Imitrex for Chronic Headaches
An Interview with Dr. Allan Bernstein, Neurologist

Trainers - We have a question about the use of Imitrex and why its use is often limited. Is it a health concern or is it too expensive for the insurance companies?

Dr. Bernstein - The answer is that it is both. It is very expensive. So there is some plain old economics involved. The second part is there is a real tendency to overuse it. When you do get relief using Imitrex, it is so dramatic that the tendency is to want to take it every time a headache threatens. People with headaches have been taught to take it at the first sign of a migraine. They have been told once a migraine is full blown, nothing is going to help. So the thought is "this headache is going to be a migraine", fear of migraine becomes an issue. There can be a tendency is to take Imitrex immediately, at the first sign of headache even if the headache is not migraine.

The other problem is it is a pretty potent vasoconstrictor. People talk about chest tightness and changes in blood pressure, all of which are transient; but there is a hypothetical risk of heart attacks and strokes. Now, we haven't seen this a lot, given how long it has been on the market and how many millions of doses have been used. It does appear to be a pretty safe drug. But frequent use raises questions about risk. Part of the answer to the question is the cost, part of the answer is potential risk and part of it is you may be treating the wrong headache.

One of the things we try to focus on is getting people to identify which headache is which. A MIGRAINE is NOT A DAILY HEADACHE. It is by definition an episodic event. Migraine headaches occur once a month or once a week, but generally not every single day. People who are using Imitrex 15, 20, 30 times a month may be treating their fear of migraine as much as they are treating migraine. They may be treating the wrong headache. They may be treating tension headaches or headaches related to neck tension; and in that case Imitrex is probably the wrong drug. There are better ways to treat tension headaches and headaches related to neck tension, such as your program.

Trainers - What you just said is really an important piece of information, about which people do not seem to be aware. In the Internet newsgroups where people are discussing headaches, they talk about "migraine" headaches and seem to be assuming all bad headaches are in the migraine category. What you are saying is imperative, because using Imitrex may not achieve the desired result. The tendency is for people to think Imitrex is the ultimate answer for all types of headache and it may not be the answer for their current headache pattern.

Dr. Bernstein - People will come to see me after they have seen 5 other doctors even other neurologists. Where I find the problem often has been, is that the patient uses the term "migraine", and the doctor accepts the term without trying to sort out whether or not other types of headaches are present and distinguish the migraine from the non-migraine headache. People with migraine can have other types of headaches as well.

Trainers - Yes we have noticed that just about any really painful, serious or bad headache is automatically termed a migraine.

Dr. Bernstein - Yes, a bad headache is often called a "migraine" on TV. The "Excedrin commercials" discuss severe headaches as if they are all migraine. It is similar to the old sinus medicine commercials where the sinuses are throbbing. The inference was that the "Headache goes away when you squirt this medicine in your nose" or "take this tablet to relieve sinus headache". Any throbbing headache was in the category of "Oh it's my sinuses", which is another misused term. Very few headaches are sinus headaches. There is a tendency in the media to talk about migraine without defining what migraine is. Also, overuse of some of non-prescription medications can cause rebound headaches.

Dr. Bernstein - Probably, there are people who take Imitrex everyday who develop headaches when the Imitrex wears off. So, then you have to go back and ask are they taking Imitrex for the right headache and when the Imitrex wears off do they then take two Excedrin or three Tylenol. Patients don't always report to their physician how much non-prescription medication they take. They always talk about how much Imitrex they are taking but may not realize how important it is to report non-prescription medication.

Here is a typical scenario:
Patient- "My Imitrex is down to three a week."
Doctor- "So that's great, what are you taking in between?"
Patient-" Well, I just take Excedrin."
Doctor- "How much Excedrin?"
Patient- "Oh, I take two".
Doctor- " How often do you take two?"
Patient- "Every three hours".
Doctor- "That's 16 a day".
Patient- "Yeah, that's about right. I take it everyday. I get up in the morning and I take it, as long as I keep taking it I'm okay. Then every now and then I really get nauseous and vomiting and I take my Imitrex."

Something is wrong....what's wrong with this picture? This person was sent by a neurologist who was treating their "migraine" and had gotten her down to three Imitrex a week which is still a lot. But she still had daily headaches. Nobody discussed the use of non-prescription medicine, and this is often not in the medical records and patients generally don't volunteer this information.

Trainers - Are there other medications like Imitrex?

Dr. Bernstein - There are 3 other medications in the same chemical family as Imitrex, triptans. There's Maxalt, Zomig,and Amerge. Amerge is slower in onset but a much longer acting drug than Imitrex. Amerge may have a physiological effect two to three times as long as Imitrex. So, for people who tell you they get a three day headache once a month, Amerge may be a better drug. Imitrex works very quickly but wears off very quickly. Maxalt and Zomig are in the middle, with a relatively fast onset but they last about twice as long as Imitrex. So more and more we are getting away from using Imitrex due to the availability of longer acting drugs and are using more Maxalt, Zomig and Amerge.

Trainers - How about tolerance to the triptans. Do people show tolerance if they are taking a lot of triptans on a regular basis?

Dr. Bernstein - There are people who start using Imitrex and tell you it works great, then tell you 6 months later it doesn't work anymore. You always wonder if they are overusing it or are they getting rebound headaches from other drugs such as Excedrin or Tylenol or are they taking it for the wrong headache. But does it wear off? I think it does become less effective if used too frequently. I think all the triptans are very good drugs for episodic headaches. For twice a month headaches, even if they are three day headaches each, they are wonderful drugs...if you take them twice a month. If you are taking them multiple times a week you are in trouble, you may need to look for alternative treatments.