There has been an increasing declaration in some of the messages here that, "Imitrex/sumatriptan causes rebound headaches."

Sometime ago the caution was, "it can cause rebound", a statement which was consistent with what is found in the medical literature.

"Imitrex causes..." is both a misstatement and--my concern in writing--it scares people away from using the most effective abortive we have. A tendency to puff up statements/claims, etc. in very common in communication but I'm urging care/caution when we are offering assistance to vulnerable folks who are seeking our help.

I've just spent a hour searching medical literature sites and it's striking just how very limited are any studies/reports/warnings about side effects with sumatriptan. I found this one definitive statement from 2003. Please note two facts: the vulnerable age and the low rate of rebound:

"Medication-Overuse Seen as Epidemic, First Management Guidelines Issued: Presented at IHC "
By Larry Schuster ROME, ITALY -- September 25, 2003 -- 

The prevalence was highest in respondents who were their 50s, with 5% of women fulfilling the criteria. Thirty five percent overused simple analgesics, 22% ergotics, 12.5% opioids, 2.7% triptans, and 27% overused combinations of drug classes."

Thanks for bringing this to our attention, Bob.

I just visited a HA specialist this week.   He was insistent that Sumatriptan only causes rebounds in migraine.   I'm not sure which to believe.

Something to look into.

Jeannie

I can only speak from personal experience, but I find that when I back off the triptans (1 or 0 uses per day), the number and intensity of my headaches the following day seems to wane. Then I most likely do not have to use any that following day. Then, if I'm lucky, I can go for a short string of days with mild to no headaches.

Then I'll get bitch-slapped again, and it's back on the triptan train.

Jeannie: In medicine it is uncommon to have absolutes guiding our choices. Your doc is voicing a view which has softened some but it is--my concern here--wrong to present an absolute--yes/no--on this issue. Individual variation is so very common in how medications affect the individual body.

This problem appears here all to frequently when you read someone write: "I refuse to use XXX because I've read the side effects and I won't risk ....." What the average reader does not understand is that side effects must be presented but what is so often missing is data on the FREQUENCY that any one appears. If you go to the Physicians Desk Reference, you find that the rate may be from 1/2% and up.

Bottom line: we are always making decisions based on benefit vs. risk--whether in medicine to driving to the store. The issue is that most people don't think in these terms; they too often live in terms of absolutes--good/bad; safe/dangerous; moral/immoral, etc..
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And then another confounding variable.....

Rebound headaches. "Rebound Headaches--A Review", Au. John S. Warner, M.D., in HEADACHE QUARTERLY, 10:3(1999). (There is some confusion on the board about the meaning of "rebound". There appears to be an emerging consensus in the medical literature to define "rebound" as a headache which is caused by the overuse of any medication used to abort a headache or relieve pain. "Recurrence" [of a headache] is being used to refer to the redevelopment of an attack when its "normal" duration is longer than the useful life of the medication which has been taken. That is, the medication effectiveness is reducing before the headache has come to an end; the pain redevelops.)
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Sumatriptan has a hard initial punch and relatively short effective life--a combination which works well for most Cluster attacks. However, some people, whose Clusters have a longer life, find that the med is wearing down even as the pain continues. One can understand how this sequence comes into one's thinking: Attack, Imitrex injection, pain continues, it's a rebound cluster which has developed from the Imitrex.

This is one of the reasons that several other triptans were developed having less initial punch but longer effective life. While aimed at the migraine crowd, at first, a number of cluster users have found this characteristic of value to them.

Bob- 
Thanks for all you do here!  I understand what you are showing us and how it is easy to refer to a headache gotten when the Rx is wearing off as a rebound headache.  I have done that unknowingly.  So, my question is...what is the problem when you use an abortive or even preventative and cannot seem to handle the taper without returning headaches, oftentimes worse than before.  It becomes a horrible cycle for me.
Thanks!!!
Joni

Joni wrote on Dec 12^th, 2009 at 2:12pm:

So, my question is...what is the problem when you use an abortive or even preventative and cannot seem to handle the taper without returning headaches, oftentimes worse than before.

What kind of prevent?  A taper seems to mean pred. 

Joni, the usual explanation is that your cycle is not yet over and you need to get back on the full dose of the preventive plus abortive, prn.

It becomes more complex when standard CH treatments do not seem to work or results are very inconsistent. These are two signs that the headache may be a "cluster-like" issue, i.e., NOT CH as a primary disorder but a headache masking another  disorder. Makes for complexity in diagnosis, to be sure.

Why it's necessary to have a sophisticated doc. Too many neurologists just don't have the training and experience to handle some headache cases.

Brew wrote on Dec 12^th, 2009 at 10:20am:

I can only speak from personal experience, but I find that when I back off the triptans (1 or 0 uses per day), the number and intensity of my headaches the following day seems to wane. Then I most likely do not have to use any that following day. Then, if I'm lucky, I can go for a short string of days with mild to no headaches. Then I'll get bitch-slapped again, and it's back on the triptan train.

 

I've been thinking about this a lot today.

It really does seem like the more I use the more often and severely I get hit later.   

