Medication overuse headaches

Overview

Medication overuse headaches — also known as rebound headaches — are caused by the long-term use of medicines to treat headaches such as migraines. Pain relievers offer relief for occasional headaches. But if you take them more than a couple of days a week, they may trigger headaches.

If you have a headache disorder such as migraine, most medicines you take for pain relief can have this effect. However, this doesn't appear to be true for people who have never had a headache disorder. In people without a history of headaches, taking pain relievers regularly for another condition such as arthritis hasn't been shown to cause medication overuse headaches.

Medication overuse headaches usually go away when you stop taking pain medicine. This can be challenging in the short term. But your health care provider can help you find ways to beat medication overuse headaches for the long-term.

Symptoms

Symptoms of medication overuse headaches may vary. They can depend on the type of headache being treated and the medicine used. Medication overuse headaches tend to:

• Occur every day or nearly every day. They often wake you in the early morning.
• Improve with pain medicine but then return as the medicine wears off.

Other symptoms may include:

• Nausea.
• Restlessness.
• Trouble concentrating.
• Memory problems.
• Irritability.

When to see a doctor

Occasional headaches are common. But it's important to take headaches seriously. Some types of headaches can be life-threatening.

Seek immediate medical care if your headache:

• Is sudden and severe.
• Occurs with a fever, stiff neck, rash, confusion, seizure, double vision, weakness, numbness or trouble speaking.
• Follows a head injury.
• Gets worse despite rest and pain medicine.
• Is a new type of headache that's persistent, especially in someone older than 50.
• Occurs with shortness of breath.
• Occurs when you're upright but goes away if you're lying flat.

Consult your health care provider if:

• You usually have two or more headaches a week.
• You take a pain reliever for your headaches more than twice a week.
• You need more than the recommended dose of nonprescription pain medicines to relieve your headaches.
• Your headache pattern changes.

Causes

Experts don't yet know exactly why medication overuse headaches occur. The risk of developing them varies depending on the medicine. But most headache medicines have the potential to lead to medication overuse headaches, including:

• Simple pain relievers. Common pain relievers such as aspirin and acetaminophen (Tylenol, others) may contribute to medication overuse headaches. This is especially true if you take more than the recommended daily dosages. Other pain relievers such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) have a low risk of contributing to medication overuse headaches.

• Combination pain relievers. Pain relievers you can buy at the store that combine caffeine, aspirin and acetaminophen (Excedrin, others) are common culprits.

  This group also includes combination prescription medicines that contain the sedative butalbital (Butapap, Lanorinal, others). Butalbital-containing medicines have an especially high risk of causing medication overuse headaches. It's best not to take them to treat headaches.

• Migraine medicines. Various migraine medicines have been linked with medication overuse headaches. They include triptans (Imitrex, Zomig, others) and certain headache medicines known as ergots, such as ergotamine (Ergomar). These medicines have a moderate risk of causing medication overuse headaches. The ergot dihydroergotamine (Migranal, Trudhesa) appears to have a lower risk of causing medication overuse headaches.

  A newer group of migraine medicines known as gepants don't appear to cause medication overuse headaches. Gepants include ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT).

• Opioids. Painkillers derived from opium or from synthetic opium compounds have a high risk of causing medication overuse headaches. They include combinations of codeine and acetaminophen.

Daily doses of caffeine also may fuel medication overuse headaches. Caffeine may come from coffee, soda, pain relievers and other products. Read product labels to make sure you're not getting more caffeine than you realize.

Risk factors

Risk factors for developing medication overuse headaches include:

• History of lifelong headaches. A history of lifelong headaches, especially migraines, puts you at risk.
• Regular use of headache medicines. Your risk increases if you use combination painkillers, opioids, ergotamine or triptans 10 or more days a month. Risk also increases if you use simple painkillers more than 15 days a month. This is especially true if you use these medicines for three months or longer.
• History of substance use disorders. A history of alcohol use disorder or another substance use disorder puts you at risk.

Prevention

To help prevent medication overuse headaches:

• Take your headache medicine as prescribed.
• Contact your health care provider if you need headache medicine more than twice a week.
• Don't take medicines that contain butalbital or opioids unless it's necessary.
• Use nonprescription painkillers less than 15 days a month.
• Limit use of triptans or combination pain relievers to no more than nine days a month.

Taking care of yourself can help prevent most headaches.

• Avoid headache triggers. If you're not sure what triggers your headaches, keep a headache diary. Write down details about every headache. You may see a pattern.
• Get enough sleep. Go to bed and wake up at the same time every day, even on weekends.
• Don't skip meals. Start your day with a healthy breakfast. Eat lunch and dinner at about the same time every day.
• Stay hydrated. Be sure to drink plenty of water or other fluids that don't contain caffeine.
• Exercise regularly. Physical activity causes the body to release chemicals that block pain signals to the brain. With your health care provider's OK, choose activities you enjoy. You might choose to walk, swim or cycle.
• Reduce stress. Get organized. Simplify your schedule, and plan ahead. Try to stay positive.
• Lose weight. Obesity can contribute to headaches. If you need to lose weight, find a program that works for you.
• Quit smoking. If you smoke, talk to your health care provider about quitting. Smoking is linked to a higher risk of medication overuse headaches.

Diagnosis

Your health care provider can usually diagnose medication overuse headaches based on your history of headaches and regular use of medicine. Testing usually isn't necessary.

Treatment

To break the cycle of medication overuse headaches, you'll need to restrict pain medicine. Your health care provider may recommend stopping the medicine right away or gradually reducing the dose.

