Safely using multiple pain-relief medications
Any medicine that relieves pain can cause medication-overuse headache if taken too often. Obviously, some medicines pose a greater risk, such as opioids and narcotics. But if you are taking over-the-counter medicines because you believe they are safe, think again.
According to a study presented June 26-9, 2014 at the 56th Annual Meeting of the American Headache Society, there is 35% lower risk of medication-overuse headache with twice weekly triptans than with use of analgesics (naproxen, acetaminophen, ibuprofen, or aspirin). Even ergotamines had a lower risk than analgesics. I understand that some people cannot take triptans or ergotamines. Even NSAIDS can be inappropriate for some patients. That leaves some of us with the difficult choice of taking over-the-counter analgesics. or addictive prescription narcotics to help manage pain. Neither medicine will abort a migraine. Yet both put you at greater risk for medication-overuse headache if used too often.
Please be careful. Regardless of what medicine you take (even triptans), remember to limit their combined use to no more than 2-3 times per week. Medication overuse headaches are terribly unpleasant to break. By over-using a medication, you put yourself at risk of not ever being able to use that medicine again. Twice a week is the limit. If you are experiencing pain more often, please talk to your doctor about safer ways to manage the pain.
What if I already have medication-overuse headache?
Maybe you’ve been taking a lot of pain medicines for a long time. Now that you know the risks, you might wonder if you already have medication-overuse headache. While only a headache specialist can accurately diagnose your headache disorder, these guidelines from ICHD-3 will give you some idea. If you think you might have medication-overuse headache, please share this information with your doctor at your next appointment.
Based on reader comments and questions, the subtype listed below is the one I think most patients are at risk of developing. Most of us know not to take a single medicine too often. However, we tend to think it is okay to mix medication types over the 2-3 a week guideline.
For example, we might take Imitrex twice a week, with a once-a-week Percocet and 2 or 3 Tylenol for non-migraine headaches. Doing this for 3 consecutive months or more is likely to create medication-overuse headaches and make your problems much worse.
In order to break this subtype, patients must stop all pain medicines. Can you imagine 6-8 weeks without any type of pain medicine? That sounds unbearable to me.
Practical tips to reduce your risk
So what are we supposed to do – suffer? I don’t know about you, but that is not an acceptable solution for me. I can’t tell you what to do instead of taking too many pain medicines. I can only describe the plan my doctor and I have created. Perhaps by reading my protocol you will get some new ideas to discuss with your doctor.
It has been over 5 years since I have been pain-free for any length of time. I have had to change my mind-set to accept a certain level of pain as “baseline”. Most of the time my pain is not treated with anything more than gentle stretching and simple exercises. I have determined that I can continue to function up to about a 4 in intensity. If my non-head pain goes above a 4, then I will use ice, heat, a TENS unit, or massage to help manage the intensity. Anything above a 6 that does not respond to conservative treatment and I will use a prescription muscle relaxer.
I reserve pain medication for migraines and cluster headaches that do not respond to oxygen. No other pain gets treated with pain medicines. The only pain medicines I use are one triptan and two NSAIDs: naratriptan, naproxen and intramuscular ketorolac injections. With my doctor’s permission, I sometimes take naproxen and naratriptan at the same time. On a rare occasion I will get more than 3 attacks in a single week. When that third attack hits, I use comfort measures from my toolkit (ice, heat, vibration, aromatherapy, massage, anti-nausea medicine, muscle relaxers, etc.). If it gets worse, I break it with an injection of Toradol and usually have no more problems. Once or twice a year, I get stubborn attacks that must be broken by using prednisone.
The only time I take narcotics or opioids is short-term while in the hospital or ER to break a stubborn cycle. Most of the time, Dilaudid is used. I haven’t needed it in over a year.
Each of us is unique. Our treatment plans will vary. However, we all have the responsibility to reduce the risk of worsening our condition. One way to reduce this risk is by not over-using our acute pain medications. If you are having difficulty with over-use, please talk to your doctor about ways to reduce your need for acute relief by finding the right preventive strategies.
Diagnostic Criteria for Medication-overuse headache
Excerpted from the International Classification of Headache Disorders – 3rd edition as published in the July 2013 edition of Cephalagia.
8.2 Medication-overuse headache:
- Headache occurring on ≥15 days per month in a patient with a pre-existing headache disorder
- Regular overuse for ≥3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
- Not better accounted for by another ICHD-3 diagnosis.
8.2.6 Medication-overuse headache attributed to multiple drug classes not individually overuse:
- Headache fulfilling criteria for 8.2 Medication-overuse headache
- Regular intake of any combination of ergotamine, triptans, simple analgesics, NSAIDs and/or opioids on a total of ≥10 days per month for >3 months without overuse of any single drug or drug class alone.
Can you tell when a migraine attack is coming?