Sunday, 15 April 2012

“The Drugs Don’t Work They Just Make You Worse…” Medication Over-Use Headache


I’ve been addicted to drugs, prescription meds and over the counter painkillers. Twice. Maybe three times.

Technically, this is not true. Technically, I’ve had Medication Over-Use Headache (MOH) a couple of times, but I say I’ve been addicted to drugs when I want to sound cool, or get people’s attention. Like now.

The lyrics of the Verve song (quoted above) make me shiver, not because I think it’s a beautiful song, but because it always make me think of Medication Over-Use Headache (MOH). MOH is an incredibly easy trap for people with migraines to fall into. I first succumbed to it in 2004 when I was living in Hanover, New Hampshire, U.S.A. studying for a Masters degree. My migraines were out of control and I knew nothing, even though I’d had migraines for about 5 years and been on nearly every preventative under the sun. At this stage I hadn’t read one single book about migraines, I didn’t know there were phases of a migraine attack, I didn’t know one should keep a diary or look for triggers. No Doctor had ever taken the time to explain any of this to me (partly because my condition wasn’t fully diagnosed yet), and I didn’t realize I needed to educate myself. At that time my vertigo was also pretty severe. I had a ‘wobble’ board in my room that I would religiously stand on each day and look at a spot on my wall, doing some vestibular rehabilitation exercises I had been given to do by a Doctor. They, of course, made me feel even dizzier. I once stumbled home from a lecture clinging to lamp posts the vertigo was so bad. I think the Yanks just thought 'there goes that drunken Brit again!'. At this point I thought jogging would help, even though every time I went for a jog I’d get a pounding migraine about half an hour later and the room would spin. And my neck and back hurt almost constantly (I also didn’t realize the extent of my neck damage). 

So, I’d basically pop painkillers like they were Smarties. My painkiller of choice at that time was Solpadeine. It’s lethal for MOH as it’s very effective, but more because it contains codeine and caffeine which, for some medical reason, make them more prone to MOH. I was also using the Triptan (acute migraine medication) Naratriptan, a slow release Triptan pill that takes a while to work. So, I’d often take a Naramaig (or Amerge in the USA) preemptively, or take two as I didn’t know if they’d worked. I also had Sumatriptan injections which I was happily self injecting on top of all this… If you know the pain of migraine this doesn’t sound so crazy. I’d wake up each day in pain, so obviously I’d take pain killers, they’d ware off, a migraine or headache would come on so I’d take more…. and the problem with these migraine medications is that eventually they actually give you a headache if you mis-use them. And the added problem is MOH feel quite similar to migraine so it’s hard to tell them apart. 

There are clues to look out for, such as you’re getting a headache of some sort every day, you feel foggy headed most days, the pain is worse when you wake up etc etc. With ‘true’ migraine you should have patches, days, in-between attacks where you feel completely fine. 

Image from http://healthlob.com/ & also used in the fabulous That M Word Migraine Blog. 

The advice for avoiding MOH is to try not to take Triptans on more than 2/3days a week (or @ 10 days a month.) The dose is not so important, but the number of days per week.

To spell it out, if you take Triptans on more than 10-15 days a month, over 3 months, you might get MOH. Obviously, this makes life really hard if you have Chronic Migraine and other pain inducing conditions. Life becomes a juggling act. Incidentally, a frighteningly large percentage of people with Chronic Migraine also have MOH. Fun times. All this makes getting prescriptions for the sacred Triptans from some Doctors quite tricky as they often say ‘Now, Victoria, are you getting into MOH territory this month’…..But I've found sticking to the 2/3 days a week rule keeps me clean! 

Anyway, the treatment for MOH is basically go Cold Turkey i.e come off the offending drug. But, if like me, you’ve managed to get MOH from TWO types of drugs you can’t be expected to give up all painkillers/drugs entirely. Most migraineurs get MOH (which, by the way used to be called Rebound headaches) because they take too many Triptans – in this instance they come off Triptans and are sometimes given other, carefully selected NSAID (usually Naproxen), or alternative pain preventatives, in tapered doses. But obviously I couldn’t do this as the other drugs they usual give MOH patients instead of Triptans were also giving me headaches….you see the sticky situation I was in!

Some mean Doctors will suggest you have to go completely Cold Turkey, i.e you can have NOTHING! To them I say – telling me I can have no pain relief at all is like:

  •  Telling the man in 127 Hours (who has his arm stuck under a rock and has to cut it off with a pen knife) that you have general anesthetic and surgical equipment but think it would be more amusing to watch him slowly cut his own arm off.

