trigger management; eating and sleeping habits; participation in the biofeedback and diaphragmatic breathing exercises I had been taught, but rarely practiced; and, give acupuncture a chance. As well as decreasing the frequency of my attacks, this plan allowed me to wean off Imitrex at my own pace, without any harmful effects.
  • If preventive medication is going to be part of our therapies, identify side effects that we find intolerable. In my situation, I have a condition, which makes me blister from many preventive medications, including antiepileptics. As well, I like to exercise, which rules out beta blockers like propranolol. Other examples include, if weight is a problem for you, drugs with a high risk of increasing weight should be avoided.

4. Work with our physicians to establish a tailored, non-pharmacological treatment plan:

  • Keep a diary (notebook, electronic, or you can always mark up a calendar like I did) to help our doctors identify possible triggers and suggest strategies to help us minimize or avoid them.
  • A diary can also help our doctors recognize the frequency and patterns of our migraine attacks, identify the severity of our pain and functional disability; assess the effectiveness of our treatment; and, recognize the need to adjust doses, alter routes of administration, and add, or change our medications.
  • Adopt healthy lifestyle habits, including regular sleeping, eating and exercise patterns. 
  • Participate in stress management  and relaxation strategies such as cognitive behavioral therapy, biofeedback, meditation, and diaphragmatic breathing techniques. Besides helping us relax and decreasing the frequency of our attacks, some of these techniques can reduce gastric stasis and allow our medications to be absorbed faster. 
  • Keep in mind, although non-pharmacological therapies produce a slower response than pharmacological interventions, they allow us to have an active role in our program.
  • Note, non-pharmacological therapies are particularly important when we have comorbid conditions, such as cardiovascular disease, that may limit our drug options. 

5. Work with our physicians to establish a tailored, pharmacological treatment plan:

  • Given our individual situation and the frequency and severity of our attacks, our treatment plan may include acute and preventive treatment.
  • Acute treatment may involve over-the-counter (OTC) and prescription medications to treat our pain and other symptoms during an attack, such as aspirin; acetaminophen; non-steroidal anti-inflammatory drugs (NSAIDs); combination analgesics that contain caffeine, opioids and/or barbiturates*; neuroleptics/antiemetics; and, corticosteroids. As well, we may be prescribed medications to abort an attack at the onset or stop its progression to severe pain, such as triptans and ergotamines. Acute medications have been classified into categories related to their effectiveness (Marmura, M.J., Silberstein, S.D., & Schwedt, T.J., 2015).
  • We need to be aware that excessive amounts of acetaminophen can result in severe liver injury, while over indulgence in NSAIDs comes with increased risk of gastrointestinal and cardiovascular disorders. As well, using multiple drugs at the same time, alcohol consumption, and combining medications with herbs and supplements, without our doctor's knowledge, can increase can our risk for a number of other problems, including bleeding disorders and poor renal function.
  • If we use acute therapy more than 2 days per week, we need to talk to our doctor about preventive therapy to reduce our risk for MOHS, and the chance of progression to chronic migraine. Preventive therapy may be started earlier if triptans and ergots are contraindicated because we have vascular disease, or if our response to acute medication is poor.
  • Preventive treatment may involve long-term therapy with daily administration of prescription medications proven to be effective to decrease the frequency of our attacks. These medications have been classified into categories related to their effectiveness (Silberstein, 2012) and include: antiepileptic drugs, beta bockers, antidepressants, ACE inhibitors and calcium channel blockers. Currently, Botox (botulinum type A) is only approved as a preventive for chronic migraine.  
  • With preventive therapy, we need to be aware that unpleasant side effects may limit our tolerance and decrease our compliance. As side effects are different for every medication, we need to be sure our doctor communicates adverse effects on initiation of each medication. Some of the less tolerable adverse effects you might want to ask about include weight gain, memory loss, depression, and drowsiness. 
  • On the other hand, with preventive therapy, we need to know that if we work with our doctor to select a preventive medication that can work for comorbid disorders we may have, this can treat both (or more) of these illnesses at the same time. For example, if you have sleep disturbances, depression, or neck pain, amitriptyline may be a good choice; or, if you have hypertension and anxiety, a beta blocker may be the best medication for you. As well, a preventive medication should take our lifestyle into consideration; and, our doctor needs to be aware of all the medications, herbs, and supplements we take to avoid potential drug interactions.
  • If adverse effects become intolerable, we need to communicate this to our physician so the daily dose of the drug can be tapered down, eventually stopped and, perhaps replaced with one that is more acceptable.    

