Migraine patients must often weigh the potential benefits of a given treatment against the potential side effects. It’s a perpetual balancing act to find the right combination of effectiveness and tolerable side effects. It helps to have realistic expectations. It also helps when we are fully informed.
Informed Consent
I hear from many patients that their doctors do not disclose the known side effects of a medication when prescribing a new treatment. Some have even had close calls because they did not know what to look for. This is inexcusable. While no one can know exactly how a person might respond to a certain treatment, there are migraine treatments with common side effects. Some are minor, while others can be life-threatening. Every patient has the right to know the most common side effects of each prescribed medication.
I understand that doctors don’t want to alarm patients unnecessarily or create a self-fulfilling prophecy. However, failure to disclose the true risks of treatment isn’t the way to build trust. A doctor who won’t tell me the truth about a recommended treatment is a doctor who will lose my trust and my business. I spend way too much time consulting with doctors to waste time with someone I can’t trust.
Common migraine treatments and their potential side effects:
Triptans: nausea, tightness of chest, neck, or jaw, rapid heart rate, fatigue, numbness or tingling, burning sensation of the skin10
NSAIDs: stomach irritation, heartburn, diarrhea, fluid retention, kidney or liver impairment (rare), increased risk of tinnitus1
Ergotamines: drowsiness, headache (during withdrawal), vertigo, dystonia, nausea, vomiting, abdominal pain, numbness and tingling of fingers and toes, muscle pain in arms and legs, weakness in the legs, cardiovascular side effects (hypertension, tachycardia, bradycardia, chest pain, heart valve disease) 3
Opioids: risk of physical dependence and psychological addiction, nausea, itching, sedation, constipation, worsening of headache, central sensitization2
Anti-epileptics:11, 12
Valproic acid, divalproex sodium, sodium valproate: tiredness, dizziness, weight gain, tremor, hair loss, skin rash, nausea, vomiting, GI distress, pancreatitis, liver failure, thrombocytopenia, altered metabolism of sex hormones
Topamax: paresthesia, cognitive slowing, tiredness, psychomotor slowing, drowsiness, word finding difficulties, poor memory and concentration, weight loss, kidney stones, glaucoma
Gabapentin: dizziness, tremor, somnolence, nausea, ataxia
Zonisamide: therapeutic action is similar to Topamax with a lower incidence of side effects
Anti-depressants
Tricyclics: Dry mouth, blurred vision, constipation, urinary retention, drowsiness, increased appetite, orthostatic hypotension, increased sweating, disorientation or confusion, tremor, increased or irregular heart rate, increase in seizures (in patients who already have seizures), sexual dysfunction5
SSRIs: nausea, nervousness, agitation, restlessness, dizziness, sexual dysfunction, drowsiness, insomnia, weight gain or loss, headache, dry mouth, vomiting, diarrhea, muscle aches, leg cramps, hallucinations, swelling of legs and feet6
SNRIs: nausea, dry mouth, dizziness, excessive sweating, tiredness, difficulty urinating, anxiety or agitation, constipation, insomnia, sexual dysfunction, headache, loss of appetite7
MAOIs: dry mouth, nausea, diarrhea, constipation, headache, drowsiness, insomnia, skin reaction, dizziness, involuntary muscle jerking, low blood pressure, sexual dysfunction, sleep disturbances, weight gain, muscle aches, tingling or numbness, difficulty urinating4
Calcium Channel Blockers: constipation, headache, low blood pressure, rapid heart rate, dizziness, rash, fatigue, flushing, nausea, swelling of feet and legs9
Beta Blockers: fatigue, cold hands, headache, upset stomach, constipation, diarrhea, dizziness, shortness of breath, insomnia, low sex drive, depressive mood8
Not everyone will experience every side effect. Some patients will experience rare or unique side effects. The important thing to remember is to keep communicating with your doctor. Together you can decide the right mix of benefits and risks that work for you. It takes mutual trust and patience to discover what works.
It took many years of serious work with my doctor to discover that anti-seizure medicines didn’t work and made me too sleepy, anti-depressants and beta blockers were tolerable but ineffective. Calcium channel blockers worked for cluster headaches, but not so well for migraine. Only Botox worked to stop the near-daily onslaught of migraine attacks. I’m lucky.
Some of you are probably still trying to find just the right treatments. Others may be discouraged, and feel like giving up.
Realistic expectations
Few patients understand what to expect from a given treatment. The results are typically more subtle and modest than we’d like. Treatment takes longer than we expect to have full effect. And side effects can lessen or worsen over time. The harsh reality about current migraine treatments is that they don’t work nearly as well as we hope. It’s all about the numbers.
