Warfarin and migrians

[murph341]

Hey everyone,
I have made my avr valve decision, going mechanical but I have a question about migraines. I'm not a chronic sufferer but I can get them on average about 4-6 per month. They can get pretty severe and being on warfarin from what I have read I can not take my Excedrin migraine medication!

Is there anyone here who also suffers from migraines? And what are you taking to combat the symptoms. I have meeting with my surgeon next week.

 

[clay_from_nj]

I used to get full blown migraines, but for most of my adult life they have been of the "silent" (painless) variety. I did have one or two actual migraine headaches within weeks after my surgery and took care of them with the percocet that they sent home with me from the hospital. Acetaminophen (and the other stuff in there) is apparently no problem at all with warfarin.

 

[pellicle]

Hi

I get migraines too ... mostly the visual disturbance and some strange inability to grasp the obvious during them.

...and being on warfarin from what I have read I can not take my Excedrin migraine medication!

I understand that some caution with Excedrin may be expressed because of the acetaminophen content

http://en.wikipedia.org/wiki/Excedrin

acetaminophen is basically paracetamol ... my feeling would be that given that you aren't going to be eating it every day for weeks that a dose here or there will have zip interruption on your INR. As I understand it the effect of paracetamol is to increase your INR ... for example one paper I have here suggests:

Acetaminophen (paracetamol) is a frequently unrecognised cause of over- anticoagulation.
...
Whilst infrequent ‘when required’ dosing is unlikely to be problematic, there is consistent evidence that regular, full dose paracetamol causes a rapid and clinically significant increase in the INR in some patients.
...
Only significant with chronic dosing

I recommend you read that quote carefully, it does not say "don't do it".

 

[maisiejane]

Hey everyone,
I have made my avr valve decision, going mechanical but I have a question about migraines. I'm not a chronic sufferer but I can get them on average about 4-6 per month. They can get pretty severe and being on warfarin from what I have read I can not take my Excedrin migraine medication!

Is there anyone here who also suffers from migraines? And what are you taking to combat the symptoms. I have meeting with my surgeon next week.

I think migraines are quite common following surgery but if you already are a sufferer then you need to tell your anaesthetist when they come to see you before your surgery, I didn't know this until after, apparently they can give you a more appropriate anaesthetic. I have experienced migraines since the age of 23 but they had reduced greatly in the past years so I wasn't too pleased when I awoke after surgery with the dreaded aura!
Deb

 

[MrsBray]

I had frequent aural migraines before surgery. I've had one very minor one since surgery (2 months). I'm happy with that! I can also tolerate caffeine better now, which has an effect of the migraine.

 

[murph341]

Thanks for the replies so far, I've had migrians for over 15 years now so i can tell when I'm about to get one( aura effect then getting sick in a dark room) and can usually diminish the symptoms with over the counter drugs. Maisiejane, i have heard of others after surgery suffering from headaches and that the anesthesiologist can help diminish this effect when coming out.

Pellicle, i will talk with my surgeon at great lengths about Excedrin and its effects on my inr count thanks.

 

[pellicle]

Hi

Pellicle, i will talk with my surgeon at great lengths about Excedrin and its effects on my inr count thanks.

Well don't he disappointed when he/she knows bugger all about it. Its out of their interest sphere. Let me know if you are interested (NB PM me here so I see it) and I can email you a PDF to print read and perhaps take along with you. Its written by an academic and has enough citations within it to satisfy a surgeon who should only give credence to peer reviewed journals.

 

[clay_from_nj]

pellicle, I didn't even follow the link in your post, but, wouldn't the big concern with Excedrin and warfarin be because of the aspirin, which is pretty commonly known as an anticoagulant and thus could increase the risk of bleeding problems? My anticoag pharmacist told me that acetaminophen is one of the safest drugs, and about the only pain reliever, to take with warfarin. (I understand that too much could be a problem, but there was that guy who died from drinking too much water as a radio contest stunt...)

