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Safely using multiple pain-relief medications

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.

Summary

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:

  1. Headache occurring on ≥15 days per month in a patient with a pre-existing headache disorder
  2. Regular overuse for ≥3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
  3. Not better accounted for by another ICHD-3 diagnosis.

8.2.6  Medication-overuse headache attributed to multiple drug classes not individually overuse:

  1. Headache fulfilling criteria for 8.2 Medication-overuse headache
  2. 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.

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

  1. Headache: The Journal of Head and Face Pain, 56th Annual Meeting of the American Headache Society Program Abstracts, Volume 54, Issue Supplement S1, Article first published online: 19 JUN 2014, retrieved online 11/4/2014 at http://onlinelibrary.wiley.com/doi/10.1111/head.12405/abstract.
  2. International Headache Society, 2013, The International Classification of Headache Disorders, 3rd edition (beta version), Cephalagia, 33(9) 629-808,Sage Publications Ltd, 1 Oliver’s Yard, 55 City Road, London EC1Y 1SP, United Kingdom, retrieved online from http://cep.sagepub.com, DOI 10.1177/0333102413485658.

Comments

  • Bulldog
    3 years ago

    Does the amount of triptan (Maxalt) doses taken per day matter regarding overuse headaches? Sometimes only one triptan does not give enough relief and I take a second dose after two hours. Does taking a second (or third) dose in a day contribute to overuse or should I only count the number of actual days I take any amount of triptan? Sometimes after taking an initial dose without achieving significant relief, I think to myself, “I should not take another dose because it may contribute to overuse problems?” Is this a valid concern?

  • Tammy Rome author
    3 years ago

    Most triptans can be taken twice in one day — once at the first sign of symptoms and a 2nd dose if not improved in 2 hours. Two is the maximum recommended dose and it is not recommended to take more than one type of triptan in 24 hours. Please check the safety instructions on your prescription, plus check with your pharmacist and doctor for specific instructions.

    Medication overuse when it comes to triptans is when you use it more than 15 days per month for 3 or more consecutive months. It’s one thing to have a bad week where you need to treat more than 3 attacks. That’s usually not a problem. But if you need to do that all the time, then it’s time to ask your doctor for either a longer-lasting triptan or a better preventive (or both).

    Overuse is defined by how many days a month you take any combination of pain medicines, not by how many you take in one day. For example, my doctor recommends taking a triptan and an NSAID together for better relief. So I take Amerge plus Naproxen at the first sign of an attack. It’s pretty rare that I need a second dose with this protocol. You might ask your doctor about using this strategy. That only counts as ONE DAY of use, even though I take more than one medicine.

  • Purity Mason
    5 years ago

    PLEASS HELP ME!!!!
    My doctor wants me to take a “medication vacation.” I am TERRIBLY worried about this. The majority of the time my scheduled medication works well, though there are times of high stress where nothing seems to help.
    Does anyone have any first hand experience in this scenario? As bad as things can get now, I can imagine how rough it might get if I quit and how long she will withold medication before she things.
    PLEASE HELP!!!

  • Tammy Rome author
    3 years ago

    I’m sorry I didn’t see this message sooner. I do hope you are doing okay. Most doctors recommend this when they suspect our frequency of using meds is contributing to the frequency of our attacks. How often do you need to treat migraines? If you need to treat attacks more than 2-3 times a week on a regular basis, you might very well benefit from a break. I know I did. It was scary and unpleasant, but it did help. It does get worse before it gets better and takes 4-6 weeks to see improvement. Most doctors are willing to help you through the process if the pain gets really bad. You just need to keep in touch.

    I do hope you are doing well and have successfully broken the cycle of MOH. Please let me know how it turns out.

  • Jules2dl
    5 years ago

    Dear Tammy;
    Thank you for this article! I’ve been in rebound, or MOH, and it’s no fun.
    However, I always thought I was safe if I used different meds and/or alternated them during the week. So if I used a triptan 2x during a week, I thought it was okay to use something else that same week. Never once has a doctor ever told me not to use ANY pain meds more than 2x/week!
    I really appreciate the fact that you included your treatment plan, as I’m freaking out now about what to do.
    I’ve got a lot to talk to my docs about, it seems.
    Thanks much,
    Julie

  • Tammy Rome author
    5 years ago

    First, relax. 🙂

    Second, I used to think that, too. The issue is so confusing that most doctors don’t understand it well enough to inform patients.

    Not everyone who overuses pain medicine will get MOH. However, using pain meds more than 2-3 times each week does increase your risk. It’s just smart to try to minimize your risk as much as possible and to monitor your headache frequency to watch for signs of MOH. If you can find ways to treat your pain without taking medicine, then do it.

