Analgesic Rebound Headaches


Analgesic agents are prescription or over-the-counter medications used to control pain including migraine and other types of headaches such as acetaminophen, ibuprofen and aspirin. When used on a daily or near daily basis, these analgesics can perpetuate the headache process. They may decrease the intensity of the pain for a few hours; however, they appear to feed into the pain system in such a way that chronic headaches may result. If under these circumstances the patient does not completely stop using these analgesics, despite any other treatment undertaken, the chronic headache is likely to continue.


What are the symptoms of analgesic rebound headaches?


Some patients telephone or visit their physicians who, with the best of intentions, may prescribe larger quantities of medication at more frequent intervals. It is easy to miss a diagnosis of headache rebound. Here’s a quick test. If you answer ‘yes’ to any of the questions below, you may have a rebound headache:


  • Do you notice an increase in headache pain 3-4 hours after your last dose of prescription or nonprescription medication?
  • Does taking the next dose of medication earlier stop your headache or make it tolerable?
  • Do you take medication earlier because you anticipate a headache?
  • Are you incapacitated or in severe pain if you do not take your usual medication?
  • Are medications becoming ineffective?
  • Do prescribed preventive headache medications no longer work for you?
  • Are your headaches getting worse, even though you are taking more medication?


What are the specific analgesics associated with analgesic rebound headaches?


  • Acetaminophen (Tylenol)
  • Acetaminophen, Aspirin, and Caffeine (Excedrin)
  • Butalbital, Acetaminophen, and Caffeine (Esgic/Fioricet)
  • Butalbital, Aspirin, and Caffeine (Fiorinal)
  • Codeine with Acetaminophen (Tylenol with Codeine)
  • Ibuprofen (Motrin/Advil)
  • Naproxen Sodium (Aleve/Naprosyn)
  • Oxycodone with Acetaminophen (Percocet)
  • Propoxyphene with Acetaminophen (Darvocet N-100)


How can analgesic rebound headaches be prevented?


Analgesics should not be used more than two days a week. Periodic excess usage such as during a menstrual period is acceptable as long as analgesic use is not persistent.


What else can cause rebound-type headaches?


Caffeine Rebound Headache

Caffeine’s ability to constrict blood vessels also helps to relieve headaches- in fact, it is a major ingredient in many migraine preparations. Unfortunately, its overuse on a regular basis may lead to rebound. Even when overuse is not a factor, abruptly stopping intake of caffeine-containing beverages may cause a rebound headache. We recommend that patients who want to stop drinking coffee cut their consumption by 5 oz per week. While this doesn’t sound like much, it enables most people to gradually taper their caffeine consumption with minimal risk of rebound.


Ergotamine Rebound Headache

Another substance used to treat migraines, ergotamine, can cause a similar type of rebound headache. However, this substance is not frequently prescribed at this time. If you suffer from rebound headache symptoms and ARE on this medication, consult your physician on its use and side effects related to rebound type headaches.


How can rebound headaches be treated?


The key to successful treatment of rebound headache is discontinuing the responsible drug to break the cycle of daily headache. Nonprescription medications can be stopped abruptly or tapered off over a few days. Prescription medications, however, should be discontinued over a longer period of time, sometimes over a week or longer. Patients who have used large amounts of narcotics (opiates), synthetic narcotics (opioids), or ergotamine drugs for more than a year may best be treated in a hospital or as outpatients with careful monitoring by a headache specialist. Rebound headache sufferers should be aware that discontinuing medications makes things worse before they get better. Headaches may increase in intensity within 4 to 6 hours of stopping the medication, and peak between 24 and 48 hours. This withdrawal period may last from 2 to 3 weeks.


While a “rescue” dose of the medication that brought on the rebound syndrome will definitely stop the headaches, it does nothing to stop the underlying problem. In my practice, we recommend medications such as Midrin; nonsteroidal anti-inflammatory drugs (NSAID’s) such as ibuprofen, naproxen sodium, or ketoprofen; antinausea medications; and anti-anxiety agents such as hydroxyzine hydrochloride. Most of these drugs are used temporarily to help patients through the withdrawal period.


Most patients improve markedly within 3 to 6 weeks, and after 2 to 3 months almost all report much less frequent and severe headaches, improved sleep patterns, and less irritability and depression. Moreover, they report less anxiety about whether a headache will occur. At this point, many patients may benefit from headache preventive agents such as beta-blockers, calcium blockers, anti-seizure medications, and antidepressants, which would likely have been ineffective during the rebound headache phase.


Summary


Rebound headache can sneak up slowly and escalate insidiously. If you get headaches and use off-the-shelf or prescription medications it is important to limit your use to 2 or 3 days per week. Limiting your use of headache pain medication is a first line of defense against rebound headache. If headaches become more severe, more prolonged, or more frequent, or change in any other ways, it is important to report this to your physician.



Excerpts from:

Rebound Headache: When Medication Backfires

By: Alan M. Rapoport, M.D. (Headache.net)

And

The National Headache Foundation

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