Medication Overuse Headache
Morris Maizels MD
Blue Ridge Headache Center
Asheville Hendersonville NC
Migraine Remembered
S
U
L
T
A
N
S
evere
niateral
hrobbing
ctivity worsens ha
ausea
ensitive to light/sound
2 of 1st 4
1 of last 2
Headache is episodic, and usually lasts 4-72 hours
Neurovascular theory
of Migraine
Goadsby, 2000.
Sensitization and migraine
1
1. Peripheral
Trigeminal Sensitization
3
1. Throbbing headache
2. Forehead Allodynia
2
3. Thalamic
Sensitization
3. Extracephalic
Allodynia
2. Central Trigeminal
Sensitization
Adapted from Ambassadors program after Burstein et al., Brain 2000
Migraine Triggers
 hormones
 emotions/stress
 disrupted sleep
 caffeine withdrawal
 foods
 change
THE SENSITIVE BRAIN
Pain control mechanisms are partially
defective in migraine patients
Symptomatic Medication
Mild to Moderate Headaches
 NSAID’s - high dose (+/- antiemetic)
 ASA/acetaminophen/caffeine (Excedrin)*
 ASA or acetaminophen/butalbital/caffeine
(Fiorinal/Fioricet)*
 Acetaminophen/isometheptene/dichlrophenazone
(Midrin) - ii po at onset, then i qhr up to 5/day
 Ergotamine tartrate/caffeine (Cafergot)*
*** Limit use to 2 days/week ***
Triptans and DHE
 Sumatriptan (Imitrex)
 Rizatriptan (Maxalt)
 Zolmitriptan (Zomig)
 Naratriptan (Amerge)
 Frovatriptan (Frova)
 Almotriptan (Axert)
 Eletriptan (Relpax)
 DHE im/sq, iv, ns
Group by
 parenteral
 po rapid onset
 po slow onset
rapid --> slow
 high --> low efficacy
 high --> low relapse
 more --> less se’s
Triptan side effects/risks
Common: sedation, nausea, muscle ache,
chest tightness (2 – 5%)
Contraindications
• CAD, CVA, PVD
• hemiplegic/basilar migraine
Risk of serious cardiac event with triptans is
~ 1:1,000,000
General approach to acute Rx
Who gets triptans?
Which triptan?
How to use the triptan?
Principles of acute therapy
Stratified care
Early use of medication for patients with
episodic headache
Limit use of all acute meds to 2 days/week
Stratified Care
Usual level of disability
Rapidity of onset
Associated nausea/vomiting
Tendency to relapse
Side effect tolerance
An approach for
triptan non-responders
Review diagnosis
• migraine?
• daily headache (drug rebound)?
Use early in attack, at sufficient dose
Try at least 3 triptans
Polypharmacy (NSAID/antiemetic)
?Mg deficiency
Alternatives for Refractory
Headaches
Chlorpromazine (Thorazine) 12.5 mg iv;
mr q 20 min x 3; total 50 mg
IV Depacon 100mg/kg over 5 min
IV DHE (q8h Raskin protocol)
IV Mg 2 gm/100 ml D5W may be added to
any other regimen
Drug Rebound Headache
 h/o episodic migraine
 more frequent/daily
 refractory to usual Rx
 narcotics for rescue
 Fiorinal - “preventive”
 escalating Rx use
 trying to survive
“The desire to take medication is,
perhaps, the greatest feature which
distinguishes man from the other
animals.”
Sir William Osler
What drugs cause drug rebound?
Worst offenders:
 Narcotics
 Ergotamine
 Caffeine-containing
compounds:
• Excedrin
• Fiorinal/Fioricet
• Cafergot
Lesser offenders:
 aspirin
 acetaminophen
 NSAID’s
 triptans
Innocent until proven guilty
 DHE
“The Unrecognized Epidemic”
• 1-2% of population is affected
• (near) daily tension-type headache, with
migrainous flares
• present upon awakening
• refractory to other abortive or
prophylactic measures
• headache worsens when medication is
stopped
Treatment of Drug Rebound
 Patient education
 Withdraw medication
 Initiate prophylaxis
 Provide rescue therapy
Impact of continuing vs discontinuing
symptomatic medication
Prevention of drug rebound
All Rx’s state:
“Limit use to 2 days/week”
eg, Triptan A, B, or C x mg #9
i po at onset migraine–mr x 2 within 24 hr
Limit use to 2 days/week
Conclusion
 Episodic disabling = migraine
 “Migraine-in-a-Minute” for triage
 Stratify care
• treat early
• migraine-specific therapy
 Refractory headache is usually due to:
• drug rebound
• co-morbidity
 Incorporate behavioral assessment/Rx