Headache

Medication Overuse Headache (MOH) – detoxing

In the article about acute treatment, I briefly discussed the problem of medication overuse headache (MOH).  This can be a problem in patients who suffer with migraine, tension-type headache, cluster headache and other headache disorders but is much more common in migraineurs.

It happens when people take pain-killers for too many days over a 3 month period: this ends up causing the headache instead of treating it.  The resulting headache can be more severe and unrelenting causing the sufferer to take more medication and… the problem continues.

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It’s a frustrating paradox for the sufferer and can be difficult to get your head around (pardon the pun).

It can happen with any headache medication but for guidance I have made a list of the common ones and how often you have to take them to cause this problem:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more than 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month
  • Ergots (an old fashioned migraine treatment) more than 10 days a month

The key point to remember is it’s the number of days not the number of doses that counts.

How do I work out if I have MOH?

I do keep bleating on about migraine diaries but I find them invaluable for teasing out a pattern or helping to work out what’s causing migraine or headache.  If a diary is kept it quickly becomes obvious if someone is using too many pain-killers: you only need to take a triptan 2 days a week or paracetamol for more than 4 days on a weekly basis to cause MOH.  It’s difficult to keep track of this without noting it down.

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What do I do?

This is the difficult part.  You have to stop taking pain-killers.  It’s tough… really tough.  I liken it to a detox: initially when the medication in question is stopped the headache gets worse.  It’s really important to be aware of this because the temptation is to reach into your purse and grab the ibuprofen to make the pain go away.  But that would be a mistake because you’d just be delaying the inevitable and your frequent headaches would continue.

The amount of time it takes to detox is dependent on which medication is causing the issue.  If the problem is a triptan, NSAID the withdrawal headache will last for 7-10 days.  If it is a simple pain-killer it’s 2-3 weeks and if codeine or an opiod is the problem it’s 2-4 weeks.

How long do I need to “detox” for.

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We advise 12 weeks to allow the medication to wash out of the system.  If there is more than one medication that is being overused it is sometimes better to stop one medication at a time.

Can anything be done to help?

There are a few options:

  1. Naproxen: this is only a possibility if you have not taken this medication much before.  This can ease the withdrawal headache.  We often start a 6 week course starting
    • 3 times a day for two weeks
    • 2 times a day for two weeks
    • 1 time a day for two weeks
  1. Greater Occipital Nerve Block: injection of steroid with local anaesthetic at the back over the head around the nerves that supply the scalp.  It works by blocking the abnormal pain signals that fire during MOH.  Typically it gives relief for up to 6 weeks: just long enough to detox from the medication.
  2. Preventative medication: see full article but often we use Amitriptyline to dampen the withdrawal headaches.

For more information please see:

The National Migraine Centre factsheet.

Headache

Migraine – Preventative Medication

As mentioned multiple times before, keeping a diary to keep track of how often you are suffering with migraine attacks and how long they are lasting can be helpful in identifying whether or not you are likely to benefit from preventative treatment.

There is guidance to decide whether or not you fit this criteria:

  1. Experience frequent disabling attacks:
    • two or more attacks per month which last 3 or more days at a time
    • quality of life is severely impaired
  1. Are at risk of Medication Overuse Headache
  2. Normal pain-killers or triptans cannot be prescribed or are ineffective
  3. Atypical migraine: hemiplegic migraine (a sub-type of Migraine with aura which causes paralysis of one side of the body) or a persistent aura.

What does it do?

I like to think of preventative medication as a sort of “reset” button: they make you less likely to have a migraine.  Essentially the aim of any preventative treatment is to reduce both the severity of the migraine and the frequency of attacks.  The best preventative can only reduce the frequency and severity of attacks by 50% so it is definitely not a cure.  It is still important to try an assess potential triggers and try to minimise them where possible.

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None of the medications we suggest for migraine prevention have been developed specifically for the treatment of migraine.  There are a few main classes of medications which I will allude to:

  • Beta-blockers
  • Anti-epileptics
  • Antidepressants:
    • Tricyclic Antidepressants (TCAs)
    • Selective Noradrenaline Re-uptake Inhibitors (SNRIs)
  • Anti-hypertensives

There are also injectable treatments which I will discuss in a separate post.

