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Medication Overuse Headache

By

Stephen D. Silberstein

, MD, Sidney Kimmel Medical College at Thomas Jefferson University

Last full review/revision May 2020| Content last modified May 2020
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NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
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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.

(See also Overview of Headache.)

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

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

However, overuse of other nonsteroidal anti-inflammatory drugs (NSAIDs), ergotamine, and triptans (used to treat cluster headaches and migraines) can also cause this disorder.

What causes medication overuse headache is poorly understood. However, people with this type of headache may have an overly sensitive nervous system. 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

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

  • 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 more than 15 days a month in people who have 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.

How many days a month a drug indicates overuse depends on the drug:

  • 10 days or more a month for ergotamine, triptans, opioids, or combination headache drugs

  • 15 days or more a month for acetaminophen, aspirin, or another nonsteroidal anti-inflammatory drug (NSAID)

Rarely, computed tomography (CT) or magnetic resonance imaging (MRI) is done to exclude other disorders.

Prognosis

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

  • Counseling to avoid overuse

  • Withdrawal of the overused headache drug

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

  • Drugs to prevent the original headache (usually a migraine)

  • If needed, other drugs to help prevent withdrawal symptoms

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

Usually, the overused drug is stopped abruptly. However, in people who 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.

Preventive drug treatment for the original headache is started before or after the overused drug is stopped.

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) include

  • 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 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.

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.

Drugs Mentioned In This Article

Generic Name Select Brand Names
D.H.E. 45, MIGRANAL
COMPRO
No US brand name
TYLENOL
Butalbital
ERGOMAR
CATAPRES
NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
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