The Scary New Migraine Mistake

Millions of women are being prescribed pain relievers that they get addicted to—and that make their headaches more frequent.

By Peg Rosen
migraines medicine hammer mallet prescription drugs picture
Photograph: Dan Saelinger

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.

 

INTRACTABLE CASES
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.

First Published October 10, 2011

What’s your reaction?

Comments

Ewizobeth Noyb07.14.2013

Wow, it's articles like this that have turned an already hostile environment for Migraineurs into a combat zone. By pigeon-hole Migraineurs along with street addicts and criminals, you have given the already insensitive, contemptuous doctor justification for moral outrage. In other words, the migraine is blamed on the Migraineur.
In medical settings, the Migraineur, already at high risk of stroke or aneurysm, is further endangered by the abusive treatment of angry doctors. In fact, imagine a ticker tape registering each unfortunate Migraineur's death caused, in part, by this bombastic article. Did you know that in the U.S. more people die each year from migraine strokes, than are killed by handguns? Picture the gunshot victim being wheeled into the ER at the top of the triage list, while somewhere in a dark back room, the lowly Migraineur sits, quaking with fear as to what comes next.
I have used morphine at home for twenty years, never needing any increase in my prescription. Recently, I have changed pain clinics, and during the interim, I stopped using morphine without tapering. I wanted to experience withdrawal full force, so I could find out what I'm dealing with.
After four days, I began wondering when the withdrawal suffering would begin. It just never happened. No physical withdrawal, no psychological withdrawal, and no change in my mental state. I had always asked my husband if he could tell when I was using morphine, and his answer was always no. But any time I use Ambien, he knows within five minutes. He says “you just took Ambien, didn't you?”
Right after discontinuing morphine, my dad was gravely ill and placed in hospice. My family took shifts 24 hours a day so that he would never be alone. This was a highly stressful situation in which a narcotics addict would be scrambling for any drug to self-medicate against the intense emotions. It never crossed my mind, except to wonder why it wasn't happening. I was fully present for my dad, and I experienced the entire spectrum of emotions from sadness to joy, without pulling away.
But before you do the Snoopy dance because I stopped using narcotics, I need to let you know that discontinuing morphine was a total disaster. I knew I was in trouble when my visual migraines returned after a 20 year absence. Since then, I've had my first seven day migraine (that's seven days in bed). The left side of my head got covered in welts. My migraines spun out of control. But at least I know I'm not such an idiot as to become a drug addict. They say that addicts have a black hole inside that can never be filled. I'm not like that. The most common nickname people give me is “Smiley”.
MAGNUM (Migraine Awareness Group for National Understanding for Migraineurs) has an excellent article about the true nature of Migraine at http://www.migraines.org/myth/mythreal.htm that you should read. Basically, all five senses are amplified in Migraineurs. Using myself as an example:. TOUCH: when I was a child, my family called me “Princess and the Pea”, because they were certain I would feel a pea under 18 mattresses. HEARING: I tell people that I have “radar” ears to explain why pick up on every conversation near me. TASTE: while the family enjoys a delicious meal, all I can taste is freezer burn that no one else notices. SMELL: I always smell things that no one else does, or I smell things first, like burning leaves in a neighbor's yard. Migraine is a genetically inherited disease, not a headache. It involves the entire body, not just inflammation of the head region.
Ever since I read the MAGNUM article, I've had one “aha” moment after another. Finally, a credible breakthrough in the understanding of migraine.
I've had to go to the ER a few times recently, and conditions have deteriorated during my 20 year absence. I can only describe the current conditions as barbaric. The doctors are barbarians. I didn't think I would have ever have a use for the word “barbaric”. Never say never. The situation is dire and dangerous for Migraineurs.
And into the mix comes your article. I'm sure your colleagues are all patting you on the back for your “insights”. You are like every other interloper. You are on the outside, looking in. You are building your own reputation on the backs of people who are already stigmatized and abused. And don't say you have migraines, because you have never had my migraines. With friends like you, Migraineurs don't need enemies.
By the way, I bookmarked your article under bullsh*t.