Beta-blockers

The most common of these used is Propranolol.  Beta-blockers are often the first preventative medication tried.  They are well tolerated with few side-effects (vivid dreams, fatigue, reduced exercise tolerance, dizziness and erectile-dysfunction in men).  It is not suitable for asthmatics.

Anti-epileptics

The main one used nowadays is Topiramate.  I call this medication “marmite”: patients either love it or hate it.  It works well if you don’t get side-effects, and some people don’t.  Others on the other hand find the tingling in hands and feet, weight loss, mood changes (specifically unmasking of anxiety or depression) and cognitive slowing too difficult to deal with.  There’s no way of telling if you’ll be lucky or not.  This is also the only one that does not cause weight gain: in fact it usually gives the opposite effect.

Antidepressants

This includes my favourite class of migraine preventative: TCAs.  This is an old fashioned antidepressant but we use it a much lower dose in this setting.  Amitriptyline or (as a patient once described it to me) it’s “more refined brother” Nortriptyline is taken 2 hours before bedtime to mitigate its main side-effect: drowsiness.  This is actually a pretty good thing as it guarantees a fantastic nights sleep.  The other major side-effect is dry mouth.  Some people have vivid dreams and weight gain with it.

The other class of antidepressant SNRI is useful if people also suffer with anxiety or depression.  Venlafaxine  or Mirtazepine tend to be more effective as migraine preventers than first-line antidepressants such as sertraline, fluoxetine or citalopram.

Anti-hypertensives

This includes the relatively new kid on the block: Candesartan.  This has a very low side-effect profile apart from dizziness due to…well…low blood pressure.  The other medication which is used more commonly overseas is (as a patient once described it to me is Flunarazine which is a calcium-channel blocker.  Unfortunately it’s difficult to get hold of in the UK so its use is limited.

Others

Some patients still come to the clinic on medications such as gabapentin, pizotifen, sodium valproate, verapamil…  these are often unsuccessful.  Pizotifen does have a place in migraine prevention, but for some reason it tends to work better for children.  Gabapentin has been shown to be ineffective for migraine (although it still features in the guidelines which have yet to be updated) and verapamil is useful for Cluster Headache but not Migraine.

But what if I don’t want to take medication?

Lots of people don’t like taking medications because of the side-effects listed above.  There have been studies on supplements and vitamins and people are always keen to know what the more natural remedies are.

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  • Riboflavin (Vitamin B2): at a dose of 400mg this has been shown to reduce the frequency (but not severity or duration) of migraine attacks.  Main side-effect: turns urine more yellow.
  • Magnesium: usually as citrate or maleate as they are better tolerated.  There is evidence that this can reduce the frequency and severity of attacks.  It is also beneficial in menstrual migraine for pre-menstrual attacks.  Dose is 600mg to be taken at night and main side-effects are abdominal cramps and diarrhoea.
  • Co-enzyme Q10: again reduces the frequency but not the severity of attacks.  Dose is 300mg per day.

The other option that people often ask us about is Botox.  But that is a discussion for another article…

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Headache

Migraine Triggers

In my post on acute treatment I discussed preventing migraine attacks by identifying triggers.  Triggers can be internal or external and are essentially any change or event which causes a migraine to occur.

How do triggers cause migraine?

Every individual who suffers with migraine will have a “threshold”.  I like to think of this as a line: anything which pushes you over the line will cause a migraine, and the factors which push you over the line are your triggers.  These triggers tend to be multiple and work together but some will be stronger or more potent than others.

triggers
Migraine Triggers National Migraine Centre

How can I spot my triggers?

There are a few useful facts about migraine that are instrumental in identifying triggers:

  1. Migraine takes 12-24 hours to develop, which is much longer than most people suspect
  2. Different people have different triggers what causes migraine in one individual may not in another
  3. Migraine thresholds vary. That line I discussed above can move up or down at different points in your life: this can make “new triggers” appear if your line is particularly low as you are more susceptible to its effects than before.

