Develop Strategy to Halt Overuse of Pain Meds

SCOTTSDALE, ARIZ. – Withdrawing patients from overused headache medications is long, hard work for them, but it can be accomplished with strong physician support, Dr. Todd D. Rozen told clinicians at a symposium sponsored by the American Headache Society.

Dr. Rozen, a neurologist at the Michigan Head-Pain and Neurological Institute in Ann Arbor, Mich., outlined a cornucopia of maneuvers ranging from medication switches to acupuncture and biofeedback that can be used to accomplish withdrawal.

Getting patients to adopt realistic expectations is crucial to successful withdrawal, he said. Chronic daily headache patients must understand at the outset that the brain has to be reset and takes time to heal after long-time overuse of medications. Eventually they may have fewer headaches, he said, but they will not be headache-free after withdrawal.

“The goal is to get away from daily headache,” he said. “I tell my patients, having migraine is normal … but daily pain is never normal.”

Whether you decide that inpatient treatment is necessary or that outpatient treatment is possible, quickly discontinue the overused medication, because tapering it does not work, Dr. Rozen advised.

Patients who overuse an over-the-counter remedy can usually withdraw with outpatient therapy, he said. Some patients can even stop “cold turkey.” In most cases, however, he recommended switching them to a longer-acting nonsteroidal anti-inflammatory drug such as naproxen sodium or indomethacin for 5–7 days per week and then tapering it down to 3–4 days per week.

Meanwhile, prepare the patient to deal with pain, he advised. “You have to have a treatment strategy for mild pain, moderate pain, [and] severe pain.”

Mild pain is the hardest to treat in some respects because the strategy is to pursue alternative therapies rather than medication, he said. These alternatives could include hydration, relaxation techniques, biofeedback, and aerobic exercise, but not medication.

“If they can get over this step, they are going to get better,” he said. “If they can't, they will not.”

For moderate pain, Dr. Rozen suggested indomethacin or naproxen sodium with or without a dopamine receptor antagonist. Start at 3–4 days per week, tapering down to 2 days per week. If the patient has nausea, add an antiemetic.

For severe pain, the medication choice can vary, but rescue therapy should be limited to two times per week. “You need rescue medication,” he said. “It is helpful if patients are sedated. They have had this headache all day long. It helps if they sleep well.”

Outpatient therapy usually works for patients who have overused triptans, but some need inpatient therapy. Triptan withdrawal is relatively fast and some patients can simply stop their medications, he explained. But triptan withdrawal also can mimic opioid withdrawal with associated nausea, diarrhea, and abdominal pain. Inpatients can be switched to intravenous DHE (dihydroergotamine mesylate) and outpatients can be given Migranal NS. A steroid taper is another option, but a longer-acting triptan is rarely the best option.

“Get them away from triptans. Switch them to something different,” Dr. Rozen said, adding that overusers of triptans also benefit from the mild-moderate-severe approach to headache pain during withdrawal.

When weaning patients from butalbital, the first step is to determine their butalbital level, he continued. If it is above 10 mcg/mL, the patient is at risk of withdrawal seizures and needs to be weaned off the drug as an inpatient.

For patients with very low butalbital levels, he suggested outpatient care and prevention of withdrawal symptoms with clonazepam. Don't try to taper patients from butalbital because they are using it to treat anxiety and will not stop. Phenobarbital is another option, he added, but be prepared to vary the dose.

Patients who are abusing opioids almost always have to be hospitalized. “I tell them I will be there every step of the way, as long as [they] show the effort and do the hard work,” Dr. Rozen said. “They have to know that.”

SCOTTSDALE, ARIZ. – Withdrawing patients from overused headache medications is long, hard work for them, but it can be accomplished with strong physician support, Dr. Todd D. Rozen told clinicians at a symposium sponsored by the American Headache Society.

Dr. Rozen, a neurologist at the Michigan Head-Pain and Neurological Institute in Ann Arbor, Mich., outlined a cornucopia of maneuvers ranging from medication switches to acupuncture and biofeedback that can be used to accomplish withdrawal.

Getting patients to adopt realistic expectations is crucial to successful withdrawal, he said. Chronic daily headache patients must understand at the outset that the brain has to be reset and takes time to heal after long-time overuse of medications. Eventually they may have fewer headaches, he said, but they will not be headache-free after withdrawal.

“The goal is to get away from daily headache,” he said. “I tell my patients, having migraine is normal … but daily pain is never normal.”

Whether you decide that inpatient treatment is necessary or that outpatient treatment is possible, quickly discontinue the overused medication, because tapering it does not work, Dr. Rozen advised.

Patients who overuse an over-the-counter remedy can usually withdraw with outpatient therapy, he said. Some patients can even stop “cold turkey.” In most cases, however, he recommended switching them to a longer-acting nonsteroidal anti-inflammatory drug such as naproxen sodium or indomethacin for 5–7 days per week and then tapering it down to 3–4 days per week.

Meanwhile, prepare the patient to deal with pain, he advised. “You have to have a treatment strategy for mild pain, moderate pain, [and] severe pain.”

Mild pain is the hardest to treat in some respects because the strategy is to pursue alternative therapies rather than medication, he said. These alternatives could include hydration, relaxation techniques, biofeedback, and aerobic exercise, but not medication.

