Migraine and MOH – How many days a week can I take what?
One of the issues that many people seem to have questions about is whether "alternating" Migraine and headache medications will help avoid medication overuse headache (MOH). The questions I see typically go something like this: "Can I take triptans a few days a week then switch to pain medications for a few days to avoid MOH?"
You can read quite a bit about MOH in Medication Overuse Headache: When the Remedy Backfires, but lets look more closely at the question above.
The simple answer to the question is, "No." Let's take a better look. The International Headache Society's International Classification of Headache Disorders, the gold standard for diagnosing and classifying Migraine and other headache disorders, breaks MOH down into eight categories. In looking at this question, we want to refer to this one:
8.2.6 Medication-overuse headache attributed to combination of acute medications
Intake of any combination of ergotamine, triptans, analgesics and/or opioids on 10 or more days/month on a regular basis for more than 3 months without overuse of any single class alone.1
Most Migraine and headache specialists recommend that the total number of days that we take any kind of acute medication for Migraines or headaches be limited to three days per week in order to avoid MOH. Obviously, this presents a problem for those of us who have headaches or Migraines more than three days a week. A strong reason to do all we can to avoid MOH is that many preventive medications can't work if we're in an MOH cycle. Take a look at what Dr. Fred Sheftell said on the subject:
"MOH continues to be a vexing problem in tertiary care centers and a major challenge to primary care physicians with these patients often requiring referrals to specialists. AMPP data demonstrates that butalbital and opiates are the 2 agents most likely to lead to overuse and are a major risk factor in the genesis of CDH. Transitioning patients from MOH (10 or more days of combination products, opiates, triptans or 15 or more days of single ingredient OTCs) can be difficult as patients get worse before they improve. Pharmacologic treatment, preventives and behavioral therapies are often required. 80% will improve with a 50% or more decrease in frequency and intensity. Failure to address MOH will likely reduce the potential efficacy of any preventive intervention. Kudrow was the first to point this out in a landmark prospective study more than 30 years ago. Many studies since that time have shown similar results."3
What are we to do?
I think we all know that the long-term answer to this is finding an effective preventive regimen, but we have to survive long enough to do that. If our Migraines or headaches are daily or nearly daily, we may have up to four days per week that we can't use our acute medications. This is definitely an issue to discuss with our doctors. Here are some tips for that discussion:
- Work with your doctor to determine which acute medications work best for you. This can help reduce the number of days you need acute medications.
- If you experience nausea, discuss anti-nausea medications with your doctor. You may find that he or she can prescribe an anti-nausea medication that doesn't have the potential to cause MOH, and you could use it even on days when you've reached your weekly limit for acute medications.
- Discuss rescue medications with your doctor. If your first-line acute medication fails, a rescue medication might help.
- Remember that some complementary therapies such as acupuncture or therapeutic massage help some people. They may even be covered by insurance with a prescription from your doctor.
Don't dismiss comfort measures.
There are some tools the can offer at least a bit of relief from our symptoms and give us some comfort when we can't take our acute medications:
- Thermal therapy: Using warm or cold packs, ice bags, heating pads, etc., works well for some people. I often end up with a cold pack on my forehead and a heat pack on my neck. They help relieve the pain a little, and they help me feel more comfortable.
- Peppermint or ginger teas or candies: These are great for relieving nausea. The only caveat is that they need to be natural peppermint or ginger, not artificially flavored.
- Aromatherapy: Essential oils can be very soothing, and some are good for relieving nausea as well. They can be inhaled from an inhaler or aromatherapy lamp or applied to the skin. Caution should be used in applying them to the skin. Almost all essential oils need to be diluted in a carrier oil before applying them to the skin. There are also some excellent aromatherapy candles available. For more on aromatherapy, see Aromatherapy for Migraines and Headaches.
If we're to avoid medication overuse headache, the bottom line is that we must limit how many days a week we take any kind of acute Migraine or headache medication. We have to add the number of days that we took any acute medication and add them together for a total number of days per week. That can be quite difficult to cope with while we're looking for an effective preventive regimen. By working with our doctors and employing complementary therapies, we can at least get a bit of relief and be more comfortable on the days when we can't use acute medications.
1The International Headache Society. "The International Classification of Headache Disorders, 2nd Edition, 1st revision." (ICHD-II) May, 2005.
2Goadsby, Peter J., MD, PhD, DSc, FRACP, FRCP; Silberstein, Stephen D., MD, FACP; Dodick, David W., MD, FRCPD, FACP. "Chronic Daily Headache for Clinicians." Hamilton, Ontario: BC Decker. 2005.
3Interview with Dr. Fred Sheftell; Director of the New England Center for Headache, Past President of the American Headache Society. January 1, 2010.
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