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Sensitivity to Drug Side Effects Increased by Migraine Attack

Nine days of dizziness following four days of migraine. That’s what I’ve been up to these last two weeks.

The migraines made sense. We had rainstorms that week and I’d blown off my diet a couple times. The dizziness, however, was surprising. Wellbutrin has been to blame every time I’ve been dizzy in the last 16 months, but it didn’t make sense. I haven’t changed my dose in a few months months. I’d eaten plenty before taking it each time and hadn’t missed a dose. Maybe I accidentally took too much one day? I skipped a dose intentionally, took it at different times, took 300 mg instead of 450 mg. When the dizziness did lessen, the reprieve never lasted long. It was as if the migraine attack had made me more sensitive to Wellbutrin’s side effects.

It seemed unlikely that one migraine attack would change how I reacted to medication I’ve been on for more than a year, but my headache specialist told me he’s seen it happen with other patients. As he put it, the brain you have after a migraine attacks is not the same brain as you had before it. Any medication that acts on the central nervous system, like antidepressants, could interact with this new brain in a different way than before, causing an increase in side effects. My dose hadn’t changed, my brain had.

The changes to your brain after an attack are not permanent, so please don’t let this scare you. It’s more like a storm with high winds came through and there’s still dirt and debris in the street. The street sweeper will get to it eventually, but it may take some time. (I live in a place with haboobs and dramatic thunderstorms. You can liken it to a snowstorm if that’s more familiar.)

I’ve been taking 300 mg of Wellbutrin for the last week. Today I can look at the computer without feeling like my head is melting as if in a psychedelic video, but I still have to be careful to minimize the chance of side effects whenever I take a dose. My fingers are crossed that this part of the change to my brain lasts and that I can keep the depression at bay on this lower dose.

My naturopath/therapist believes that my depression is directly tied to migraine attacks. Since I started seeing her almost two years ago, every increase in depression has followed a long migraine attack that didn’t respond to acute medications. This fits with my headache specialist’s explanation. I haven’t waited to see if the depression abates without medication, but I wonder if it would. Not enough to find out, but I will ponder it.

My fingers are crossed that I have the internal mess from this latest storm cleaned up. Now it’s time to attend to everything I haven’t been able to attend to while weathering it. I’m going to read and approve a slew of comments now, but it will take me a while to respond to all of them.

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Acetaminophen Safety: How Safe is Tylenol’s Active Ingredient?

Acetaminophen, the active ingredient in Tylenol, is an over-the-counter drug that many people think is benign. It’s been regarded as safe enough to use through pregnancy. As someone who used to pop large numbers of OTC painkillers each day, I’m increasingly horrified when new information comes out about the safety risks of acetaminophen. Most people don’t take high enough doses to be in danger, but people with headache disorders or chronic pain are at risk of taking too much without even knowing it. The risk isn’t necessarily in long-term use; exceeding the maximum daily dose in one 24-hour period can cause severe liver damage.

This infographic from the University of Florida’s pharmacy program highlights some of the risks and dangers of acetaminophen. If you’re concerned about your acetaminophen use, please talk to your doctor about alternatives. Some of the alternatives recommended below, like NSAIDs and opioids, also have limits to how often they should be taken; many opioids are packaged in pills that contain acetaminophen, which negates their use as an acetaminophen substitute.

(Click anywhere in the infographic for a larger, easier-to-read version.)

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Wellbutrin Side Effects

Dizziness is one of Wellbutrin’s most well-known side effects, one with which I’ve become intimately familiar. Since I know I need an antidepressant right now and refuse to take any with sexual side effects, I’ve become experienced in managing Wellbutrin side effects. In addition to dizziness, I’ve had some trouble with insomnia. This information stems from dealing with those problems, but it may be helpful for other side effects, as well.

The main points:

  • Try different release types
  • Take the meds with food
  • Try different ways of taking different dosages (example: for 300 mg, take 200 in the morning and 100 in the afternoon or vice versa)
  • Try generics from different manufacturers
  • Try the name brand drug, if possible

Wellbutrin (generic: bupropion) comes in regular release, sustained release (SR) and extended release (XL). I started on 200 mg of the generic sustained release. My diet is heavily restricted, so I don’t eat many calories at once and eat few carbohydrates, both of which seem to make me more susceptible to dizziness. I could manage as long as I consumed 800 calories before my first dose and took the second dose six hours later.

Then I increased my dose to 300 mg a day, which added insomnia to the dizziness. If I took 200 mg in the morning, I got dizzy and stayed that way all day. Taking 200 mg in the afternoon caused less dizziness, but made it difficult for me to fall asleep and stay asleep.

So I switched to 300 mg of the generic extended release, taken in two 150 mg tablets with breakfast. I still had a little bit of dizziness, but it was pretty mild, and no trouble with sleep. Then I started taking the 300 mg in a single tablet and wound up with intense dizziness that even kicked up when I rolled over in bed.

The question is whether I did better with two 150 mg tablets because there were two pills or because they are manufactured by a different company than the 300 mg tabs. I’m guessing the latter since generic drugs have the same active ingredient as name brand drugs, but the other ingredients may differ and, thus, may have different side effects.

