For many people, reliance on medication that reduces symptoms of migraine (especially with chronic frequency) can become a daily occurrence. Anything that minimizes the pain can seem like the best option in an attack. However, this can develop into a condition known as medication overuse or rebound headache. In this post, we explore what it is, the risk factors, and prevention strategies.

What is medication overuse headache?

By the medical definition, medication overuse headache (MOH) is present in patients previously diagnosed with a primary headache disorder. It is characterized by recurring headache episodes in excess of 15 days a month—similar to that of chronic migraine—as well as frequent overuse of acute medication designed to prevent or diminish symptoms. The cruel irony is that the medications often prescribed to treat migraine and reduce the debilitating pain pose a serious risk of worsening attacks when used improperly.

Medication overuse headache has also been described as “rebound” headache and only affects those with a preexisting headache diagnosis. In fact, taking regular pain medication for another condition (where there is also absence of an existing headache disorder) has not been associated with the onset of headache or migraine attacks, according to the Mayo Clinic. Other symptoms of MOH include nausea; irritability; and cognitive symptoms such as memory loss or difficulty concentrating. Some experts have also cited neck pain as a prominent feature of MOH. Unfortunately, like other headache disorders, it can be easily misdiagnosed or overlooked.

Risk factors for rebound headaches

High frequency of headache associated with medication overuse affects 1% to 2% of the worldwide population. Migraine and tension-type headache are most commonly associated with medication overuse, but cluster headache and new daily persistent headache have also been connected to the condition. In general, daily or weekly use of analgesic (or pain relieving) medication for several months is a defining precursor for MOH. Other risk factors or signs might include:

• Low socioeconomic status
• Smoking
• Obesity
• Physical inactivity
• History of depression
• Insomnia
• Family history of MOH or prior substance abuse

A person does not necessarily have to display medication dependence behaviors either, although researchers have seen a possible correlation. Still, the fact is medication overuse headache can occur for anybody who experiences worsening symptoms as a result of increasing reliance on pharmaceuticals to treat their condition.

Are certain medications more likely to lead to overuse headache?

Specific medications have also been linked to greater instances of overuse or rebound-related headache. Although any migraine treatment drug can lead to MOH, over-the-counter analgesics (such as acetaminophen or ibuprofen) can be problematic, especially when the dosage exceeds the recommended daily limit. Combination pain relievers that include caffeine, aspirin or acetaminophen also have the potential to develop into MOH.

Opioid treatments (oxycodone, codeine for example) also pose significant harm in exacerbating existing headache disorders, which has been further supported by recent research showing the negative outcomes tied to opioid use for migraine. Triptans were shown to be less likely to lead to the rebound phenomenon, but there still is a moderate risk that must be considered. The key point to remember is that these medications can and often do make you feel better—even reduce symptoms of migraine—but it is usually short lived. As their effectiveness wears off, the attacks can worsen in duration, frequency or intensity.

One of the scarier consequences of medication overuse is the potential to transform migraine from episodic to chronic. Every year, 3% of people with episodic migraine develop increasing frequency of attacks, much of which can be attributed to extensive use of acute medication.

The stigma of medication overuse headache

As with other migraine and headache disorders, people with MOH generally have a reduced quality of life. Higher levels of anxiety and depression as well as disability have been observed in patients with rebound headaches. MOH patients may also face stigma or blame—which is already high in migraine—with others believing that their behavior constitutes abuse or dependence and therefore directly contributes to the onset of the condition. However, prominent headache specialists have emphasized that it may actually reflect the ineffectiveness of migraine treatments and preventatives. As a result, patients are forced to turn to anything that can relieve the pain of chronic migraine or headache.