Fifty percent
50% is the “magic” number. A treatment is considered successful if there is at least a 50% reduction in either the frequency or severity of attacks. For most treatments to be considered effective, at least 50% of patients who use it will get a 50% reduction in either frequency or severity. For an episodic migraineur with 4 attacks per month, an effective treatment results in only 2 attacks per month. That sounds wonderful. Now let’s think about chronic migraine. A patient with 15 or more headache days in a month might see a 50% reduction in severity, improved responsiveness to acute treatment, but still experience just as many attacks. Patients who experience chronic daily headache might see a 50% reduction in frequency, but they are still facing down migraine attacks more than half the time.
Ninety days
90 days is the minimum time a treatment should be used before deciding it isn’t effective. But there’s a catch. Let’s say your doctor starts you on 25 mg of Topamax. That’s a medication commonly used to prevent migraine. The maximum effective dose can be 200 mg or more daily. So unless your doctor gives you specific instructions on how to titrate up safely, you might be faced with 90 days at each dose change. If you increase by 25 mg every 90 days, it might take almost two years to determine if Topamax is the right treatment for you. Patience and persistence are essential to endure medication trials.
Even though most of my family and friends are well educated about migraine, they still struggle to understand why I keep getting attacks. It isn’t unusual to hear, “I thought you said Botox was working,” when someone finds out I am having a migraine attack.
It is human nature to believe that an effective medicine is one that eliminates all symptoms. Living with an incurable illness doesn’t afford us that luxury. Medicines and other treatments can reduce the impact of symptoms, but certainly won’t eliminate them all. Choosing a migraine treatment plan is a never-ending series of trade-offs.
Tammy’s first experience with Migraine started in 1975. Currently disabled by multiple pain conditions, Tammy still uses her expertise to help others. She holds a Master’s degree in Professional Counseling and is a skilled Herbalist and Reiki Master. She shares her extensive experience in both conventional and complementary medicine here at Migraine.com and on her own blog, Brain Storm.
Dr. Goodwin, you are so right. Many of us are in journalistic positions and we are also pain patients or medical professionals. The maddening part of all this has us reeling with emotions and anger. Thank you for reminding us of our duty to professionalism. And thank you for writing your reply. We need so many of you to do that, but understand the current ramifications.
I am a neurologist, adult and pediatric pain and headache specialist, and past chief of the division of pain medicine at a major west coast university medical center, trained at Stanford and Harvard, with degrees in psychology and comparative (neuro) pathology at the undergraduate and graduate level from the University of California at Davis. I am a strong advocate of patients and feel that the current government stance is not supported by the evidence and is totally misguided in its approach,often harming patient care where chronic non cancer pain is concerned even if it does address some legitimate concerns about poor prescription practice, addiction, accidental and deliberate overdose, abuse and misuse of controlled substances. Many of my colleagues who feel similarly are too afraid to speak up because of the perceived threat to their state licenses by the 50 medical boards of the USA. That threat is real snd clinicians have paid the price. The state board attitudes and actions are often not in line with their sanctioned publications that are required reading for all clinicians. California is an excellent example of this.
The topic of this article is excellent but it’s execution is as poor as that of the 60 minutes ‘exposé aired recently. That was certainly not a documentary. It had s one sided agenda. This article I s one sided too and loses its ‘punch’ because of that.
This ought to be expanded into a more neutral position showing both sides and without the sarcasm. It would then be more useful in countering misguided governmental agency attacks on how pain is treated.
There is much judgment and hipocrisy involved on both sides and this needs to be resolved and removed in order for the as yet improperly acquired evidence to be subdivided to analyze very different circumstances, practices and behaviours of disparate groups currently lumped together as one. There is overlap and misinformation as well as disinformation involved by patients, clinicians and scientists alike where the fields of pain and addiction medicine is concerned. This must stop in order for a rational and carefully administered change to take place.
Kristy: I think mono vision only affects depth perception.
He is clearly blind.
Just blind.
Diane:
“A person convinced against his will
Is of the same opinion still”
It is a shame we don’t get the same kind of support from our families as those with cancer.
That just means we have work to do in sharing our stories.
Our predicaments.
Our authentic anguish at being betrayed and abandoned
That pendulum is already swinging.
God bless us every one.
It is so sad to think in this’enlightened’ time we live in that pain is still a bad word. Tell anyone you have something hurting and their minds automatically go to addiction. And to think someone can’t get pain meds after something as painful as hip or any surgery is asinine. It is abusive. Even our beloved pets get pain meds because the vets don’t want to see them suffer anymore than we do.
Thats it!! Yes I will go to my vet !! Bet I would be treated better than by my doctor. Anyway I could go on for days, ha! but who has the energy to write let alone read a long post.
Thanks for listening,,Brenda in Bama….
I would like to point out that the CDC is equating long-term opioid use to “abuse”, even if you are taking them as prescribed.
“According to the CDC, about 12 million Americans abused or were dependent on opioids in 2013. “
This Article shows the misinformation that is spreading, with no real common sense to counter it. Whether the subject is Opiates, The “War” on whatever is popular this week, it seems to be getting worse. It is truly frightening and disappointing. People watch the “News” go Online, or read Newspapers and think that they are informed. There does not seem to be any real analysis of what is “True” anymore. The DEA has been spreading misinformation for years, leading to a bigger Drug Problem. Apparently they can say whatever they want to justify their funding. They never get called out on the Lies, or have any sort of accountability.
