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Ask the Pharmacist: Afraid of Needles Used for Blood Samples

All questions answered by: 

Richard Wenzel, PharmD
Diamond Headache Clinic Inpatient Unit
St. Joseph’s Hospital, Chicago, IL

Q. I hate being poked with needles. In the past I have taken medications (for a non-headache illness) that required monthly blood samples. Now I have migraines and suspect that my physician will soon prescribe a preventive drug. Given my aversion to needles, which medications would be best?

A. Drawing a blood sample to measure the amount of a medication is suggested for some, but not all, medications. The main reason to obtain a sample is to determine if a patient is receiving too little, too much or the desired amount of medication. Based upon the results, a patient’s dose can then be increased, decreased or left the same.

For migraine, the most common preventive medication requiring blood level samples is Depakote (divalproex). Sampling is usually done if a healthcare provider believes too little of the drug is being given (thus the patient is experiencing more migraine attacks) or too much (leading to more side effects). If a patient’s migraines are well controlled and s/he is not experiencing significant side effects, a Depakote blood level is typically not needed.

Another drug that may require blood samples is lithium, which is often prescribed to people suffering from cluster headache. Outside of Depakote and lithium, I am not aware of any headache drug that requires routine blood-level monitoring. Otherwise, only special circumstances would cause a blood level test to be ordered. One example is a suspected overdose of acetaminophen. Another example is if a significant drug-interaction is suspected, such as of between Depakote and some newly prescribed medication. I encourage you to communicate your needle fears with your healthcare provider so that s/he selects a drug that does not require blood-level monitoring.

Could Arthritis Medication Be Causing Rebound?

Q. My arthritis continues to worsen and I now take ibuprofen on a daily basis. In recent weeks, my headaches seem to occur every day not really bad attacks, just a daily dull ache. Is my arthritis medicine causing rebound headaches?

A. Perhaps. For people with a history of migraine, daily or near-daily use of any acute pain medication, such as ibuprofen, places them at risk for chronic headaches, even if the purpose of that medication is for a non-headache illness such as arthritis.

Your letter does not say if you use a migraine preventive medication, but this is one option to help reduce your headache frequency (although it obviously involves taking yet another medication). Additionally, ibuprofen is a short-acting drug and you may benefit from switching to a long-acting anti-inflammatory medication such as naproxen, nambumetone or celecoxic, among others. The longer duration of action of these medications should decrease the potential for rebound headaches. Balancing effective arthritis treatment with avoiding rebound headache is not always easy. If you have not already done so, I encourage you to seek a healthcare provider who specializes in headache therapy.

Better Drug Options for the ER

Q. On occasion, bad migraine attacks cause me to go to the Emergency Room. Why do ER doctors insist on using narcotics? Usually these drugs just cause me to go home to pass out, which I do not like. This also disrupts my husbandýs workday, as he has to drive me home. Isn’t there some better choice?

A. Your question highlights a common problem numerous studies have concluded that narcotics are woefully overprescribed in the Emergency Department (ED). Furthermore, these studies also highlight that the majority of patients, you included, simply go home to sleep after leaving the ED. Obviously, this negatively impacts patients as well as spouses, employers, children, etc.

The goal with all migraine treatment should be a rapid return to normal functioning, not merely pain relief. Unfortunately, far too many healthcare providers view migraine only as a pain problem, and therefore prescribe ýpain killers,ý often resulting in drowsy, unable-to-function patients.

Other non-narcotic, non-sedating medication options in the ED for migraine are injectable sumatriptan, dihydroergotamine, valproic acid, magnesium and ketorolac. Non-narcotic, but potentially sedating, choices include diphenhydramine, promethazine and dropertidol, among others.

I encourage you to speak with your healthcare provider today to develop a proactive plan regarding drug options for the ED. You may even want to obtain a letter from your healthcare provider listing your best options. You can then present this letter to ED doctors when needed and hopefully avoid any narcotics.

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