 Or 
  • Telling a Granny with a rotting, pus-filled tooth that she needs root canal and some fillings but the dentist doesn’t want to give her those nice numbing injections. He’s just going to slowly pull out those teeth, then cut out those nerves while she’s fully conscious. And actually maybe she should just go around with gaping holes instead of teeth, leaving those rotting nerve ends exposed….

Or
  •  It’s like telling a tree surgeon who has accidentally cut into part of his leg with a chainsaw that he should just keep on going and chop the rest of the leg off himself…

I could go on. I don’t think I’ve found the perfect analogy yet, if you can think of another, let me know. I’m a bit paranoid about this as can tell. But basically, if a Doctor offers you no relief find a new Doctor as you can get a lot of support (more info at the bottom). Some people, with severe cases, even 'detox' in hospital. Obviously every case is individual. For some, ceasing all medications straight away is the quickest and best way to get over MOH. I, however, was put on a tiered course of the steroid, Prednisone for about 15 days and also had, I think, a Greater Occipital Nerve Block. It worked wonders and broke the cycle. However, being an idiot, about four months later, I, um, got lots of headaches again so started taking loads of Ibroprufen and maybe Solpadeine and Triptans…..um… You’ll be pleased to hear I have not touched Solpadeine since 2004! But this is before I realized getting educated about your migraine is the key to managing them! (see Tried & Tested) Also, I’m not alone in getting MOH twice, or even thrice, there is a very common reoccurrence rate within a year… see, I’m not that stupid! It was only years later that a lovely Migraine Specialist took the time to explain to me, that the danger and trouble with MOH is your body basically runs out of its own natural pain killing abilities, i.e the tiniest trauma will trigger migraine/pain. New research suggests MOH makes our brains more sensitive to pain. Plus, if you have MOH other migraine preventatives probably wont work.

Anyway, the real reason I wanted to talk about MOH today is not because I currently have it/them (?), touch wood, but because of my lovely new friend Fran, aka the writer of the fabulous blog Skulls and Ponies. Fran had been going through a very tough patch with her migraines, (which she’s had for over 8 years) so tough she actually googled ‘migraines’ and for some reason, known only to God, came across my hysterical interview with Talk Radio Europe - that went out in Spain. If you want to listen to it – click here. I sound like a very posh 12 year old. But luckily this led Fran to my blog. Yay! But poor Fran did not realize that I would then find her email address and stalk her. I get a bit overexcited when I meet fellow migraineurs, especially ones who need to go to the National Migraine Centre, as Fran consequently did (and got the help she needed.) But Fran was already pretty clued up, so would have got there eventually.


I shall now let Fran take over the story and tell it far more eloquently than I! Click here to get to the relevant post. She is currently in week 4 of Cold Turkey. And it is hell. Going Cold Turkey sucks big time. You feel sick, get dreadful headaches and generally feel lousy. However, once Cold Turkey is over, usually you feel a whole lot better and your migraines fit the ‘normal’ pattern and acute attack medication works far more effectively.

Please read Fran’s story and support her through her Cold Turkey Hell. Go Fran, you’re nearly there! Also search for other migraine posts in Fran’s blog as she’s written some brilliant pieces recently and in the past. They're informative, insightful and much shorter than mine! Go Fran, Go! 


This is Fran's very cool Twitter pic. Follow her @skullsandponies
So neither Fran or myself are, or were, pill popping crack addicts but sometimes, "the drugs don't work they just make you worse... especially when you take too many Triptans on too many consecutive days la la la la la la la!" You have been warned! (Apologies to The Verve)

For more detailed information about MOH check out:
There are also two fabulous chapters in “Coping with Headaches and Migraines”.
As usual if you think you may be suffering from MOH get thee to the National Migraine Centre henceforth! 

P. S - Usual legal disclaimer applies. I'm not a Doctor and the drugs mentioned should NOT be taken without first consulting your own Doctor. The drugs mentioned were only given to me due to my specific circumstances and diagnosis. 

ADDENDUM:  Since writing this post NICE (National Institute for Clinical Health and Excellence) have issued new Guidelines on managing and diagnosing Headaches. A portion of the Guidelines are concerned with MOH - they state that:


"Regarding medication overuse, NICE advises the NHS to be alert to the possibility in people whose headache developed or worsened while they were taking the following drugs for three months or more:
  • Triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or
  • Paracetamol, aspirin and an NSAID [non-steroidal anti-inflammatory drug, e.g. ibuprofen], either alone or any combination, on 15 days per month or more."
The press release and guideline can be read here. 