What sorts of things act as triggers?

As I have said, triggers vary greatly from person to person but there are a few themes that are common to most people who suffer with migraine and I will list some examples:

  • Diet: You just have to enter the word migraine into a search engine and lots of posts about specific food triggers like cheese, chocolate and citrus will come up.  Although specific triggers do exist, these have largely been disregarded by headache professionals.  Historically, when people have tracked their migraine they have identified that they would ingest cheese, chocolate etc two hours before attacks: these must be triggers right?  Unfortunately not.  They are now thought to be cravings brought on by a drop in blood sugar level before the migraine starts.  However, rapid changes in blood sugar level can act as a migraine trigger so I advise people to avoid fast-burning carbohydrates (i.e. very sugary foods) where possible and concentrate on a high-protein diet eating slow burning (i.e. brown rice, brown pasta etc) carbohydrates where possible.  People should also avoid skipping meals and consider adding in healthy snacks during the day and before bed-time to prevent their blood sugars from fluctuating to often.

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    • Sleep:  changes in sleep pattern are another common trigger.  Many people identify lack of sleep as a trigger but do not always think about their sleep routine: shifts in this normal pattern of even up to an hour each way can precipitate a migraine.  An example of this is a weekend where someone may have stayed up an hour later on the Friday night or treated themselves to a lie-in on the Saturday morning.  This can be one of the factors that results in a weekend migraine.  It can also be a particular problem for shift-workers as I certainly found when rotating through my hospital jobs.
    • Stress: this emotion does get implicated in a lot of medical and psychological problems but it certainly has a role in migraine.  Often it is noted that the migraine occurs when the stress has been alleviated (i.e. when people relax).  However, other emotions can trigger migraine too: anger, excitement, sorrow, joy… this can be particularly evident in children who often have attacks when they’re excited about events such as birthday parties or trips out.

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  • Hormones:  a study at the National Migraine Centre showed that 50% of women were more likely to suffer a migraine attack at the time of their period.  Menstrual migraines exclusively occur during a woman’s period but most women have attacks at other times of the month too which means this is one of their triggers but not the entire cause.  Some women who are sensitive to hormonal changes benefit from regulation of their cycle with the contraceptive pill or coil, unfortunately this can exacerbate symptoms in others.  Women who are hormonally sensitive may find their migraine attacks are much worse around the menopause and thus can benefit from HRT.
  • Neck and back pain: any type of muscular or joint pain in the neck and back can exacerbate migraine.  This can be as simple as poor posture or a muscular injury.  This can be improved with gentle exercises, physiotherapy or osteopathy.
  • Light sensitivity: although this can sometimes be a prodrome rather than a trigger, some people are light sensitive between migraine attacks and this can contribute towards causing further migraines.  Computers or VDUs can be a source of this and it is the blue-green wavelengths emitted which are troublesome.  There are programmes available which act as a screen filter and some people benefit from tinted lenses on their glasses.  Taking frequent breaks from looking at a screen is also important.

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Why should I bother?

Most people who have migraine do not want to take medication, and taking too much can lead to problems such as medication overuse headache.  If you can identify your triggers and try to eliminate them through life-style measures you can reduce the number of attacks you have (some studies show by 50%!).  The way to identify these triggers is to keep a diary.

For more information see:

The Migraine Trust – Triggers

The National Migraine Centre Factsheet

Headache

Treating Migraines (acute treatment)

So you’ve established you suffer with migraine.  So what do you do?  As I’ve said before, I didn’t used to do much to help myself.  I’d take the wrong pain-killers and suffer through my day and I know, from my job as a headache specialist, countless others do the same.

Treatment is divided into two types: acute (immediate) treatment and preventative treatment.

