Migraine and Drug Dependence

 

This post is in response to Arabella’s post regarding the difference between medication overuse headache (MOH) and addiction. We are both responding to redOrbit’s article Migraine Meds Can Become Addictive  (BTW, the original AP article is better. Thanks, Parin). What followed was not on addiction, but on medication overuse headaches (MOH) or rebound headaches. These headaches occur when the culprit medication wears off and a severe headache occurs.

RedOrbit’s headline conjures images of Migraineurs sneaking out at night in dark alleys looking for their next fix. This is unfortunate because there is some truth to it. Anyone who takes a medication runs a risk in becoming addicted or dependent. This is NOT the same as abusing the drug. That is a whole other ball of wax.

In the medical community addiction or drug dependence means

is a state in which the body relies on a substance for normal functioning and develops physical dependence, as in drug addiction. When the drug or substance on which someone is dependent is suddenly removed, it will cause withdrawal, a characteristic set of signs and symptoms

It doesn’t mean that the person is liable to engage in dangerous behaviors to get another “fix”. That is drug abuse. Indeed, for most patients on pain medication, the fix is not necessarily just euphoria, but pain relief. And that certainly brings a sense of well-being.

There are many pain relievers that have the potential to cause drug dependence. Two of these are mentioned in the redOrbit article: Fiorial and Percocet. Fiorinal is a combination of three drugs: butalbital, aspirin, and caffeine. Butalbital is a sedative barbiturate that slows down the central nervous system. Patients can become dependent on butalbital and may find themselves taking Fiorinal more frequently just to function.

There is a double whammy in Fiorinal in that the butalbital can cause dependence; the aspirin and the caffeine can cause medication overuse headaches. So the woman highlighted in the article may have had both drug dependence and MOHs.

The same is true for Percocet. It is a similar drug prescribed for pain. It contains oxycodone and acetominephin. Oxycodone is an opoid narcotic pain reliever, similar to morphine. Acetominephin (Tylenol®) is a milder analgesic and enhances the pain relieving properties of oxycodone. Like butalbital, oxycodone can cause drug dependence, especially if taken more frequently than prescribed. The acetominephin can be the culprit in medication overuse headaches.

So it appears that drugs that combine a barbiturate or an opioid analgesic with aspirin, caffeine, or acetominephin carries the risk of both drug dependence (addiction) and medication overuse headaches. It does NOT necessarily lead to drug abuse.

Have an AWAP day,

Debbie

Photo courtesy of http://content.answers.com/main/content/wp/en/d/d7/VariousPills.JPG

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Migraine and Pregnancy: Fetal Exposure to Valproate

The topic of migraine treatment and pregnancy has surfaced several times in the past few months. I had always thought I would blog about pregnancy and migraine at some point. I guess now is the time.

Some of the questions about pregnancy or the contemplation of starting a family center around medication. Depakote, or divalproate sodium, was recently approved for the prophylaxis of Migraine attacks. It can be extremely effective (long ago I was on Depakote and my migraine frequency went from nearly daily to no attacks!). It is also teratogenic and can cause severe cardiovascular anomalies and neural tube defects in infants exposed to valproate during the first trimester. The package insert warns patients of this danger.There is one flaw in the warning. The information in the package inserts was obtained from women who were being treated for epilepsy and not Migraine.

An Israeli study (Diav-Citrin, Schlectman, Bar-Oz, Cantrell, Arnon, & Ornoy, 2008) included all callers who contacted the Israeli Teratology Informations Service during 1994-2004 concerning gestational valproate exposure. From this initial population there were 154 valproate exposed pregnancies. This included women who were taking valproate for reasons other than epilepsy. The control group (1315 pregnancies) were people who were counseled for nonteratolgic concerns during the same time period.

The results showed that valproate exposure increased the risk of major anomalies 2-fold as compared with controls. When the valproate-exposed group was divided into subgroups (treated for epilepsy and treated for other medical problems), the authors found that all of the fetuses with major anamolies were found in the epilepsy group and had been exposed to valproate throughout the pregnancy. None of the women taking valproate for problems other than epilepsy had babies with birth defects.