    Good luck with your doctors. Except for my headache specialists, the rest give me that “deer in the headlights” look every time I refuse their offer for more meds.

  • Tammy Rome author
    5 years ago

    Having a well-stocked migraine toolkit that you use often can help to minimize the number of pain meds you must take.

    http://migraine.com/infographic/tips-for-building-your-migraine-emergency-toolkit/

  • Luna
    5 years ago

    1.3 Chronic migraine
    A. Headache (tension-type-like and/or migraine-like) on ≥15 days per month for >3 months

    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

    Please explain to me the difference between chronic migraine and medication-overuse headache. The above descriptions look quite the same. Is MOH a headache and not a migraine? What is that? If a person is not getting worse by using an OTC daily but is able to function and have a life is that a problem? Sometimes articles have just enough information to confuse and leave many unanswered questions. Thanks.

  • Luna
    5 years ago

    Tammy, Thank you for the very good detailed explanation for MOH. That helps very much. I’m one of those that preventatives don’t prevent and migraine drugs either don’t really work or are contraindicated. Happy New Year.

  • Tammy Rome author
    5 years ago

    All this information can be very confusing. Taking too much pain medicine increases your risk of MOH, but doesn’t necessarily guarantee you will get MOH. You know you’re in MOH when the attacks change in quality from migraine to more of like a tension headache. The pain will feel like a band around the head and you won’t have all the other neurological symptoms of a migraine. Also, MOH has a unique timing. The pain shows up just as the medicine is wearing off. So let’s say you are taking daily Aleve for arthritis and you also get migraine attacks. Gradually you start feeling a tension-type headache every day just as the Aleve wears off. It only goes away when you take more Aleve. Now Aleve usually isn’t strong enough for most migraineurs, so it wouldn’t do anything for your migraine attacks.

    I know it is confusing. There is absolutely nothing wrong with wanting to function and have a life. That’s what we all want. The take-home is that if you find yourself needing pain medicine more than 2-3 times each week, then tell your doctor about it. It could mean that your preventives are not working and you need to try something else.

    It’s also safer to use migraine-specific abortives than OTC or narcotics. There is still a risk of MOH, but it is greatest with narcotics, then OTC, then migraine abortives.

    I recently had orthopedic surgery and had to take strong pain relievers for a few days, and then continue to take Aleve for breakthrough pain during PT. However, I know this is a temporary situation. It does mean I take more than 2 pain relievers each week. So my headache specialist was informed and we are both watching for any increase in frequency or severity.

    Just be careful and keep your doctor in the loop. We are all just trying to do the best we can.

  • migrainestl
    5 years ago

    I have read so many articles & blogs about MOH. I know that it exists, but I also think each patient is different. When my symptoms are low (as they have been the last 2 wks–yay!), I can completely abide by the rules. However, when I’m in the midst of an attack & life cannot stop, I have a hard time.

    Twice in my 3+ years since turning from an episodic to a chronic migraineur I have gone off all pain meds & triptans. First, I did the Dr. buccholz 123 diet for 8wks….I was miserable. The second, I was 5mo preggo & my migraines disappeared. When you have no pain, there’s no need to take anything.

    I have stressed so many times over how many meds I’m taking, but at the end of the day–we only get one life. Do your best, but allow yourself grace….it’s ok to want to function.

  • Tammy Rome author
    5 years ago

    I totally agree with your last paragraph! We’re all just trying to do our best. It’s important to know about the risk of MOH. However, it’s not worth stressing ourselves out. My rule of thumb is that when I get to the point that I feel I must take that 3rd dose for the week, I do it so I can not be miserable and then I call my doctor to let him know what is going on. He and I work as a team to get my frequency back down. Maybe it’s just an “off” week and things go back to normal the next week. But if he and I start to see a pattern, the first thing we do is look at lifestyle and triggers, then we look at preventive meds.

    A few years ago, I had a breakthrough on this issue when we realized my attacks tend to go on for 24+ hours and my abortive only lasted about 6. My doctor switched me to a longer-lasting medication and now I only get 1-2 attacks per week because the medicine works better. I can easily stay in the recommended limits most of the time.

    Then a few months ago, my frequency ramped up again. I called my doctor and he recommended I start Botox. You just need to keep your doctor informed about how often you take your pain meds so he can help keep it to a minimum as much as is possible.

    Then, when you’ve done your best, you just live your life. Some rare patients do need more frequent treatment. You may just be one of them.

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