This is to get rid of the symptoms you experience during a migraine.  The easiest way to work out what to take is to know why your taking it:

1.  Domperidone (anti-sickness or pro kinetic medication)

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The first medicine I advise to take is Domperidone and it helps with nausea and vomiting.  This occurs because the stomach is directly affected by the migraine process: it stops emptying in a process called gastric paresis.  This means anything sitting in the stomach cannot move forward into the part of the gut where it will be absorbed.  This happens in all migraine regardless of whether or not people feel queasy.  Gastric paresis also means that any medicines taken won’t be absorbed properly.  The main function of Domperidone is get the stomach to empty (termed pro-kinesis) and this helps any pain-killer to work better.

2.  Soluble Aspirin

The next medication is a good old fashioned pain-killer: Aspirin.  This has largely fallen out of favour as a analgesic for most conditions but it works well for migraine and headache.  Because the gut has slowed down it is best to take this in the soluble form so it is better absorbed.  Better still, it should be dissolved in a sugary, fizzy drink.  The fizz helps improve the absorption of the aspirin.  The sugar helps to reverse a drop in blood sugar that occurs before the migraine starts (often making people crave sweet or salty food such as cheese or chocolate… more on this in the article about triggers).

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Other non-steroidal anti-inflammatories (NSAIDs) such as Ibuprofen or Naproxen can be used at high dose if this does not help. This is not a suitable medication if you suffer with gastritis or for some asthmatics so I would advise speaking to your GP if this applies to you.

3.  Triptans

If the migraine is severe or if the symptoms don’t improve 45 minutes after steps one and two have been take a Triptan should be tried.  This class of medicine are specific painkillers developed for the treatment of migraine and headache.  There are 7 of them on the market and treatment usually starts with the first one that was developed: Sumatriptan (Imigran) which is available over the counter.

Some people find they can have side-effects (usually drowsiness or nausea) with this medication or it is not effective.  It can be tried in higher doses via the GP or taken via a different route if it does not work fast enough (a nasal spray and self-injection are available).  If it is not suitable, one of the other 6 triptans can be tried.

Is there a limit to how often I can take pain-killers?

In a word: yes.  Unfortunately, if you suffer with migraine you can develop a problem called Medication Overuse Headache.  It’s a strange phenomenon which seems only to affect people who suffer with headache disorders, most commonly migraine.  It happens if you take too many painkillers in a month for 3 consecutive months and causes a more severe headache or worsening of migraine features.  As a guide it occurs if:

  • NSAID medications such as ibuprofen, naproxen or aspirin and other simple pain-killers such as paracetamol are taken on more that 14 days a month
  • Triptans are taken on more than 8 days a month
  • Codeine and other opioids are taken on more than 6 days a month.

If you think this may be a possibility, I would advise speaking to your GP about how to detox from painkillers and consider whether a preventative medication may be suitable.

Are there any medications I should avoid?

Yes. There are some strong pain-killers which are not suitable for the treatment of migraine.  The advice of most headache specialists is that patients who suffer with migraine should avoid codeine and other morphine-type medication (opioids).  They are not particularly helpful in getting rid of migraine symptoms and often worsen the gastric slowing I described earlier.  They also are prone to cause rebound-headaches.  They are often prescribed by doctors due to the fact that migraine can be very painful but they should be avoided at all cost where possible.

What can I do to stop getting migraines?

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Most people don’t like taking medications.  This is where migraine prevention comes in.  The most effective way to stop having migraine is to identify what your triggers are.  These are different in everyone but I have written an article to help identify them.  Again, keeping a diary is key to identifying what your triggers are.

If you find you are suffering with migraines more than 4 times a month, or if they are so severe they are stopping you from effectively carrying out your daily life, it is worth considering preventative treatment.

Headache

Migraine

“I’ve come to see you about my headache.” It’s a phrase that leaves many GPs with a feeling of dread.  Headache is a bit of a nightmare.  Most people with a severe or new headache are terrified about the worst case scenario: Cancer.  Doctors worry about missing other critical headaches and, once they’ve been ruled out, trying to reassure the patient that the headache is unlikely to be sinister but…what do they do about it?  What’s the diagnosis?

