How do you balance taking acute migraine medications as soon as you feel a migraine attack starting, without taking too many to tip you into medication-overuse headache?
Solving that problem is enough to bring on a headache.
Medication-overuse headache, also called medication adaptation or medication-induced headache, is something many people with migraine struggle with.
Medication-overuse headache is the commonly used term, even though it blames the person for using the medication too much, instead of recognising that the fault is with the medication (that induces the headache) and the response of your brain (that adapts to the medication), neither of which are within your conscious control.
Medication-overuse headache can occur if you take too many acute medicines to treat your headaches and migraine – over a period of at least three months (so if you have an off month when you have to take more pain medication than usual, that doesn’t mean you’re destined for medication-overuse headache).
Medication-overuse headache can feel like a tension-type headache or a migraine-like attack and often becomes daily.
To minimise your risk of medication-overuse headache, you need to limit your use of acute medications.
- Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs): don’t take on more than 14 days per month.
- Triptans and opioids: don’t take on more than 9 days per month.
In general, opioids such as codeine and tramadol should be avoided long-term for migraine headache, although they’re sometimes used as ‘rescue’ medication in severe attacks unresponsive to other treatment (e.g. in emergency departments).
Opioids can make headaches and migraine worse (and turn migraine chronic) and they’re not as effective as other migraine medications and can lead to dependence and addiction. This article contains a recent discussion during the American Headache Society Symposium that looks at both sides of the argument about using opioids for migraine.
One thing to know about pain medication is that if you have a history of migraine, taking pain medication for another issue, such as back pain or arthritis, can also induce medication-overuse headaches. The migraine brain doesn’t distinguish between NSAIDs taken for a migraine and those taken for a sprained ankle.
Not taking too many medications is all very well in theory, but what do we do if we are taking too many? And what if we have so many migraine and headache days we need to take more than is recommended?
Firstly, if you’re reaching for your acute medications more often than what’s recommended, finding the right preventive medication may stave off the development of medication-overuse headache. Ask your GP about trialling a preventive medication – or a different one if what you’re already taking isn’t helping. A list of medications available in New Zealand is available here.
Unfortunately, once established, the treatment for medication-overuse headache is to stop taking acute medications as frequently. We recommend talking with your GP or neurologist if you’re concerned you may be experiencing medication-overuse headaches. Depending on what acute medications you’re taking, they may recommend reducing to the monthly limit, stopping all of them and going ‘cold turkey’, or a tapered withdrawal (required for opioids and benzodiazepines).
On a practical level, this isn’t easy. Your headaches and migraine attacks will probably get worse for the first couple of weeks, but if you can stay strong and persevere, you may start to see an improvement within 14 days, though it can take up to six weeks.
Your doctor may want to start a preventive medication during or after the reduction or withdrawal of the acute medication, and this will be more effective when the medication-overuse headache is gone. There is evidence that onabotulinum toxin A (Botox) injections and the new calcitonin gene-related peptide monoclonal antibody medications can treat medication-overuse headache even without tapering or withdrawing acute medications, but these are expensive options in New Zealand as they’re not funded.
If you’re concerned about medication-overuse headache, it can help to have some non-medication treatment options in your migraine toolkit. Supplements such as magnesium, vitamin B2 (riboflavin) and co-enzyme Q10 have evidence for use for migraine, and are best trialled for at least three months to see if they’re effective.
Neuromodulation can also help; regular exercise is helpful if it doesn’t trigger an attack; maintaining a regular sleep schedule is good; eating regularly is important; minimising alcohol also helps. And while we know genetics play a key role in migraine – like a loaded gun – often it’s environmental factors that pull the trigger and cause an attack.
And if you’re not already, we recommend tracking your migraine attacks – check out this blog post about tracking migraine attacks by Sarah, one of our co-founders.
Remember, you are not alone. Many people with chronic migraine (headache for 15 days or more a month) also have medication-overuse headache. Talk to the people around you about how they can support you when you reduce acute medications. Get help for any anxiety or depression you’re feeling. Find resources about managing chronic pain and know there’s hope that this type of headache can resolve.
And remember to join our private Facebook support group if you’re on Facebook. It’s a great place to find practical tips from other people in New Zealand living with migraine.
References
- Auckland Regional Health Pathways
- Evidence-based integrative treatments for headache
- Medication-overuse headache
- Neuromodulation for migraine treatment: An overview
- British Association for the Study of Headache (BASH). 2019. National Headache Management System for Adults 2019
- Medication-overuse headache
- SEEDS for success in migraine management