11 comments:

  1. Its been ages since weve heard from you. Im guessing you are suffering pain. If so, snap! Hope you are ok tho,

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  2. Hello Gill! Thank you so much for your message, really kind of you! It has been a crazy two weeks with migraines and having the final prolotherapy injections in my neck which triggered some more migraines. Every migraineur I know is having a terrible April, especially in the USA where the weather is playing havoc with people's heads. Sorry you're having a tough time too. Hoping to put up a little post today then resume my usual tirade! xx

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  3. Nice to hear from you. Since march15th Ive had tooth/jaw pain and migraines or headache all mxed in. Dentist gave me the all clear. not sure which problem is causing the other. Im off to read your latest post now. Take care. Gillx

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  4. You know you're now the third migraineur who has recently talked to me about possible problems with the tooth/jaw pain all mixed in. If the trigeminal nerve is involved in migraine - and if in some way the jaw/teeth are aggravating that then it's worth investigating. I woke up one morning in 2004 with half a tooth in my mouth - quite horrified - and the dentist said a lot of people clench their teeth in the night without evening realising! It was a tooth from the left side of my mouth - and my migraines are left sided.... Likewise, I think a lot of migraineurs grind teeth without realising? Did your dentist suggest a mouth guard at night maybe? I also know of a women who, when she changed her old silver fillings, to those new white ones, go much better! (very random I know!) Another friend, who left a comment on here recently, I forget where, is currently having steroid shots in her jaw as her Doctor thinks TMJ could be the cause of her severe migraines....so it can be a vicious cycle, with one aggravating the other.. Really hope you get the bottom of it! x

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    1. Hi, Ive had a night time mouth guard (made with material used by NASA!) for several years. It has definitely helped me stop teeth clenching and so lowered the amount of migraines I get. Next week my dentist is going to check its still doing its job properly. I really hope this will lead to an answer as Im still getting daily jaw +/- head pain. x

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    2. Hi Gill, I love the idea of you wearing a space station mouth guard! It sound like something is deff going on there if you're getting daily jaw pain....keep investigating! I think we have to leave no stone unturned and be detectives into our migraines and keep pestering everyone and researching till we figure it all out! x

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  5. Very insightful and well observed as ever. Gave up my sugar free diet and electro-acupuncture two weeks ago and started on cranial-sacral therapy straight afterwards supported by Magnesium Citrate. Had a super couple of weeks - only one migraine in two weeks!!! Decided not to get excited about it (clearly the three exclamation marks would belie this), so we'll see. Sorry to hear you've been through the mill lately. I absolutely agree about your GP post too. At a migraine conference I learned that every GP spends only fifteen minutes in their career learning about migraine, so we must assume that they know significantly less than us, if of course we spend more than fifteen minutes learning about our condition...Amanda

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  6. Hi Amadana, lovely to hear from you. So glad so far things are improving a little, fingers crossed! Where I live there is the most amazing cranial-sacral lady - we all actually call the white witch (Doctors actually refer tricky patients to her)- its quite incredible, I can't explain or even really describe how or what she does but its basically amazing. She will put her hands on your shoulder and go 'oh your broke your little toe when you were four didn't you?' - this is a terrible example - but the whole body parts heating up when she touches you, feel like you're falling off the table etc etc.I tried it once in NYC and felt nothing, so as always I think it really does depend on who is doing it doesn't it?

    My new mission in life is to also try to work out a way to sort out this whole GP training thing - as migraine will be - I believe - the most common neurological complaint they will see - surely they need some more basic training in it!!! And I think it needs to go back to med school where they only get 4 hours - in total - in headaches. I'm on it......and I know that places like the National Migraine Centre and our lovely Migraine Trust do run training days for GP's but they're busy people so...that's why I wonder if the key is to get to them earlier in med school.... and I think the American approach to treating migraines generally of 'Headache Centres' (but this is a whole other long conversation) is also something the UK could learn from, in a team based approach where you have physio/diet people/specialists of all sort who approach you as a team and your initial consult is 5 hours - not half an hour....though obv NHS budget might not allow for that just yet!! Anyway, let me know how you get on! x

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  7. I think that it will help especially when your in pain, or if you can't tolerate the pain any longer.

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  8. I have found some natural remedies that have worked wonders when triptans have failed me. First off, Dr Singha's Mustard Bath is a miracle worker. I basically sweat it out for at least 45 min(or until i wake up :))and migraine is gone. I have also found that turmeric in high enough doses will reduce inflammation and prevent migraines. At the moment 1500mg is keeping my headaches away.

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  9. Sorry to hear about the problem with the meds Ms. Victoria. Around the time you posted this, I read on one of those online pharmacies reviews that triptans were pretty much off the fully effective list of migraine meds. It would've helped if you knew, I guess.

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