Robbins' Nest Blog

Posts Tagged ‘chronic daily headache’

No Truth Allowed

“Pain must be regarded as a disease… and the physician’s first duty is action–heroic action–to fight disease.” –Benjamin Rush

The impetus of this post originally came from the very brave and truthful comments posted by Dr. Robbins in regards to opiate medications for chronic pain, and the difficulty legitimate pain patients face in receiving appropriate treatment for their pain, mainly owing to drug abuse by non-pain patients. I shared his post, as I do many of his wonderful insights on my Facebook page, and a person responded with a comment that really struck a nerve with me. The author of the comments (who shall remain anonymous for obvious reasons) had made previous statements, which led me to conclude that they were addicted to illicit drugs before trying to illegally obtain narcotic pain medication, and I stated as much in my response to them. The person responded again with the following comments:

You were correct in stating I was on other drugs before I began abusing pain medication, yet it was perscribed to me by a Gen. Practitioner. He perscribed me 40mg of Methadone a day for stomach pains he could not identify. In his defense he did send me to other specialists, and ran many test. I also will admit that I was a GREAT actress. I will concur and say it is not fair to those with legitiment pain. And those who are abusing the medication should be the most penelized. Yet. this is not a perfect world. And laws are not made to meet individual needs. I feel docters need laws of this nature to proctect the amount of blood on thier hand. I realize thats a little dramatic sounding, but RX meds is the #1 cause of death in the US (or at least in the top 5). I can only imaigen how frustrating is, ecpspecially if you are a victim in this case, yet we must do whatever ever it takes to protect people that obviously cannot protect themselves, or dont’ know how to protect themsleves, and even those that don’t want to protect themselves.” [sic]   (Emphasis in bold added by me)

Now if you are a doctor that is trying to treat legitimate pain patients or you are a chronic pain patient, then those comments probably make you as upset as they did me. The biggest problem I have with these comments is that they are simply not true. It may sound true, especially if you are only gathering your information from the media, but there is not one iota of truth in these claims. Not one.

The fact is that narcotic medication is not the number one cause of death in the US. It is not even in the top five, nor the top ten. It is not even in the top fifteen, and it has never been the case in all of US history.  As a species on the whole, we tend to rely too much on group-think and media sound bites in order to form our opinions and ideas, and then these falsehoods are repeated and spread over and over again throughout our society like a virus, and it is almost impossible to cure. The hardest thing to cure in our existence is not a bacteria or a virus; as we can take a round of antibiotics for the bacteria and a vaccination for the virus. The hardest thing to cure in our existence, across all of humanity, is an idea, especially a bad one.

The truth is that more people die every year in the US from NSAIDs like Advil, Aleve, Toradol and aspirin than die from narcotic medication, whether a doctor is involved or not. In fact, if the deaths from NSAID medications were tabulated by themselves in the same Centers for Disease Control (CDC) vital statistic reports, they would rank as the 15th leading cause of death in the nation. (1-7) Furthermore, those mortality statistics do not even include the NSAIDs that were bought over the counter, and thus the total amount of deaths and hospitalizations should rank even higher. The truth is that more than 107,000 patients are hospitalized annually for gastro-intestinal bleeds and complications as a result of using NSAID medication exactly as recommended. That means there have been more people hospitalized for using NSAIDs than casualties suffered in all American wars combined in our nation’s history. (5-7)

The highest number of deaths related to opioid analgesics was in 2008, and in that year a total of 14,800 people died due to overdose. (1-4) Compare that figure with numbers cited by The American Journal of Medicine, which stated the following: “Conservative calculations estimate that approximately 107,000 patients are hospitalized annually for nonsteroidal anti-inflammatory drugs (NSAID)-related gastrointestinal (GI) complications and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone.” (5)

In other words if we just count the patients being treated for arthritis, more of them will die each year due to NSAIDs than in the highest year of deaths attributed to narcotic pain medication in our nation’s history. Another way to look at it is that more people die from NSAID medications each year than die from AIDS, cervical cancer, asthma, and Hodgkin’s Disease, and that is just the numbers from one category of patients being treated for arthritis. Imagine if we had the numbers for every type of malady that NSAIDs are used to treat, and then you get a better understanding of how illogical the war on pain medication and pain patients has become.   (1-7) How many of you remember the AIDS epidemic scare? Now how many of you remember the NSAID scare? Exactly, you have never heard of an NSAID scare, and neither have I.