 

[pellicle]

Hi

I didn't even follow the link in your post, but, wouldn't the big concern with Excedrin and warfarin be because of the aspirin

I included the link because it gave some of the formulations of Excedrin on the market:

* Excedrin Tension Headache Contains 500 mg acetaminophen and 65 mg caffeine.
* Excedrin Sinus Headache Contains 325 mg acetaminophen and 5 mg phenylephrine HCl as a decongestant.

... which it would seem contain no aspirin. So check the package.

As to Aspirin being a problem, well I'm not a pharmacologist or a pharmacist, but from what understand it all things it depends on issues of dose intensity and regularity (as well as other factors).

I am on Aspirn (50mg) as a daily dose on instructions from my surgeon, on a thread here I noticed that others take 100mg daily.
(for instance http://www.valvereplacement.org/forums/showthread.php?24678-coumadin-and-aspirin )

According to this research
http://www.ncbi.nlm.nih.gov/pubmed/15242475

Pooling the results of the first four studies demonstrated that combination of warfarin plus aspirin significantly decreased thromboembolic events (relative risk [RR], 0.33; 95% confidence interval [CI], 0.19 to 0.58), increased major bleeding (RR, 1.58; 95% CI, 1.02 to 2.44), and decreased all-cause mortality (RR, 0.43; 95% CI, 0.23 to 0.81) compared to warfarin alone. The one valve trial using a reduced INR in the warfarin plus aspirin group reported no difference in thromboembolic outcomes but found decreased major bleeding and a significant mortality benefit with combination therapy.
...
CONCLUSIONS:
For mechanical heart valve patients, the benefits of continuing aspirin when starting warfarin therapy are clear. For other routine warfarin indications, there are not adequate data to guide this common clinical decision.

My anticoag pharmacist told me that acetaminophen is one of the safest drugs, and about the only pain reliever, to take with warfarin.

I agree, and that's why I said it shouldn't be a problem but added in the other bits about 'chronic' usage acting as effecting the INR:

Acetaminophen (paracetamol) is a frequently unrecognised cause of over- anticoagulation.

but added the clarifications to make it clear that it required chronic usage (long term) and probably high levels. For instance my Dad (not on warfarin) was taking 2 650mg tablets 4 times a day for back pain. That would perhaps effect his INR.

A table from the article I quoted from originally:

Drug or drug class	Risk of bleeding	Mechanism of interaction
Aspirin, clopidogrel and dipyridamole	Increased (INR not raised)	Antiplatelet effects

HTH

 

[Protimenow]

The fear about chronic use/overuse of acetaminophen (paracetamol outside North America) is reported liver damage. Too much, for too long, can be deadly.

There area a few concerns about taking aspirin. Aspirin makes the platelets 'slippery.' When the anticoagulant effects of warfarin are added to the platelet effects, the risk of hemorrhage or too much bleeding increases. When I broke my wrist a few months ago, the doctors advised against aspirin for pain, using the 'platelet' explanation as a somewhat understandable reason for avoidance of chronic overuse. Fortunately, I didn't need anything for pain for very long.

I am taking 85 mg/day of aspirin and haven't seen any problems.

When I had my TIA a couple years ago, I took two full dose aspirin when I first experienced symptoms -- it's good to keep aspirin in the house.

I get the visual migraines -- usually with no pain. If I got the migraines with pain, I'd probably use aspirin, but be wary of using it for too long at doses that are too high.

The other concern about aspirin is gastric upset (stomach bleeding and other problems) because aspirin is acidic (acetylsalicylic acid). For people who are very sensitive to aspirin and who are prone to gastric bleeding, aspirin in combination with warfarin is really not a very good idea. This secondary risk may be one of the things that doctors are most concerned about.

 

[pellicle]

Hi there ... long time no see.

