STOPPING TAKING TRIPTANS
My doctor says I have to stop taking my triptan every day but he wants me to take another tablet every day instead. I’m happy taking my sumatriptan when I need it, as it takes away my pain and allows me to get on with my life. I think what my doctor is suggesting could lead to lots of side effects and my headache will get worse. What do you think?
It is my opinion that, if you have to take sumatriptan every day, you have a medication overuse headache – that is, a triptan rebound headache. The headache develops as the effect of the triptan wears off, stimulating you to take another dose of the triptan; it does work but in this case is actually responsible for the headache developing the next day even though it seems to ‘fix’ the problem in the short term.
The only way to stop this rebound headache from happening is to stop the triptan. Yes, your symptoms will get worse in the short term but you will then go back to an episodic migraine rather than a daily migraine-like headache. I encourage you to take a preventative drug in the short term to reduce the severity and impact of the withdrawal
symptoms and possibly even in the medium term to minimize the number of headache days that you get, reducing the chance of developing rebound headache symptoms again in the future.
I use a triptan to treat my migraine. My doctor says that I am taking too many but I have to take the triptan or the migraine doesn’t settle. Is my doctor right?
Your doctor is probably right. The threshold for what is called ‘triptan rebound’ is about 8 to 10 triptans a month and this applies to any triptan. If you are taking more than 10, it is almost certain that your triptan is contributing to your headache. Headache recurrence when treating migraine is not unusual and occurs in 25–50% of attacks.
Repeating the dose is the right thing to do provided you get migraines only every now and again. The more frequent your migraines, the more headache days you have and the more days you take an acute treatment. The shift from episodic headache to medication overuse headache occurs with remarkable ease in some individuals!
Why does my migraine seem to come back? I am taking a triptan every day now. If I don’t take it early the headache just gets worse instead of better.
It sounds as if you have a triptan rebound headache. The headache often comes back at the same time every day. The brain’s pain receptors stop working properly, the headache creeps back and you feel you have to take another triptan – it becomes a vicious circle. It is just the same as getting medication overuse headache when taking ordinary painkillers.
COPING WITHOUT TRIPTANS
I only take my triptan because the headache gets really bad. I just don’t know how I am going to avoid taking one for at least six weeks. What else can I do?
Stopping triptans is never easy because the rebound headaches tend to be quite significant. Careful planning as to when you stop is as crucial to success as the how. Using preventative drugs as a routine measure is recommended, which, as always, is a balance between effectiveness, side effects, and possible risks.
Is there anything I can do to make it easier to stop taking my triptan?
Everyone is different in how they set about making such a significant change. You need to think carefully about potential triggers and stresses that contribute to your migraines. Also, make sure that you are in the best possible situation with all the support you need in place.
The specialist nurse has suggested that I may need to be admitted to hospital to stop my triptan. Why might this happen?
The nurse has probably suggested this so that you are given the best possible chance of success. In hospital you will have none of the sorts of stresses and hassles that would occur at home. It also means that there will be people around who can help with any rebound symptoms you get and offer appropriate drug treatment if needed.
The specialist nurse has suggested that I take some beta blockers when I stop taking my triptan. Can they help?
I have found that beta-blockers seem to work well in relieving or easing the rebound symptoms when triptans are stopped. I usually recommend a 160 mg dose of propranolol as a slow-release preparation, which is taken just once a day.
However, if you have asthma or a history of asthma, beta-blockers are not an option for you. If that is the case, the nurse will discuss other preventative drugs with you.
I have been told to expect nausea and vomiting as well as the chance that the headache may get worse before it gets better. Is there any way to ease those symptoms?
Research offers a variety of options, although none of them gives an absolute guarantee of success. The suggestions that I offer are based on the published evidence base and the experience we have built up at the headache clinic in York.
I suggest using metoclopramide or domperidone to ease the nausea and vomiting, and often suggest using diazepam as well. The diazepam is optional, but I usually encourage patients who have been overusing triptans for months, rather than days and weeks, to consider it. Diazepam is helpful if you are likely to get mood swings, irritability or sleep disturbance when stopping your medication – which in my experience is most likely when stopping triptans.
I would normally suggest using this mix of drugs for seven to ten days to ease the most severe ‘rebound’ symptoms.
I have stopped my triptans and feel that the propranolol has helped. How long should I take the propranolol after stopping my triptan?
Well done for having successfully stopped your triptans – not an easy thing to do. If the propranolol is helping to ease your symptoms, I suggest continuing to take it for a minimum of eight weeks. There is no absolute rule to help you decide how much longer after that you should carry on taking the propranolol. There are times when it is a good idea to take the propranolol for three months; sometimes it may be longer. The decision has to be taken on a day-by-day or week-by-week basis.
I had a lot of rebound symptoms when I stopped taking my triptan and was given diazepam and metoclopramide. The nurse has said I should stop taking them now. Are my symptoms likely to return?
Diazepam and metoclopramide should be used only in the very short term and I tend to suggest using them for no longer than the first seven to ten days. This provides cover for the most severe symptoms experienced in the first few days after the triptans have been stopped. The most severe symptoms should not return, and are most commonly associated with stopping triptans. Your headache symptoms will take longer to settle and this is why you will be encouraged to take preventative medication. If you are already on a preventative drug, it makes sense to carry on taking it in the short term and possibly in the medium term.
A friend of mine was given steroids when she stopped taking her triptans. It has not been suggested to me. Why not?
It is difficult to give you a simple answer to that question. There has been some research looking at what drugs offer the best way of easing or completely alleviating the symptoms associated with triptan withdrawal. One piece of research looked at using high-dose oral steroids, at a dose of 60 to 80 mg taken over the first three days that no triptans are taken. The results of the published trials were not very conclusive, so it is an option that tends not to be used as much now.
I can’t take beta-blockers because I have asthma. What are my options to try to ease my withdrawal symptoms?
You can try any of the standard migraine-preventative drugs, including tricyclic antidepressants and anti-epilepsy drugs. There is no ‘right’ choice.
