What to do for Migraine when nothing works? 2023
What To Do For Chronic Migraine Headaches When Nothing Works?
So, you’ve had a headache every day now for several months. It started with a plain old normal migraine but now nothing you take works. You’ve taken your sumatriptan, like your doctor said, although you didn’t take it right, like at the beginning of your migraine like your doctor told you to.
At first, you tried Tylenol and then Advil, and then you took sumatriptan. And you feel you’ve got to stay on your 4 cups of coffee a day and occasional Tylenol and Advil because they help a little, but not much.
But now the headaches just keep coming. What is wrong? Should I go back to the Vicodin I’ve got in the drawer from that time I sprained my ankle? Or maybe use Tramadol my family doctor gave me for my headaches? What to do?
Missing class with a Migraine
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.
Read my Mini Book on Migraine Here.
To treat Intractable Migraine you have to stop all your painkillers, coffee, and acute treatment drugs like triptans. If stopping suddenly is too difficult, then slowly taper off. Continue on any preventive treatment medication and consider switching over to a preventive CGRP drug. If headaches are bad go to the ER and get a scan. Later see a headache neurologist and get on acute treatment medication. Do the Migraine lifestyle by eating right, exercising, dealing with stress, and trying to sleep better.
Stopping all medication is tough but it works. It works better if you are under a headache doctor’s care and can take medications that do not cause continuous headache while you get off the offending ones.
What are medication overuse headache and chronic Migraine?
The International Classification of Headache V 3 describes Medication Overuse Headache (MOH), old name Rebound Headache, as a syndrome related to over treating with painkillers. In America caffeine is the number one drug that causes this, but in Germany it is Tylenol.
Chronic Migraine is a term that implies having headache over 15 days a month, 8 of which have migraine features. A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly.
MOH may come from over treating with simple pain killers like caffeine, Tylenol or Advil, opioid narcotics, pain killers with barbiturates, or triptans. Patients typically rotate different drugs and take many drugs at the same time that may cause MOH.
After a while the preexisting headache problem, which is usually migraine, but may also be tension type headache, becomes transformed from an intermittent to a chronic headache problem.
It is like what happens to the patient who drinks a lot of coffee every day and then gets a headache when they don’t. When the brain becomes sensitized to these drugs repeat dosing causes neuro-inflammatory chemicals to be released in the brain which keeps the headache going.
There are two features to medication overuse headache:
1. Daily or very frequent headaches which may come with sensitivity to light and sound, nausea, and irritability
2. This syndrome causes serotonin, a calming brain neurochemical, levels to drop so the patient may also develop anxiety, depression, poor concentration, panic attacks, and insomnia, which also are core symptoms of the disorder.
First these folks need to learn that they are taking too many painkillers or headache medicines and that this causes or aggravates headaches. If you don’t believe me then Google “medication overuse headache from caffeine, or Tylenol, or Advil, or sumatriptan” and read what comes up.
Awful Migraine
Related questions.
Why should I stop my painkillers?
The patient above has Medication Overuse Headache, a syndrome usually found with migraine patients, but also with tension-type headache patients. Many of these persons are drinking some or a lot of caffeine a day as coffee and that’s a drug that can keep a migraine going for as long as you take caffeine.
The International Headache Society criteria for levels of drugs causing medication overuse headache are:
Triptans or Ergotamine intake >10 days/month (like sumatriptan).
Sumatriptan injection
Non-opioid simple analgesics >15days/month (like Tylenol, caffeine, or Advil)
Opioids or Analgesics combined with barbiturates >10days/monthBarbiturates (like Fiorinal, Fioricet, Phrenilin, Esgic, or generic butalbital).
Are there limits of the amount of drugs to treat headache? The deal here is to limit all headache drugs, over the counters, and triptans to no more than 2 days a week. This usually means taking only 1 acute therapy drug at a time. Migraine causes the 3 neurochemicals to come out and it takes 3 days for these neurochemicals to be metabolized, to get from the brain, circulate through the body and deposit in the toilet.
