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Killing the Pain: Choices and Risks of Headache Drugs

Headaches are a common malady, and medications to treat it are equally common. But how do you know which one is right for you?

Because medicines come with risks, “the basic rule of thumb is to take just enough to get the job done — no more, and no less,” says Premier Health Clinical Neuroscience Institute physician Bryan Ludwig, MD.

But how much is enough? And what’s the difference between all these products and their benefit, if any, in treating headaches?

Analgesics (Painkillers)

Over-the-counter (OTC) painkillers are usually what most of us choose first to treat our headaches, because they are easier to obtain and sometimes less expensive than prescription medication. Analgesics can be effective in treating tension-type headaches as well as less severe migraines.

Analgesics include:

• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen and naproxen

“Despite being available without a prescription, there are risks to these meds,” says Dr. Ludwig. “Read the materials that come with the medication, and talk to your doctor if you have any concerns or the drug is not working for you.”

Remember that children should not take aspirin. Aspirin can cause a serious illness called Reye's syndrome in children younger than 18 years of age.

Combination OTC Drugs

A number of OTCs are promoted for migraines, “sinus” headaches, and other problems that combine a painkiller with one or more other active ingredients (like caffeine). While they can be effective, the medical community does have some concern about them.

Products containing acetaminophen are especially worrisome. For example, some OTCs designed to ease sinus headaches contain acetaminophen in addition to a decongestant or antihistamine, but people don’t always know this. Then, they take the "sinus" drug along with a traditional acetaminophen drug (like regular Tylenol). That basically puts them over the recommended dosage for acetaminophen.

Even more concerning is if you have a long-lasting headache and consume too much acetaminophen repeatedly. This could lead to an unintended overdose. In fact, liver damage from acetaminophen overdose is the leading reason for liver transplants in the U.S., according to the American Headache Society.

Overuse of OTCs also can cause rebound headaches.

Prescription Medicines

Numerous prescription medicines can be helpful to people who suffer from severe headaches, like migraines, for whom OTCs are not effective.

Some of these are considered “abortive” medicines, which are used to stop a headache in progress. Others are “preventive” medications, which are taken daily to reduce their onset.

Some of these meds were developed to treat other problems, like depression or seizures, but have since been found to aid with serious headache pain (especially migraines) as well.

The prescription medicines include:

• Tricyclic antidepressants, such as amitriptyline and nortriptyline, which help by regulating levels of the neurotransmitter serotonin. Serotonin causes blood vessels to constrict and blocks pain pathways.
• Anti-epileptic drugs, also known as anti-convulsants, including valproic acid, gabapentin and topiramate. These may have an impact on neurotransmitters and block electrical signals in nerve and brain cells.
• Beta blockers, such as propranolol, which may have an effect on blood vessels, the nervous system, serotonin, and anxiety
• Triptans, which increase serotonin levels in the brain
• Ergot derivatives, which decrease the transmission of pain messages along nerve fibers
• Narcotics, which are used to block pain (but only rarely and briefly)
• OnabotulinumtoxinA (Botox), which is injected in the muscles of the forehead and neck (in fact, Botox was found to have cosmetic benefits only after people began receiving forehead injections for migraines!)

Sometimes, your physician may also need to prescribe medications to counter side-effects of these prescription drugs.

Medication Overuse: More Harm than Good

According to the National Institute of Neurological Disorders and Stroke at the National Institutes of Health (NINDS), taking pain relief medicine more than three times a week can lead to medication overuse headache (MOH).

Analgesics can be effective in treating tension-type headaches as well as less severe migraines.

Also known as a “rebound headache,” MOH occurs when the initial headache pain is relieved, but then comes back as the drug wears off. Taking more of the drug to treat the new headache leads to shorter and shorter periods of pain relief, resulting in taking even more medication. Ultimately, this results in a chronic headache that no longer responds to the painkillers.

MOH pain ranges from moderate to severe and may occur with nausea or irritability. It can take weeks for the headaches to go away once the drug is stopped.

“If you are taking pain relief meds more than twice a week, it’s time to see your doctor, because they’re clearly not helping,” says Dr. Ludwig. “We can work with you to figure out what other options there are to address your problem.”

Talk to Your Doctor

As always, communication with your physician is key in finding a safe and effective solution to your headaches. “It is always a good idea to tell your physician about all the medicines you are taking, including OTCs, so he or she can determine not only what works best for you, but whether there is the potential for harmful interactions,” explains Dr. Ludwig.

Source: National Institute of Neurological Diseases and Stroke (NIH); American Academy of Family Physicians; American Headache Society; Bryan Ludwig, MD, Premier Health Clinical Neuroscience Institute