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Migraine Medication Detox, Week One: Easier Than Expected

migraine medication detoxMy first week of migraine medication detox began with a final dose of Amerge (naratriptan) and two Midrin after breakfast on Sunday, August 21. Despite a rough start, the week’s been surprisingly easy.* I feel better than I have in almost two years! Here’s how the week of detox went.

The treatments to get me through the week were:

  • Compazine 30 minutes before each meal. Although it’s a nausea med, some people get migraine relief from Compazine. (It only made me tired and helped the nausea; it did not give me any migraine relief.)
  • Oxytocin as an acute medication once a day. (Which I discovered is a migraine trigger for me.)
  • A new treatment I’ve been using since June 22. It is a preventive treatment that can also be used acutely. That’s all I can tell you right now, but will share more as soon as I can.

Day 1: Monday was the worst day by far. I was too nauseated and dizzy to eat breakfast until 1 p.m. and that required dosing with Zofran and Compazine. The pain, which felt cold and high on my head, hovered around a 4 and peaked at a 5, which lasted a couple hours. Ice exacerbated the pain. Thanks to Compazine, I slept from 2 p.m. to 7 p.m. I definitely had a migraine attack in the night and didn’t sleep well (probably because of the Compazine-induced nap).

Day 2: I started Tuesday with a decent amount of energy and little pain. I even showered and did housework before eating. The migraine attack that followed breakfast was slight, but definitely present. Between it and the Compazine, I was laid up until I took a nap. Within 30 minutes of waking from my nap, I was perky and functional. I spent three hours working on chores and even did some writing. All with overcast skies! I once again had a migraine attack in my sleep, but it didn’t keep me up. Night sweats and vivid dreams were the only evidence that an attack happened at all.

Day 3: I switched from taking oxytocin at night to taking it after breakfast on Wednesday. It was a remarkably good day. I slowed down for a couple hours after eating, but am unsure if migraine or Compazine was the culprit. I even ran errands in the afternoon. After dinner was the first time I felt like my new treatment actually aborted a migraine attack! It was also the first night in almost a year where I didn’t fall asleep minutes after getting into bed.

Day 4: I woke up feeling fine Thursday and skipped the pre-breakfast Compazine hoping that I would be less sluggish without it. I used my new treatment after eating and it once again appeared to abort the migraine attack. I felt a little slow for maybe an hour afterward, but was able to write all day. My mind got a little fuzzy in the late afternoon, so I decided to rest. Before I did, I cleaned up a mess in the laundry room and put a coat of sealant on the bathroom tile… and discovered I no longer needed to rest. I finally stopped “doing” for the day at 7 p.m.

The other big news of the day: I ate three meals instead of two! I can use my new treatment three times a day, so I wanted to see if it would abort all three eating-triggered attacks. It did!

I then stayed awake the entire night. It wasn’t one of those maybe-I-slept-maybe-I-didn’t kind of nights. I read and did housework all night long. What kept me up? NOT having a migraine attack. I’m one of those fortunate folks who gets sleepy during an attack. After 17 months of nightly attacks, I think my body had gotten used to using migraine as a sleep aid.

Day 5: Despite not sleeping one wink, Friday was another remarkable day. It was house-focused, including signing the paperwork to have the grass removed from our yard and replaced with waterwise plants. (I’m so excited!) And I finally fixed the mess created when shelves in the laundry room fell a few months ago. Nothing to write home about… except that having a day of normal chores is absolutely worth writing home about.

I’m trying to temper my excitement about how much better I feel (Hart is, too). I feel so different, so much better, that I want to believe the ketogenic diet, my new treatment, and getting out of MOH have made a huge, lasting difference. And maybe they have, but I don’t want to go (too far) down that path until I have more data. I don’t want to be (too) crushed if this improvement turns out to be a fluke. Then again, I know my body really, really well. This feels different. (I might hate myself later for writing those words.)

Day 6: I felt great all day Saturday! I woke up at 8 a.m. and organized the house until 11 p.m. I didn’t even check Facebook. I slept well, too.