The fear about chronic use/overuse of acetaminophen (paracetamol outside North America) is reported liver damage.

well given that the vast majority of the population are not on Warfarin I would expect that for those without such a compounding issue as INR regulation that would be the case.

Are you suggesting that you disagree with the research?

Aside from the article I mentioned there are other researches, for instance
http://www.ncbi.nlm.nih.gov/pubmed/17145598

RESULTS:

Mean INR rose rapidly after the start of paracetamol and was significantly increased within one week of paracetamol intake compared to placebo, p=0.0002. The INR values reached a mean maximum of 3.45+/-0.78 with paracetamol versus 2.66+/-0.73 with placebo (p=0.03), corresponding to a maximum increase from baseline of 1.20+/-0.62 with paracetamol versus 0.37+/-0.48 with placebo (p<0.001).

Personally I have nothing vested in the information either way, but would like to know. I am not a chronic user of paracetamol so its not an issue for me to take 500 or 1000mg on the odd evening

 

[clay_from_nj]

I included the link because it gave some of the formulations of Excedrin on the market:

* Excedrin Tension Headache Contains 500 mg acetaminophen and 65 mg caffeine.
* Excedrin Sinus Headache Contains 325 mg acetaminophen and 5 mg phenylephrine HCl as a decongestant.

... which it would seem contain no aspirin. So check the package.

Here in the US, "Extra Strength" (the original) and "Migraine" (same formula, different label) are the varieties that most people are familiar with and likely to take and do contain aspirin.

As to Aspirin being a problem, well I'm not a pharmacologist or a pharmacist, but from what understand it all things it depends on issues of dose intensity and regularity (as well as other factors).

I am on Aspirn (50mg) as a daily dose on instructions from my surgeon, on a thread here I noticed that others take 100mg daily.
(for instance http://www.valvereplacement.org/forums/showthread.php?24678-coumadin-and-aspirin )

I had never routinely taken aspirin but the hospital sent it home with me after surgery. When my cardiologist found out about it, he was surprised and advised me to discontinue it immediately. Maybe it is related to the fact that I have no artery disease or blockages, which I understand is usual reason for daily aspirin regimen.

I agree, and that's why I said it shouldn't be a problem but added in the other bits about 'chronic' usage acting as effecting the INR:

but added the clarifications to make it clear that it required chronic usage (long term) and probably high levels. For instance my Dad (not on warfarin) was taking 2 650mg tablets 4 times a day for back pain. That would perhaps effect his INR.

I generally take what I would consider to be a reasonable approach and not use OTC medication such as Excedrin as a long-term, daily drug. To me, that kind of treatment is for prescription medications and doctor supervision. OTCs should be used for minor, short-lived problems, like a headache or an allergy season. If I had the kind of chronic pain that would require taking 8 tablets a day for an indefinite period, I would surely talk to my doctor about it.

I did not know about the effect of acetaminophen on INR, but did know about the potential for serious liver damage, which would apply whether one is taking warfarin or not. I still feel comfortable with my pharmacist's advice that occasional use of acetaminophen would not be a problem.

And, according to the table you quoted, aspirin does not increase INR, but does increase bleeding risk, which to me is what really matters. Keep in mind that your specific use of aspirin is a regular low dose as prescribed by a doctor, not the 1000mg doses I've taken in my younger days to try and fight a bad migraine. You take 50mg per day, but two Extra Strength Excedrin contain 10 times that much.

Whichever way you come to it, we can all agree that taking too much Excedrin is a pretty bad thing for those of us on warfarin.

(Protimenow: I agree, stomach bleeding while on warfarin - major problem.)

 

[dornole]

Well - for what it's worth - I used to get migraine auras 1-2x times a month (though not the excruciating pain thankfully - though having to pull over when driving was still sub-optimal . . . ). But after my procedure and being put on a full strength aspirin (325mg) daily, I no longer get them. (except once when I forgot to take the aspirin for three days). Maybe a coincidence? But I do wonder about it. If either the aspirin or the whole "functioning heart" thing changed something. I am not on warfarin, the aspirin is sufficient blood thinning for my current condition. Hope you can consult various docs, maybe if the Excedrin works but is not okay to keep taking, you can ask about combining some other pain killer with caffeine like Excedrin migraine has (my sister, a doctor, swears by diet Coke along with some painkiller, I forget which).