Which leads to what will be my next experiment — taking two 150 mg tablets of Wellbutrin XL, the brand name extended release version. If my insurance company approves it, I’ll let you know how the experiment goes.

(And now you know why my posts have been sporadic and I’ve been slow to respond to email and comments the last few months. Computer time is the first thing to go when I’m dizzy. Today it feels manageable; we’ll see if that lasts.)

Update: I got the dizziness under control a few ways:

  1. I always take it with food, usually about 30 minutes after eating.
  2. I split the dose, one with breakfast and two around 3p. (It can cause insomnia, so you might need to take it earlier.)
  3. When those two things stopped being sufficient, I switched to name brand Wellbutrin XL (I was on generic XL before that).

If name brand Wellbutrin isn’t an option (insurance companies often don’t cover it), you could try generic bupropion from a different manufacturer. Ingredients vary enough from one manufacturer to the next that switching to another generic can do the trick. The downside is that you may have to try generics from multiple companies to find one that doesn’t have side effects for you. To switch, find out which company makes the bupropion that’s causing your dizziness (it should be on the bottle or your pharmacist can tell you). Then ask your pharmacist if they stock another brand or are able to order a different brand for you. This usually is no problem, but there’s a chance you’ll need to try a different pharmacy.

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Insurance Companies Shifting Drugs to “Non-Preferred” to Raise Co-Pays

Health insurance companies can no longer deny patients coverage because of pre-existing conditions, but there’s no denying we’re expensive to insure. The latest strategy to increase profit is shifting even generic medications to “non-preferred” status, according to a story by ProPublica and The New York Times’ The Upshot. Patients pay higher co-pays for non-preferred medications. For some illness, all generics are listed as non-preferred. Migraine is mentioned in the story, which probably means triptans will be shifted to non-preferred (which could affect people with cluster headache as well).

Here’s the report in full, republished with permission:

A New Way Insurers are Shifting Costs to the Sick

By charging higher prices for generic drugs that treat certain illness, health insurers may be violating the spirit of the Affordable Care Act, which bans discrimination against those with pre-existing conditions.
by Charles Ornstein
ProPublica, Sep. 17, 2014, 11 a.m.

Health insurance companies are no longer allowed to turn away patients because of their pre-existing conditions or charge them more because of those conditions. But some health policy experts say insurers may be doing so in a more subtle way: by forcing people with a variety of illnesses — including Parkinson’s disease, diabetes and epilepsy — to pay more for their drugs.

Insurers have long tried to steer their members away from more expensive brand name drugs, labeling them as “non-preferred” and charging higher co-payments. But according to an editorial to be published Thursday in the American Journal of Managed Care, several prominent health plans have taken it a step further, applying that same concept even to generic drugs.

The Affordable Care Act bans insurance companies from discriminating against patients with health problems, but that hasn’t stopped them from seeking new and creative ways to shift costs to consumers. In the process, the plans effectively may be rendering a variety of ailments “non-preferred,” according to the editorial.

“It is sometimes argued that patients should have ‘skin in the game’ to motivate them to become more prudent consumers,” the editorial says. “One must ask, however, what sort of consumer behavior is encouraged when all generic medicines for particular diseases are ‘non-preferred’ and subject to higher co-pays.”

I recently wrote about the confusion I faced with my infant son’s generic asthma and allergy medication, which switched cost tiers from one month to the next. Until then, I hadn’t known that my plan charged two different prices for generic drugs. If your health insurer does not use such a structure, odds are that it will before long.

The editorial comes several months after two advocacy groups filed a complaint with the Office of Civil Rights of the United States Department of Health and Human Services claiming that several Florida health plans sold in the Affordable Care Act marketplace discriminated against H.I.V. patients by charging them more for drugs.

Specifically, the complaint contended that the plans placed all of their H.I.V. medications, including generics, in their highest of five cost tiers, meaning that patients had to pay 40 percent of the cost after paying a deductible. The complaint is pending.

“It seems that the plans are trying to find this wiggle room to design their benefits to prevent people who have high health needs from enrolling,” said Wayne Turner, a staff lawyer at the National Health Law Program, which filed the complaint alongside the AIDS Institute of Tampa, Fla.

Turner said he feared a “race to the bottom,” in which plans don’t want to be seen as the most attractive for sick patients. “Plans do not want that reputation.”

In July, more than 300 patient groups, covering a range of diseases, wrote to Sylvia Mathews Burwell, the secretary of health and human services, saying they were worried that health plans were trying to skirt the spirit of the law, including how they handled co-pays for drugs.

Generics, which come to the market after a name-brand drug loses its patent protection, used to have one low price in many insurance plans, typically $5 or $10. But as their prices have increased, sometimes sharply, many insurers have split the drugs into two cost groupings, as they have long done with name-brand drugs. “Non-preferred” generic drugs have higher co-pays, though they are still cheaper than brand-name drugs.

With brand names, there’s usually at least one preferred option in each disease category. Not so for generics, the authors of the editorial found.