*A word about opioids and barbiturates

We need to be aware that recent studies show opioids do not work well in migraine. In assessment of the frequency of opioid use for acute migraine treatment (Buse, Pearlman, et al, 2012), results demonstrated opioids are associated with more severe headache-related disability; comorbidities like depression, anxiety, and cardiovascular disease; increased headache frequency, and, increased headache-related health care resource utilization. Other reports indicate opioids interfere with triptan effectiveness, increase response to pain stimuli (hyperalagesia), prevent reversal of migraine central sensitization and increase the progression of episodic to chronic migraine (Tepper, 2012, Johnson, Hutchinson, et al, 2013). In a review of MOH (Tepper, 2012), use of any opioids and barbiturates was reported to increase the likelihood of transformation (chronification) from episodic to chronic migraine. The report goes on to say opioids and butalbital should be avoided in acute migraine treatment. As well, we should know that data from the AMPP revealed opioid users were more likely to be occupationally "disabled" compared with nonusers and users with probable dependence were more likely to be "on disability" (Lipton, Buse, et al, 2013).       

Given the information addressed in this article, it would seem the role of effective communication between ourselves and our doctors is crucial to help us overcome our unmet treatment needs and achieve optimal therapy. For us, we need to listen to our doctors and respect them for their knowledge. For our doctors, they need to listen to us and know "the most important part of the patient is the person inside of the patient" (Girgis, 2014).    

Note:

"To provide healthcare professionals with updated guidance in the use of novel preventive and acute treatments for migraine in adults", The American Headache Society published a "Postion Statement On Integrating New Migraine Treatments Into Clinical Practice", Headache: The Journal of Heada and Face Pain/ Volume 59, Issue 1, December 10, 2018. The statement includes a discussion of the emerging preventive options , "the new CGRP drugs". as well as neuromodulation devices and evidence-based complementary therapies like Cognitive Bhavioral therapy , Biofeedback, Meditation and Relaxtion Techniques.  

References:

American Headache Society. "Acute Migraine Treatment." PDF. Retreived May 5, 2014 from www.americanheadachesociety.org/.../NAP_for_Web_-_Acute_Treatment_of_Migraine.pdf

Buse, D.C., PhD.,  Pearlman, S.H., PhD., et al. (2012). "Opioid use and dependence among persons with migraine: results of the AMPP study." Headache. Jan;52(1):18-36. doi: 10.111/j. 1526-4610.2011.02050.x.  

D'Amico, D., Tepper, S. (2008). "Prophylaxis of migraine: general principles and patient acceptance." Neuropsychiatr Dis Treat." Dec;4(6): 1155-1167. Retrieved May 5, from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646645/

Girgis, L., M.D., (2014). "Marcus Welby versus the 21st Century." Medcity News.  

Johnson, J.L., Hutchinson, M.R., et al. (2013). "Medication-overuse headache and opioid-induced hyperalgesia: A review of mechanisms, a neuroimmune hypothesis and a novel approach to treatment." Cephalalgia. Jan;33(1):52-64. doi: 10.1177/0333102412467512. Epub 2012 Nov 9.

Lipton, R.B., M.D., Buse, D.C., PhD., et al. (2013). "Examination of Unmet Treatment Needs Among Persons With Episodic Migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study." Headache. Sep;53(8):1300-11. doi: 10.1111/head.12154. Epub 2013 Jul 23.

Marmura, M.J., Silberstein, S.D., & Schwedt, T.J. (2015). "The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies". Headache. 55;(1):3-20.   

Murray, S., M.S., R.N. Migraine:Identify  Your Triggers, Break Your Dependence on Medication, Take Back Your Life. San Francisco: Conari Press, 2013.

Silberstein, S.D., M.D., F.A.C.P., Holland, S., PhD., et al. (2012). "Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults." Neurology.April 24;vol.78 no.17 1337-1345. doi: 10.1212/WNL.ObO13e3182535d20 

Tepper, S.J. (2012). "Opioids should not be used in migraine." Headache. May;52 Suppl 1:30-4. doi: 10.1111/j.1526-4610.2012.02140.x. 

Tepper, S.J., (2012). "Medication-overuse headache." Continum (Minneap Minn). Aug;18(4):807-22.doi: 10.1212/01.CON.0000418644.3203.

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, and her website www.sharronmurray.com

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

Updated, February, 2019.

Copyright 2014, Sharron E. Murray

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