Jeannie

Bob Johnson wrote on Dec 12^th, 2009 at 4:25pm:

Joni, the usual explanation is that your cycle is not yet over and you need to get back on the full dose of the preventive plus abortive, prn. It becomes more complex when standard CH treatments do not seem to work or results are very inconsistent. These are two signs that the headache may be a "cluster-like" issue, i.e., NOT CH as a primary disorder but a headache masking another  disorder. Makes for complexity in diagnosis, to be sure. Why it's necessary to have a sophisticated doc. Too many neurologists just don't have the training and experience to handle some headache cases.

Thanks, Bob.  It has never occurred to me that I might not have Clusters.  I have read the info on this site about similar headaches but I don't seem to fit the bill for them.  Mine have very typically followed the cluster pattern in every way for 25 years.  Could I still be missing something? 

The typical medications work for me, I just seem to have a hard time being able to taper or stop them without recurring headaches when their effectiveness wears off.  For instance...if I take nothing, I usually have 1-2 HA's a day about 4-5 days of the week for 6 weeks, once a year.  When I take medication, I will have a HA as soon as the medication wears off, so the # of HA's will directly relate to the life of the medication.  With Zyprexa, I would have a HA in 33 hours (a little over the 24 hour mark), so I had to take it every day.  With Relpax, it was much faster so I might have 3 HA's a day...and so on.  But my cycle is always 8 weeks long, regardless of what I do.  The end of my last cycle was 6 weeks ago, however, I am still taking 40mg of Verapamil divided twice daily and with each taper I made, the affected side felt really strange so I would bump it back up just a little.  I really don't want to take the Verapamil all of the time, but I am afraid to quit or taper any further.  Coincidentally, I can now have the usual triggers with no effects at all, as usual.  So, what do you think?

I'm sorry...I didn't mean to rattle on, but it did concern me when you mentioned a "cluster-like" issue masking another disorder (I scare easily).  I do have an appointment with a new headache specialist in February.  If you know something I should ask...let me know.

Thanks for your time!
Joni   

Oops, that should have said 8 weeks (my cycle)...typed the wrong #.

Joni, I'm not sophisticated enough to put my toe in this pond!

It tastes like CH. I've known a couple of people whose doc has them on Verap 100% of the time because their cycles are so erratic. There is no medical barrier for not doing so and if you find a reduced dose effective during quiet periods, I'd do it. But in the end, it's what you are willing to bear....

Joni,

Coming off of the Verap is very difficult for me.  Every time I try to wean off of it ( in the past) I  experience strong shadows.  My doc wants me to stay on it for at least six months after my cycle ends.  This, however, puts me right back at a new scheduled cycle so, if I choose to continue with this treatment I may be on the Verap continuously.  I am still looking a seeds to act as my prevent once I kick this cycle.

Jeannie

Several years ago my neurologist switched me from Imitrex to DHE injections.  He said that he was convinced that imitrex caused rebound headaches.  The use of DHE did cut the number and frequency of headaches.  I believe that he was correct. 

Jeannie wrote on Dec 14^th, 2009 at 9:23am:

Joni, Coming off of the Verap is very difficult for me.  Every time I try to wean off of it ( in the past) I  experience strong shadows.  My doc wants me to stay on it for at least six months after my cycle ends.  This, however, puts me right back at a new scheduled cycle so, if I choose to continue with this treatment I may be on the Verap continuously.  I am still looking a seeds to act as my prevent once I kick this cycle. Jeannie

Thanks Jeannie!!!  I was needing to hear that, but I am sorry it runs into your next cycle.  Between my last 2 cycles (a year apart), I had it down to 10mg per day, but if I forgot it, I got that funny felling again...I guess you could say very mild shadows....just enough to worry me.  I cannot say id I stopped it then or now, that I would have a full blown cycle.  I really don't THINK I would but am too afraid to find out.  Have you ever stopped it?

Bob Johnson wrote on Dec 14^th, 2009 at 8:23am:

Joni, I'm not sophisticated enough to put my toe in this pond! It tastes like CH. I've known a couple of people whose doc has them on Verap 100% of the time because their cycles are so erratic. There is no medical barrier for not doing so and if you find a reduced dose effective during quiet periods, I'd do it. But in the end, it's what you are willing to bear....

Oh, Bob!  I feel like Dorothy on The Wizard of Oz just finding out he didn't have all the answers.  I need you to depend on...you are my wizard.  :)   Thanks for the info!

Joni

My 2cents just in case it matters.

Before I found Imitrex. I had a typical 10 week cycle that resembled an upside down V. I would start out getting 1 a week, and ramp up to about 5 a week and then ramp back down. My CH's would typically last about 1 1/2 hours from start to end. After being prescribed Imitrex, My CH's would start out at 1 per week but would quickly ramp up to about 20 per week. At 1st I couldnt put my finger on it, but I did notice that if I just rode out the CH, then I'd get a break before the next 1. BUT, If I took a Imitrex, I would within 4-8 hours get another CH. My rebound CH's typically ranged in the 8-10 Kip scale. My non-rebounds typically ranged in the 5-9 range.
Dont get me wrong..... Imitrex can be a real lifesaver when out of the house, or when attending functions. But for myself, It was almost like I was just staving it off for a later time.
When my cycle starts now, I go straight to my Neuro and get the Prednisone taper with the Verapamil. So far that works everytime for me.

Happy Holidays,
                        Patrick_A

Thanks, Patrick!