How about the H1N1 swine flu scare the media was bleating and baying about for months- did any of you rush out in a panic with the millions of other people to get vaccinated in order to protect yourself? My educated guess based on the numbers indicates that all of these people had an NSAID medication in their purse or medicine cabinet. Would it surprise you to know that according to the CDC that four times as many people die each year from NSAIDs than swine flu? (1-7) It shouldn’t surprise anyone who is paying attention and using evidence and reason to make decisions about health care, rather than media hype and “Drug War” propaganda. And yet millions of people rushed out to get vaccinated for swine flu, and all the while they were four times as likely to die from the NSAIDs in their medicine cabinet.

What confuses me is why I don’t hear people clamoring for Advil or Aleve to be removed from the shelves or that the makers of these drugs should be held accountable for “the blood on their hands.” I assume because it is not discussed with the same hysterical hyperbole as used by mainstream media or the Drug Enforcement Administration (DEA). The truth is too boring for most people, and thus it rarely makes headlines or generates advertising revenue. Because of the tendency of most people to use group-think instead of using evidence and reason to make decisions, pain patients have ended up in the no-win situation we are facing, and unfortunately, very capable, honest, and trusting doctors are right there with us. Paint patients are degraded, treated as criminals and drug addicts, under-treated or not treated at all, and in the vast majority of cases this happens to the patient without one shred of evidence to support these assertions or discrimination. It is beyond immoral and illegal that we have reached this stage in our country, it is a crime against humanity.

Why do I read about “bad” doctors who should be sanctioned, and those that have been arrested and suffered criminal penalties due to the DEA inquisition against doctors, and yet I have not  read about even one DEA raid against a Walgreens or Wal-Mart for the distribution of Advil? I have not seen the DEA recommend scheduling of NSAIDs, and yet they kill and hospitalize more people than narcotic medications ever have in our history. Where is the reason and logic in this? How are doctors expected to work in an environment where science and evidence is not even used to make rational, empirically based medical decisions?

Here are the actual ranking of causes of death from 1999 to 2009, as reported by the agency charged by law with tracking and providing research on this information to the government; the CDC vital statistics reports. (1-4)

1. Diseases of heart
2. Malignant neoplasms
3. Chronic lower respiratory diseases
4. Cerebrovascular diseases
5. Accidents (unintentional injuries)
6. Alzheimer’s disease
7. Diabetes mellitus
8. Influenza and pneumonia
9. Nephritis, nephrotic syndrome and nephrosis
10. Intentional self-harm (suicide)
11. Septicemia
12. Chronic liver disease and cirrhosis
13. Essential hypertension and hypertensive renal disease
14. Parkinson’s disease
15. Assault (homicide) *Bearing in mind the CDC does not count the deaths from NSAIDs

Just as there are laws in place to prevent drug addicts from obtaining cocaine and heroin; in the same vein, there were already laws in place to prevent people from obtaining pain medication that they do not need and were never prescribed. The problem is that drug addicts don’t care about laws, nor do these laws thwart drug addicts from obtaining narcotics illegally. They simply modify their behavior to circumvent those laws and get the drugs anyway. They will lie, manipulate, violate the law, and are “GREAT actresses” in order to get their fix.

