Why can triptans cause rebound headaches? / Managing pain

Specific Illnesses & Conditions VM/MAV
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I was just wondering: why exactly can triptans specifically perpetuate headaches (i.e. lead to chronic daily headaches)?

And is it for the same reason that other painkiller drugs can do so (NSAIDs like Advil, or other drugs like Tylenol, etc)?

I just don’t understand how something that is supposed to help take pain away can end up doing just the opposite in the longer-term.

I’m finding it extremely difficult to go a month without taking at least 2 Zomig tablets (my avg # of headaches/month for 2013 = 9.25). My doctor says I shouldn’t go beyond 6 Zomigs/month: is that “safe” in terms of avoiding rebound headaches?
I’m not currently on any daily preventative (tried amitriptyline & verapamil - both stopped due to side effects). I’m waiting to see a doctor to trial a new med. But in the meantime, I’m having a lot of trouble managing my head pain without meds and feel like my head hurts mildly every day, and then every few days I get a severe headache (with nausea, photophobia, etc).
On a related note, what are the best medication-free ways to deal with severe throbbing head (including neck) pain? My VM is currently mostly pain, with only low-level vertigo and disequilibrium in the background. For pain I’ve tried: cold packs, heat packs, massaging my own head and neck, lying down trying to sleep in a dark room…these work a little bit, but when the agony keeps going for hours on end (and sometimes worsens), and it leaves me disabled - I find myself reaching for my Zomig in desperation, no matter how badly I want to avoid using it.

If anyone could help with some insights or things I haven’t considered for VM pain management, I’d appreciate it very much. I feel at my wit’s end.

Thank you in advance.

-Bren

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I don’t know if you get knots in your neck and shoulders from this too but I bought a great back/neck massager thing from bed bath and beyond- they make these shiatsu massagers that are great for getting knots out when I have a headache. Like you said I also use ice and that helps a lot. Sometimes I put something cooling like menthol toothpaste or vicks vapo rub on my forehead where it hurts- the cooling can help a little too. Do you ever drink coffee? I find that that sometimes helps my headache pain too (although at other times it can bring on a headache which is weird). Good luck and I hope you find something that works!!!

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Sarah, do you know which massager you bought? I’ve been getting a lot of knots in my shoulder/neck.

I use cold packs and peppermint oil for my headaches. A little peppermint oil on the temples and back of neck. (Works similarly to the Vicks that Sarah mentioned.) Also drink tons of water.

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I think it was this one:

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A good overview of medication overuse headache (MOH) here:

http://www.healthcentral.com/migraine/medications-32544-5.html

Triptans impact serotonin I believe in some sort of way. No doubt the overuse of them throws things out in the brain. Not sure what the exact biochemistry is here but rebound does occur not only in migraine but for other medicines as well. I used to use a nasal drug called Ortrivin when I was a teenager. I was hooked on it for a year because of rebound!

S

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Yeah, rebound seems to be really common with certain meds - Afrin has nasty rebound, and has nothing to do with migraines. Cholinergic rebound is a thing too…

I imagine the exact mechanisms are a bit different (since the drugs themselves are different and each has a different threshold for how often you can take it before you risk MOH), but the end result might be the same:

"A possible explanation of why migraine becomes chronic is that a yo-yo effect of repeated migrainous pain processes, followed by repeated medication, results in structural changes. These propagate central sensitization with a lowered threshold for activation of all of the central processing of head pain. "

(ccjm.org/content/77/4/236.full)

This one is a bit more technical, but basically says the same thing:

“Recent animal experiments have shown that chronic medication exposure profoundly affects the function of several areas in the nervous system related to headache pathogenesis. These changes include upregulation of calcitonin gene–related peptide, substance P, and nitric oxide synthase in trigeminal ganglia; expansion of receptive field and decreased nociceptive threshold of central trigeminal neurons; decrease in diffuse noxious inhibitory control; and increased susceptibility to develop cortical spreading depression (CSD). These changes indicate an increase in excitability of cortical and trigeminal neurons. The neuronal hyperexcitability may be the result of derangement of a central, possibly serotonin (5-HT)-dependent, modulating control system. Experiments with animals with low 5-HT showed that the processes of CSD and trigeminal nociception are enhanced in this condition. Derangement in the central 5-HT–dependent modulating system as a result of chronic medication use may underlie the chronification of headache as observed in patients with medication-overuse headache.”

(link.springer.com/article/10.100 … 011-0234-y)

So basically, it appears repeated use of rescues or abortives start to chemically change our brains, reducing our trigger threshold, and thus increasing the frequency of migraines. Then it gets reaaaallly easy to get stuck in a loop of more headaches → more meds → even more headaches → even more meds… and then you are in a REALLY bad place. At least that’s the vibe I get from these studies and other articles I have read. I could be interpreting them totally wrong.

As for pain management, I also have a massage cushion but due to allodynia find it way too intense during the worst of the migraine (great for in between though!). That said, I find gentle self massage just with my own hand to be really helpful. Sipping on warm, slightly sweetened chamomile tea is very soothing to me. It helps me calm a queasy stomach and allow me to relax a bit. With heat and cold, it’s not just about heat and cold for me - it’s about moist heat and cold. Using a wet washcloth seems to help me better than traditional dry heating pads or ice packs. Sometimes I respond to heat better, and sometimes to cold, depending on the headache - I haven’t quite figured that out yet. Also, if the temperature is too extreme, it can make things worse for me - warm and cool work better than hot and cold. Since everyone is different, it may take some experimenting.

Some people swear by lavender and/or peppermint oil applied to the temples - can’t vouch for that one myself, as I am way too odor sensitive to do it.

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Thank you all so much for your helpful replies.