A transformation occurs if one continues treating with painkillers or headache medications more than 2 days, then every time a person takes one cup of coffee or one Tylenol, that individual gets 3 more days of neurochemical release.
Then the process in the brain is like putting lighter fluid on a charcoal fire, the fire, or headache, keeps burning until one stops using the lighter fluid. The reaction is exactly like this.
What are the stages of Migraine?
Migraine has 4 stages called the Migraine timing cycle:
1 Trigeminal activation, the sensory pain fibers in the fifth cranial nerve send pain to the face or back of the head, usually on one side.
2 Within 20-40 minutes the ganglia in the brain of the trigeminal nerve and the arteries start to release 3 toxic neurochemicals which last 3 days and inflame the brain and dilate the arteries.
3 At 2 hours arterial vasodilatation occurs with the pulsing blood from the heart stretching the chemically inflamed arteries.
4 The thalamus, which is the pain center of the brain, is inflamed by the chemicals and migraine process usually about 3-4 hours into the headache causing severe, level 10 pain headache and allodynia (the head is sensitive to touch.)
The Migraine Timing Cycle
Are there certain drugs that should not be used by headache patients? Yes, headache patients should never take opioid narcotics, like Vicodin, hydrocodone, or Tramadol, or drugs with butalbital in them such as Fiorinal.
Butalbital is the number 1 drug IN THE WORLD that causes medication overuse headache and has been banned in every country in the world except Canada and the United States.
What would happen if I just stop all drugs, would that work? Yes, it will be a sudden detox with lots of headache for a while and then ultimate clearing. I tell my patients that if they have an emergency landing from their jet airplane on a ocean island and they end up without any drugs at all, all alone on the beach with the surf and the coconuts, they will go through a quick detox off headache medicine with a likely a lot of headaches for days on end and then clearing.
But most persons still have a primary headache problem which is usually Migraine, but could be Tension-Type Headache and will need long term treatment after they get over chronic migraine and medication overuse headache.
The principal of detoxing off the use of chronic headache medications and caffeine is a cardinal Idea for treating these bothersome daily headaches. The caring physician needs to be upfront and to talk strongly about this issue, reassuring their patient that they will feel better, and have fewer headaches in the future if they do this.
Another strong idea—chronic headache medication overuse is a drug addiction, words most people don’t want to hear, but it is the truth.
Often times no one previously, no parent, no spouse, no friend, or even no previous doctor has ever said anything about the fact that over treating causes headache.
How long does it take to clear up headache if you stop all drugs? It takes a different time to clear for different drugs.
For over the counters like caffeine, Tylenol, or Advil it takes about 10-14 days.
For Triptans it takes about 14 days.
For opioid narcotics it takes several months although it seems that the longer you’ve taken it and the more of the drug you have taken makes the time to clear longer.
For butalbital it may take 2-3 months with a similar problem that the longer you’ve taken it and the more you’ve taken makes the time to clear longer.
Well, why can’t I just do this at home. Stop all my drugs and gut it out? That can be done, but it usually is a miserable experience and working with a headache doctor is better and he can use safe drugs to treat your headaches that won’t aggravate headache occurrence.
Look, if you’ve got medical insurance with a drug plan and can find a good headache doctor, getting off headache medicine is a much easier course of medical treatment.
Migraine is genetic, it’s in families, you’re born with it. You can’t run away from it. Face up and get some help.
If you don’t have drugs, Ice will suffice
Well, if I work with a headache doctor how does that go? Some headache doctors admit the patient, and go ahead and do a work up with MRI scanning and blood work which is reasonable although a work up can be done cheaper as an outpatient.
Then, in the hospital the doctor will usually give IV dihydroergotamine (DHE), a migraine drug with a long half life that has lots of data indicating it can control headache without causing the headache to keep going.
The usual admission here is for about a week and then the patient is followed as an outpatient.
See a Headache Doctor
Does everybody have to be admitted? I don’t usually admit these patients because you really don’t have to admit most patients to get them out of the headache problem successfully. Patients can be treated with Migranal nasal spray, intramuscular injected dihydroergotamine, timolol eye drops, or Nurtec OTC which can control the headache ok, while the patient stays off the offending drugs.
