Reader’s Mail: Complex Problem May Require Change and Reduction of Medications

Q. I have been on Depakote® and amitriptyline for migraines since about 1996. I kept the headaches reasonably under control (I’ve had them since 1985) with those two preventive medications and lifestyle management (strict diet, regular exercise, enough sleep and decreasing stress). I do, however, have moderately severe arthritis of the neck from a car accident in the 1970s.

For the past year, I have had a migraine every day except four intermittent days; I can’t figure out what I could be doing wrong. I avoid rebound headaches by alternating my use of Norgesic Forte® with Tylenol 500®, or when necessary, Imitrex® or Amerge®. I’m careful not to take more than the prescribed amount of any medication. My question is this: Would Neurontin® be of help to me? Has Depakote ceased to be effective? Or could the arthritis in my neck have finally won the battle I’ve been having with it? My neck pain is excruciating at the end of a work day, especially if I’ve had a headache. Neck pain is one of the precursors to a migraine for me.

A. There may be several contributing factors to the deterioration you’ve noticed in your migraine control. Occasional patients do “get used” to their preventive medications, a condition we call “tachyphylaxis.” Since you’ve been taking these medications, Depakote has also been released in generic forms, and some patients recognize a difference between the brand and generic medications via headache escalation. Despite your rotation of acute anti-migraine medications, you may still be experiencing “rebound” headaches, which we now refer to as medication overuse headaches, if you are treating more frequently than 10 to 12 days per month with any acute medication. Finally, the potential development of arthritis in your cervical spine may also be driving your headache frequency higher. Neurontin (gabapentin) may be a reasonable choice if the neck is a contributing factor, and although the data supporting its benefits in migraine prevention are not as extensive as that with either Depakote or amitriptyline, you might benefit from a change. Regardless of change in preventive medication, it is imperative that the sum total of acute headache treatments be limited to 10 to 12 days per month.

Robert Kaniecki, M.D.
Assistant Professor of Neurology
Chief, Headache Division
University of Pittsburgh