Too Few Get Best Migraine Drugs
Survey: Potentially Addictive Drugs Too Often Prescribed for Migraines
Migraine Treatment -- Addictive Drugs Sometimes Needed continued...
"There may be patients using opiate medications to manage their
headaches in a very appropriate way," Penzien says. "It should not be a
first-line choice -- but the truth is, there is a substantial minority of
patients for whom triptans have no effect or have too many side effects.
Triptans are a godsend to many patients, but they are not the entire answer to
The role of barbiturates is much more controversial -- despite doctors'
decades-long history of prescribing butalbital for severe headaches.
"Butalbital has been used forever without any clinical trial evidence
that it is effective," Penzien says. "The potential for dependence and
withdrawal is clearly there. Barbiturates should be used only in a limited
fashion, and in clearly controlled circumstances."
Grosberg agrees that while barbiturates are a controversial migraine
treatment, they may be helpful for patients whose individual circumstances
preclude other treatments.
"It's never good to use a cookie-cutter approach. Each patient has
different needs, so treatment must be tailored to the patient," he says.
"If people are having very frequent headaches, they should certainly not be
prescribed opiate or barbiturate medications -- but it is important to not
overuse any type of headache medicine."
Overtreatment: A Common Cause of Migraine
The average patient in the survey reported five migraine headaches a month.
That puts them at risk of what doctors call "rebound headache" --
headaches caused by too-frequent doses of headache medicine.
"Patients really must limit acute-headache medications to no more than
two days a week -- obviously except for the occasional very bad week -- to
avoid rebound headache," Grosberg says.
"About 15% of our patients come in with medication-overuse headache,
usually from overtreatment with opioids or barbiturates," Penzien says.
"Our first job is to get patients to stop using medicines prescribed by
well-meaning doctors. And for many, that is all they need. We get them over
rebound headaches, and that is all they need for control."
That's because well-managed migraines become less and less of a problem.
"When you have confidence in your own ability to manage headache
symptoms, they don't distress you as much," Penzien says. "Distress is
one of the triggers for migraine. If you sense a migraine coming on and you
think, 'Oh, I am going to spend the rest of the day writhing in bed,' it is
distressing and your headache is worse. When you have a treatment you know will
help, you feel more in control, and you avoid that trigger."
Penzien and Grosberg note that triptans, opiates, and barbiturates aren't
the only treatments for migraine. There's also a role for over-the-counter
painkillers such as ibuprofen and naproxen -- although like their prescription
counterparts, these drugs can have serious side effects and should never be
taken regularly without a doctor's advice.
Nondrug strategies, such as stress management and improved sleep hygiene,
also play a major role in migraine control.