Why Care About Medication Overuse Headache with Daily Migraine?

Health Professional

Question:

My migraines became chronic almost five years ago, and I have a migraine every day. Imitrex is hit or miss for me. My neurologist refuses to prescribe enough Imitrex for me to take it every day because of rebound headaches, and my family doctor refuses to prescribe anything for my migraines. He just says to talk to my neurologist. Let's get real here. Why should I care about rebound headaches since I have a migraine every day anyway? Can you tell me why it makes any difference? Thanks, Jodie.

Answer:

Dear Jodie;

This is an excellent question and one on which not everyone who cares for headache and migraine patients would necessary agree. There are really a few questions here that need to be answered.

First, does sumatriptan (Imitrex), or any other triptan, cause medication overuse headache (MOH)? The answer is that yes, it does. The MOH caused by triptans tends to be less malignant and somewhat easier to reverse because there's no clear risk to triptan withdrawal other than worsening headache and/or migraine.

Second, it isn't clear that you currently experience MOH. Since you don't take sumatriptan frequently enough to cause it, are you overusing a different acute migraine medication, such as acetaminophen, caffeine, butalbital, or opioids? If so, it will be far more important to limit the use of these than to limit your use of sumatriptan, but the important number to watch is the number of days you use any acute medications.

Third, are you currently being treated with preventive medication such as a daily oral preventive, onabotulinumtoxinA (Botox), or one of the various devices which can improve headache frequency? If not, or if what you are using is ineffective, it's very important that you talk with your headache doctor about your options.

And finally, once all those questions are answered, we can try to address sumatriptan quantity limits. It's a fair question that you ask — if you already have a daily migraine, why should you worry about MOH?  There are many goals when treating patients with headache and migraine: reduce pain and suffering, improve quality of life, and retain or regain social and work functioning are just a few. It's also important to avoid doing things which may prevent any of these goals from being achieved now or in the future. That's where it becomes important to be cautious with the use of medications that have potential for causing MOH. As an example, let's say that a new preventive agent becomes available that would be effective for you, but due to the daily use of sumatriptan, it doesn't work. It's clear that many preventives don't work in the face of MOH. By taking sumatriptan daily, you would be trading the potential for significant and sustained improvement for short-term and quite possibly short-lived relief.

There's no easy answer to your question, and I'm sorry that you are stuck between that rock and hard place. Keep talking with your doctor about your options, and don't give up hope.

Thank you for your question,
Dave Watson and Teri Robert

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