Many headache doctors will also:
1. Start a preventive drug, like one of the new CGRP drugs given subcutaneously every month. Drugs here are Aimovig, Emgality, Ajovy, or Vyepti which can be effective for controlling headache in the future.
2. Give a week or 2 of oral prednisone, an anti-inflammatory drug that helps control the headache. This is what I usually do and without causing a lot of side effects or weight gain.
The following list of drugs may be used for patients who have a contraindication for using triptans or dihydroergotamine (DHE), such as patients with stroke, coronary artery disease, or out of control hypertension.
These patients are difficult to treat, but Nurtec, Reyvow, or Ubrelvy, which are acute Migraine treatment drugs, may be tried.
Are there other drugs to use for this? Patients need to work with a headache doctor for this type of treatment.
The dopamine antagonist group consists of drugs are usually indicated for psychiatric disorders such as schizophrenia or bipolar disease. They may be used "off-label" for treatment of headache. "Off label" means the drugs work for another indication than the usual illness the medication treats.
An "off label" example would be that chlorpromazine is indicated for bipolar disorder but also helps treat migraine. They work in migraine patients because dopamine is a major brain neurochemical released during the migraine process and blocking dopamine may help headache. This group of drug may have a side effect of drowsiness.
Dopamine antagonists may be used. Dopamine modulates processes involved in migraine such as nociception, autonomic response, and vasodilatation. Dopamine antagonists also help with many of the symptoms of migraine including nausea, vomiting, mood changes and fatigue. Dopamine antagonists are appropriate for patients who do not respond to triptans. They should be limited to using only 10 days per month.
Prochlorperazine (Compazine) can be given 5/10 mg oral or rectal 25 mg repeat q 6-8 hours PRN for status migrainosus.
Chlorpromazine (Thorazine) 25 mg orally every 6 hours to a total dose of 100 milligrams for cluster headache or refractory migraine.
Droperidol (Inapsine) intramuscularly 2.7 mg, is highly effective for intractable migraine, but it can prolong QT on an EKG test and shouldn’t be used with patients with heart disease.
Haldol (Haloperidol) 5 mg IV gives significant relief or 2 mg/5 mg oral haloperidol outpatient treatment to abort headache.
Prokinetic Agents
The prokinetic drugs listed below are usually indicated for treating nausea or vomiting but also help migraine.
Oral metoclopramide (Reglan) can be used 10 mg three times a day (TID).
Promethazine (Phenergan) can be given 12.5, 25, 50 mg every 4-6 hours
Atypical Antipsychotics
Olanzapine (Zyprexa) can be used orally as 2.5-5 also 7.5, 10, 15, 20 ODT mg nightly for 5 to 10 nights to break status migrainosus.
Quetiapine (Seroquel) at 25 to 75 mg orally, reduces headache frequency and severity, can be used as rescue medicine. Quetiapine may help with sleep and headache for treating medication overuse headache also.
The most beneficial oral medication is olanzapine followed by chlorpromazine.
NSAID
Ketrolac 60 mg IM every 6 hours. An NSAID (nonsteroidal anti-inflammatory drug) which may be given intramuscularly as an injection 60 mg as single dose or 30 mg every 6hr, not to exceed 120 mg/day.
Betablocker eye drop
Timolol (Timoptic) eye drops 0.5 % solution 1-2 drops in each eye every 2-4 hours. Betablockers work orally for migraine prevention but don't work for acute therapy, yet some patients respond well to Timolol given as an eyedrop and there is no rebound problem. See my article on Timolol eye drops under acute treatment of migraine.
Miglizzo, et al wrote in Mo Med. 2014 Jul-Aug; 111(4): 283–288 on Beta Blocker Eye Drops For Treatment of Acute Migraine.
Abstract
We report seven cases of successful treatment of acute migraine symptoms using beta blocker eye drops. The literature on beta blockers for acute migraine is reviewed. Oral beta blocker medication is not effective for acute migraine treatment. This is likely due to a relatively slow rate of achieving therapeutic plasma levels when taken orally. Topical beta blocker eye drops achieve therapeutic plasma levels within minutes of ocular administration which may explain their apparent effectiveness in relief of acute migraine symptoms.
