I have suffered from migraines for approximately 30 years. In the past year or so, I have gotten into a cycle of a migraine every day for weeks at a time, then will have a period of some relief for a few weeks, then back to the dailies. My neurologist keeps trying varioius preventives, many of which have had horrible side effects, none of which have really helped. I recently purchased Ms. Roberts' book, and have self-diagnosed rebound headaches. I have been taking Imitrex daily, sometimes twice daily, until I run out. My specific question is this: if the Imitrex is causing the rebounds, is it okay for me to take something else for a headache, like Migranol, or narcotics? Or do I have to stop any and all medications? Once I am out of the rebound, how do I best prevent it starting again -- should I alternate different drugs if I am having headaches on successive days?
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Q: How do I get out of cycle of rebound headaches?
Hi, Kara,
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Research has been discovering and teaching us more and more about medication overuse headahce (MOH), aka rebound. In fact, were I to write my book today, I'd need to change parts of the section about MOH.
It used to be thought that we could alternate classes of medications, as you described, to avoid MOH. More current information shows us that this can lead to MOH too. 
I recently rewrote the MOH article here to reflect the newer information. I hope you'll take time to read the article Medication Overuse Headache: When the Remedy Backfires. In particular, note this section from the second page of the article:
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.
If you're still referring to my book for information, may I suggest that you print this article fold it, and stick it in the book so you'll have the most current information?
Most doctors are still saying we should limit "acute" medications, those we take to relieve a Migraine, to no more than two or three days a week.
Usually, using no acute meds for two weeks will "reset" our system and stop the MOH, but this can vary from person to person.
One thing to note is that even if we're at our limit of days for Migraine abortives and pain medications for the week, we can probably still take an antinausea medication to relieve nausea, if it occurs, and that will often also help us releax and, hopefully, sleep. Sleep is a natural Migraine abortive.
Once you're read the updated article, please let me know if you have more questions?
Welcome again,
Hi,
long story short: last October I was admitted to the hospital after a 5 day headache that was unresponsive to drugs. My specialist told me that I had been over using Imitrex for the past 4 years and recommended that I completely detox my system for up to 6 months. So for a few months I took nothing but muscle relaxers or ibuprofen if I got a migraine. I also had access to lunesta in case I needed to sleep off a migraine or was unable to tolerate the pain.
That process was really a tough time in my life. I was trying to finish my senior year in college and was very involved in my major. I worked a few times a week at a restaurant too. I took a leave of absense from my waitressing job and tried to just focus on school. I had to plan ahead in case of headaches and played a lot of catch up with my school work.
Luck for me, my family, boss and professors were all incredibly understanding and supportive. Also during those 6 months I started trying a lot more holisitc approaches to dealing with migraines and tried to make some overall lifestyle changes as far as diet and exercise go. Over the summer I was in the best health I've ever been in. I only got 3 or 4 headaches/month. Gradually I've become less attentive to my health and I'm starting to regress. I still try to monitor the amount of medication that I'm taking each week because I have a great fear of rebound cycles now. It will definitly be a life long process even once you've broken the rebound pattern.
Wow, the thought of taking nothing for six months is just staggering to me. That's just not feasible for me at this time. I do agree with the whole-lifestyle approach, though, and I'm working on that, too. I can see why alternating Imitrex and Relpax wouldn't work, as they are both triptans. I'm wondering, though, if alternating different families of medications, like a triptan-ergot-narcotic cycle, would be more effective.
Thanks for responding! I just found this site after reading Ms. Robert's book, and have spent a whole afternoon so far clicking around.
I have had the same problem - tried every medication, every injection, every alternative therapy and got nowhere. I have experienced what I now believe to be triptan rebound headaches - different from the original migraine but so painful that I reached for the triptan anyway and it did work but then it creates a horrible cycle of daily headaches that seem to never go away. I vow to never touch another triptan and the very thought is terrifying. I've had my neurologist break the rebound cycle with prednisone (3 week taper) but then it started all over at the next migraine attack. I can't take motrin, naproxin, or aspirin; acetaminaphin also causes rebound headaches, you know. I have valium to help me sleep, so I'm going to stick with just that when I get my next migraine and stay away from the triptans. Funny how no one mentions this horrible side effect - which is technically withdrawal from a few days of triptan use. Good luck to all. It sucks.
In my experience triptans give me the worst rebounds. I had a local doctor who said max 4 days per week on the triptans but once I started seeing docs at headache clinics they tend to think 2 days a week is the max on triptans. I read one book (Heal Your Headache) where the doc claimed more than 2 days a MONTH on triptans could cause rebounds. I've found that intermuscular DHE injections work better than triptans and don't cause the kind of severe rebounds triptans do. That being said, I just finished a cycle of prednisone which I'm hoping will kick me out of my latest rebound cycle (probably caused by overuse of advil, aleve and caffeine). I kept the DHE to 2 days per week so I'm pretty sure that's not the problem. If it turns out not to be effective I will probably have to do another inpatient treatment at Jeffereson Headache Center (really hoping to avoid that).
Hmm . . . that's the second time recently I've heard about DHE injections. Is that the same drug as in Migranol, or am I way off base? My doctor recently let me try Migranol, and while it didn't work as well as the triptans, it was good enough that I'm going to try alternating it with the triptans to try to help with the rebound. I think I'm going to ask about the injections, though -- is that a self-injection?
