Daily use of #triptans for #migraines?

Clearly not for me since I have side effects that suggest I am rather sensitive to this type of medication and more is definitely not better in my case. Yet I know of people with chronic migraines who would not function without the being able to take triptans daily. It enables them to function. They do not rebound, their migraines are better, not worse with the treatment and they have no side effects from the use of them daily.

Why does this seem astonishing? Because we are told rather rigidly that we should only take a maximum of three per week to avoid rebound headaches. If I did not have such an issue with side effects I would be tempted to go over that rule and see because as it stands we are left with four days of the week rather unaccounted for. Assumed the one we take is effective for the migraine day we treat. Some neurologists however say that while the Rebound rule is valid of OTC medications, opiates and NSAIDs it was never really firmly established with Triptans. For people who have run through a great deal of preventatives and nothing works, this form of management can apparently be effective. If it is ever considered. That Rebound rule is a firmly established believe among neuros, even if patients may be skeptical that we all respond the same way for every single medication.

"A small number of my patients take triptan medications daily. Many doctors, including neurologists and headache specialists think that taking these drugs daily makes headaches worse, resulting in rebound, or medication overuse headaches (MOH). However, there is no evidence to support this view. Sumatriptan (Imitrex, Treximet), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan (Amerge), eletriptan (Relpax), almotriptan (Axert), and frovatriptan (Frova) have revolutionized the treatment of migraines. I started my career in 1986, five years before the introduction of sumatriptan when treatment options were limited to ergots with and without caffeine (Cafergot), barbiturates with caffeine and acetaminophen (Fioricet), and narcotic or opioid drugs (codeine, Vicodin, Percocet). These drugs were not only ineffective for many migraine sufferers, but they also made headaches worse. Dr. Richard Lipton and his colleagues followed over 8,000 patients with migraine headaches for one year. Results of their study showed that taking barbiturates (Fioricet, Fiorinal) and narcotic pain killers increased the risk of migraines become more frequent and even daily and resulting in chronic migraines. We know from many other studies that withdrawal from caffeine and narcotics can result in headaches. However, taking triptans and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin (Migralex), naproxen (Aleve), ibuprofen (Advil, Motrin) does not lead to worsening of headaches. Only those patients who were taking NSAIDs very frequently to begin with were more likely to develop even more frequent headaches at the end of the year. Aspirin, in fact, was found to have preventive properties – if you were taking aspirin for your migraines at the beginning of the year you were less likely to have worsening of your headaches by the end of the year." The New York Headache Blog

And we see where the issue is. It is an established rule they are following based on old research. Then they simply applied it to everything. I for one was put on NSAIDs once to replace triptans, as I mentioned those side effects do once in a while disturb doctors (not all, but the good ones, yes) and I had no rebound headaches at all from taking the NSAIDs regularly. It was also a treatment for my menstrual migraines to take the NSAIDs daily for the duration of those brutal long lasting migraines. And effective really. I had side effects from them unfortunately but not rebound headaches. In fact, I didn't even know at the time doctors even considered that possible but when i read that it was it made me wonder if then we do not respond to medications the same way in regards to this Rebound rule... given I was on two different NSAIDs regularly for a good duration... until a GI bleed that is. They helped with the migraines. Didn't make them worse. Didn't make them more frequent. However, I also know codeine, in the form of T3s is a horrible rescue medication for me because it always gives me an after headache. Can't use it two days in a row, more than one a day, more than a couple days a week. Which rather makes it a piss poor choice for a rescue medication given it isn't that strong to begin with and causes something similar to what it is in fact helping with. Not my preference. Tramacet on the other hand does not. Maybe if I used it more than three days a week it would as well, but in moderation I have never had that same response to that as a rescue medication. Nevertheless, I understand the need to be wary of my use with painkillers as I understand the potential of rebound headaches. I know what they feel like though. And definitely do not get them with NSAIDs.

"“Daily triptan use for intractable migraine” is the title of a report by Dr. Egilius Spierings published in the latest issue of the journal Headache. This is a controversial topic, which I addressed in a previous post. Dr. Spierings, who is affiliated with both Tufts Medical Center and Harvard Medical School presents a case of a 50-year-old woman who failed trials of multiple preventive medications. This woman responded well to sumatriptan, 100 mg, which she took daily and occasionally twice a day with excellent relief and no side effects. Dr. Spierings discusses the evidence for Medication Overuse Headaches (MOH), which is common with caffeine-containing drugs, butalbital (a barbiturate), and opioid drugs (narcotics). It is less clear whether triptans cause MOH and he mentions that most patients who end up taking a daily triptan do so only after they failed many preventive (prophylactic) drugs and after they discover that they can have a normal life if they take a triptan daily. This applies not only to sumatriptan, but any other similar drug, such as Amerge (naratriptan), Zomig (zolmitriptan), Maxalt (rizatriptan), Relpax (eletriptan), and other. After 20 years of being on the market, we have no evidence that these drugs have any long-term side effects. In Europe several of these drugs are sold without a prescription. The major obstacle to their daily use has been the cost. However, several of these medications are now available in a generic form and a 100 mg sumatriptan tablet costs as little as $1.50." The New York Headache Blog

The fact is assuming you have a neuro open minded enough to try daily triptans for you because it literally works for you and enables you to function... cost is a factor. It can be a battle to get an insurance company to pay for anything over 9 pills a month. Here in Canada I recall when i went over that I just had to have my doctor sign something to say he was aware of the 'risks' associated with my using more than 9 a month. That went into the file and I am covered. However, it is rare if ever I do so. I would I assure you if it were not for side effects. They are the most effective medication to help with migraines. End of story. However my side effects are not in the normal range and get worse the more I use within a close time frame so it isn't an option, which I assume is the case with some people who have similar side effects... apparently that isn't that common. Anyway, I am not sure all Canadian insurance companies are the same. Coverage differs on many of them for one thing and if you are forking out even a fraction of the cost, let alone all of it, this is a costly venture. Triptans are not cheap. In the US insurance companies are even more rigid about the 9 a month rule it seems. Maybe neuros writing letters to our insurance companies would help, maybe we would have to pay out of pocket. Maybe if we could afford that it would indeed be worth it if it helped us function on a daily basis. Generics certainly do help with this issue.

Either way with chronic migraines where many treatments and preventatives have been explored I do not see why this is not an option that is considered. With careful supervision at first of course to monitor response.

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