COPING WITHOUT PAINKILLERS
I get a headache every day and the last time I tried to stop the painkillers the headache got so bad I had to start taking them again. I have to go to work and the only way to get through the day is to take the tablets. I just don’t think I can stop; what can I do?
Stopping painkillers is never easy. If your headache started off as migraine, the ‘rebound’ symptoms can be quite severe and be similar to the severity of migraine attacks themselves. The only way to completely break the medication overuse headache cycle is to stop using painkillers completely, no matter how bad your headache gets.
To be successful you need support. This can come from your friends, your family, or your work colleagues or it can come from medication that is not a painkiller but can help the pain from your headache. Your doctor or nurse will encourage you to seek help from those around you. It is about putting a strategy in place that can help you not only now but also in the future.
You need to consider all the options and decide exactly what you must do to reduce the chance of a headache developing. Finding a way of not taking the painkiller is about changing how you react and respond to pain or finding a way of stopping the pain happening in the first place.
I have young children and there are times when the headache gets so bad that I have to take something for it. Even though it does not get rid of the pain, it means I can look after the children until my husband gets home. What can I do if I can’t take the painkillers?
The challenge you have is that with medication overuse headache you must break the cycle. To break the cycle you have to stop taking the painkillers completely during the washout phase. To do that you have to do away with all the circumstances or situations that will provoke you into taking a tablet. You have to find a way of doing this, whatever it takes.
If the barrier to stopping the painkillers is ‘who’s going to look after the children?’ you need to find a time when it won’t be a barrier. This could mean arranging for a friend or family member to look after the children, so that you can concentrate on stopping the painkillers. You might need only a short period of time (a few days) or it could take a little longer (a week or two); there is no way of knowing just how long this it will be. It is one of those times when you really do have to take each day as it comes. To stop successfully, you need to plan carefully and ask for help and support from people around you.
The nurse at the clinic has been talking to me about different drugs I can use during the washout phase. How do I decide which one to take?
Choosing which drug to use is not an easy or straightforward decision. Some are automatically ruled out if you have specific medical conditions, such as asthma, so this is a ‘negative choice’. Some are automatically chosen because you have another medical condition that would benefit from a particular drug, so a ‘positive choice’. Some are chosen because of their possible side effects: sedation if you need to sleep, weight loss if you could do with losing some weight.
When the nurse sees you she will talk to you about the different drugs available and deciding which best meets your needs or suits you. There is no way of predicting which choice is the right one; there is the one that works for you but it is not always possible to choose the right one first time. Sometimes trial and error is the only way to move things forward.
The nurse has said that there are tablets I can take to help the pain that are not painkillers. She said that they are antidepressants but I am not depressed. Why should I take antidepressants?
Medication overuse headache can be seen as a form of chronic pain, and there is range of drugs that are used to help chronic pain that are not painkillers. One of these is a group of drugs called tricyclic antidepressants. Stopping this headache is about stopping the painkillers, and if taking a tricyclic antidepressant will help you do that, it is worth thinking about. It is another one of those ‘nothing ventured, nothing gained’ situations.
It could make the difference between taking back control and just not getting there, so why not give it a try? Why can’t I just take prophylaxis to make the headaches go away?
Prophylaxis can help, but if you have medication overuse headache you have to stop the painkillers as well. Understanding why this is essential is often difficult. It just doesn’t seem to make sense that tablets designed to stop pain should apparently cause it. Perhaps I can explain it here. Pain is felt when a receptor in the brain is stimulated.
What happens with medication overuse headache is that the receptors get reset and, instead of being ‘switched off’ by the painkiller, are actually kept ‘switched on’.
Pain is a response to a stimulus or irritant. When you have medication overuse headache, the receptor is so sensitive that it takes very little to produce a pain response. The only way to reset the receptor is to stop the painkiller. Painkillers and triptans seem to wind things up, making the nerves ‘irritable’, whereas preventative drugs help calm this response down and stabilise the nerve so that pain is felt less often and the response is at a lower and more normal threshold.
How can I make sure I succeed? I have tried to stop painkillers before but it just got too hard.
Success is about how badly you want to succeed and who else you get to help and support you while you go through the washout phase. It may be that you need to arrange some time off work, or get help with the children. Think about what will be happening during the washout period. Take positive steps and make positive choices and decisions. If you couldn’t do it on your own before, ask for help and support this time. People will help if they know you need it and why.
The nurse has said that I cannot take any painkillers during my ‘washout’. Why not?
The receptors in the brain have been reset by your taking regular painkillers, and as a result it takes very little to stimulate the receptor to send signals telling that you are in pain. The receptors have to learn to respond correctly rather than over-enthusiastically.
The washout means exactly that, it is a washing out of the receptors so that they respond more appropriately in the future.
My nurse at the clinic has said that I can call her any time. Will that really make a difference?
Yes, it can. Changing what you do is always difficult. It is easier to change if you have someone to help you. In some ways stopping your painkiller is like trying to deal with an addiction to anything, such as nicotine or alcohol. You need all the help you can get, so grab the opportunity with both hands! If you feel the need to take a painkiller, phone the nurse and talk to her instead.
Is there a good time to stop taking painkillers? I really want my headache to get better but it just seems so hard.
There is a good time to stop, and that is the time when you feel that you can do it successfully. This may take a little planning and thinking about. It means making sure that you have all the help and support in place that you feel you need.
I’m not getting a headache every day now, but I’m still getting some bad days when I have to go to bed. When are the headaches going to stop?
It is always difficult to know exactly what will happen when you stop the painkillers. The background headache should improve slowly with time. This means that you will shift slowly from a daily or near-daily headache to an episodic headache. The episodic headache is the one that you started with before your headache increased in frequency as a result of your use of painkillers.
If this headache is bad enough to send you to bed, it is probably migraine. But you still need to complete your washout because the longer you can keep going the better. Eventually all that you will be left with is the occasional bad headache, probably migraine, which you can then treat.
What happens if the headaches don’t get better when I stop taking the painkillers?
It would be unusual for the headaches to not change at all. You should notice a reduction in the total number of headache days that you get. There will be a gradual shift from daily headache, to fewer headache days, to no dull aching background headache to just the occasional migraine. It is unlikely that the headaches will stop completely but they should significantly reduce in frequency so that they become manageable and treatable.
If your headaches do not improve, you should continue not taking painkillers but think about taking a preventative drug. This would help control your headache and make it easier to stay off the painkillers. It may be that you need the preventative drug to ‘switch off ’ the nerve response completely.
I have done really well and have stopped all my painkillers. That nagging background headache has gone but I still need to treat the migraine. I am worried that if I start treating the migraine my daily headache will come back. What should I do?
There is always a chance that your daily headache might return. Your migraine is a high-impact headache that needs treating. The best thing to do is to find the most effective acute treatment that gets rid of your migraine attack and makes sure that it stays away. This is called a ‘sustained pain-free response’. What you need to look out for are shifts in how your attack responds to your acute treatment. If your migraine seems to become less responsive, takes longer to settle and recurs more often, you need to be aware that the medication overuse headache may be coming back. If the number of headache days starts to increase, you may need to think about prophylaxis. Prophylaxis, or prevention, is about reducing the total number of headache days so that you don’t have too many days taking acute treatments.
