Headache pills, are they hurting more than they are helping?


Headache is a common problem.  Almost 20% of men and 40% of women in the USA experience recurrent headaches.  Headache is the most common reason for a neurology office visit, the third most common cause of missed work, and the seventh most common reason for a primary health care visit.

Headaches are  broadly divided into two categories:  Primary headaches, such as migraine and tension headache, are most common.  Secondary headaches are symptoms caused by other diseases, some of them serious like a ruptured aneurysm, brain tumors, acute glaucoma or vasculitis.

Most headache sufferers are using abortive medication as needed every time they experience the symptom:

Some are taking prescription medications such as triptans or drugs containing butalbital (such as Fioricet (c) or Esgic (c)).

Many more are using over the counter medications such as acetaminophen, ibuprofen or combination pills such as aspirin/acetaminophen/caffeine (Excedrin (c)).

This strategy can work, particularly for infrequent headaches, such as once or twice a week.


However, more frequent use of these medications, particularly short-acting triptans (such as sumatriptan) and drugs containing caffeine and butalbital, can lead to rebound headache, which leads to more medication use and more headaches, culminating in chronic daily headache from transformed migraine.


The only way to deal with this is to temporarily stop the offending abortive drug and  start a daily preventative drug.  This will lead to short period of drug withdrawal, when the headaches may get worse before they ultimately get better.  This can sometimes necessitate short term headache infusions with dihydroergotamine (DHE) or a course of steroids.

Any headache sufferer who finds themselves in this situation should consult with a neurologist or other headache specialist.


Alice in Wonderland Syndrome

Caused by a disturbance of perception rather than an actual physiological change
Altered body image (Ex: big buildings look same size as person’s own body)
Distorted perception of size (micropsia, macropsia)
Distorted perception of the shape of objects
Loss of spatial perspective (sense of time and space)
Auditory or tactile hallucinations

AIWS generally affects a younger population and has several associated conditions. Migraine is the classic disease linked to AIWS, the distorted sensations can either begin before a migraine (aura or “warning”) or afterwards, and in younger patients can even occur without headache

Check out these first-hand accounts of people with this interesting phenomenon:
Size Matters: Living in a Lewis Carroll ‘Wonderland’ – ABC News

When the world looks like a real-life Wonderland

Experience: I have Alice In Wonderland syndrome 

A Not So Pleasant Fairy Tale: Investigating Alice in Wonderland Syndrome | Serendip Studio

Other causes of Alice in Wonderland Syndrome are:
psychoactive drugs
infectious mononucleosis
temporal lobe epilepsy

Certain tests & imaging studies help rule out secondary causes:
urine toxicology screen
monospot test   
(for mononucleosis)
MRI brain
with and without contrast (to look for malignancy)
(to detect seizures or seizure-like activity)

Sounds scary, right? Well, good news is it’s not as bad as it sounds. Most patients who experience AIWS as children will outgrow the condition as adults. Patients should be monitored for worsening of symptom severity and frequency. If all studies are negative and the patient continues to improve clinically, then further evaluation and/or treatment is not needed. Best management for future attacks is focused on migraine prophylaxis and lifestyle modifications (healthy diet, regular exercise, adequate sleep).

Posted By Sidra Ghafoor, Drexel University College of Medicine Class of 2013