And yet these same people who game the system and use fraud and deceit to get high are the same ones that claim, “Laws protect those who don’t want to or cannot protect themselves.” In reality everyone is hurt because of their actions, and the laws passed as a result. The addict gets hurt by either overdosing or ruining their lives due to drugs, the doctor gets hurt by lawsuits or criminal sanctions or perhaps loses their license to practice medicine, but further, the only people who are not able to protect themselves are the legitimate pain patients who need the medication to improve their quality of life and stop the excruciating pain that they legally, morally, and justifiably should not have to suffer.  The legitimate pain patients are hurt the worst and they are also completely innocent of any crime or wrongdoing.

The drug seekers and professional patients have the ability to protect themselves, and they certainly have the knowledge, they just don’t care about the repercussions to everyone else or themselves. Now the doctor who has been duped will be less likely to prescribe the medication to his cancer patients, AIDS patients, patients with spinal injuries, people needing the medication for “end of life care”, and patients like migraine and cluster patients who need the medication to treat one of the most painful, and incurable diseases to ever exist.

They don’t call them “suicide headaches” because they are an enjoyable experience, they call them that because patients suffering from the genetic, hereditary, neurovascular disease that causes the “headaches” are not properly treated, and they end up committing suicide because of the incomprehensible chronic pain they must needlessly endure. The patient’s quality of life is destroyed, and their existence becomes unbearable. If you will look up, you will see that suicide was the 10th leading cause of death in the US, and narcotic pain medication was not even listed. In regards to the comments posted on my Facebook page, the doctor didn’t violate a single law or ethical requirement in this instance, the drug addict did. I find it difficult to believe that this person was prescribed methadone on a first visit, especially by a general practitioner, and I suspect that we may not be getting all the information in this instance. However, even if this was the case, the doctor may have had a reason to prescribe the medication as he truly believed that the patient was suffering. He ordered all the proper tests, did a complete examination, and sent the patient to specialists in order to help find the cause of the pain. What more can a doctor do to prevent people from breaking the law besides be given a crystal ball along with their MD? It was the drug addict that violated every law and ethical requirement on the books concerning obtaining pain medication, and not one of those laws stopped them, and they never will. No matter how many laws are passed, the only people that laws affect are people that actually follow them.

However, these laws do stop the majority of legitimate pain patients from receiving proper treatment as doctors are now afraid of the same thing happening to them that happened to the doctor in the case above, and they are afraid of being hounded by the DEA and medical boards for behavior that is out of their control. Thus a majority of doctors now treat every patient that needs pain medication as a drug addict that needs psychological help and possibly criminal sanctions, instead of prescribing them the medication that the addicts have no trouble obtaining on the street. The addicts who wantonly, knowingly, and purposely abuse the drugs; and violate the ever increasing laws are the ones causing legitimate paint patients to suffer, as well as their doctor, and you cannot stop them by stacking redundant laws on top of already redundant laws.

Further, the majority of the studies that espouse the idea that legitimate pain patients are becoming addicted or overdosing are not studying pain patients at all, they are studying drug addicts. For one example, out of many, a study on overdose deaths in West Virginia from 1999-2004 found that 63.1% of the deaths occurred in persons who had never actually been prescribed an opioid, and had either stolen the medication or bought it from a drug dealer.(9) This study and others with the same methodology all fail to recognize the fact that pain patients are not the problem, and yet they are cited numerous times by media, law enforcement, and even doctors as a reason to never prescribe pain medication.  The laws in place did nothing to stop these deaths or deliberate drug abuse, and a doctor was not even involved in over 63% of the cases. Even if the doctors had prescribed these people (not patients) medication, no doctor can control the behavior of the patient once they leave their office.