Kara,
DHE-45 is the same medication as Migranal, but in injectable form. It's injected subcutaneously (under the skin), not into the muscle.
Alternating the ergotamines such as DHE and Migranal with triptans won't avoid MOH. Since they have many of the same actions, they actually count as the same type of drug.
I was prescribed triptan meds and eventually put in the hospital with an IV of DHE-45. This gave me a heart attack. So, absolutely NO triptan meds for me. I have since then been taking about 4-6 excedrins per day and the pain is getting worse and worse. I have had MANY thoughts of suicide because the pain is the worse pain ive ever had and it stays ALL DAY EVERYDAY! I literally feel as though my head will explode (mostly on the left side). Doc gave me a prescription for Demerol and one night it was so bad that i took 2 of them and a percocet. It took about 2 hrs. for me to calm down enough to fall asleep, then I was awaken with horrible chest pain and taken by ambulance to the ER. My life has been a living HELL with these and I simply cant take the pain anymore. Ive had so many people pray over me and NOTHING has worked. I now have hemorrhagic episodes during my menstrual cycles (losing extreme amts. of blood) due to the excessive intake of aspirin, and now have to have a hysterectomy. But before the surgery, i have to come off the excedrin for at least 10 days. I can't even fathom how i will do this. PLEASE SOMEBODY...HELP ME, IM SO DEPERATE AND DO NOT WANT TO LOSE MY LIFE. I have 4 beautiful children and am a single mom. One child is autistic and I can hardly care for them the way i want to. I LIVE ONLY FOR THEM, but I really want to end this pain.
oops, my mistake, i meant to say no triptans or DHE-45. The triptan meds simply had way to many side effects and did not help the pain.
My doctor had said that DHE 45 is used in hospitals only. I do not know if that means he does not prescribe it or if it means that it is not given out as a self injectable medication.
Migranal is very similar to DHE 45 as they are both in the ergot family. They work very much the same, although I have heard of more people having success with DHE 45 than Migranal.
From what I understand about MOH (rebound headaches) is that alternating medications do not work at all. If you alternate with narcotics or any other type of medication you will end up still having MOH. Many people also take care with OTC, narcotic and barbituate medications as they will cause similar effects.
The only known way to hault a MOH is to stop taking all medications. Please talk to your doctor regarding this as he may have an easier method to help you get through this. (I.E Trigger point injections/botox/acupunture/massage therapy/biofeedback) Sorry to be the bearer of bad news. I hope you feel better soon!
I am prescribed DHE 45 by my doctor for home use. It comes in vials and I use 25 gauge needles for injection into muscle tissue. It is exactly the same medicine as in migranol. I have used migranol as well, it gave me nose bleeds and was not nearly as effective as the injections. IV DHE 45 is only administered in hospitals (because it is delivered into veins). I've been instructed not to use triptans on the same day as DHE. Unfortunately both can cause rebounds, so switching between days won't work. I limit my DHE/triptan to two days a week max. Even though its tough, to prevent rebounding, rescue meds should only be used 3 days per week. The other days I just suffer through. Zanaflex on those days is sometimes a relief (and doesn't cause rebounds).
Hi, lovegia. It's nice to see you here.
Your doctor is very much mistaken. DHE-45 has been around AND being used by patients at home since 1945. It's injected into the veins only in the hospital or clinic, but it can be injected under the skin at home.
Thank you very much for the information guys 
I think my Neurologist is scared of Migranal and DHE-45. I went to my appointment and once again asked for it and was turned down, however I got stadol instead. Strange, huh?
You're very welcome. :-)
I have to say that if my dotor did that, I'd be finding a new doctor. Stadol canNOT abort a Migraine. It's not even similar to DHE. All Stadol can do is mask pain for a few hours; it's an opioid.
It's not a first-line Migraine medication. It should be reserved, as shoud all opioids, for use as a rescue medication to be used if abortives fail. ANY use of opioids or barbiturates and frequent use of triptans and NSIADs are associated with increased risk of transformed Migraine. See Transformed Migraine - Risk Increased by Some Medications for more information on this.
If your doctor isn't able to help or is to afraid of medications to work better with you, it may well be time to consult a Migraine and headache specialist. It's important to note that neurologists aren't necessarily Migraine and headache specialists. Take a look at the article Migraine and Headache Specialists - What's So Special? If you need help finding a Migraine specialist, check our listing of Patient Recommended Migraine and Headache Specialists.
Hang in there,
Thank you Teri.
I already have an appointment booked with a headache specialist as per your recommendations. I should have included that she gave me Relpax to try first but it doesn't work for me; triptans and I do not get along. She also gave me a Methylprednisolone pack to use with the Stadol. I also get a script for Fioricet w. codiene every month. Fioricet isn't strong enough for 1-2 of the migraines I get a month.
On the topic of MOH, I get auras with my migraines. Do auras present themselves in MOH? I always get one-sided migrainous pain. I am always light and smell sensitive and the pain is intense. I have wondered if it is MOH however the pattern of my migraines has not changed since taking medications.
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Also - I don't think that it's a good idea to alternate medications. Right before I was forced to detox I was alternating Imitrex and Relpax because my headaches were so frequent that only one perscription wasn't enough to get me through the month. I'm not sure if the kind of preventative makes any different - your body is still being conditioned to expect medication everyday.