Days 7 & 8: Both days started well, but migraine attacks crept up through each morning. Both attacks made me so tired I couldn’t avoid napping. Both times, the migraine attack lifted within 30 minutes of waking up. Napping usually gives me some degree of migraine relief, but it only began aborting attacks completely this summer. I’m still surprised when it happens. (I was so afraid of losing another day that I took one Amerge (naratriptan) as soon as I felt symptoms on Monday. My background headache was more painful that day.)

Day 9: I spent this morning preoccupied with Sunday and Monday’s migraine attacks and obsessing over whether an attack was coming on. As I sifted through potential triggers, I kept worrying that my new treatment is backfiring. Although that is unlikely (I’ve been using it for two months with no problem), it’s my biggest fear, so it’s what my mind settled on. Other possibilities are that oxytocin is a trigger, I’ve developed reactions to some foods I thought were OK, or that merely touching cleaning product bottles now triggers attacks. I went with the oxytocin hypothesis and skipped my dose this morning. I’m going strong at 3 p.m., so I’m guessing oxytocin was the culprit.

Future weeks: Medication overuse headache symptoms can last six months after the final dose. Given how easy my migraine medication detox has been and that I’ve only been using excessive amounts of medications for 16 months, I doubt I’ll have symptoms that long. Still, I’m hopeful that the next few weeks or months could bring even more improvement. Maybe I’ll one day be able to eat without having a migraine attack at all.

*My experience does not represent the typical migraine medication detox. It has been easy because of the preventives I was on before I started (and possibly because I was only in MOH for a year). The drugs I used as a bridge were ineffective—Compazine only made me sleepy and oxytocin made my migraine attacks worse. In the six months before starting the detox, my pain rarely got above a 4 and my most disabling symptoms were fatigue and cognitive dysfunction.

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Migraine Medication Detox: Getting Started

migraine medication detoxI’ve been taking an Amerge (naratriptan) and two Midrin twice a day since April 2015. The medications allow me to function, but have the potential to increase the frequency, severity, or duration of my migraine attacks through medication overuse headache (MOH), which is also called rebound headache. My headache specialist is aware of my medication use. We discuss its potential impact at every appointment and he reiterates that the odds of it being a problem for me are quite low. Although my history showed MOH was unlikely to be a concern for me, I was still concerned. With my doctor’s consent, I persisted taking the drugs because they were the only way I could function.

Since eating anything is my migraine trigger and no preventive medications have been able to address that issue, I feel stuck. Going off the medication is not going to stop eating from being a migraine trigger. But my last visit with my headache specialist got me thinking about the two treatments I’ve been trying this year. One is the ketogenic diet and the other I can’t tell you about yet. Both have helped a small amount, but neither has had a huge impact. They have helped enough that I don’t want to stop either one, but I’m having trouble quantifying the extent of each one. What if MOH is somehow keeping me from realizing the full benefit of either or both treatments?

What if…? When a question like that lodges itself in my mind, I have to learn the answer. My migraine medication detox began last night.

My doctor offered to admit me to the hospital to keep me comfortable through detox. I declined because I don’t think I need it. Instead, I will take Compazine (prochlorperazine) 30 minutes before meals and use an oxytocin nasal spray after the migraine attacks begin. Compazine is known as a nausea drug, but it can also help reduce migraine symptoms. Oxytocin is being studied as a potential acute migraine treatment and could also have preventive effects. If my migraine attacks take a sharp turn for the worse, I’ll add DHE or Migranal to the lineup (assuming they aren’t out of stock). I have the option of starting another preventive at the same time, but think I’m going to wait in an attempt to control variables.

If you’re reading this to learn how to do a migraine medication detox with as little pain as possible, please be aware that my treatment may not be an applicable template. For most people with MOH, going off the medications would result in horrendous pain. My symptoms and situation are different than most. Thanks to my current preventive treatments and dietary restrictions, my pain rarely gets above a 3 on a 0-10 scale. I expect that it won’t exceed a 6 even while detoxing. Fatigue and cognitive dysfunction have been more disabling than the pain for me for the last few years. Those symptoms will be bad, but as long as I can feed myself and plan to limit my work for a couple weeks, detox shouldn’t be too bad for me.