The same study found that 79.3% of the deaths were a result of people who had a “multitude of other medications”, including illegal drugs in their system when they died. In short, this study which is used to “prove” the dangers of treating legitimate pain patients with opioid pain medication are not even discussing the legitimate pain patient, they are discussing drug addicts who obtained the medication illegally, and were never prescribed the medication in the first place. Further, 80% of the people that supposedly overdosed due to pain medication were actually mixing the medication with other drugs, which nobody ever bothers to mention. (9)

Neither the addict nor society can blame what happens to the drug abuser on the doctor or the legitimate pain patient, as it was the drug addict’s fault, every single bit of it. I understand that the popular notion of addiction is recognized as a disease, but I have a hard time accepting that line of reasoning, as the behavior began with sober intent. Cancer is a disease, malaria is a disease, muscular dystrophy, migraine and cluster headaches are a disease,  and all of these are completely out of the patients control. However drug addicts deliberately chose to start using drugs, and they  used fraud, deceit, manipulation and broke the law so that they could get high, and caused great injury to the doctors and legitimate patients that need the medication to live in the process. The blood is not on the doctor’s hands, it is on the people that abuse the system, break the law, and violate the trust of doctors to the detriment of society and specifically legitimate pain patients.

To the regulatory authorities and doctors that refuse to look at the actual data, and thus deprive legitimate pain patients from the essential and often live saving treatment they need, I say you are violating the very oaths and principles you swore to uphold. If you simply refuse to allow legitimate patients the opportunity to try and relieve their suffering and lead some life of value, what do you expect them to do? I’ll say that again: What do you expect us to do?

“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.” -Mark Twain


by Jeff Poleet, Chronic Migraine Patient


1. Minino A, Murphy SL , Xu JQ, Kochanek KD. Deaths: Final data for 2008. National Vital
Statistics Report; vol 59 no. 10. Hyattsville, MD: National Center for Health Statistics. 2011
2. Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008
Weekly November 4, 2011 / 60(43);1487-1492
3. Anderson RN, Kochanek KD, Murphy SL. Report of final mortality statistics, 1995. Monthly vital statistics report; vol 45 no 11 suppl 2. Hyattsville, MD: National Center for Health Statistics. 1997. Available from:
4. Hoyert DL, Kochanek KD, Murphy SL. Deaths: Final data for 1997. National vital statistics reports; vol 47 no 19. Hyattsville, MD: National Center for Health Statistics. 1999. Available from:
5. Singh Gurkirpal, MD, “Recent Considerations in Nonsteroidal Anti-Inflammatory Drug Gastropathy”, The American Journal of Medicine, July 27, 1998, p. 31S
6. Wolfe M. MD, Lichtenstein D. MD, and Singh Gurkirpal, MD, “Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs”, The New England Journal of Medicine, June 17, 1999, Vol. 340, No. 24, pp. 1888-1889.
7. Edward J. Frech and Mae F. Go, “Treatment and chemoprevention of NSAID-associated gastrointestinal complications”, Therapeutics and Clinical Risk Management, 2009, pp. 65-73
8. Congressional Research Service: American War and Military Operations Casualties: Lists and Statistics,

9. Hall  AJ,   Logan  JE,   Toblin  RL,   Kaplan  JA,   Kraner  JC,   Bixler  D.  et al.  Patterns of abuse among unintentional pharmaceutical overdose fatalities.. JAMA. 2008;3002613-20

DISCLAIMER: The views and opinions expressed herein are those of the author and do not necessarily reflect those of  Dr. Robbins or the Robbins Headache Clinic. I am not a healthcare provider, and I do not provide any medical advice, diagnosis or treatment. The information presented here is designed for general informational purposes and discussion only, and is not intended to replace a physician’s judgment about the appropriateness or risks of a procedure, medication, product or diagnosis. Always consult your doctor about any medical questions or conditions you may have.


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Preventatives on the left, abortives on the right, and me stuck in the middle

This is a post taken from excerpts from comments I shared between another migraine patient and I in regards to preventive migraine treatment. I wanted to share it in a blog post, as I didn’t want the information to be overlooked in the comments section. With that said, here is my non-medical, non-authoritative, non-expert, simpleton opinion. If you haven’t tried preventatives to decrease the frequency of the migraines or other headache conditions, I absolutely think you should.

