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Medication Overuse Headache - Causes and Symptoms

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Medication overuse disorder is a condition where frequent use of painkillers can induce headaches. The headaches are refractory to further medications.

Written by

Dr. Sabhya. J

Medically reviewed by

Dr. Abhishek Juneja

Published At November 3, 2023
Reviewed AtNovember 3, 2023

Introduction

Individuals with headache disorders who take pain-relief medication experience headaches. Pain relievers provide relief from occasional headaches. However, if taken for a more extended period may trigger headaches. Patients with other medical conditions like arthritis who are on long-term medication do not get headaches. The condition predominantly affects females and individuals between 30 to 50 years.

What Is Medication Overuse Headache?

Also known as rebound headache, the condition develops due to the long-term use of medication to treat migraines. It is a common neurologic disorder that causes disability and suffering. The condition plays a vital role in transforming episodic to chronic headaches. Medication overuse headache is seen in patients with established primary disorders like migraine and tension-type headaches. The symptoms of headache disappear on stopping pain medications. The criteria to be classified as medication overuse headache are:

  1. Headache occurs for over or equal to 15 days per month for individuals with a pre-existing headache disorder.

  2. Regular medication overuse for over three months or multiple painkillers are taken for acute or symptomatic treatment.

  3. It cannot be classified under any other criteria of the ICHD (International Classification of Headache Disorders) classification.

What Are the Causes of Medication Overuse Headache Occurrence?

The exact etiology of medication overuse headaches is unknown. Consuming caffeine every day can cause medication overuse headaches. Coffee, soda, and painkillers contain caffeine. A few medications that are responsible for headache development is

  • Simple Pain Relievers: Frequently used pain relievers like Aspirin or Acetaminophen can contribute to the development of medication overuse headaches. At the same time, other medications like Ibuprofen and Naproxen sodium have a lower risk for medication overuse headache development.

  • Combination Pain Relievers: Combination medications that are available over the counter, such as Caffeine, Aspirin, and Acetaminophen, are common factors for developing headaches. Butalbital (sedative) containing medicines have a higher risk of developing medication overuse headaches. Hence, they must be used for a short time.

  • Migration Medicines: Medications for migraine like Tryptan and Ergotamine have a moderate risk of developing medication overuse headaches.

  • Opioids: Painkillers that are obtained from opioids have a higher risk of developing overuse headaches. Medication with a combination of Codeine and Acetaminophen can also lead to headaches.

What Are the Risk Factors for Medication Overuse Headaches?

Individuals with a history of migraine or life-long headaches are at higher risk. A combination of painkillers, Opioids, Ergotamine, or Triptan for more than ten days a month can cause medication overuse headaches. A headache occurs if simple painkillers are taken for more than 15 days a month. Risk is increased when the individual has a habit of substance abuse or alcohol use disorder.

What Are the Symptoms of Medication Overuse Headache?

Symptoms of medication overuse headaches depend on the type of medicine taken and the underlying medical condition. The symptoms appear daily, often in the early morning. Neck pain may appear due to overnight drug withdrawal or poor sleep quality. The symptoms improve with pain medication but return when the effect of the medication wears off. In addition to headaches, other symptoms of nausea, runny nose, tearing, vomiting, restlessness, trouble concentrating, memory problems, and irritability may develop. Central sensitization from medication overuse of headache can cause skin hypersensitivity and expansion of headache. The condition is diagnosed based on the history of headaches and medication used.

What Is the Differential Diagnosis for Medication Overuse Headaches?

All chronic headaches are considered for differential diagnoses of medication overuse headaches. Migration-tension type headache (caused by stress), cluster headache (headache that occurs in clusters during the middle of the night), short-lasting neuralgiform headache attacks with conjunctival injection and tearing (rare headache that lasts for seconds), hypnic headache (headache that occurs during sleep), and nummular headache (uncommon headache that occurs in the small focal area of the brain) are some of the differential diagnoses. It is essential to take a proper history, physical examination, and diagnostic testing to differentiate the disease.

How to Treat Medication Overuse Headaches?

Medication overuse headaches have been found to cause headaches to be refractory to pharmacological and non-pharmacological treatments. The medications used in the treatment of migraine are found to be less effective.

To prevent headaches from occurring, pain medications must be restricted. The medications may be stopped immediately or tapered slowly. Other painkiller medicines like nonsteroidal anti-inflammatory drugs, corticosteroids, or nerve blocks that do not cause headaches are used. Hospitalization may be required for patients with severe anxiety or depression, consuming high doses of drugs (opiates, sedative Butalbital), or using barbiturates, opioids, and tranquilizers.

  • Detox for Medication Overuse Headache: Early detoxification must be carried out in patients with medication overuse headaches. Detoxification is achieved by stopping or gradually tapering off medication responsible for headache development. After two months of stopping the medication, the headache transforms into a typical headache.

  • Medication Overuse Headache Withdrawal Symptoms: Stopping the medication abruptly can worsen the symptoms initially. Frequently observed withdrawal symptoms are nervousness, restlessness, nausea, vomiting, insomnia, and constipation. The symptoms may last two to ten days or persist for several weeks. Bridge or transitional therapy (strong painkillers used for a shorter time to control headaches) may be necessary to improve headaches. Withdrawal symptoms from codeine, ergotamine, triptans, or morphine-based medicines are difficult to manage. Withdrawal from Paracetamol or NSAIDs (nonsteroidal anti-inflammatory drugs) like Aspirin, Ibuprofen, and Naproxen is less severe.

  • Preventive Medications: During withdrawal, preventive medications like Topiramate (anticonvulsant), Amitriptyline (tricyclic antidepressant), Propranolol (beta-blockers), and Verapamil (calcium channel blockers) may be prescribed. Medications are prescribed to control pain without causing headaches. Injection of CGRP (calcitonin gene-related peptide) monoclonal antibodies, like Erenumab, Galcanezumab, and Fremanezumab, are used as monthly injections. Injections like OnabotulinumtoxinA (botox) can decrease the frequency of headaches in a month and reduce the headache severity.

  • Cognitive Behavioral Therapy (CBT): The therapy enables the management of headaches with behavioral modification. Healthy lifestyle habits are practiced in this method.

  • Other Therapy Methods:

    • Biofeedback is a mechanism by which the patient learns to reduce pain by controlling the body’s response to pain.

    • Counseling

    • Physical therapy.

    • Diaphragmatic breathing, medication, and relaxation therapy.

How to Prevent Medication Overuse Headaches?

  • Taking medications according to prescription for headache. The healthcare provider must be contacted if there is a need to take headache medicine more than twice a week. Painkillers must be taken for less than fifteen days a month.

  • Medications containing Butalbital and Opioids must be taken only if necessary.

  • Triggers that can cause headaches must be avoided.

  • Individuals must sleep adequately.

  • Avoid skipping meals.

  • Regular exercise is a must since the body releases chemicals during exercise to block pain signals to the brain.

  • Reducing stress and being positive may reduce the frequency of headaches.

  • Obesity is one of the factors that can lead to the development of headaches. Hence, weight reduction is essential.

  • Patients must avoid smoking.

Conclusion

Medication overuse for headaches is a common condition that is prevalent worldwide. The condition is often misdiagnosed and disrupts the patient’s quality of life. Long-term use of several migraine medications can cause this type of headache. To break this cycle of headache development, intervention with counseling, detoxification, and prevention therapy is necessary.

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Dr. Abhishek Juneja
Dr. Abhishek Juneja

Neurology

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