I very much want to discover that MOH has crept up on me and is keeping two somewhat effective treatments from reaching their full potential. But I’m not holding my breath. I suspect I’ll go through migraine medication detox and discover that I still have a migraine attack every time I eat. While the acute medications may be increasing my susceptibility to migraine attacks outside of eating, they are also managing the attacks I get twice a day no matter what. My best hope is that the ketogenic diet and the other treatment are far more effective than I think because MOH is hiding their efficacy. Or maybe oxytocin will provide great relief. Whatever happens, I’ll have at least one more data point to help determine what my next course of action will be.

(Pardon any typos. Editing is beyond me right now.)

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Opioids Under-Prescribed Due to Addiction Fears?

Fear of Addiction Means Chronic Pain Goes Untreated, according to an NPR story that aired last weekend. While there’s definitely some truth to the headline, it obscures the nuances of physicians’ reluctance to prescribe opioids (a.k.a narcotics) for chronic pain in general and headache disorders specifically (particularly migraine).

Opioids were originally prescribed for short-term pain, like from surgery or an injury, or for use in end-of-life care. Chronic pain is a serious medical issue that is both under-treated and has limited treatment options, so it’s understandable that opioid painkillers filled that void, especially because opioids are the only source of relief for many people with chronic pain. Unfortunately, they began to be prescribed for long-term use before there were a lot of studies on their long-term effects. Now that research is catching up, this use is being questioned.

Beyond addiction, other potential problems for using opioids for chronic pain include opioid-induced hyperalgesia, tolerance and the systemic effects of long-term use. Opioid-induced hyperalgesia, when opioid use increases a person’s sensitivity to pain, is one concern. Tolerance — which requires taking increasingly higher doses of the medication for it to still be effective — is another. The repercussions of regular (and often increasingly higher) doses of opioids could have on the body’s systems should also be considered.

Headache disorders have additional issues. Rebound headache (medication overuse headache) is the most widely addressed concern. In addition, the American Migraine Prevalence and Prevention study found that using opioids more than eight times a month can cause episodic migraine to transform into chronic. (Diana Lee recently reported that there may be a difference between short-acting opioids and long-acting ones and that long-acting opioids may be OK for long-term pain management for people with chronic migraine.) Headache specialists also believe opioids impair the efficacy of preventive medications.

On top of all that, opioids aren’t even particularly effective for any type of head pain. In the video I shared last week, headache specialist Mark Green explained why:

“Part of the reason for that is there are fundamental differences in the chemistry of head pain compared to visceral pain. In the receptors subserving head pain, we really don’t have a lot of opioid receptors, so the upside for the use of opioids is rather low. That’s why we use, for example triptans and ergots. Those serotonin receptors are very well represented on those receptors that subserve headache.”

What do I get from all this?

  • Boiling down concerns about opioid use to a fear of patients becoming addicted is an oversimplification.
  • There are a lot of unknowns about opioid use for chronic pain. As more research is published, the less they seem like a good long-term solution.
  • Head pain is different than bodily pain and migraine may different still.
  • Chronic migraine isn’t a chronic pain disorder, nor are chronic cluster headaches. I don’t know where tension-type headache falls on the continuum, but I’m inclined to believe it’s more on the side of other types of headache disorders.
  • Using opioids can significantly alter treatment for an underlying headache disorder.
  • Mostly, I’m left with a lot of questions (and so are researchers and physicians).

I’m not anti-opioid, but want anyone who takes them for headache disorders to know the facts and to be very, very careful. Ideally, your headache specialist would be the prescriber, but fewer and fewer are willing to prescribe opioids (not out of fear of addiction or the DEA, but because of the ramifications for treating the condition you’re using opioids for in the first place). If your headache specialist won’t prescribe them, still be honest with them about how often you use them and at what dose — without that information, your specialist can’t treat your headache disorder properly.

Note: I’ve used words like “potentially” and “can” a lot in this post because not everyone’s the same. It’s important to be aware of the risks, but also to remember that not everyone will have all the same issues.

