Top 75 Migraine and Headache Questions, #20

Full Question:
How do you decide when to treat migraines, when the theory is that if you treat them more than twice a week, you're put yourself into a rebound cycle? I have "intractable migraine with migraine variants" according to my neurologist, with a 20 year history of headaches and this current one now lasting continuously for 28 months (I'm 44 years old, female). The pain averages about a 7/10 for the past three months. I've asked my neurologist about rebound, and she indicates that she doesn't prescribe enough pain medication to me to cause rebound. I do not take any OTC pain medication; only what my neurologist prescribes. What I struggle with is when to decide to treat my headache. All of the pain meds (especially the migraine-specific ones) say to take at the first sign of pain, but what is the first sign of pain when the pain is continuous? If I have a limited number of times to medicate, how do I decide that it's bad enough to medicate, and how do I weigh that with the notion that it would work better if the pain wasn't as severe when I take the meds?? And what if I decide to go ahead and medicate it at a 7, and then it gets worse, but I've already treated it twice that week?

I've tried several of the most commonly-prescribed preventatives (although admittedly not all of them, nor all possible combinations); am currently on atenolol and Cymbalta with Stadol NS as my abortive/rescue. Last week I tried a series of DHE SC injections to try to break the cycle, but reacted badly and ended up in the ER with chest pains, dizziness, nausea, so no more DHE injections for me. Sad, as they seemed to be helping. Also, I need to find a new neurologist; I was informed last week that mine will be closing her practice. Any recommendations for a great headache specialist in Utah? I'm aware of Dr. Kathleen Digre at University of Utah, but she isn't on my insurance and has a long waiting list to get in.

Thank you for all the time and effort you put into this site! It is very thorough and informative. ~Vicki

Answer:

Dear Vicki;

First off, thank you for your kind comments. I don't know any other headache specialists in Utah. If you can travel to Colorado, Judy Lane is near Denver (799 East Hampden Ave, Englewood, Colorado -- 303-781-5505). 28 month-long headaches aren't likely to be migraines. I agree with your concern and dilemma about frequent dosing with triptans, but that caution is not an absolute.

I would wonder about your sleep pattern because, if made more secore and restful, that might help the pattern.

DHE (or its cousin, Migranal Nasal Spray), should be used after an antinauseant is taken. Maybe that's why the side effects. I wish you well on your quest for defeating your headaches.

Here's some information that may help you as you prepare to work with a new doctor:

• What is Transformed Migraine?
  Transformed Migraine (TM) is Migraine disease which began manifesting in episodic Migraine attacks, increasing in frequency and changing characteristics, and resulting in almost daily less severe headaches punctuated by severe and debilitating Migraine attacks.
• Stopping Medication Overuse Stops Transformed Migraine
  Data from a study released this month in Headache: The Journal of Head and Face Pain, confirms once again a major point we've discussed about transformed Migraine. When medications that are being overused and leading to medication overuse headaches are discontinued, there is significant improvement in headache frequency and transformed Migraine reverts back to episodic Migraine.