Dr.Scher- important #patient oriented considerations about MOH narrative #AHS17BOS pic.twitter.com/GY1vMlXZrq

— Elizabeth Seng (@SengElizabeth) June 9, 2017

Steps to improve and prevent rebound headaches

Effective strategies to manage rebound or overuse headaches are critical for helping patients overcome this challenging condition. It can even help them revert back to episodic migraine if they have become chronic, with one study showing that 52% returned to less frequent attacks after three months. Other findings have shown that many are free of MOH after 18 months. In general, there are high rates of success when overuse of medication is properly addressed with a combination of treatment strategies. Here are a few recommended approaches.

1. Wean off acute medications

If your doctor suspects overuse may be causing your recurring headache or migraine attacks, they likely will recommend that you start reducing your medication intake. It may be gradual over the course of several weeks or more abrupt depending on the needs of the patient. This often takes place through outpatient care but, in certain instances, inpatient therapy may be necessary. As part of this process, symptoms of withdrawal can be prominent— including nausea, worsening head pain, anxiety and sleep disturbances; it typically lasts between 2 to 10 days, and duration varies by specific medication. The entire detox period may take several months.

2. Support with behavioral therapy

It is especially important to find multiple avenues of support during the detoxification process as relapse rates have been shown to be as high as 40 percent within the first year. In many cases, it may be appropriate to implement behavioral strategies that reduce the likelihood of relapse. Ask your doctor if he or she can recommend any local programs or support groups; these resources can help patients move away from the mentality that they need to take a pill whenever they feel a headache or migraine attack coming on. And remember: in most cases, it is NOT your fault. Any options that can help you move beyond any guilt or blame you may feel is key to help overcome the challenge of MOH.

3. Utilize non pharmaceutical prevention

A core strategy to avoid relapse among patients with MOH is to identify prevention therapies that do not involve the use of medication. Preventative treatments may have varying results but are generally safer and offer few, if any, side effects. Tinted lenses that block certain light from triggering migraines, acupuncture, dietary or other behavioral adjustments can all be effective ways to reduce the reliance on pharmaceuticals.

4. Explore other medications for treatment

It may not be appropriate for every patient, but alternative options for acute or rescue medication can be incorporated into a treatment regimen for medication overuse headache. It is generally recommended that these be explored for those who do not benefit from other prevention and behavioral approaches and only after it has been determined that the effects of overuse are no longer present. This will help you and your specialist determine which medicinal options are actually able to reduce symptoms of migraine without the risk of reverting back to MOH diagnosis.

The BEST non-drug migraine alternatives ➜

References:

Kristoffersen ES, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and treatment. Therapeutic Advances in Drug Safety. 2014;5(2):87-99. doi:10.1177/2042098614522683.

International Headache Society Classification ICHD-3 Beta. 8.2 Medication Overuse Headache MOH. https://www.ichd-3.org/8-headache-attributed-to-a-substance-or-its-withdrawal/8-2-medication-overuse-headache-moh/

Wilson, MC, Jimenez-Sanders R. Medication Overuse Headache. American Migraine Foundation. https://americanmigrainefoundation.org/understanding-migraine/medication-overuse-headache-2/

Thorlund K, Sun-Edelstein C, Druyts E, et al. Risk of medication overuse headache across classes of treatments for acute migraine. The Journal of Headache and Pain. 2016;17(1):107. doi:10.1186/s10194-016-0696-8.

Cevoli S, Giannini G, Favoni V, et al. Treatment of withdrawal headache in patients with medication overuse headache: a pilot study. The Journal of Headache and Pain. 2017;18(1):56. doi:10.1186/s10194-017-0763-9.

Cheung V, Amoozegar F, Dilli E. Medication overuse headache. Curr Neurol Neurosci Rep. 2015 Jan;15(1):509. doi: 10.1007/s11910-014-0509-x.

Viana M, Bottiroli S, Sances G, Ghiotto N, Allena M, Guaschino E, Nappi G, Tassorelli C. Factors associated to chronic migraine with medication overuse: A cross-sectional study. Cephalalgia. 2018 Jan 1:333102418761047. doi: 10.1177/0333102418761047. [Epub ahead of print]