On 21 May 2024, we held our first webinar for Migraine Foundation Aotearoa New Zealand members with neurologist Dr Rosamund Hill. We had a list of questions from members and put them to Dr Hill for an hour-long session that was full of straightforward and useful information.
Here are some highlights. If you would like to attend the next member’s webinar in November, please join up! But if you can’t, we’ll share highlights from this in the coming months.
What is medication overuse headache? How do you know you have it and what does it feel like? Is it different to a migraine attack? What’s the best way to manage medication overuse headache if you do have it?
Medication can transform a headache into one that is more frequent – this can happen when you take nonsteroidal anti-inflammatory drugs (NSAIDs, e.g. ibuprofen or aspirin) or paracetamol for more than 14 days in a month or triptans or opioids (e.g. tramadol or codeine) for more than 9 days in a month.
What does it feel like? It varies. You can’t really tell from the nature of the headache whether or not it is a medication overuse headache. Triptans may trigger more headaches that feel just like ‘regular’ migraine attacks. Or the headache may be worse than the regular migraine. NSAIDs and paracetamol may be more likely to trigger a mild persistent nagging headache that is there all the time.
Remember that it takes times for medication overuse headache to develop – it doesn’t happen straight away but over more than three months. Also remember that it is the number of days in which you take medication that counts. You could take several doses of a medication in a day and that still just counts as one day.
If taking more than the recommended limit of medication, do consider whether the medication could be making the headache worse. Remember that the body doesn’t know what you’re taking the medication for – you could be taking regular NSAIDs for back pain and still develop a medication overuse headache. You don’t have to completely stop the medication, can reduce to the recommended limits. If you have medication overuse headache, you should improve if you either stop taking the medication of get it down to under the limits.
Can you explain what a greater occipital nerve block injection is as a treatment option, how effective it is and any drawbacks or side effects?
Occipital nerve block is when you inject local anaesthetic, with or without a steroid, over the greater and lesser occipital nerves which are on each side in the back of the head. Local anaesthetic injections can be given every 3 weeks, but the steroid only every 3 months.
Can be used for people with very severe, frequent headache to try and settle it down. Can also be used even if the pain isn’t primarily at the back of the head because the nerves spread over the head. The injections can be given by GPs and in emergency departments but not every doctor is familiar or comfortable with the technique, which means it can be tricky to get and not usually a regular treatment.
It can work well but is unpredictable – it’s hard to know who will benefit and who won’t. It can give a few weeks to a few months of relief.
Is it OK to take Emgality a few days early or late to fit in with travel, to avoid having to take it out of the fridge?
It is fine to have Emgality out of the fridge for a week which can make travel a bit more flexible. It’s also fine to take it early – some patients inject it every 3 weeks and it can also be given at a higher dose. If you take a 3 month break, then you will need to 2 injection loading dose to get back up to a therapeutic level (otherwise it can take 4-5 months to get there). If you want to see whether you still need to take Emgality, could try spreading it out rather than going off it completely – e.g. take a dose every 5, 6 or 7 weeks and see what happens.
How do I prepare for a GP or neurologist visit so I can get the best out of it? What do I need to bring and what information do they need to make sure I get the right diagnosis and best treatment?
You can get a lot from your GP if you have done your preparation. Be prepared to give a concise history of your migraine attacks (assuming you know you have migraine) e.g.
- When did they start (age and circumstances, e.g. around menstruation)
- Description of a typical attack, including what the headache feels like and any other features (such as nausea and vomiting, aura symptoms, sensitivity to light, sound)
- Frequency, duration and severity of attacks
- Current (and past) treatment of acute attacks
- Current (and past) preventive treatment especially for how long and at what dose did you take medications, side effects and if it worked. Your pharmacist could help with records of this.
Your GP can then work through what options you haven’t tried. GPs can prescribe and do almost everything that a neurologist would do, except Botox and perhaps occipital nerve blocks.
Any tips for menstrual migraine – is it worthwhile ‘preloading’ with medications knowing your period is due?
If you have a regular cycle, can start treatment 2-3 days before the menstrual migraine usually starts and continue for a week (e.g. a triptan or NSAID). If you have irregular periods you could try to suppress the periods entirely, as it is hormonal fluctuations that trigger the migraine. Can do this with continual use of the combined oral contraceptive pill, for example (skip the sugar pill).
Rizatriptan is designed to be dissolved on the tongue. If you don’t like the taste and want to swallow them with water instead, is that okay?
Yes, that’s fine. A lot of people don’t like the taste of rizatriptan. It is absorbed in the small intestine so it doesn’t matter if it is dissolved in the mouth. You can just swallow it or even take it with food.
Also note that if trying sumatriptan, make sure you try the 100mg dose if the 50mg dose hasn’t worked. And if the oral tablet doesn’t work, do try the injection. Your GP can prescribe all of these.
It’s also worth trialing metoclopramide with other medication taken for a migraine attack, even if you don’t have a lot of nausea (metoclopramide is an anti-nausea pill). It can make a difference as well.
I get neck pain with a migraine, should I go to a physio or chiropractor for this?
Neck pain and migraine can be tricky as the nerve supply to the upper neck and brain all goes to the same place. Neck pain can be the first symptom or part of a migraine attack. Muscle spasm in the neck can also be part of the pain cycle and trigger migraine attacks. Going to a physio or for a massage can provide temporary relief but it doesn’t fundamentally fix the problem over a long period of time.