“If they can get over this step, they are going to get better,” he said. “If they can't, they will not.”

For moderate pain, Dr. Rozen suggested indomethacin or naproxen sodium with or without a dopamine receptor antagonist. Start at 3–4 days per week, tapering down to 2 days per week. If the patient has nausea, add an antiemetic.

For severe pain, the medication choice can vary, but rescue therapy should be limited to two times per week. “You need rescue medication,” he said. “It is helpful if patients are sedated. They have had this headache all day long. It helps if they sleep well.”

Outpatient therapy usually works for patients who have overused triptans, but some need inpatient therapy. Triptan withdrawal is relatively fast and some patients can simply stop their medications, he explained. But triptan withdrawal also can mimic opioid withdrawal with associated nausea, diarrhea, and abdominal pain. Inpatients can be switched to intravenous DHE (dihydroergotamine mesylate) and outpatients can be given Migranal NS. A steroid taper is another option, but a longer-acting triptan is rarely the best option.

“Get them away from triptans. Switch them to something different,” Dr. Rozen said, adding that overusers of triptans also benefit from the mild-moderate-severe approach to headache pain during withdrawal.

When weaning patients from butalbital, the first step is to determine their butalbital level, he continued. If it is above 10 mcg/mL, the patient is at risk of withdrawal seizures and needs to be weaned off the drug as an inpatient.

For patients with very low butalbital levels, he suggested outpatient care and prevention of withdrawal symptoms with clonazepam. Don't try to taper patients from butalbital because they are using it to treat anxiety and will not stop. Phenobarbital is another option, he added, but be prepared to vary the dose.

Patients who are abusing opioids almost always have to be hospitalized. “I tell them I will be there every step of the way, as long as [they] show the effort and do the hard work,” Dr. Rozen said. “They have to know that.”

SCOTTSDALE, ARIZ. – Withdrawing patients from overused headache medications is long, hard work for them, but it can be accomplished with strong physician support, Dr. Todd D. Rozen told clinicians at a symposium sponsored by the American Headache Society.

Dr. Rozen, a neurologist at the Michigan Head-Pain and Neurological Institute in Ann Arbor, Mich., outlined a cornucopia of maneuvers ranging from medication switches to acupuncture and biofeedback that can be used to accomplish withdrawal.

Getting patients to adopt realistic expectations is crucial to successful withdrawal, he said. Chronic daily headache patients must understand at the outset that the brain has to be reset and takes time to heal after long-time overuse of medications. Eventually they may have fewer headaches, he said, but they will not be headache-free after withdrawal.

“The goal is to get away from daily headache,” he said. “I tell my patients, having migraine is normal … but daily pain is never normal.”

Whether you decide that inpatient treatment is necessary or that outpatient treatment is possible, quickly discontinue the overused medication, because tapering it does not work, Dr. Rozen advised.

Patients who overuse an over-the-counter remedy can usually withdraw with outpatient therapy, he said. Some patients can even stop “cold turkey.” In most cases, however, he recommended switching them to a longer-acting nonsteroidal anti-inflammatory drug such as naproxen sodium or indomethacin for 5–7 days per week and then tapering it down to 3–4 days per week.

Meanwhile, prepare the patient to deal with pain, he advised. “You have to have a treatment strategy for mild pain, moderate pain, [and] severe pain.”

Mild pain is the hardest to treat in some respects because the strategy is to pursue alternative therapies rather than medication, he said. These alternatives could include hydration, relaxation techniques, biofeedback, and aerobic exercise, but not medication.

“If they can get over this step, they are going to get better,” he said. “If they can't, they will not.”

For moderate pain, Dr. Rozen suggested indomethacin or naproxen sodium with or without a dopamine receptor antagonist. Start at 3–4 days per week, tapering down to 2 days per week. If the patient has nausea, add an antiemetic.

For severe pain, the medication choice can vary, but rescue therapy should be limited to two times per week. “You need rescue medication,” he said. “It is helpful if patients are sedated. They have had this headache all day long. It helps if they sleep well.”

Outpatient therapy usually works for patients who have overused triptans, but some need inpatient therapy. Triptan withdrawal is relatively fast and some patients can simply stop their medications, he explained. But triptan withdrawal also can mimic opioid withdrawal with associated nausea, diarrhea, and abdominal pain. Inpatients can be switched to intravenous DHE (dihydroergotamine mesylate) and outpatients can be given Migranal NS. A steroid taper is another option, but a longer-acting triptan is rarely the best option.

“Get them away from triptans. Switch them to something different,” Dr. Rozen said, adding that overusers of triptans also benefit from the mild-moderate-severe approach to headache pain during withdrawal.

When weaning patients from butalbital, the first step is to determine their butalbital level, he continued. If it is above 10 mcg/mL, the patient is at risk of withdrawal seizures and needs to be weaned off the drug as an inpatient.

For patients with very low butalbital levels, he suggested outpatient care and prevention of withdrawal symptoms with clonazepam. Don't try to taper patients from butalbital because they are using it to treat anxiety and will not stop. Phenobarbital is another option, he added, but be prepared to vary the dose.

Patients who are abusing opioids almost always have to be hospitalized. “I tell them I will be there every step of the way, as long as [they] show the effort and do the hard work,” Dr. Rozen said. “They have to know that.”