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Treatment Medications & Transformed Migraine

One thing we’ve learned about Migraine through research in recent years is that there are identifiable patterns among people who transform from Episodic to Chronic Migraine. While it’s not possible to say there is a direct cause-and-effect relationship, if you are an episodic Migraineur, empowering yourself with knowledge about modifiable factors only makes good sense. One thing you can control is paying attention to what medications you use for treatment and the frequency with which you use them.



A category of medications called triptans, which include well-known medications like Imitrex and Relpax, are a godsend for many Migraine patients. These medications were a huge breakthrough when first introduced in the early 1990s because they abort a Migraine attack rather than simply treating the symptoms.

But as people have used them for the past couple of decades, we’ve learned more about how frequent use for ending Migraine attacks can affect some patients.

We advise patients to limit their use of triptans to no more than three doses in a seven day period to avoid developing a condition called Medication Overuse Headache. However, it’s important to note that based on what we know at this time, Medication Overuse Headache based on frequent use of triptans does NOT tend to lead to chronification of Migraine Disease.

Butalbital Compounds

Researchers have observed that use of butalbital compounds, such as Fioricet, for treatment of acute Migraine attacks is more frequently associated with a risk of transformation from Episodic to Chronic Migraine than other treatment medication.

Using data from the groundbreaking American Migraine Prevalence and Prevention Study (AMPP), researchers determined that patients using butalbital compounds were almost twice as likely to end up experiencing transformed Migraine than patients using triptans, over-the-counter pain relievers or ergotamines.

Based on what we currently know, more than five days of butalbital compound use in a month increases a Migraineur’s risk for transformation to Chronic Migraine. But there is no magic formula, of course, and this may vary from person to person.


In the same study that analyzed data from the AMPP study to look at butalbital compounds, researchers determined that opioid use is also twice as likely to be associated with transformation to Chronic Migraine than triptans, OTC pain relievers or ergotamines.

The point at which opioid use tends to become excessive and more likely to lead to transformation appears to be eight days a month based on the data we currently have available.

Interestingly, there seems to be a difference between use of short acting and long acting opioids, however. While this may not be especially useful for episodic Migraineurs, it may be comforting knowledge for Chronic Migraineurs who find themselves in a position to consider long term pain management options.


It’s important to note that once a patient’s Migraine Disease has transformed from episodic to chronic, different considerations come into play. The need to try to help improve the patient’s quality of life and level of function may warrant use of medications like butalbital compounds and opioids that are not good front-line treatments for patients. These decisions should be made on a case-by-case basis depending on your needs.

As more research is conducted regarding Chronic Migraine and transformation from episodic to chronic I hope it will be possible to give patients more guidance about what to watch out for and how to approach their treatment.


This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Marcelo E. Bigal and Richard B. Lipton, "Modifiable Risk Factors for Migraine Progression," Headache 2006; 46: 1334–1343.
  2. Zaza Katsarava, Dawn C. Buse, Aubrey N. Manack; and Richard B. Lipton, "Defining the Differences Between Episodic Migraine and Chronic Migraine," Current Pain and Headache Reports 2012; 16(1): 86–92.
  3. Richard B. Lipton, "Tracing transformation: chronic migraine classification, progression, and epidemiology." Neurology 2009; 72: S3-7.
  4. Lawrence Robbins, "Refractory chronic migraine: long-term follow-up using a refractory rating scale," Journal of Headache Pain 2012; 13:225–229.


  • lk26
    5 years ago

    I had episodic migraines for 20yrs, treatment varied from nothing(time)(which was before I knew what they were), OTCs, ergotamines, fioricet, Triptans, which I had adverse reactions to multiple ones but did not get any relief from anyway. It would vary from 1-2 a year, sometimes several years in between, so none of the meds were taken on a regular basis. Then around 40ish, the pain increased in frequency, duration & severity and soon become daily. Having tried multiple meds, Fiorcer with codeine and/or Ultram were my only reliefs. I then chose a new neurologist, as well as seeing a migraine specialist for the first time, had no idea there was such a specialist. Both were familiar with each other and had managed multiple patients together. I thought great, finally a glimmer of hope, but by the time I was seen by both MDs, the pain was constant to some degree. After I failed multiple attempts of meds, therapies, injections, herbs, even occipital stimulator, etc…They both agreed they had tried all the “tricks in their bag”, I was sent to Pain Management. I never knew that you could have that much pain, for so long! There were trials of multiple narcotics taken on a scheduled basis that left me “zombie like”, but still not pain free. Then I was given Vicodin & Dilaudid to take on an as needed basis. That was about 4 yrs ago, while my pain still remains, the frequency of med taking has decreased. Recently I voiced concern to my Neurologist about long term narcotic use. His response was I am addicted to my pain meds, need to stop them and manage me on Topamax & Botox. Simple, right? I’ve tried those TWICE already with no so good side effects. With family members(siblings) having thrown the term “drug addict” around to the point that I had to divorce them. Did I forget to mention recently, within a 10 month span, my Mother, Father and younger Brother all died unexpectly? So I’m very sensitive to the term. Upon deep reflection, I have come to the conclusion that my reluctancy to “give up” narcotics is mainly because they are the only thing that has ever given me relief! Knowing that is not ideal therapy currently, I don’t know what to do. I did get Botox injections 3 days ago and agreed to re-start Topomax for the 4th time in 2 monthes.

