Treatment Medications & Transformed Migraine
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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.

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Triptans

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.

Opioids

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.

Conclusion

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.

 

view references
  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.
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