 

[slipkid]

I've had migraines since I was about 16.

The worst part is the aura - starts with a gap in my vision, then a small visible shimmering shape in that gap, then that shape grows into a crazy colorful psychedelic lightning bolt, sometimes HUGE, sometimes multiple shapes. I hate that aura stuff. Makes it very hard for me to do anything like reading, and usually lasts around 20-30 minutes. When it goes away I don't have a very bad headache though, just sometimes a dull ache in my forehead, my eyes get very light sensitive, and I feel kind of like I have a hangover or something like that (brain foggy).

I've never found any medication that helps, if possible I just try to take a nap, or at least go into a dark room. Is really a bitch when it happens somewhere away from home like in the workplace, or when driving.

I don't get them very often although it varies. Usually maybe just a few times a year. But, like some other folks have mentioned in threads here, after my heart surgery I have had more migraines in the subsequent month than I have had probably in the last 30 years! This started in the hospital with multiple ones per day, which I think I only had maybe ONCE before in my entire life (the aura shows up, the aura goes away, then the aura comes back later - what I call a "double" migraine. Not fun).

During the month of May (I was sent home on May 1st) I have been trying to keep track and I have had at least 28 migraines for that month alone!!!!!!! That's like a migraine EVERY DAY. And I may have had more - sometimes I get these when I am asleep and it is only if I happen to wake up at the right/wrong moment and see the aura that I know I am having one, I could have even slept through some. Sheesh.

I did discuss the abnormal post-op quantity of migraines with both my surgeon's staff and the cardiologist's. No one offered any explanations other than "well you've been through a lot, your body is all stressed out, you need time to heal". However, I was switched from metoprolol/lopressor to atenolol/tenormin about a week ago and since then I have had only 2 migraines instead of say 7-8. I don't know if the metoprolol was causing some of the migraines or if my body is just calming down. Just had a migraine today though. I am obviously still on the migraine train, but hoping that train derails soon.

 

[cldlhd]

I've had occasional migraines with aura ( around 1-3 a year ) since I was around 12 but since my diagnosis of BAV with ascending aneurysm in March I've had around 8 of them with 5 in the last month. It could be stress i guess but I was also prescribed metoprolol and simvastain at the same time. I had heard metoprolol is suppose to prevent migraines but had my cardiologist give me a different beta blocker yesterday -propranolol- but I'm not sure that was the issue. I googled 'simvastatin and migraines ' and apparently a lot of casual migraine victims had a big increase in attacks on it. I tried a not too scientific experiment of not taking it for 9 days -no attacks- then on wednesday night I took it and bam I got the dreaded aura first thing thursday morning. I realize this is anecdotal but it has me very hesitant to take the simvastatin all weekend as my son has his first ever all- star pee wee baseball games today and tomorrow . I have blood work scheduled for tuesday so I hope my cholesterol isn't high or the Doc will want to up my dose. Guess I'll have to come clean at that point that I only took it once in the last 2 weeks. My HDL was good and my LDL was on the high side of normal so I'd rather use diet and exercise to control it. I've lost 14 pounds since March and my diet and exercise regimen is definitely better so hopefully my levels will be better then I can tell her it wasn't the statin that did it so I don't need it. Also my blood pressure has always been good so hopefully once I have my OHS and the aneurysm is gone I can get off the beta blocker as the surgeon said the risk of another aneurysm is very small. The cardiologist says it depends on what the surgeon sees when he's "in there' but she would like me to stay on it for life. think she may be med happy.
Anyone else out there who got the occasional migraine see a big increase once they were put on simvastatin?