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I have a vested interest in this subject.  I suffer with migraine with varying degrees of regularity.  If you’ve read my post about me you’ll know my Mum suffered with them and my sister does too.  I used to be appalling at managing them: I’d take a couple of paracetamol, which didn’t take the pain away, and pop myself in a dark room until the worst of it eventually eased enough for me to carry on with the merest semblance of my normal life.

I’ve suffered with migraine since I was 12.  I vividly remember my first attack.  I was in the school playground, queuing for lunch and I had felt a bit more tired that usual.  I felt like the sun was dazzling me (even though it was a typical cloudy, autumn day in England) and I couldn’t really see because bright spots were dancing in my field of vision.  Then my head was throbbing, not the worst pain I’d had, but it bothered me.  I couldn’t speak, the words just wouldn’t come out.  And it lasted for the rest of the day.  I told my Mum and she solemnly told me I’d had a migraine.

In my early 20s, when I was at medical school I sat in on a clinic with a GP who was headache specialist.  It changed my life.  I’m not exaggerating.  “Does anyone here suffer with migraine?” He looked at the four of us: two medical students, two GP-trainees.  I tentatively put my hand up.  He figured one out of four of us would suffer.  He asked what I did.  Did it work? No.  Why did I do it?  Had I seen my doctor?  No.  What was the point?  What could they do?  Apparently, quite a lot.  He gave me a little plan for what to take: Aspirin (who knew people still took that for pain?!), if that didn’t work I could try a “triptan” (more on these wonderful drugs later) and if I got them more than 4 times a month I should try a preventative medication.  And it worked.

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And ever since then, I’ve wanted to do the same: improve people’s migraines.

Migraine – what is it?

Migraine is the 7th most debilitating disease globally. The word Migraine comes from the Greek Hemicrania meaning half a head as historically it referred to pain which affected only affected one side.  Now it is defined as a pain which can affect one or both sides of the head which is often throbbing in nature with other troublesome features such as:

  • Light or sound sensitivity
  • Nausea or vomiting
  • Tiredness

There are many different migraine subtypes and people do not have to experience flashing lights or other visual changes to be diagnosed with this.  People that do have that symptom are described as having an “aura”.  Only 10-30% of people with migraine suffer aura.  Aura doesn’t have to be visual.  The symptoms of aura typically start before the headache people can get:

  • numbness
  • dizziness
  • problems speaking
  • memory loss
  • paralysis

The headache doesn’t always have to be severe.  This is the most common misconception.  Like with most problems you can get mild, moderate or severe attacks.  Often people can take a day or two to recover and a lot of people describe this as feeling like a hangover.

Migraine does not have to start when you’re young.  It often starts at puberty and commonly affects those between in their 20s and 30s.  It affects around 1 in 7 people and women are three times more likely to suffer than men.

What causes migraine?

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We don’t fully understand what happens during a migraine.  We know some of the substances that are involved in migraine (like serotonin and CGRP) which has helped with the development of some of the medicines used to treat it, but the full process is still a bit of mystery.  We also know that it runs in families with more that half of patients with migraine having a relative who also suffers.

Impact on society

Migraine is debilitating.  A lot of people find the headache bearable but try going to work and trying to carry on with

  • impaired vision
  • problems concentrating
  • feeling queasy
  • difficulty looking at a computer
  • not being able to sleep

It makes simple things like checking your emails or sitting through a presentation a mammoth task.  But people don’t like calling in sick for work.

“Surely you can come in… it’s just a headache”.

In the clinic I see people week on week referred in because work are concerned about their sickness absence and they give a sense that the patient is just… putting it on.

“Migraine leads to reduced productivity at work and has major implications for society”  NICE CKS

Migraine costs the UK economy an estimated £2.5 billion per year due to absenteeism.  It’s a big deal.

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How is it diagnosed?

The most frustrating thing about migraine is that there are no tests to confirm the diagnosis: we listen to the pattern, find out if the features above are present and make the diagnosis on that basis.

The best way of knowing whether or not you have a migraine and decide on the best course of treatment is to track it.  This can be done via countless apps or using a good, old fashioned diary.  The National Migraine Centre has a version here.

For more information please see:

The Migraine Trust

The National Migraine Centre