The headache pills that cause headaches

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Reading the British Medical Journal today I saw an item in the ‘news’ section which caught my eye. Entitled ‘Too frequent use of painkillers can cause rather than cure headaches’, it relays information coming from the National Institute of Health and Clinical Excellence (NICE) in the UK. It seems that in some cases, painkilling medication can cause headaches, which in turn can encourage an unhealthy dependence on these drugs.

Dr Martin Underwood, a general practitioner (family physician) and professor of primary care admits in the piece that explaining to patients that they should abruptly stop their treatment and endure weeks of worsened pain was not an easy task. When I read this, I wondered why the withdrawal from the medication need be abrupt. How about g-r-a-d-u-a-l withdrawal?

I have lost count of the number of patients who have been on some sort of medication (blood pressure lowering, hormone replacement therapy, antidepressant, medication for acid reflux, you name it) who had tried to abruptly stop their medication and then found themselves landed in trouble, who went on to have success with a gentler approach. Yes, gradual weaning down over some time (say a few weeks) may take longer, but I’ve found the results are much better overall than sudden stopping.

And while we’re thinking about gradual withdrawal of painkillers, how about also thinking about what might have caused the headaches in the first place, and addressing that at the same time?

I note that NICE classifies headaches into three type: tension, migraine and cluster. This classification reminded me of how often in medicine we are geared up to making the diagnosis, but sometimes fall short regarding what really matters (effective management). Often when talking to patients I will discuss the likely diagnosis and it may even have a fancy name. However, as I sometimes tell my patients, making the right diagnosis is not really the point of the exercise, it’s working out what’s causing the problem and then doing something about it.

Many years ago I was at a social event and ended up talking to a professor of neurology. The subject of migraine came up, and I mentioned that I’d found magnesium supplementation to be useful in the management of this condition. He asked me what the ‘proposed mechanism of action’ of magnesium was. I ventured an explanation, but he wasn’t having any of it. In fact he became quite hostile. I did not take this personally, though, as later in the evening he ended up having a physical fight with an old school ‘friend’ who was at the party. But I digress…

While we were still on the subject of migraine and magnesium, I made the point that the proposed mechanism of action of magnesium was not really important – the important thing is if the magnesium provides relief to migraine sufferers. The professor was not open to line of reasoning, and it reminded me of how some doctors’ priorities seem to have become drawn away from what medicine is really about (helping people).

In case you or someone else is interested, I wrote about the potential value of magnesium in migraines recently here.
I would add that I find this approach to work in people with more common-or-garden ‘tension’ headaches too. Some have suggested that magnesium deficiency can cause tension in muscles, including those in the neck, which can manifest as a headache.

Another simple approach that often works wonders for headaches is ensure adequate hydration. It’s possible that some dehydration will cause a degree of brain shrinkage or some pressure on the brain from its outer covering (known as the ‘meninges’). I don’t know if this is correct or not, but I don’t very much care either seeing as I’ve found improved hydration to be a very useful strategy for curing headaches. I recommend drinking enough water to keep the urine pale yellow and non-odourous throughout the day.

Another quite-common cause of headaches, I find, is caffeine withdrawal. Anyone who has gone ‘cold turkey’ of a good coffee or tea habit is likely to know how this fells (typically the headache comes on within a day and lasts for 1-2 days before resolving – often, for good). It is interesting to note that some headache remedies contain caffeine, despite caffeine having no painkilling properties. Could it be that the manufacturers know that headaches can be caused by caffeine withdrawal and caffeine can therefore help get rid of a headache? But might they also know that putting caffeine in the medication will likely, ultimately, lead to some caffeine withdrawal and another headache requiring, yes, more medication. I have no idea but I think we should at least ask the question. I wrote about this issue some years ago here.

I do hope our friend the professor isn’t reading these ideas about unfounded approaches that have the capacity to genuinely help people, lest he boils over and starts another bout of fisticuffs.

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