I remember first getting migraines in high school after an accident on the hockey field in a father-daughter game. I crashed into the shoulder of a huge man (not his fault) as I went for the ball in an attacking move resulting in significant nosebleed. Later migraines started on a regular basis. Sometimes I ended up vomiting in public toilets and sleeping off the pain leaning against a toilet basin, before I was stable enough to drive home. I didn’t know at the time, but it was the beginning of a complicated 30+ years of medication management.
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On average I could have a migraine for 20 days in a month. Sometimes one could last for anywhere between 2 to 6 weeks, with brain fog after the migraine finished. Brain fog is like having a hangover as you recover from the actual migraine. I would avoid ED if I could, and just take medication and sleep until the worst was over. I developed a strong ability to work and do family time despite a migraine. I don’t remember when I first started taking codeine in an effort to ward off the pain and stop the vomiting that usually came with the worst of migraines. Codeine products could be purchased over the counter at the pharmacy (you didn’t need a pharmacy script to purchase). Effectiveness could be increased when taken at the same time as paracetamol or aspirin.
MEDICATION REVIEW When it was announced that over-the-counter codeine sales were going to be stopped the first question was ‘What were they going to be replaced with'?’ - there didn’t seem to be a ready answer. Eventually, when February 2018 came around, the advice was to take paracetamol and aspirin in the first instance. I was pretty confident this wouldn’t do anything to stop my migraines. This was a very stressful time for me. Knowing you don’t have effective medication to stop pain is very stressful. Stress makes migraines worse. Paracetamol and aspirin weren’t an appropriate first line of attack for my chronic illness and after few trips to ED I was now being prescribed more medications than before, including a higher codeine dose. It was also a wakeup call. It was clear that my migraines were not being managed by the medications I was using. I requested a medication review by a neurologist.
The medication review resulted in a complete restructuring of my medications, including a two-week detox from codeine-based products. It was a fuzzy two weeks, and while I didn’t end up in ED during this process I probably should have gone at least twice. It was great to have the support of my neurologist in changing the medication and to have alternative painkillers powerful enough during that change over to manage the extra migraines that resulted. I take a combination of medications that include prevention, blocking an acute onset, and management of an ongoing migraine. This combination needed to be reviewed to better manage the intensity and frequency of my migraines using suitable medications.
The purpose of a medication review is: to ensure that all your medications are working together; that you are being prescribed medications according to best practice; and that the blend of medications and instructions for when they are taken, minimises the risk of medication-related problems.
ARE THERE HEALTH CHALLENGES HERE FOR YOU? Codeine is an opioid, in the same family as morphine and heroin. In Australian on 1 February 2018, codeine or codeine combination products were removed as over-the-counter medications. While codeine in specific higher regulated doses can be helpful, it had been found that low dose over the counter medication was not any more effective than other options, but it could have potentially negative health effects. The risk of tolerance and dependence is high with a codeine product - people can become dependent on it; and need higher doses to get a pain reduction. It can lead to addiction, poisoning and in high doses, even death. Between 2000 and 2009, codeine related deaths (accidental and intentional) almost doubled (from 3.5 deaths per million to 8.7 per million). Combining codeine with other products also leads to health complications from the other products: overuse of paracetamol can lead to liver disease and kidney failure; and the overuse of aspirin can lead to gastrointestinal bleeding or a stroke caused by a burst blood vessel. The need to increase the dose of codeine to get impact pain management could easily lead to an increase in these other medications as well.
LIFE AS I KNOW IT I have noticed a slow change in clarity since I have been able to rely less on codeine based products. I feel more like myself. My migraines have also improved; they don’t appear to last as long as they were previously.
I still use a strong codeine product if required but I have a limit per month that I aim to keep under. I do not have the perfect combination of prevention, acute and management medication yet, and the medication I’m on does make me tired, but the extra clarity I have when I’m not having a migraine is wonderful. Whenever feasible, I try to stop as soon as I feel a migraine coming these days and to minimise the duration of the migraine with more informed management.
WHAT THIS MEANS FOR YOU? Regarldess of your reason for medications, when was the last time you had a full review of your medications (including over the counter medications)? The little tweaks that have occurred to your medications over time with each illness or acute episode may have resulted in a build up of a poor or less effective combination of medications. The number of medications you take, their effectiveness and the way they interact with each other, can also change over time as you age and your health changes. It is important to take time for a specific medication review by your GP, a pharmacist or a specialist managing your illness. You may need to specifically request this review. This is particularly important if you take five or more medications. Also, take a look around your house and identify any out of date medications. Talk to your pharmacist or doctor about thoughtful disposal of these medications.
A WAY FORWARD. Pain can make you desperate. You feel the need to hang on to whatever solution you have, even if it isn’t the best solution. Changing access to codeine as an over-the-counter medication helped to increase awareness of the problems associated with this medication; and from my perspective it started me on a path of rethinking my medication management. It was nerve-racking and has taken more than a year to get this far, but it has been worth it.
Whatever medication you are taking, if you have been taking multiple regular prescription medications for some time, make an appointment for a medication review.
References: Some of the useful academic papers and websites used in the preparation of this blog post.