What’s more, frequent dosing puts migraine patients on a path to making their headaches worse, not better. Using opioids and barbiturates at least eight days a month can change pain receptors in the brain and make migraines go from being an every-now-and-then problem to a daily affliction, according to a rapidly growing body of research. This is called “transforming,” and it causes a vicious circle: Headaches spur patients to take meds for their pain; dependence and tolerance build; patients require more medication for relief; and the headaches just keep getting more frequent, leading to even more pill popping.
Overusing other acute-pain drugs—from Excedrin to triptans such as Imitrex—can also cause patients to develop more-frequent headaches. “But opioids and barbiturates pose twice the risk of transformation,” says Silberstein. So the rebound effect is much more of an issue with these drugs, which also carry the possibility of physical dependence.
If there were a magic bullet for migraine sufferers, physicians obviously wouldn’t be prescribing opioids and barbiturates at the current rate. “But the reality is that the conventional therapies create side effects that not everyone can tolerate; plus, no single medication or treatment works for every patient,” explains Saper. “For the most difficult cases, we might have to try 30 medicines, in different dosages and combinations, before finding something that is effective.”
Perhaps the only doctors in the United States who have deliberately signed up for this kind of challenge are certified headache specialists, who are typically neurologists. There are about 300 of these specialists in the U.S., which means just 4 percent of migraine patients are under their care. An additional 20 percent of migraine sufferers seek treatment from general neurologists, who are often—but not always—willing to take on intractable headache cases. Other migraine sufferers go to pain centers, frequently run by anesthesiologists, and some to psychiatrists. But about half of these patients are treated by primary care physicians (PCPs), who generally have received only minimal headache education during their medical training.
And that can be a problem. Many PCPs do a great job of taking care of migraine patients, “but treating headaches well is not always a huge priority in primary care, perhaps because they are nonfatal disorders,” Lipton says. So even though triptans are now considered a first-line treatment for migraine pain, they are vastly underprescribed by PCPs, many headache experts believe. “Some primary care physicians are uncomfortable prescribing triptans because they worry about stroke or heart attack risk. But this is a significant danger primarily in people who have heart disease, atherosclerosis or a history of strokes. In patients at low risk for heart disease or stroke, triptans are quite safe and an underused option,” says Lipton.
Another problem: “PCPs may try one or two medications, not achieve the results they or their patients are hoping for and give up too soon,” says Elizabeth Loder, MD, MPH, chief of the division of headache and pain in the department of neurology at Brigham and Women’s Hospital in Boston. And sometimes patients, in search of immediate relief, are unwilling to experiment with other possibilities. “I couldn’t even consider the idea of trying out different preventive drugs or practicing deep breathing when my doctor proposed it,” recalls King. “It was as if I’d caught on fire and someone handed me a damp washcloth. All you want is that bucket of water now.”
Lack of reimbursement is also a deterrent to optimal treatment by any kind of doctor. “Talking to patients and trying out medications takes time, and doctors do not get paid to spend time with their patients,” Loder says. PCPs in particular work in an insurance-pressured environment that pushes them to spend a limited number of minutes with each patient.