  • bluesguy
    5 years ago

    I commend you for your effort in providing information to those who may not have it. I will not get into a medical discussion on the internet, as it is not productive. I meant no disrespect. I am certain that your article was written with only the best of intentions. The intent of illuminating some of the more complex issues related to the treatment of migraine headaches is thoughtful. I am simply stating that there is a wealth of clinical data in various medical journals. These experts often do not often come to the same judgment when it comes to the treatment of this terrible problem we are all struggling with. I wish you the best.

  • bluesguy
    5 years ago

    I read this article with some pause, as it seems to contradict the “Rules” regarding “Medical” advice or information. In my humble opinion, it is fine to offer information regarding treatment options for the variety of Migraine syndromes that exist today. However, to offer medical information (correct or not) as if it is fact, when one does not show that they hold some form of Medical degree, PhD., or related degree, is irresponsible. I have found this site to be quite helpful as a support network. I hope that those who are in position to monitor the article content will take this under consideration.

  • Diana-Lee author
    5 years ago

    Feel free to review the references for this article if you’d like more information about the research on which it is based.

  • JeanyB
    5 years ago

    When triptans first arrived I thought they were the wonder drug for migraines. Then after years of using them I needed to take then more and more as my migraines increased. I would take sumatriptan and almost exactly 24 hours later the migraine would return, so I would take another and this went on for days. I just thought my migraine was worsening but in reality the sumatriptan was prolonging symptoms.
    Now I just take OTC painkillers and suffer for a day then the migraine has gone. I did try them once again with a severe migraine, the same happened, it relieved the pain but 24 hours later I was in pain again. I won’t go near them now.
    I think the triptans contributed to my now chronic migraine.

  • Diana-Lee author
    5 years ago

    Even though triptans don’t seem to contribute to transformation for the majority of people, it’s not outside the realm of possibility that they can and do for certain people, like you.

  • Crc1289
    5 years ago

    I have migraines daily and have gone back and forth with trying to figure out of these medications were contributing factors. Some doctors are so convinced opioids will cause rebounds and fioricet will only make it worse. I find it frustrating to advocate for myself when these things are sometimes the only things to break the pain when it gets unbearable. I really wonder if they understand the level of pain I live with daily.
    I also would like to say that it is sometimes very difficult to not lose hope completely and just give up this struggle but since I found this site I at least don’t feel alone and would like to thank you for that.

  • leannrs
    5 years ago

    I’m with you. Migraine is not simple. I have chronic daily migraine (have had 3 MRIs that show the migraine plaques and my sister also has them) and have had so much trouble getting insurance to cover my triptans–which work perfectly fine. But I also have chronic Lyme, fibromyalgia, a degenerative TM joint with bone spurs and multiple chemical sensitivities. I am in chronic pain. I cannot take any aspirin or NSAIDs (allergic), am highly sensitive to opioids and have found the best treatment for chronic pain is fioricet (which does NOT help my migraines, btw). So, I take it to have a quality of life that makes me productive. I have NO SIDE EFFECTs. This is what works for me. When will doctors understand that we are all unique and what works for one person may not be right for another. I am waiting for the FDA to lower the hammer on fioricet and I will be in so much trouble. I am an author. I need pain relief so I can concentrate. I am very frustrated by all this “stuff”. Not many people understand.

  • Diana-Lee author
    5 years ago

    Not feeling alone is SO important. There is so much to sort out and handle day-to-day when you live with this kind of chronic, debilitating condition. I’m glad you feel less alone since you came to the site. Hang in there!

  • Nicole
    5 years ago

    I have been on medication so long for my migraines and always ask my doctors about the long term risks/ side effects. They are always telling me there is nothing to be concerned about and would look at me blankly when I asked what long term studies had been done that gave them the confidence to say that.

    3 years ago I went from episodic to chronic migraines. I was given opioid drugs before triptans existed and after for when they didn’t work. Guess I was right to be concerned.

  • taralane
    5 years ago

    I too went from episodic to chronic, and because the triptans only worked once for me, and then did nothing I was put on a small dose of morphine to counter the constant pain. I took the small dose only when needed, and then, as the migraines got worse, I started daily doses (approved by my doc), and I finally decided that the meds were causing MOH and I got off them completely. Getting off an opiod is no fun!

    I now use one triptan which is working well for me, but I am finding I have weeks when I have one headache after another, and am taking the one triptan that is working more than 3x/week.

    I am worried now that this triptan will stop working, and I am just hoping that I can go back to another one of the triptans which might start to work after a long absence.

    Looking back I feel like the morphine contributed a lot towards keeping me chronic, and other drugs like percodan, vicodin, & fioricet helped me to get chronic in the first place. There is no easy answer. The knowledge base is much greater than it was back when I was first looking for pain relief some 40 years ago. The most we can do is keep other’s experience with these meds in mind, know that we all are different, and keep trying to find a solution that will work – even if it’s only for a short time.

  • Diana-Lee author
    5 years ago

    Yes, unfortunately this is an issue that too many docs don’t have on their radars. And it is complicated because it varies widely from person to person, but I do believe it’s something every patient should be made aware of.

    Maybe we would have transformed anyway, but it’s hard not to wonder what might have been different if we’d known this back then.

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