In general, for a patient with no other organic cause of headaches, if headaches have grown markedly worse or more frequent, the problem is almost always medication overuse. Headaches that occur eight or more days a month along with frequent use of abortive medicines are likely to be rebound headaches. Overuse is defined as taking abortive medications for 10-15 days or more a month depending upon the medicine.
All too often patients fall into a trap of treating their headaches everyday, thinking that they are having migraines when they are really rebounding from medication overuse. Part of this problem is due to the limited understanding of the medical community about the treatment of headaches. All too often physicians fail to educate the patient that “abortive” medications to “stop an ongoing headache” are different from the “preventative” medications aimed at reducing the frequency or severity of the headaches.
Fortunately, Botulinum toxin A (Botox®) was approved in 2010 by the FDA to treat chronic migraines occurring more than 15 days in a month. It seems to lessen the severity and frequency of the headaches but it is not a panacea. It is injected by a trained professional in 31 sites, with an extremely thin needle, in the muscles around the head and neck. Numbing cream can be applied for those who are sensitive. Most people describe the discomfort from the needle as 1-2 on a scale of 1 to 10. The exact mechanism of action is not clearly understood but may involve action of Botox on nerves and muscles. Most of the injections are done in the vicinity of trigeminal nerve (fifth cranial nerve) branches. Botox has been in clinical usage since 1988 and in almost 30 years of clinical experience it has been a remarkably safe medicine. It is now covered pretty much by all insurance plans if the criteria of chronic migraines is met which includes the failure of two or three preventative medicines.
The correct approach to treating chronic migraines is to identify if there is any rebound going on and to stop the offending agent. This is often easier said than done and requires courage both on the part of the patient and the doctor. Preventative medicines and close follow up is needed. This used to require hospitalization but now can be done safely in the outpatient. The best approach is often a combination of medication management, massage therapy, nutritional supplements, Botox, biofeedback and psychotherapy. With the correct approach most patients can be completely or nearly headache free. In the present era of medicine most people should not have to live in a life of continued misery from their migraines.