The American Academy of Neurology (AAN) just issued new guidelines on preventive medications for migraines, and listed them according to “proven to be helpful” and “probably helpful.” Drugs that were “proven” to be helpful were given a “Level A” rating. Among the A rating drugs “proven” to be helpful, one triptan made the list, and it was Frovatriptan (Frova). The other medications receiving a Level A rating were the following: [1]

Divalproex sodium (Depakote)
Sodium valproate (Depacon)
Toprimate (Topamax)
Metoprolol (Lopressor, Toprol-XL)
Propranolol (Inderal)
Timolol (Blocadren, but no longer sold under that name in the U.S.) [1]

Personally, I have not had any luck with the anticonvulsants reducing the frequency of migraine attacks, and I can’t tolerate the side effects either. Some patients, including myself, refer to Topamax colloquially as “Dopamax”, as it can make some patients feel like their mind has turned into mashed potatoes. My mind felt slower, my wit duller, and I couldn’t ever find my car keys. I still can’t find my cars keys most mornings, so the latter example may only apply to me. Matter of fact, do a search for the slang word “Dopamax” (a completely made up word by patients on the medication) on Google and you will see over 14,000 results. However, this drug has received a Level A rating as proven effective from the AAN, and it is widely reported as helpful in a great deal of patients in reducing the frequency of migraine attacks. All of our bodies are different, and this might just be the medication you need for relief. I know of migraine patients that swear by it, and you couldn’t take it out of their medicine cabinet with a SWAT team, so this may be a medication you want to talk to your doctor about adding to your arsenal.

Next, I would try an herbal supplement (I know, I know, don’t give me that look) called Butterbur, that is used as a headache preventive as well. It is widely reported that Native Americans used the root of Butterbur to treat headaches and some types of inflammation. There are also a variety of double-blind studies that show that Butterbur is effective for reducing the frequency of migraines, and may even relieve a migraine in progress.[3] One of the better known and recommended forms of this herb is a patented drug called Petadolex. I take this medication and I do believe that it has helped in reducing the frequency of migraine attacks, but I have not had any success with it relieving the pain of the attack once it has started. I like Petadolex, as they have a patented process for removing all of the unnecessary alkaloids from the Butterbur that can be toxic to the liver and may cause some cancers, leaving only the good stuff to prevent migraines. I order my Petadolex online and I am signed up for monthly delivery. I order from here:

I have also had some success with a beta-blocker called Metoprolol (Lopressor, Toprol-XL) and take this medication daily. Propranolol (Inderal) and Toprol-XL are recommended by the American Headache Society as a preventative for migraine headaches. [3] Both of these medications received a Level A rating by the AAN as well and are stated by the AAN as a proven effective medication for the prevention of migraine attacks. [1]

Another factor you may want to consider is your diet, and the amount of essential vitamins you are fueling your body with, such as vitamin D, magnesium, vitamin B6 and vitamin B 12. Studies have shown that a lack of these essential vitamins can lead to a host of health problems, including migraines. [4] [5] Unfortunately, none of these essential vitamins are included in sufficient amounts in the junk food most of us put into our bodies, so you might need to talk to your doctor about taking supplements. I have done extensive research with Oreos and chocolate cake, but I have no solid evidence that they are increasing my vitamin levels sufficiently, the rigorous research continues . You might also need to have your vitamin D levels checked, as many people, not just migraine patients, have a low level of vitamin D, which can cause all sorts of problems, including headaches.

