Medication overuse & “rebound” headaches

Medication overuse headaches are a major health issue and a significant cause of chronic daily headache.

Curr Pain Headache Rep. 2009 Dec;13(6):463-9.

Tension-type headache with medication overuse: pathophysiology and clinical implications

Summary of the abstract

Tension-type headache (TTH) is the most prevalent primary headache disorder.

An important factor in the long-term prognosis of TTH is the overuse of acute medications used to treat headache. There are many reasons why patients with TTH overuse acute medications, including biobehavioral influences, dependency, and a lack of patient education.

Chronic daily headache occurs in 4.1% of the general population, and chronic tension-type headache and medication overuse headache (MOH) occur in approximately 2.2% and 1.5%, respectively. A proper diagnosis is essential for the treatment of these patients.

Medication overuse is especially common with over the counter medications.

One reason OTCs are especially subject to abuse is, of course, that they are easily obtained in unlimited quantities. Several experts have suggested that caffeine containing products are among the medications most likely to lead to rebound headaches e.g. Excedrin Extra Strength (which is identical to Excedrin Migraine except for the label) and the generic equivalents of these. Caffeine is a vasoconstrictor and is known to enhance the efficacy of pain relievers when used in the treatment of migraine or headache generally. When the caffeine wears off, headache can ensue, as anyone who has suffered a ‘caffeine withdrawal’ headache can attest.

Rebound headache is closely associated with medication overuse. The headache medication itself makes the patient more prone to their next episode of pain – which requires further dosing – leading to a yet worse follow on headache, etc. A vicious cycle ensues in which the patient quickly finds themselves medicating daily, even continuously, while suffering now continuous, daily headache.

Proper diagnosis of medication overuse is essential. Unfortunately, patients are unlikely to confide the true extent of their medication use.

Treatment for medication overuse may include complete cessation of headache medication for an extended period. This sometimes requires hospitalization, both to treat any associated effects other than pain, and to enforce the ‘cold turkey’ regimen.

As the following case study suggests, medication overuse headache may also result from the overuse of prescription medication. The case study involves migraine, but the course and progression, as well as the treatment, is not unlike that which is common for chronic daily headache of a non-migraine type when caused by medication overuse.

J Neurosci Nurs. 2007 Aug;39(4):213-6.

The impact of migraine: a case study

Summary of the abstract

Patients often self-diagnose and self-medicate, resulting in inadequate treatment. Consequently, patients may take additional doses, trying to gain relief with inappropriate medications. Rebound can ensue. With adequate treatment, a patient’s condition and quality of life may improve considerably.

Patient education is extremely important to help patients identify appropriate self-care measures, such as identification of triggering events and coping with the chronic nature of their condition. This case study presents a patient who began experiencing migraines following a neck injury. His headaches became more frequent, and ergotamine and caffeine (Cafergot) suppositories were prescribed.

When he presented, he was experiencing daily headaches and using daily ergotamine and caffeine suppositories. He was using the emergency department (ED) frequently because of severe headaches. Cervical spasm was recognized as his trigger, and the ergotamine and caffeine suppositories were discontinued. After 3 days of severe headaches, his rebound ceased. He has maintained reasonable headache control for 2 years.

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