Pharmacy Pearl 25 September 2002

*** "Pearls" return! Now from beautiful Lackland AFB, TX, Gateway to the AF!

As usual, if you have a good clinical case that would make a good Pearl, please contact me. ***

A 27 y/o female patient presents to your clinic with a history of migraine headaches. Her previous provider started her on sumatriptan oral tablets with instructions to take up to 100mg per migraine attacks, not to exceed 3-4 attacks per month. Currently, her chief complaint is almost daily migraine headaches. She has seasonal allergies treated with OTC antihistamines and has no drug allergies. She does not smoke cigarettes but drinks large amounts of regular coffee. Her labs were within normal limits when last checked about 3 months ago. She's asking for another prescription for her sumatriptan and/or another agent to treat her migraines. After interviewing the patient and reviewing her pharmacy profile, you see her use of triptan has increased significantly over the last 30-60 days. She describes her headaches as long lasting (often > 6-8 hours/day), occurring almost daily, varies in location and severity, and trials of preventive meds (from another provider) were ineffective.

Do you write the prescription? Why or why not?

SELECT here for discussion

Probably should NOT write the prescription. This patient likely has a case of rebound (or drug-rebound) headaches. Drug rebound headaches have reached almost epidemic proportions. This kind of headache is caused by over use of abortive medications like ergots and triptans. The issue making this kind of headache difficult to treat is patients do not view analgesic use (or overuse) as a contributing factor to rebound headaches, esp since they take analgesics to ELIMINATE headache pain. Return of the headache is often viewed as a 'wearing off' of the previous dose of analgesic. Re-dosing may help the headache acutely but further contribute to the rebound syndrome.

A 1986 international workshop listed the following characteristics of rebound headaches:

        -    Frequency > 20 or more headaches per month
        -    Daily headache duration > 10 hours
        -    Analgesics/anti-migraine meds taken on > 20 days per month
        -    Regular intake of these meds in combination with barbiturates, caffeine, codeine, antihistamines, and/or tranquilizers
        -    Increased frequency/severity of headaches when meds are stopped
        -    Type of underlying headache isn't related to development of syndrome

Preventing rebound headaches:

        -    Limit amount of abortive meds to 2-3 times a week (MAX)
        -    Use lowest effective dose
        -    Alternate abortive meds has been useful in some patients
        -    If headaches occur > 2-3 times a month, consider long term prophylactic meds such as beta blockers, calcium channel blockers, tricyclic antidepressants, valproate, etc.
        -    Stress 'life style changes' such as limited caffeine intake, stress reduction, getting enough sleep, etc.

Treating rebound headaches:

        -    Patient education is critical. Trying to convince a patient to take LESS medication to treat a painful headache can be VERY challenging, esp when the medication relieve the pain.
        -    OTC analgesics may be discontinued abruptly.
        -    Prescription meds (triptans, ergots, opiates, barbiturates) require tapering of the dose. Clonidine may help opiate withdrawal symptoms.
        -    Maintain fluid and electrolytes balance, patients may tolerate the withdrawal symptoms better.

REFERENCES:
- Kehoe WA. "Drug Rebound Headaches" The Pharmacist's Letter, 20 May 98

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.