Other over the counter medications that were rated as “probable efficacy” in the prevention of migraines were: magnesium, riboflavin, histamine SC, and the herbal supplement feverfew. [2]  Feverfew has been used for centuries in Europe, and many people find relief from acute pain from migraine, and well as a reduction in frequency of attacks. [2] I have had some luck with feverfew in combination with magnesium, vitamin B2, vitamin D, and certainly think you should give it a try if your doctor approves. Feverfew can increase a bleeding risk, much like aspirin, so be certain you have talked to your doctor before taking this supplement

Some antidepressants can work as a preventive for migraines as well, and may help with the depression and anxiety often associated with migraine patients. Talk to your doctor about which medications might be right for you.  

Other things I would suggest are getting some exercise. Slow, moderate, exercise (e.g. walking, Pilates, Yoga, Tai Chi, etc.) are good ways for migraine patients to get some physical activity, without the overexertion that can trigger a migraine in some patients. So grab the leash and take the dog for a stroll or find a local facility to try some of the suggested activities. Even using videos at home can be effective, and can be bought cheaply over the internet.  I have also found that getting a massage can help reduce the tension and anxiety that can trigger my migraines, and can be a wonderfully needed break from the hustle and bustle of daily life. I actually have a prescription for one massage a week (Thank you Dr. Robbins!) and these work wonders for relaxation and releasing tension in muscles that trigger my migraines.

You may also want to try aromatherapy. I have had success with peppermint oil and rub it on my temples and forehead, as this can give that tingling feeling that can sometimes help reduce pain and the smell of peppermint can help with the nausea. I also rub this on my pillow when I have a migraine so I can smell the peppermint, as my sense of smell gets so strong during an attack that I can smell my dogs like they are in my lap. I also like the product CryoDerm, which is a topical roll-on ointment that contains Menthol as the active ingredient. I rub this on my neck, shoulders, temples, and forehead when I feel tension or a headache starting to occur and it can help ease muscle tension and sometimes keep the headache from progressing as quickly.

As you probably are aware, you are going to have to try combinations of these medications and supplements, play with the dosages, and give them time to work. Don’t expect to see any change until at least a month or so of taking them per your doctor’s orders. Basically, I have to take a shotgun approach to treating my migraines, as there is just nothing in existence I have found that stops the migraine in its tracks. Even when I have to go to the ER (maybe once a year) for strong opiate and nausea medication injections, when everything else has failed, it doesn’t stop all the pain, but it does reduce the pain and nausea allowing me to finally go to sleep, which allows my brain to “reboot” as I call it.

Finally, read and learn as much as you can about your specific headache condition, as knowledge is power, especially in the world of a migraine patient. Many doctors are not aware or as educated as they should be in the treatment of headache disorders and medications, and in the end, your body and input to your doctor is going to determine what works best for you.

If you are suffering from headaches of any type, and your current method of treating them isn’t working, talk to your doctor about adding preventatives to your treatment plan to decrease the frequency of attacks. If your book shelf doesn’t look like mine, and your medicine cabinet does not contain the copious amounts of preventatives and supplements that mine does, perhaps it should.

As always talk to your doctor about these medications and supplements before you begin taking them, and get their educated opinion on what they think you should try or what could be contraindicated for you based on current medications you are taking. Remember, I am just a migraine patient, and all I am sharing is my opinion based on my personal experience of living with chronic migraines for over 30 years. You should always talk to your doctor before beginning any exercise, medication, or herbal supplement program.

Please feel free to share your experiences and what you have found that works best for you. I hope my comments are of some use to those of you suffering. Take care of yourself, give yourself a break, remember you are not alone, and as always, try your best to “Keep Calm and Carry On.”

Wishing you all the best in life and your treatment,

Jeff Poleet
Chronic Migraine Patient


1. Silberstein S, et al “Evidence-based guideline update — pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society” Neurology 2012; 78: 1337-45.

2. Holland S, et al “Evidence-based guideline update — NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society” Neurology 2012; 78:1346-53.

3. Lipton RB, Göbel H, Einhäupl KM, Wilks K, Mauskop A (December 2004). “Petasites hybridus root (butterbur) is an effective preventive treatment for migraine”. Neurology 63 (12): 2240–4. PMID 15623680.

