Doctor on Call
Erica, a 37-year-old female living in Bogota and teaching “English as a foreign language”, writes:
I have migraine, and my friends and family keep nagging me that I should go see a headache doctor either here in Columbia or when I travel back to the States. I really don’t see the point. On my own I’ve found a treatment that works, and my headaches are hardly ever severe. The farmacias here don’t require a doctor’s prescription for prescription-strength ibuprofen 800 mg, and along with being cheap, it works perfectly well to keep my migraine under control. I take 3 doses a day with an extra 1 or 2 doses on those days when my background headache begins to act up. I’m happy. What’s the point of seeing a headache specialist?
The Doctor’s Reply:
Well, there is a lot to chew on in this short letter. For one thing, taking ibuprofen or any other nonsteroidal anti-inflammatory drug at a relatively high dose and on a scheduled basis may be asking for drug related complications. Even if Erica is not suffering the ibuprofen-induced heartburn that heralds gastritis or a developing ulcer, peptic ulcer disease can be ominously quiet until it causes life-threatening perforation or gastrointestinal bleeding. Furthermore, without any blood and urine testing to indicate otherwise, the ibuprofen she is taking could be causing asymptomatic, progressive and irreversible damage to her kidneys or, less likely, her liver.
Furthermore, although she refers to the ibuprofen as working “perfectly well”, she is taking that medication on a scheduled daily basis and doing so because she has chronic headaches that at times intensify and require additional “as needed” doses. From her words it sounds as if she is often or always experiencing a low intensity “background headache”. If what she is describing is chronic migraine, it is being incompletely treated and perhaps even aggravated by her current treatment (see below). If this is chronic migraine, she could do better than taking a nonspecific therapy such as ibuprofen which lacks any scientific basis for use as a prevention medication in migraine, be it episodic or chronic.
Finally, there exists the possibility she is making things worse by her chronic overuse of ibuprofen and that “medication overuse headache” accounts for at least some proportion of what she perceives to be her migraine burden. Cutting back on her use/frequency of ibuprofen might well result in a significant decline in that burden.
There are approximately 40 million Americans actively afflicted with migraine, and our healthcare system currently lacks the capacity to evaluate and manage all of them. Many migraineurs do not require headache management from a healthcare provider, let alone a headache subspecialist; they infrequently experience migraine episodes and often are able to control those they do experience with non-prescription medication, non-pharmacologic treatment or both. On the other hand, it is hard to imagine an individual with chronic migraine who does not require medical attention, and, unfortunately, at present only a small minority of the upwards of 6 million Americans with chronic migraine present to a healthcare provider for evaluation, are diagnosed accurately and receive appropriate treatment. Hopefully Erica will join that small minority.