Breaking the cycle

When you stop your medicine, expect headaches to get worse before they get better. You can develop a dependence on some medicines that result in medication overuse headaches. Withdrawal symptoms may include:

• Nervousness.
• Restlessness.
• Nausea.
• Vomiting.
• Insomnia.
• Constipation.

These symptoms generally last 2 to 10 days. But they can persist for several weeks.

Your health care provider may prescribe treatments to help with headache pain and the side effects of medicine withdrawal. This is known as bridge or transitional therapy. Treatments may include nonsteroidal anti-inflammatory drugs, corticosteroids or nerve blocks. Your provider also might recommend the ergot dihydroergotamine given through a vein.

There's debate over how much benefit bridge therapy may offer. There's also debate about whether one treatment works better than others. Withdrawal headaches tend to improve in less than a week.

Hospitalization

Sometimes it's best to be in a controlled environment when you stop taking pain medicine. A short hospital stay may be recommended if you:

• Have other conditions, such as depression or anxiety.
• Are taking high doses of drugs that contain opiates or the sedative butalbital.
• Are using substances such as tranquilizers, opioids or barbiturates.

Preventive medications

Preventive medicines may help you break the cycle of medication overuse headaches. Work with your health care provider to avoid relapsing and to find a safer way to manage your headaches. During or after withdrawal, your provider may prescribe a daily preventive medicine such as:

• An anticonvulsant such as topiramate (Topamax, Qudexy XR, others).
• A tricyclic antidepressant such as amitriptyline or nortriptyline (Pamelor).
• A beta blocker such as propranolol (Inderal LA, Innopran XL, Hemangeol).
• A calcium channel blocker such as verapamil (Calan SR, Verelan, Verelan PM).

If you have a history of migraine, your health care provider might suggest an injection of a CGRP monoclonal antibody such as erenumab (Aimovig), galcanezumab (Emgality), fremanezumab (Ajovy) or eptinezumab (Vyepti). Erenumab, galcanezumab and fremanezumab are monthly injections. Eptinezumab is given every three months with an IV infusion.

These medicines can help control your pain without risking medication overuse headaches. You may be able to take a medicine specifically meant for pain during future headaches. But be sure to take them exactly as prescribed.

Injections

Injections of onabotulinumtoxinA (Botox) may help reduce the number of headaches you have each month. They also may make headaches less severe.

Cognitive behavioral therapy (CBT)

This talk therapy teaches ways to cope with headaches. In CBT, you also work on healthy lifestyle habits and keep a headache diary.

Alternative medicine

For many people, complementary or alternative therapies offer relief from headache pain. However, not all of these therapies have been studied as headache treatments. For some therapies, further research is needed. Discuss the risks and benefits of complementary therapy with your health care provider.

Possible therapies include:

• Acupuncture. This ancient technique uses fine needles to promote the release of natural painkillers and other chemicals in the central nervous system. This therapy may ease headaches.
• Biofeedback. Biofeedback teaches you to control certain body responses that help reduce pain. During biofeedback, you're connected to devices that monitor you. They give you feedback on body functions such as muscle tension, heart rate and blood pressure. You then learn how to reduce muscle tension and slow your heart rate and breathing. This helps you relax, which may help you cope with pain.
• Herbs, vitamins and minerals. Some dietary supplements seem to help prevent or treat certain types of headaches. But there's little scientific support for these claims. They include magnesium, feverfew, coenzyme Q10 and riboflavin, also known as vitamin B2. If you're considering using supplements, check with your health care provider. Some supplements may interfere with other medicines you take. Or they may have other harmful effects.

Coping and support

You may find it helpful to talk to other people who've been through the same experience you're having. Ask your health care provider if there are support groups in your area. Or contact the National Headache Foundation at www.headaches.org or 888-643-5552.

Preparing for an appointment

You're likely to start by seeing your primary care provider. You may then be referred to a doctor who specializes in nervous system disorders, known as a neurologist.

Here's some information to help you get ready for your appointment.

What you can do

• Keep a headache diary. Write down your symptoms, even those that seem unrelated to headaches. Note what you were doing, eating or drinking before the headache began. Also note how long the headache lasted. Include the medicines and amounts you took to treat the headache.
• Write down key personal information, including major stresses or recent life changes.
• List questions to ask your health care provider.

For medication overuse headaches, some questions to ask your health care provider include:

• How could I cause a headache with medicine I took to treat a headache?
• Could there be other reasons for my headaches?
• How can I stop these headaches?
• Are there alternatives to the approach you're suggesting?
• If my original headaches return, how can I treat them?
• Are there brochures or other printed material I can have? What websites do you recommend?

Don't hesitate to ask any other questions.

What to expect from your doctor

Your health care provider will ask questions about your headaches, such as when they started and what they feel like. The more your provider knows about your headaches and medicine use, the better care your provider can give you. Your provider may ask:

• What type of headache do you usually have?
• Have your headaches changed in the past six months?
• How severe are your symptoms?
• What headache medicines do you use, and how often?
• Have you increased the amount or frequency of taking them?
• What side effects have you had from medicines?
• Does anything help improve your symptoms?
• What, if anything, appears to worsen your symptoms?

What you can do in the meantime

Until your appointment, take your medicine only as directed by your health care provider. And take care of yourself. Healthy lifestyle habits can help prevent headaches. They include getting enough sleep, eating plenty of fruits and vegetables, and getting regular exercise. Avoid any known headache triggers.

A headache diary can be very helpful for your health care provider. Keep track of when your headaches occurred, how severe they were and how long they lasted. Also write down what you were doing when the headache began and what your response to the headache was.