4. European Journal of Neurology (2004;11:475-7), Genomics Research Centre (GRC) at Griffith University in Brisbane.

5. “Journal of Headache and Pain”; The prevalence of headache may be related with the latitude: a possible role of Vitamin D insufficiency?; S Prakash, NC Mehta, AS Dabhi, O Lakhani, M Khilari, ND Shah; 2010

*Additional Sources and article review: By John Gever, Senior Editor, MedPage Today
Published: April 23, 2012; Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania. Full Article may be read at:

DISCLAIMER: I am not a healthcare provider, and I do not provide any medical advice, diagnosis or treatment. The information presented here is designed for general informational purposes and discussion only, and is not intended to replace a physician’s judgment about the appropriateness or risks of a procedure, medication, product or diagnosis. Always consult your doctor about any medical questions or conditions you may have.



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According to research published in Neurology, the medical journal of the American Academy of Neurology, most children who suffer from chronic daily headache may outgrow the condition.

The study found 60% of the children no longer had chronic daily headache after one year, and 75% showed no symptoms after two years. Only 12% of the children tested still had symptoms of chronic daily headache after eight years.  However, 75% of the children had episodic migraine or probable migraine, while 11% of the children were headache free after eight years.

“Our results suggest there is hope for children who experience these headaches and for their parents, who also deal with the frustration and considerable disability that this condition can bring,”  said study author Shuu-Jiun Wang, MD, of the National Yang-Ming University School of Medicine in Taipei, Taiwan.  ”Parents and children should be prepared for the possibility that while chronic daily headache may get better over time, headaches in general may never fully go away, but for most children the headaches are much less frequent when they become young adults,”  said Wang.

According to the study, a history of migraine was a major risk factor for children with chronic daily headache.  The likelihood of having higher headache frequency and the condition eight years later was found in children who had chronic daily headache before the age of 13, those who overused pain medications, and those with the condition for more than two years….. Science Daily  4/8/12

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A new product is out, with less acetaminophen than Fioricet or Esgic: Orbivan, which has 50mg of butalbital, 300mg of acetaminophen, and 40mg of caffeine….very similar to Fioricet/Esgic(brand names), or the generic for those.
Also out is a version without butalbital, similar to Phrenilin, is Orbivan CF, which has 50mg of butalbital and 300mg of acetaminophen, without caffeine.
I feel that butalbital meds are a 2-edged sword: they are useful as painkillers for headache patients, but on the downside they may add to medication overuse headache(MOH) and may cause addiction. Despite these downsides, i do feel they play animportant role in a # of situations, and should remain on the market.
There was a negative anti-butalbital article out in the journal Headache several weeks ago; I wrote a Letter to the Editor titled “IN DEFENSE OF BUTALBITAL”, stating all the pluses and minuses of these meds. I will post that letter, which was accepted into the journal for publication, at some point.

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The cost of Botox, unfortunately, just went up.. from about $390 per 100unit vial to approx $417 a vial.

The cost of Botox does limit it’s use;  the average patient now recieves 50 to 100 units per treatment.  In the earlier days, we used lower doses.  I do think Botox has a role to play in migraine, CDH, and clusters, but the role is still being worked out.

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Rebound, or withdrawal headache does exist, but has generally been overstated as a cause of chronic daily headache (CDH). Headache clinic studies, which tend to be skewed toward the more severe patients, indicate a much higher percentage of rebound than better ‘population-based’ epidemiologic studies. These larger studies indicate that only 15 to 20% of CDH patients have rebound.

Rebound is more likely from the analgesics than from the triptans, particularly the ones with more caffeine (such as Excedrin). Too many patients are told ‘You are causing your own headaches, do not take anything for them for at least one month’.  It is enormously frustrating to patients who say “maybe the Excedrin IS causing my headaches, but I had the same headache BEFORE the Excedrin!”   More on this later…

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