Introduction
Sporadic case reports have suggested that beta blocker eye drops are effective for acute migraine treatment and chronic prevention of migraine attacks 1–5 (See Table 1 and Figure 1). Although widely prescribed for glaucoma therapy, beta blocker eye drops are rarely used for acute or chronic migraine treatment. Recent comprehensive reviews on migraine therapy do not mention the potential therapeutic value of beta-blocker eye drops.
Beta blocker eye drops are inexpensive, available worldwide, and have rapid trans-mucosal systemic absorption when taken topically. Sporadic case reports and the literature collectively 1–12 suggest that the success of beta blocker eye drops in treating acute migraine may be due to the rapidity of eye drops in achieving effective blood levels when instilled shortly after symptom onset.
Timolol eye drop
Local Anaesthetic
Lidocaine spray 4 %, generic (lidoderm, xylocaine) is available over the counter at drugstores. For one sided frontal headache the spray should be injected on the involved side; use both right and left nostrils for bilateral headache. Spray toward the back of the nose about 3 inches and medially toward the hard cartilage part of the nose. Dose is one spray at onset, may repeat in 10 minutes if needed and then every 6 hours.
Maizels, et al wrote in Headache. 1999 Sep;39(8):543-51 on Intranasal lidocaine for migraine: a randomized trial and open-label follow-up.
OBJECTIVE:
To study the efficacy of intranasal lidocaine for the treatment of migraine when administered by subjects in a nonclinical setting.
DESIGN:
A 1-month, randomized, controlled, double-blind trial, followed by a 6-month open-label follow-up.
SETTING:
Ambulatory subjects treating themselves outside of a medical setting.
SUBJECTS:
One hundred thirty-one adult subjects with migraine, diagnosed according to International Headache Society criteria, were enrolled in the study: 113 treated at least one headache in the controlled trial, and 74 treated at least one headache in the open-label phase. All subjects were members of the Kaiser Permanente Southern California Medical Care Program and were recruited at two urban medical centers.
INTERVENTION:
Intranasal lidocaine 4% or saline placebo 0.5 mL was dropped into the nostril on the side of the headache, or bilaterally for bilateral headache, according to study protocol.
MAIN OUTCOME MEASURES:
Trial: percent of headaches relieved to mild or none at 15 minutes and relapse of headache within 24 hours. Open-label: percent of headaches relieved to mild or none at 15 and 30 minutes and relapse within 24 hours.
RESULTS:
In the controlled trial, headache was relieved within 15 minutes in 34 (35.8%) of 95 subjects treated with 4% intranasal lidocaine compared with 8 (7.4%) of 108 subjects receiving placebo (P < .001). Headaches relapsed in 7 (20.6%) of 34 subjects treated with 4% intranasal lidocaine compared to 0 of 8 placebo subjects (P = .312). In the open-label follow-up, headaches were relieved in 129 (41.2%) of 313 episodes within 15 minutes and in 141 (57.6%) of 245 episodes after 30 minutes. Headaches relapsed in 28 (19.9%) of 140. The response did not diminish over time: 32 (62.8%) of 51 first headaches were relieved at 30 minutes and 10 (71.4%) of 14 seventh headaches were relieved. Relapse occurred in 28 (20%) [corrected] of 129 headaches at a mean time (+/- SD) of 7.4 (+/- 6.6) hours.
CONCLUSION:
Intranasal lidocaine 4% provides rapid relief of migraine symptoms. For those subjects who do respond, the effect does not diminish over 6-month follow-up.
Summary
Most persons with frequent headaches do better working with a headache specialist. They need to be on a preventive medication like Aimovig and treat their Migraines quickly with a triptan when they come. They should do the Migraine lifestyle and not overtreat. Following these rules most persons are able to come to a peaceful adjustment to living with Migraine.
Read my Big Book on Migraine Here.
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All the best.
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Britt Talley Daniel MD