A medication overuse (rebound) headache occurs when people who take too many headache medications have a headache for more than 15 days a month for more than 3 months.
Medication overuse headache develops most often in people who have migraines or a tension-type headache.
The type of headache pain varies from person to person.
Doctors diagnose medication overuse headaches based on how often people take headache medications and have headaches.
Doctors treat medication overuse headaches by stopping the overused headache medication, by prescribing a different type of headache medication to manage symptoms caused by stopping the medication, and often by prescribing medications to treat the original headache disorder.
(See also Overview of Headache.)
If certain medications are taken frequently or every day to treat occasional headaches, headaches may start to occur more often and become chronic.
Medication overuse headache occurs 1 to 2% of the general population. It is more common among women than men.
Most people with this type of headache are taking headache medications for migraines or tension-type headaches, They are taking too much of the medication or taking it too often, usually because the medication is not effectively relieving their pain.
Causes of Medication Overuse Headache
The most common causes of medication overuse headache are overuse of the following:
Opioids
Pain relievers (analgesics) that contain butalbital (a barbiturate)
Triptans (medications that prevent and treat migraines)
An overly sensitive nervous system is thought to cause medication overuse headache. That is, the nerve cells in the brain that trigger pain are too easily stimulated.
Substance dependence is more common among people with medication overuse headaches. They may also have a genetic predisposition to develop medication overuse headache.
Symptoms of Medication Overuse Headache
Medication overuse headaches occur daily or nearly daily and are often present when people first wake up. The location and type of pain vary from person to person. People may also feel nauseated, become irritable, and have difficulty concentrating.
Diagnosis of Medication Overuse Headache
A doctor's evaluation
Doctors base the diagnosis of medication overuse headache on how often people who are regularly taking headache medications have headaches and on how often people take the headache drugs.
Medication overuse headache is diagnosed when all of the following are present:
People are regularly taking too much of one or more medications to relieve the headaches and have been doing so for more than 3 months.
No other headache disorder better accounts for the symptoms.
Rarely, computed tomography (CT) or magnetic resonance imaging (MRI) is done to exclude other disorders.
Treatment of Medication Overuse Headache
A different medication to prevent the original headache (usually a migraine)
Withdrawal of the overused headache medication
Use of a different type of headache medication (called a transitional medication) to manage withdrawal symptoms that occur after stopping the drug
Biofeedback and cognitive techniques
Usually, doctors first give the person a preventive medication to treat the original headache disorder. The overused medication is stopped later, often abruptly. However, if people are taking high doses of opioids, barbiturates, or benzodiazepines, the amount of the overused medication is gradually decreased, over 2 to 4 weeks. Sometimes people can be treated as outpatients when the medication is stopped. However, people with headache due to opioid overuse are hospitalized. Stopping these medications more abruptly can cause symptoms such as nausea, restlessness, anxiety, and poor sleep. Stopping any kind of pain reliever can cause headaches to occur more often, last longer, and become more intense. Symptoms after stopping a medication may last a few days or up to 4 weeks.
A transitional medication is used to treat headaches that occur after stopping the overused medication.
Transitional (bridge) medications are used to help prevent headache symptoms of withdrawal if stopping the overused medication causes too many, sometimes dangerous symptoms The transitional drug should be a different type of headache medication from the one that caused the overuse headache. Doctors limit use of transitional medications to less than twice a week if possible.
Transitional drugs (see table Some Medications Used to Treat Migraines) include the following:
NSAIDs
A corticosteroid
After medication overuse disorder has been treated, people are instructed to limit their use of all rescue and transitional headache medications used to stop (abort) headaches as follows:
For NSAIDs, to fewer than 6 days a month
Medications used to prevent headaches should be continued as prescribed.
Doctors encourage people to keep a headache diary. In it, people write down the number and timing of attacks, possible triggers, and their response to treatment. With this information, triggers may be identified and eliminated when possible. Then, people can participate in their treatment by avoiding triggers, and doctors can better plan and adjust treatment.
Biofeedback and other cognitive techniques (such as relaxation training, hypnosis, and stress management) can help people control, reduce, or cope with their headaches by changing the way they focus their attention. Biofeedback enables people to control the pain.
People are counseled to avoid using previously overused medications. They are also taught and encouraged to adopt healthy lifestyle habits.
Prognosis for Medication Overuse Headache
With treatment, the pain disappears (goes into remission) in about 50% of people after 10 years. People with migraines tend to do better than those with tension-type headaches.
People who have fewer headache days a month after 1 year of treatment tend to stay in remission longer.
