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Medication Overuse Headache


Stephen D. Silberstein

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Full review/revision Jul 2021 | Modified Sep 2022

A medication overuse (rebound) headache occurs when people who take too many headache drugs have a headache for more than 15 days a month for more than 3 months.

  • Medication overuse headache usually develops 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 drugs and have headaches.

  • Doctors treat these headaches by stopping the headache drug, by prescribing a different type of headache drug to manage symptoms caused by stopping the drug, and often by prescribing drugs to treat the original headache disorder.

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 drugs for migraines or tension-type headaches, They are taking too much of the drug or taking it too often, usually because the drug 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)

  • Aspirin or acetaminophen taken with caffeine

  • Triptans (drugs that prevent and treat migraines)

Overuse of other nonsteroidal anti-inflammatory drugs (NSAIDs) and ergotamine can also cause this disorder.

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.

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 drugs have headaches and on how often people take the headache drugs.

Medication overuse headache is diagnosed when all of the following are present:

  • Headache occurs 15 days or more a month in people taking acetaminophen, aspirin, or another nonsteroidal anti-inflammatory drug (NSAID) or 10 days or more a month in people taking ergotamine, triptans, opioids, or combination headache drugs as treatment for a headache disorder.

  • People are regularly taking too much of one or more drugs 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.

Prognosis of 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.

Treatment of Medication Overuse Headache

  • A different drug to prevent the original headache (usually a migraine)

  • Withdrawal of the overused headache drug

  • Use of a different type of headache drug (rescue drug) to manage withdrawal symptoms that occur after stopping the drug

  • Sometimes another drug (transitional or bridging drug)

  • Biofeedback and cognitive techniques

Usually, doctors first give the person a different headache drug to prevent the original headache disorder . The overused drug is stopped later, often abruptly. However, if people are taking high doses of opioids, barbiturates, or benzodiazepines, the amount of the overused drug is gradually decreased, over 2 to 4 weeks. Stopping these drugs 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 drug may last a few days or up to 4 weeks.

A rescue drug is used to treat headaches that occur after stopping the overused drug. A different type of headache drug is used if possible. Doctors limit use of rescue drugs to less than twice a week if possible.

If rescue and preventive drug treatments seem unlikely to be effective at relieving symptoms, other drugs (called transitional or bridging drugs) can be given. Transitional drugs (see table Some Drugs Used to Treat Migraines Some Drugs Used to Treat Migraines Some Drugs Used to Treat Migraines ) include

  • NSAIDs

  • A corticosteroid

  • Dihydroergotamine

  • Prochlorperazine and diphenhydramine

  • Clonidine (to relieve symptoms due to withdrawal when the overused drug was an opioid)

  • Phenobarbital (used to prevent withdrawal seizures when the overused drug was a barbiturate)

After medication overuse disorder has been treated, people are instructed to limit their use of all rescue and transitional headache drugs used to stop (abort) headaches as follows:

  • For NSAIDs, to fewer than 6 days a month

  • For triptans, ergotamine, or combinations of headache drugs, to fewer than 4 days a month

Drugs 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.

People are counseled to avoid using previously overused drugs. They are also taught and encouraged to adopt healthy lifestyle habits.

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