One of the authors, Gerry Oster, a vice president at the consulting firm Policy Analysis, said he stumbled upon the issue much as I did. He went to his pharmacy to pick up a medication he had been taking for a couple of years. The prior month it cost him $5, but this time it was $20.

As he looked into it, he came to the conclusion that this phenomenon was unknown even to health policy experts. “It’s completely stealth,” he said.

In some cases, the difference in price between a preferred and non-preferred generic drug is a few dollars per prescription. In others, the difference in co-pay is $10, $15 or more.

Even small differences in price can make a difference, though, the authors said. Previous research has found that consumers are less likely to take drugs that cost more out of pocket. “There’s very strong evidence for quite some time that even a $1 difference in out-of-pocket expenditures changes Americans’ behavior” regarding their use of medical services, said the other co-author, Dr. A. Mark Fendrick, a physician and director of the University of Michigan Center for Value-Based Insurance Design.

Fendrick said the strategy also ran counter to efforts by insurance companies to tie physicians’ pay to their patients’ outcomes. “I am benchmarked on what my diabetic patients’ blood sugar control is,” he said. “I am benchmarked on whether my patients’ hypertension or angina” is under control, he said. Charging more for generic drugs to treat these conditions “flies directly in the face of a national movement to move from volume to value.”

If there are no cheaper drugs offered, patients might just skip taking their pills, Fendrick said.

The authors reviewed the drug lists, called formularies, of six prescription drugs plans: Harvard Pilgrim Health Care in Massachusetts; Blue Cross Blue Shield of Michigan; Blue Cross and Blue Shield of Illinois; Geisinger Health Plan in Pennsylvania; Aetna; and Premera Blue Cross Blue Shield of Alaska. They wanted to see how each plan handled expert-recommended generic drugs for 10 conditions.

The conditions are not all high cost like H.I.V. and Parkinson’s. They also include migraine headaches, community acquired pneumonia and high blood pressure.

Premera and Aetna had preferred generic drugs for each of the 10 conditions the authors examined. Harvard Pilgrim, a nonprofit often considered among the nation’s best, did not have a lower-cost generic in any of the 10 categories.

Four of the six plans had no preferred generic antiretroviral medication for patients with H.I.V.

In a statement to ProPublica, Harvard Pilgrim said it charges more for some generics because they are more expensive. The cheapest generics carry a $5 co-payment for a 30-day supply. More expensive generics range from $10 to $25, or 20 percent of the cost for a 30-day supply. The health plan said its members pay less for their medications than the industry average.

Blue Cross and Blue Shield of Illinois said that its preferred generics had no co-payment at all, and that non-preferred generics cost $10. “We historically only had one tier of generic drugs at a $10 co-pay,” the spokeswoman Mary Ann Schultz said in an email.

The Blue Cross Blue Shield of Michigan spokeswoman Helen Stojic said the editorial looked only at its drug plan for Medicare patients, which the government closely regulates. Under Medicare, patients can appeal a drug’s tier and seek to pay a lower co-payment, she said.

Geisinger did not respond to questions.

Health plans that participate in Medicare’s prescription drug program, known as Part D, have been moving rapidly to create two tiers of generic drugs. This year, about three-quarters of plans had them, according to an article co-written by Jack Hoadley, a health policy analyst at Georgetown University’s Health Policy Institute. The practical effect of such arrangements probably varies based on the difference in cost, he said.

Dan Mendelson, chief executive of Avalere Health, a consulting firm, has studied the way in which health insurers structure their benefits. He said the increasing number of drug tiers in some plans was confusing for patients.

“Consumers often don’t understand which drugs are where,” he said. “They don’t understand the purpose of tiering. They just get to the pharmacy counter and it gets done to them.”

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Hormonal Birth Control for Menstrual Migraine & Insurance Denials

Despite the Affordable Care Act’s required coverage of birth control, some insurers are denying coverage of the birth control patch or NuvaRing, NPR reports. There are a few exceptions to the rule, but nearly all health plans are required to cover all FDA-approved birth control. If you have been denied coverage, NPR recommends appealing the denial and contacting your state insurance board.

How is this relevant to headache/migraine/chronic illness? Hormonal birth control is one method of managing menstrually associated migraine attacks, which tend to be more severe than the migraines a woman has other times of the month. The patch and the ring provide a steadier dose of hormones than a pill does, which makes them more effective for this purpose.

I’ve been using NuvaRing continuously (with one-week breaks every three or four months) since January 2010 and it has been tremendously helpful. Now, the most severe migraines I get happen the few times a year I have to stop the ring for a withdrawal bleed. (You can learn more about skipping periods on The Well-Timed Period.)

This method is generally not recommended for women who have migraine with aura, who are at greater risk of stroke if they use hormonal birth control. However, I recommend talking it over with your headache specialist to decide if it is a good option for you, whether you have migraine with or without aura. Given the frequency and severity of my migraines, my headache specialist said he’d advise me to continue using the NuvaRing even if I did have migraine with aura.

(If you don’t want to/can’t use hormonal birth control for some reason, triptans can be used to prevent menstrual migraine attacks.)

I always love to read your comments, but I’m on vacation and won’t be able to reply until the week of Sept. 8. Please don’t think I’m ignoring you!