Why Medications Are My Last Resort

by Josh Turknett, MD

“It’s hard to achieve wellness within a system that profits from our illness.”

– Amanda Gelender

“When did your migraines start,” I asked Carol, a 41 year old customer service rep who’d come to see me for chronic headaches.

“Not until I was 37,”she said. They started out of nowhere. I may have had the occasional hunger headache before that, but nothing like these.

“When did you start taking the Sumatriptan?” I asked, bracing myself for the answer I feared was coming next.

“That’s the first thing I was prescribed, back when they started.”

“So you’d had maybe the occasional headache until age 37, and then ever since then they’ve become worse, both more frequent and more intense.”

“Yes, it’s crazy,” she replied. I don’t understand it.

I wanted to scream. Again.

I want to scream because I’ve heard this story so often.

And for so long it just didn’t sink in. Or maybe I didn’t want it to sink in.

I’m pretty sure I’ve heard this story at least once in every clinic day for a decade now. And, if anything, I seem to be hearing it MORE often.

It also happens to be my story, too.

When I took my first sumatriptan at the age of 26, it was incredible. Within 30 minutes, I went from disabling, mind-numbing, all encompassing pain and vomiting to feeling like a human again.

This, I thought, is what modern medicine is all about. And, from a purely scientific viewpoint, sumatriptan is one of the few pharmaceutical breakthroughs over the past half century. It was a miracle drug, as far as I was concerned.

Yet, I’d give anything to go back in time and pull that first pill out of my hands.

Because what I didn’t realize then, or for more many years thereafter, was that I’d unwittingly set in motion a chain of events that would take me over a decade to unravel.

“Take it at the first sign”

“Take it at the first sign of headache.”

This has been the mantra dispensed to migraine patients for years. Take your medicine early, before it’s too late!

And this advice does have merit. Certain categories of medications (especially the non-specific pain remedies) are more likely to help if taken early in the migraine cascade.

With the migraine specific medications like the triptans, the validity of that advice is less clear. The cynic in me observes that, if you own a business that makes pills, this “swallow-first, ask questions later” mentality is bottom-line-boosting advice (see top quote…). Unless you’re already in rebound, I’m no longer convinced that timing matters.

And what’s been overlooked here is the tremendous downsides to this early intervention strategy. A downside that I think my rose colored glasses prevented me (and perhaps many others) from seeing for so long.

One downside is that this directive reinforces and perpetuates the idea that migraines can ONLY be relieved by a pill. Or that pills are even a reasonable solution at all to this sort of complex, systemic problem – a naive idea, in retrospect.

But the gigantic, Godzilla-sized reason is that it too often turns what would otherwise be an occasional and episodic condition to one that’s chronic and lifelong.

Firing Your Firefighters

To help understand just how migraine medications can both be a short term benefit and a long term problem, let’s talk about firefighters.

So to set this up, imagine that migraines are a fire inside your brain. For most of you, I’m sure this analogy isn’t much of a stretch.

(Furthermore, in the “Spark and the Fuel” post recently, I likened migraines to a burning flame, so now it qualifies as a recurring theme.)

Migraine in the Natural State

Now, as you probably know, we have system in the brain for causing pain, including pain in the cranium. These systems are turned up as high as they’ll go during a full-on migraine.

We also have systems for relieving pain. Pain evolved for a purpose, which is to alert us to a potential danger in the body so that we can adjust our behavior accordingly.

When the pain system is working right, pain is short lived. Long enough to prompt us to change our behavior, but not long enough to render us incapacitated.

Which is why we have pain relieving systems as well (for the jargonically inclined, these are our “endogenous” pain relieving systems), so that they’ll shut off the system before the line between helpful and needlessly disabling pain has been crossed.

So back to our migraine flame that’s been ignited inside our brain.

We can think of our pain relieving systems as the firefighters in this case. In our brain’s unaltered state, they spring into action to help extinguish the flame. It’s a big ass flame, so they have their work cut out for them, but they give it their all.

Migraine Brain in Normal State

Migraine with Drugs Added

But what happens when we outsource the pain relief?

Our brain’s firemen come on the scene, only to find that there’s another crew there. Some hired guns who’ve been called into to take care of things.

So our guys pack up and leave.

Migraine Brain With Meds (hired firefighters)

This pattern repeats a few times: a fire starts, our guys come, only to turn back when they find they’re not needed.

Over time, our fire team downsizes. No sense wasting money on a resource that isn’t needed. Ultimately, the team disbands altogether.

Now the only ones putting out fires are the hired guns. Our firefighters have left to take on jobs as accountants and customer support representatives.

PROBLEM #1: Outsourcing pain relief (i.e. medications) causes the brain to suppress its own pain relieving system. i.e. NO MORE HOME TEAM FIREFIGHTERS!

But that’s not all. It gets worse!

You see, our hired guns just aren’t to the same level as our home team, naturally. And over time, the fire becomes resistant to their efforts. Eventually, they’re unable to put out the flame at all.

Now look at our predicament: our own fire team has left for new work, and the new guys can’t do the job.

So what happens? Our brain goes up in flames.

Migraine Brain After Chronic Med Consumption

As the story indicates, this is something that happens OVER time. Our brain on fire is the FINAL outcome of a process that’s been going for some time. Yet, it’s only at this point at the end of the story that we typically recognize a headache as rebound, or recognize the medications as a major contributing factor.

That notion, as our analogy illustrates, is VERY misleading.

Because the medications had been a contributing factor since the very first dose. And each subsequent use of a migraine medication, each time we outsourced our pain relief to another team, we amplified their contribution.

With each dose, we reiterated the message to our home team: “you guys aren’t needed any more.”

Our situation is now far worse than where we started, since we’ve obliterated our own ability to alleviate migraine, and neutralized the effects of drugs.

PROBLEM #2: Consistent use of migraine relief medications over time both obliterates our own natural migraine relieving mechanisms, AND renders our brain resistant to the effects of those medications, leaving us in a state far worse than where we started.

It’s these types of changes in the brain, provoked by the consistent use of abortive medications, that turn what would otherwise be an an episodic, occasional condition into one that’s consistent and unrelenting.

And it’s for this reason that my personal goal is to never take any drug to relieve a migraine ever again. I’ve spent the last several years unraveling a process that I unknowingly set in motion with that first triptan years ago, and the last thing I want to do is undo all that hard work.

Does this mean I’ll never take one again? Not necessarily.

But it does mean I will only do so in the most dire of circumstances, where it’s clear that the potential short term gain is worth the longer term price I know I’ll have to pay. Rather than being my first resort, a position I advocated for so long, it is now my LAST.

I’ve spent the last several years unraveling a process that started all those years ago with my first triptan, and that’s not a road I ever want to go back down.