Migraine disease is a complex neurological disorder that affects millions worldwide, presenting not just as a headache but as a symphony of symptoms that can significantly impair quality of life. While preventive measures and treatments are vital, the role of over-the-counter (OTC) acute medications cannot be overlooked. These medications, when used correctly, can offer relief during migraine attacks. However, their use must be approached with care to avoid potential complications, such as medication overuse headache (MOH), also known as rebound headache.
What is Medication Overuse Headache?
This is a drug-induced headache which develops more than 15 days out of the month as a consequence of regular overuse of acute/symptomatic headache medication. The MOH develops when the overused medication is taken more than 10 days/month (for Excedrin) or more than 15 days per month (for ibuprofen, acetaminophen, and aspirin). Usually, this headache goes away after a detox period where the medication is not taken at all.
Knowing this, let's delve into the details of some commonly used OTC acute medications for migraine.
NSAIDs: Ibuprofen, Naproxen, & Aspirin
Length of Action and Potential for MOH:
Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen are popular choices for acute migraine relief. They typically start working within an hour of ingestion, with effects typically lasting 6 hours for ibuprofen and 12 hours for naproxen. Aspirin generally lasts 4-6 hours. The ease of acquiring NSAIDs and their effectiveness can lead to overuse.
Using NSAIDs more than 15 days a month can significantly increase the risk of MOH.
Risks of Chronic Use:
Long-term, frequent use of NSAIDs can lead to gastrointestinal issues, including ulcers and bleeding, kidney damage, and increased risk of heart problems.
Tylenol (Acetaminophen)
Length of Action and Potential for MOH:
Acetaminophen is another common choice for treating acute migraine attacks. Its pain-relieving effects can be felt within an hour and last about 4-6 hours. While Tylenol is often perceived as mild and safer, it can become overused and lead to more headaches in the long run.
Using acetaminophen more than 15 days a month can significantly increase the risk of MOH.
Risks of Chronic Use:
The most significant risk of chronic Tylenol use is liver damage. The safe upper limit is generally considered to be no more than 4000mg per day, and exceeding this can lead to serious, even fatal, liver injury. The safe upper limit is reduced to 3000mg per day for older/elderly adults and those with preexisting liver problems.
Combination Meds: Excedrin
Length of Action and Potential for MOH:
Excedrin combines acetaminophen, aspirin, and caffeine, offering a multi-pronged approach to migraine relief. This combination can be particularly effective, with effects kicking in within 30 minutes to an hour. The caffeine is thought to speed up the absorption and efficacy of the medication. However, it can lead to MOH even more rapidly than ibuprofen or acetaminophen!
Using combination products like Excedrin more than 10 days a month can significantly increase the risk of MOH.
Risks of Chronic Use:
Combination products have both NSAIDs and acetaminophen, so they carry the risks of both of those categories with them.
Antihistamines: Benadryl
Benedryl (diphenhydramine) can be effective in aborting a migraine attack for some people. Due to its status as a Pregnancy Category B drug, it's common for pregnant women to take as well. There is not a good base of scientific evidence to show that diphenhydramine works consistently for acute migraine management, but it also does not carry risks of MOH development as the other OTC drugs discussed here do. Adverse effects of diphenhydramine include dry mouth and drowsiness. The drowsiness may actually be beneficial in some individuals as it may allow them to "sleep off" their migraine more easily. diphenhydramine is not without risks, though; overdose can be fatal. Ultimately, taking this medication as directed on the bottle or by a medical provider for acute migraine relief may be helpful, but we need more studies to assess its effectiveness.
The Importance of Finding an Effective Preventative
The potential risks associated with chronic use of OTC acute medications highlight the importance of finding an effective preventative strategy. Preventive therapy aims to reduce the frequency, severity, and duration of migraine attacks, thereby reducing the need for acute medications. Effective prevention can include lifestyle changes, prescription medications, or other interventions like biofeedback or acupuncture. With so many options, it can be hard to know where to begin. It's usually a good idea to start by reducing acute medication use if you think you might be in a cycle of MOH. Talk to your healthcare provider about doing this safely and starting on a preventative medication to hopefully reduce the number of attacks you get.
If you think you might be in a MOH cycle, don't blame yourself or feel bad about this--it's not your fault, and there is hope! It's challenging to manage migraine effectively without falling into the trap of medication overuse, especially when immediate relief from OTC medications is readily available and we have life obligations to attend to. There's never a good time for a migraine to strike! However, the evidence clearly shows that over-reliance on these medications can worsen headache disorders over time. For this reason, a balanced treatment plan includes both preventive strategies and the mindful use of acute medications.