Gillean McLeod09.24.2012

Last year, after five days straight of the scariest migraine ever, I was driven to the emergency room of a local hospital in Los Angeles. I was given an iv for fluid, and into
that the er doc. put a dose of benadryl. It took four hours for the headache to wear off.
He claimed that this particular hospital treats migraines as an allergy. From that
day forth I have had no alcohol, no gluten, no wheat, very little dairy and the headaches that have plagued me for 45 years are virtually gone. Of course hormones must play a large part in the disappearance of the weekly headaches, but I feel like a new person. So glad that I no longer have to take any medication.

Teri Robert08.26.2012

The basic premise of your article, stated under the title - "Millions of women are being prescribed pain relievers that they get addicted to—and that make their headaches more frequent. - IS FLAWED.
Medication overuse IS NOT ADDICTION. What's more, medication overuse headache (MOH) can occur if we use pretty much any type of medication to treat a Migraine more than two or three days a week - opioids; triptans such as Maxalt, Imitrex, Zomig, etc.; simple analgesics such as acetaminophen; NSAIDs such as ibuprofen or aspirin; anything. We're caught between a rock and a hard place.
Migraines are already very misunderstood and surrounded by stigma. If you're going to write about Migraine, be responsible, and get it right instead of adding to our problems.
Teri Robert
Migraineur, patient educator and advocate

M.K. Hajdin01.27.2012

Yet another scare story that would have us believe that opiates are evil and turn all migraineurs into drug addicts.
The stigma of "drug addict" or "drug seeker" is all-powerful in our society. Why? Drug addicts are scapegoats, viewed as lazy, weak, irresponsible, sociopathic. Nobody wants to get tarred with THAT brush. Nobody asks why we need to scapegoat people in the first place.
Opiates work well for many migraineurs. But they're being increasingly restricted and rationed - hoarded for the wealthy, who can get whatever they want with no questions asked. The poor had better content themselves with triptans and NSAIDs, if they even get that much, if their pain is even believed at all.
Stories like this only rationalize and justify anti-opiate paranoia. Even if a frequent migraineur develops a tolerance to opiates, tolerance is not addiction. And in cases of very frequent debilitating migraines, it would be better to have an addiction than constant uncontrolled pain. This is of course, anathema to our puritanical nation, who hate and despise drug addicts more than anything. We should try the U.K. model of harm reduction rather than deprive suffering people of cheap and effective medicine that works.

Jennifer Nelson10.26.2011

Headaches are troublesome enough; but when it gets to the point that you become addicted to your pain meds, you've added additional trouble in exchange for only temporary relief. This is such a great article, particularly because it shows how important it is for doctors to have the right training to treat headache sufferers. I know it is difficult when patients have many different triggers and reactions to medications, but that is why, right now, it is important for patients to go to a headache specialist. Once primary care physicians become better trained in headache and migraine, I hope that patients will be able to go to them for questions, but this is something that is so lightly covered in medical school. I recently read a great article on Headwise.com about when it is time to go to see a specialist (see http://www.headachemag.org/Articles/Lifestyle/The-Benefits-of-Seeing-a-H...).

Deborah 10.20.2011

Thank you for this article. I discovered/realized my husband's addiction to his migraine medication seven years ago. He's been free of pain meds now (specifically ultram/tramadol -- which he was prescribed by a well-known pain clinic back in 1997) for almost four years.
I started blogging about it this year and have found that we are far from alone...and your article is further evidence that this silent epidemic has been going on unnoticed and unheeded far too long. Sad to me that this is "new" when for too many migraine sufferers, it's been going on for decades.
My blog is enduringandafter.com. Maybe some who read this article will find encouragement from our story.
By the way, my husband has had MAYBE three migraines in the past four years -- ever since he came clean from the drugs. Prior to that, migraines were at minimum, a weekly occurrence.
Also, some of these drugs, like Tramadol, are dangerous to get off cold-turkey. Finding the right doctor or clinic to help you do so is critical. We know from far too much experience.

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