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Ibuprofen & Life-Threatening Potassium Loss

Ibuprofen and prescription NSAIDS (non-steroidal anti-inflammatory) are among my most effective meds, so this article caught my attention: Research finds ibuprofen linked to life-threatening potassium deficiency.

[Patients] were diagnosed with hypokalaemia, a dangerously low level of potassium in the blood that can lead to abnormal heart rhythms, the breakdown of muscle fibres, fatigue, muscle weakness, spasms, and paralysis.

Although hypokalaemia from ibuprofen isn’t a huge risk, I was surprised that one man was taking less than 4,800 mg per day. That’s still way too much to take regularly — 1,200 mg (or six regular-dose Advil or generic ibuprofen) is the maximum recommended daily dose for short-term use — but it is easy to creep to excessively high doses when you’ve got a killer headache or migraine.

An issue of far greater concern to people with migraine or headache is rebound or medication-overuse headaches. According to the National Headache Foundation’s rebound information sheet,

When used on a daily or near daily basis, [over-the-counter painkillers] can perpetuate the headache process. They may decrease the intensity of the pain for a few hours; however, they appear to feed into the pain system in such a way that chronic headaches may result. [emphasis added]

I must repeat: frequent use of over-the-counter painkillers like acetaminophen (Tylenol) and NSAIDs (Advil & Aleve) can turn occasional headaches or migraines into chronic ones.

If you’re having frequent headaches, see your doctor. Of course, few medical professionals know much about headache and migraine, so weaning yourself off may be the better option. Before you do, read Teri Robert’s excellent article, Medication overuse headache — when the remedy backfires and visit some forums to learn about other’s experiences. Migrainepage, My Migraine Connection, and WebMD are my favorites.

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Treating Migraines with Codeine, Oxycodone or Barbiturates Increases Risk of Chronic Migraine

Treating migraine episodes with opioids or barbituates as few as eight times a month doubles the risk of developing chronic migraine. I’m in a Phenergan fog, so I’ll let the American Academy of Neurology‘s press release tell the story:

Overuse of Codeine, Oxycodone and Barbiturates Increases Risk of Chronic Migraine

People who overuse barbiturates and opioids, such as codeine, butalbital, and oxycodone, to treat migraine are at an increased risk of developing chronic migraine, according to research that will be presented at the American Academy of Neurology 60th Anniversary Annual Meeting in Chicago, April 12–19, 2008. People with chronic migraine have headaches on 15 or more days a month.

For the study, 24,000 people with headaches in the United States were surveyed about the types of medications they use to treat their headaches. From this sample of people with headache, the researchers selected those who had been diagnosed in 2005 with episodic migraine (fewer than 15 days of headache per month). Their risk of chronic migraine was then calculated based on the types of medications they used in 2005. Among those with episodic migraine in 2005, 209 people had developed chronic migraine in 2006.

The study found people who took drugs containing barbiturates or opioids for only eight days a month were twice as likely to develop chronic migraine a year later as those who didn’t take such drugs. [emphasis mine]

“People who use drugs that contain barbiturates and opioids, if only for a total of seven to eight days a month, appear to significantly increase their risk of migraine progression,” said study author Marcelo Bigal, MD, PhD, with Albert Einstein College of Medicine in Bronx, New York. “Strict limits for these types of drugs should be enforced among people with migraine as a way of preventing their migraines from becoming more frequent and more painful.”

The study found no evidence that the risk of developing chronic migraine increased among people who frequently used triptans, which are commonly prescribed drugs to treat migraine, or non-steroidal antiinflammatory drugs (NSAIDs), such as aspirin, ibuprofen and naproxen.

The study was supported by the National Headache Foundation.

Another interesting conundrum of treating pain with opioids: Opioids appear to change the brain so that the patient actually becomes more sensitive to pain. Building tolerance is not only your body getting use to the drug (called desensitization), but you actually become more sensitive to pain overall (referred to as sensitization), not just the pain that you are specifically treating. Treating Pain With Opioids has information on this research.