opiates for migraine prevention
A man, age 29, came to me for treatment of incessant headache. It would awaken him about 6 AM and last all day My life, he said " is a constant headache". He gad not responded to any of the many antidepressants and anticonvulsants which we use for migraine. His only relief came with the use of aspirin in high dosage, some 12-15 tablets each day. Without that drug, he told me, he simply could not function. But he paid a price. He had been hospitalized twice for gaastrointestinal bleeding due to his aspirin therapy and had required blood transfusions on both occasions.
He had a strong family history of migraine and also a history of attention deficit disorder requiring treatment with Ritalin. That therapy was discontinued about age 10 for the drug as beginning to speed him up rather than slow him down. (Please see my previous blog- our response to drugs change occording to time and circumstance)
I believed the young man suffered migraine although it's presentation was most atypical. It lacked most of the defining features of that disease but I viewed the positive family history of typical migraine (father and sister) as supportive. Also supportive was the appearence of headache at the same time every day, very tycical for migraine. Lastly, the past history of attention deficit disorder because that disease and other features of the bipolar spectrum (see my books and blogs) has a high concordance with migraine. Interestingly. his. headaches began at age 10, shortly after he stopped Ritalin. A coincidence?????. Personally, I kind of doubt it.
My treatment options? He had failed conventional therapy. Would resumption of Ritalin have helped? Perhaps, but he refused. He recalled its unpleasent effects. He then offered my an incredible clue ( as my patients often do-and I have written on this subject) He told me that he had recently had dental surgery and been given the pain killing opiate, hydrocodone ( brand named Vicodin, Lortab, and Lorcet). The drug gave him immediate relief from headache and he remained pain free until his supply was exhausted.
It was an easy trade off for me. A marginally functional existence and repeated intestinal bleeding both under the sponorship of 12-15 aspirin tablets versus freedom from headache pain under the sponsorship of a widely used and relatively safe low order opiate. I prescribed hydrococone, 10 mg.
four time daily (a rather small dose of opiate) and now several months into treatment is is doing quite well and his infrequent mild headache always respond to a couple of aspirin tablets.
Opiate therapy is not without risk but it can be effective in preventing migraine.
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