Dr. David Buchholz published Heal Your Headache: The 1-2-3 Program for Taking Charge of Your Pain in 2002. While controversial, the book is still the #1 best seller on Amazon for headaches. I checked in with Dr. Buchholz to find out which of his recommendations still stand, which he’s changed his position on, and why he continues to take other doctors to task. In Part 1 of this 4-part series, we talk about migraine meds.
Thirteen years after it came out, your book is still the best-selling headache book on Amazon. If you were writing your book now, would you change any of your recommendations regarding abortive migraine medications?
No, I stand firm on those. I continue to recommend that my patients either strictly limit or altogether eliminate triptans and other abortive medications like caffeine-containing analgesics (e.g. Excedrin for Migraine), ergotamines, decongestants, and butalbital compounds (Fioricet and Fiornal). That’s where I disagree with mainstream headache medicine.
Why do you recommend that, when those drugs are incredibly effective at stopping migraine pain?
They are effective, but they are only a short-term fix and they actually cause rebound headaches if used too often. They create a vicious headache cycle where they cause more headaches, and often they become less effective. An even bigger issue is that they prevent patients from being responsive to preventive measures that do work long term, like diet changes and preventive medications. When my patients get off these rebound-causing medications, they generally respond well to diet changes; many never need a preventive.
Why are these medications such a problem?
Rebound-producing drugs are vasoconstrictors, exerting a temporary constricting action on painfully dilated blood vessels. The problem is that the long-term effect is that those vessels tend to swell more and more in the wake of that drug. Instead, I recommend medications like aspirin, acetaminophen, and ibuprofen (NSAIDs), which don’t have a vasoconstrictive action.
The second rebound problem is with migraine abortive drugs that bind to opiate receptors, such as oxycodone, tramadol, and others. Over time, when those receptors are bound too often, they become less responsive to our natural pain-killing mechanism, endorphins. NSAIDS don’t do that.
What is your experience with getting people off these drugs? I assume you don’t say, “Just suck it up.”
No, of course not! I caution that in about half of my patients, as they withdraw from rebound-causing drugs, they see worsening headache activity for up to a few weeks. The other half don’t get worse. In either case, they soon get better. I guide them through what they can take. Admittedly, non-rebound-producing medications won’t be as effective during this period, which I am completely sympathetic toward.
What I tell them is that they will be more responsive once they get through this out-of-control period. And there are rebound-free medications for nausea as well as other options (such as certain injectable drugs) for a crisis situation.
It sounds like you spend a lot of time on patient education and motivation.
Yes. I might say, “The truth is, there is no reliably painless way for you to make the transition from where you are to where you want to be. But no matter how much pain you might experience in that relatively short interval, it’s a small amount relative to the amount of lifetime pain you will have if you don’t address the problem of rebound.”
When patients come back for their follow-up appointment after several months, I ask them, “How are you?” The large majority of my patients say, “Much better.”
I go through my list of action items from the initial visit with them. The first one is to give up the rebound-producing drugs. “How did that go?” About half of them say, “I spent a weekend in hell,” or “It was two weeks of misery.” And half say, “No worse than usual.”
But even with those people who had a really rough time, not one patient in over 30 years has ever said, “I wish I hadn’t done that, you gave me bad advice.” Not one. So I continue to be convinced that this is the best approach not only for my patients but all headache sufferers plagued by rebound.
Dr. David Buchholz is a practicing neurologist in Maryland, and is affiliated with Johns Hopkins Medical School. Download his recommendations for rebound-free medications to discuss with your doctor. We provide interviews with leading migraine experts so you can decide what works best for you.