The Media appears to be giving us the “News” but it is Slanted in the favor of sensationalism, and has an agenda. The Coverage of our current National issues is frightening. It is very one sided, I watched the coverage of the protests against Racism, clearly showing how awful the Protesters were while downplaying the reason for the Protests. People who I though were at least Open Minded, were parroting the theme. We have a System that is functioning by instilling fear, hate and misdirection.
Our Country seems to be breaking down. The Media Targets a new group every couple of days.
Chronic Pain patients are just another scapegoat for the problems this country is facing. There is no empathy or common sense because of the labels. In watching some of the Political discourse lately some really ugly themes are emerging. I try to look at the big picture, and ask “who does this benefit?”. Big Insurance, Big Pharma, even Workman’s Comp.
There is a theme, that it is OK to ignore people in pain, because Mainstream Media, and the Insurance companies have made the subject about “Addiction” . Even when people have direct personal knowledge they ignore it, and it is OK. It is like an alternate universe. It is not just pain patients it is anyone painted as a scapegoat to avoid the real problems. It is deeply disturbing to me the misdirected hatred and rage turned to whatever group. It rings of the Nazi’s. The misinformation campaign is not being questioned. People I though were descent human beings now have an ugly opinion about so many fellow human beings. These ugly opinions are being repeated by the Media, as if they are true. They give credence to the justification for some horrible acts. A certain percentage are actually worked up to violence against the latest target for rage. Immigrants, refugees, the disabled, certain races, it is getting out of control. The ones benefiting form this are the ones profiting off of it, The War Machine, the Pharmaceutical Industry, Insurance are all making Billions while the real issues are ignored, The DEA and other Agencies get more funding if they can scare us. It is getting ugly out there. I am afraid to even mention Chronic Pain, I would be patronized and judged. I am afraid to speak up anymore, it has come back to bite me. I am shocked at the people who believe this nonsense, and there are some that don’t but have to repeat it no matter how ridiculous. There is no accountability in Health Care anymore, I can’t imagine the mindset it takes to ignore the suffering of even Cancer Patients, and people with clearly visible injuries. There is no though to their quality of life, only the fear that they might get addicted! This has led to the justification for not treating people and not having the least shred of empathy. My Mother passed in a Nursing Home and was not even given Acetaminophen after hip surgery. She could not articulate that she was in pain. I know people with serious pain that drank themselves to death, and were afraid they would get addicted to pain meds. That is what their Doctors told them. Death by Alcohol does not seem to register, but it is a horrible drawn out death. They eventually bleed out. This does not get mentioned in their Articles.
Opiates have been around for thousands of Years, they don’t get Patented, unless they are formulated slightly different. The “new” pain medications have more side effects, minimal effect on pain, but they are Marketed as if they work. The effect of the ignorance and the pursuit of profit has undermined Scientific research. Very few new drugs on the market are significantly better than the old ones, but they are marketed like they are. Some are more dangerous, yet they make Billions for the drug companies. Medicine is so profit driven that there are not many real “Breakthroughs”. There is no real Science behind being applied.
I used to wonder how do these people sleep at night? I suppose they can, because they believe they are “helping”. Many have contempt for patients, they blame the patients for the lack of re-reimbursement and paperwork generated by the Insurance Companies. The misinformation helps to justify treating people this way. It is not just pain patients either, it is whatever group they blame this week.
@Krissy,
My kids are the same way. My youngest just tells me I’m a junkie. At 1st it hurt but then angered me because of the BS he looks at on Google, etc…. I have up trying to explain anything to him.
All one has to do is look at this websitehttp://www.dea.gov/pr/news.shtml it lists all the press releases by the DEA’s HQ and 21 district offices… which is then regurgitated by much of the news media. To understand the Google results.
What you don’t hear about is that every time that you see a BIG DEA drug bust.. that normally represents only 1% of what is actually getting past the DEA and on to our streets for abusers/addicts to us.
“If you tell a big enough lie and tell it frequently enough, it will be believed.”
― Adolf Hitler
I find it interesting that they are lumping addiction and dependency into the same group.. but.. this follows the recent CDC guidelines that basically states that there is no longer a distinction between addiction and dependency.. everyone who consumes opiates on a long term basis has a OPIATE USE DISORDER..
Good thought to do this, NPR, but I’m not surprised. I recently wrote a small article for you and I sent a link to my brother so he could see it. He sent me back a link on drug addiction. I have to give up trying to convince him what is wrong with me. He doesn’t read about my illness, he only sees the “frightening” thing he calls addiction. I don’t even think he looks at “medically dependent,” because I tried to explain that to him too. He is a highly-intelligent, successful business man who knows a lot about a lot. But he seems to be somewhat blind in one eye.