What does this study mean to Migraineurs? Valproate is a known teratogen. That’s the bad news. However, this study seems to say that women whose valoproate doses are less than mg/day and includes another anticonvulsant. The authors stated, “[i]t was noteworthy that, in the present study, a daily valproate dose of less than 1000 mg was not associated with increased risk of major anomalies.” To me this is good news.

References: Diav-Citrin O., Schlectman, S., Bar-Oz, B., Cantrell, D., Arnon, J., & Ornoy, A. (2008). Pregnancy outcome after in utero exposure to valproate: Evidence of dose relationship in teratogenic effect. CNS Drugs, 22, 325-334. Picture courtesy of the Headache-Adviser.

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Vacation and Migraines: An Oxymoron?

I would say that the answer to this question is a wholehearted, NO. And I say it after going to Boston, Chicago, Myrtle Beach, and Raleigh, NC all in the space of 6 weeks. Each trip I learned something new. I have found that stress added to other triggers will put me over the edge. I always thought of stress as being negative. But happy stress is still stress. I found this out after going to a wedding, bridal shower, and just plain excitement can help trigger a migraine. Planning and going on vacation is that kind of “happy stress”. In these cases, I expect a migraine.

I think that expecting a migraine is the best way to head it off before it gets me. Some may think that expecting to have a migraine is negative thinking and THAT will “cause a migraine”. I beg to differ. If I expect to have a migraine, I will be prepared. I will have my meds ready; I will try to manage my other triggers (poor sleep and eating habits, alcohol, dehydration, etc.).

Unless your destination is already a given, give thought to where you decide to go. If changes in the weather trigger your migraines, I wouldn’t suggest the Ohio Valley in the summer because of the higher probability of thunderstorms. The same suggestion would apply to the Eastern seaboard and the Gulf because of hurricanes.
You can check the Weather Center-Air Sports.net for predictions on the chances for a thunderstorm in any given area. There are also barometric pressure maps as well. I like to choose places that have consistently sunny weather. I particularly like North Carolina for this reason.

If bright sunlight triggers a migraine, I would suggest a pair of good sunglasses rather than tell you to go somewhere cloudy. A sunglass buying guide can be helpful in your search for a good pair that protects your eyes, has good frame construction, and doesn’t break the bank.

Medications: for years, I tried to count out the number of pills I would need and dump them all in a bottle. I never, never got it right. Then, after the Boston trip (and being short of meds), I developed an Excel file that would automatically calculate the number of pills I would need. This only works if I remember what I take and I put the numbers in correctly. It worked for Chicago like a dream, but I still had to pick through a mountain of pills to find the right ones.

My 86 year-old mother solved the problem. (It actually my sister who devised this system.) Pill boxes! I never used them because they were too small. I now have 2 (AM and PM) and most of the pills fit. Now why didn’t I think of that?!

Rest and relaxation: every vacation needs a time of rest. I should take my own advice. Boston was a whirlwind weekend with sorority sisters I had not seen in 30 years. Every minute was scheduled. Chicago was a 3 day tag along with my DH. I went sight-seeing, saw long lost relatives, enjoyed the city. But I took time to rest every day. Raleigh was different; I accompanied my elderly parents from Myrtle Beach to Raleigh for my nephew’s wedding. It was stressful, but I carved out time to rest. There was 3 hours between the wedding and the reception. I took a nap. In Myrtle Beach when my mom was cared for, I went to the beach, walked, went swimming. I made sure the lay-over in Charlotte was adequate to eat and to rest.

Packing: pack light. The fewer items you take, the fewer you will have to take care of. You are on vacation. No one will notice you are wearing the same 3 outfits. If they do, they won’t say anything. Make a check list of things you need. This will require some forethought. What will you be doing? Where will you be going? Do you have access to a washing machine? I have 2 suitcases that are already semi-packed with travel sized: shampoo, toothpaste, toothbrush, body wash, comb, brush, and other things I have forgotten on previous trips. Don’t forget the charger for your cell phone. Allow extra room in your suitcase to bring home souvenirs.

One carry-on is enough for me to handle. I pack everything I can, even my dresses (if I have to wear one). I even have a travel purse that has only the essentials: abortive meds, handcream, lip balm, a pen, ATM card, one credit card, cash, driver’s license, and cell phone. It is small enough to fit in my carry-on.

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