Stopping the cycle of rebound headaches
EXPERT ADVICE: From Dr. Mark Saleh
Updated 6:59 pm, Tuesday, December 4, 2012
Headache disorders are extremely common in the United States, representing a major health problem. Tension headaches are most common, with 95 percent of women and 90 percent of men experiencing at least one tension headache in their lifetime. Migraine headaches are the second most common, with 1 in 4 U.S. households having at least one family member who suffers from migraines.
But there is a third disorder known as the rebound headache, a relatively new concept when compared with tension and migraine headaches. Rebound headaches are brought on by the overuse of common over-the-counter, first-line treatments for tension and migraine headaches - aspirin, ibuprofen, acetaminophen and combination headache remedies containing caffeine.
When these medications, as well as some prescription pain medications, are overused, they may paradoxically lead to worsening headaches, which can then transform into chronic daily headaches.
Rebound headaches, first reported in the medical literature in 1982, can come about when as-needed pain medications are taken more than two to three times per week. When the pain medication wears off, withdrawal symptoms may occur in the form of a headache, neck pain, nausea, restlessness, irritability or sleep disturbance. These symptoms, in turn, prompt more medication use, which only leads to more headaches and the desire to take even more medication.
As this cycle continues, chronic daily headaches may result with more severe headache pain. Rebound headaches are thought to occur because the body has adapted to the pain medications. However, the exact underlying pathophysiologic mechanisms are not entirely understood.
Aside from the overuse of medication, there are other factors that lead to rebound, including the presence of an underlying headache disorder, particularly migraine.
On the other hand, frequent use of analgesics for other types of pain, such as arthritic pain, typically do not result in rebound headaches. Also, those who take daily aspirin for cardiovascular disease prevention generally do not develop rebound headaches.
If you are already in rebound, there are strategies that may help to break the cycle. First, a gradual reduction of the medication is often required. Abrupt withdrawal is also possible but should be undertaken only under the direction of a physician; new problems may occur if certain analgesics are stopped abruptly. For example, an abrupt stop to medications that contain butalbital can result in seizures. As an analgesic is withdrawn, headaches may temporarily worsen, but over time, the headache pattern should improve.
Preventive pharmacologic treatment is sometimes necessary. Most preventive medications were initially developed to treat other diseases - such as seizures, depression or hypertension - but have been shown to provide a beneficial prophylactic effect for the cycle of rebound headaches.
Non-pharmacologic measures may also be helpful, such as aerobic exercise, massage and biofeedback. In severe cases, hospitalization may be required to break the cycle.
If you think you may be experiencing rebound headaches or are afraid they may start, you should talk with your doctor about all of your medications - both over-the-counter and prescribed - to make sure their use isn't contributing to the problem.
Medications that are associated with rebound headaches include:
-- Other nonsteroidal anti-inflammatory medications such as ibuprofen and naproxen, which are sold under the brand names Motrin, Advil, Aleve, etc.
-- Over-the-counter combination headache remedies containing caffeine.
-- Sinus relief medications.
-- Sedatives for sleep.
-- Ergotamine preparations, which include Cafergot and Migergot.
-- Butalbital combination analgesics, which include Fioricet, Fiorinal.
-- Opioids or medications that contain codeine or hydrocodone that include Tylenol No. 3, Vicodin, Norco, Lortab.
-- Triptans, which are prescription migraine-specific medications that include Imitrex, Zomig, Maxalt, Axert, Relpax, Frova, Amerge, and Treximet.
-- Analgesics containing butalbital are most likely to result in rebound headaches after only five or more doses in a month.
Tips for avoiding rebound headaches
-- Follow the labeling instructions of your medications.
-- Limit the use of analgesics to no more than 1-2 times per week.
-- Use the smallest dose possible that is effective.
-- Limit caffeine consumption.
-- Contact your doctor if your headache frequency or severity worsens.
Dr. Mark Saleh is a neurologist and the director of General Neuroconsultative and Referral Service at California Pacific Medical Center. Are you obsessed with a brain or physical fitness activity in the Bay Area? Tell us about it at firstname.lastname@example.org.