Medication Overuse Headache

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Medication Overuse Headache

• Morris Maizels MD
• Blue Ridge Headache Center
• Asheville Hendersonville NC

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Migraine Remembered

• S evere
• U ni-
• L ateral 2 of 1st 4
• T hrobbing
• A ctivity worsens ha
• N ausea
• S ensitive to light/sound 1 of last 2
• Headache is episodic, and usually lasts 4-72 hours

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Neurovascular theory of Migraine
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Sensitization and migraine
1. Throbbing headache
1. Peripheral Trigeminal Sensitization
2. Forehead Allodynia
3. Thalamic Sensitization
3. Extracephalic Allodynia
2. Central Trigeminal Sensitization
Adapted from Ambassadors program after Burstein
et al., Brain 2000
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Migraine Triggers

• hormones
• emotions/stress
• disrupted sleep
• caffeine withdrawal
• foods
• change

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Headache Medications

• Acute
• non-triptan
• triptan
• Prophylactic
• FDA-approved
• non-FDA-approved
• natural supplements

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Symptomatic Medication Mild to Moderate
Headaches

• NSAIDs - 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

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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 --gt slow
• high --gt low efficacy
• high --gt low relapse
• more --gt less ses

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Triptans and DHE

• Sumatriptan (Imitrex) po, sq, ns
• Rizatriptan (Maxalt)
• Zolmitriptan (Zomig)
• Naratriptan (Amerge)
• Frovatriptan (Frova)
• Almotriptan (Axert)
• Eletriptan (Relpax)
• DHE im/sq, iv, ns

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Triptans

• Group by onset of action
• parenteral
• po - rapid onset
• po - slow onset

• rapid --gt slow
• high --gt low efficacy
• high --gt low relapse
• more --gt less ses

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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
  11,000,000

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General approach to acute Rx

• Who gets triptans?
• Which triptan?
• How to use the triptan?

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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

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Stratified Care

• Usual level of disability
• Rapidity of onset
• Associated nausea/vomiting
• Tendency to relapse
• Side effect tolerance

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Therapeutic Phases of Migraine
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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

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Alternatives to Narcotics in the Emergency Room

• IM
• antiemetic 10 mg
• NSAID 60 mg /-
• DHE 1mg /-
• glucocorticoid

• IV
• antihistamine 25 mg
• antiemetic10 mg
• DHE 1mg
• /- NSAID 30 mg
• /- glucocorticoid

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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

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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

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• The desire to take medication is, perhaps, the
  greatest feature which distinguishes man from the
  other animals.
• Sir William Osler

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What drugs cause drug rebound?

• Worst offenders
• Narcotics
• Ergotamine
• Caffeine-containing compounds
• Excedrin
• Fiorinal/Fioricet
• Cafergot

• Lesser offenders
• aspirin
• acetaminophen
• NSAIDs
• triptans
• Innocent until proven guilty
• DHE

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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

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Treatment of Drug Rebound

• Patient education
• Withdraw medication
• Initiate prophylaxis
• Provide rescue therapy

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Impact of continuing vs discontinuing symptomatic
medication
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Treatment strategies for DRH

• Combined prophylaxis (TCA BB AC)
• NSAID
• Tizanidine
• Daily naratriptan
• DHE im/sq
• IV rescue regimens (esp. IV DHE)
• Steroid burst

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Prevention of drug rebound

• All Rxs state
• Limit use to 2 days/week
• eg, Triptan A, B, or C x mg 9
• i po at onset migrainemr x 2 within 24 hr
• Limit use to 2 days/week

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Medication Overuse is not the same as Drug
Rebound!

• Medication overuse - the ongoing use of
  symptomatic medications gt/ 3 days/week
• Drug rebound headache implies
• medication overuse
• secondary headaches excluded
• headache may first worsen, but then improves with
  withdrawal of symptomatic medications

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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