You have a headache so you reach for a couple of Tylenol, aspirin, or maybe something your healthcare provider prescribed. It’s a common routine played out by millions of people every day. For most, it’s an effective remedy. The pain medication gets to work and the headache goes away.
But for some people—especially those with recurrent headache disorders such as chronic migraine or cluster headaches—long-term or frequent use of pain relievers can trigger what’s known as medication overuse headaches (MOH).
What is a medication overuse headache?
A medication overuse headache, also known as a rebound headache, is a regular headache that stems from the repeated or excessive use of acute pain-relieving medications. Here’s what happens: The medication quells the pain for a few hours, but as it starts to wear off and the pain is no longer suppressed, the headache “rebounds.” So you take more medication—which can become less effective with repeated use. The medication again tapers off and the headache returns. Again. It’s a vicious cycle that can lead to the development of a chronic daily headache that produces more and more disabling pain. This type of headache can be caused by over-the-counter medications, like aspirin or acetaminophen, or prescription drugs, such as migraine medications like triptans.
Whether an MOH is a headache that’s secondary to the one that first made you reach for pain medication or a continuation of the original one is a matter that’s debated by researchers. According to the International Headache Society, people with medication overuse headaches are typically people with a headache disorder, such as episodic migraines. The diagnostic criteria listed in the international classification of headache disorders specify that patients have headaches 15 or more days per month, regularly take pain medications 10 or more days a month for three or more months, and the headache can not be classified as any other medical condition.
“Development of medication overuse is linked to the baseline frequency of headache days per month and acute medication class used, among other risk factors,” says Cristina Cabret-Aymat, MD, a neurologist and headache care specialist at Ochsner Health Center in Covington, Louisiana.
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Who’s at risk?
“Medication overuse headaches most commonly occur in people with primary headache disorders like migraine or tension-type headache who use less effective or nonspecific medications resulting in an inadequate treatment response with the need to repeat dosing,” explains Brian Grosberg, MD, director of the Hartford HealthCare Ayer Neuroscience Institute Headache Center in West Hartford, Connecticut. According to experts at the Cleveland Clinic, medication overuse headaches occur three times more often in women than men and are most common in midlife.
Medication overuse headaches are rare in the general population. According to current research, 2.6% of people live with them. However, they’re very common in those with persistent headaches. In fact, up to 70% of people with chronic daily headaches get headaches from medication overuse. What’s more, “People with migraine could develop overuse even if they’re using the analgesics [drugs that relieve pain] for other medical conditions,” Dr. Cabret-Aymat says.
Symptoms of medication overuse headaches include:
- Headaches that occur daily or almost daily
- Headache pain that decreases with pain-relieving drugs, but returns as the drugs wear off
- Headaches that start in the morning, often upon waking
That’s because by the time the sun comes up, the pain-relieving drug you took before sleep will most likely have worn off. Pain can be dull or stabbing, and last four or more hours a day. And thanks to that debilitating pain, you may also experience certain side effects such as:
- Difficulty concentrating
- Problems sleeping
- Depression or anxiety
What drugs cause medication overuse headaches?
No one’s really sure what causes medication overuse headaches. But there are some theories. In the case of migraines, for example, “studies suggest that the overuse of acute medications may cause changes in the nervous system of headache-prone patients that result in a reduced threshold for experiencing migraine and an enhanced sensitivity to stimuli that trigger migraine,” reports Dr. Grosberg.
The list of medications that can cause a medication overuse headache is long. Pretty much anything you might reach for to relieve a headache or other type of pain has—if used regularly or excessively—the potential to trigger an MOH in certain people. According to the Cleveland Clinic, these drugs include:
- Simple analgesics like aspirin, Tylenol (acetaminophen), and nonsteroidal anti-inflammatory drugs (NSAIDs), including Advil (ibuprofen),Aleve (naproxen), and aspirin
- Combination analgesics, such as medications that combine pain relievers and caffeine (Excedrin and Anacin)
- Drugs that treat sinus pain
- Opioids, such as Tylenol (acetaminophen) with codeine, OxyContin (oxycodone), Vicodin (hydrocodone/acetaminophen), and Percocet (oxycodone/acetaminophen)
- Ergotamine-containing drugs such as Ergomar, Migergot, and Bel-Phen-Ergot S. For many people, headaches occur when blood vessels in the head expand and press against sensitive nerve endings. Ergotamine works by constricting those blood vessels and reducing pain.
- Butalbital-containing drugs such as Fiorinal and Fioricet. Butalbital is a barbiturate and acts as sedative. It’s typically combined with aspirin and caffeine.
- Triptan-containing drugs such as Imitrex (sumatriptan), Zomig (zolmitriptan), and Maxalt (rizatriptan). Triptans help to calm overactive pain nerves and stop vasodilation and inflammation.
So how much of a medication can produce a medication overuse headache? It depends on the medication used and for how long. Research indicates you can develop an MOH when you take:
- NSAIDs such as ibuprofen and naproxen for 15 days a month
- Combined analgesics, such as drugs that blend things like codeine with aspirin, for 10 days a month
- Prescription medications such as triptans and ergotamines for 10 days a month
- Opioids for eight days or more per month
- Butalbital-containing compounds (like Fioricet) for five days a month
RELATED: How much ibuprofen is safe to take?
How to treat rebound headaches
Management of medication overuse headaches typically involves the discontinuation (or, in some cases, the reduction) of the overused medication. Research indicates that what clinicians call withdrawal therapy, or detoxification, is effective in reducing the prevalence of medication overuse headaches in about 50% to 70% of patients. But given that you’re regularly reaching for painkillers because your headaches are frequent and intense, medication withdrawal is easier said than done. Withdrawal symptoms can include an initial worsening of the headache (aka withdrawal headaches) along with nausea, low blood pressure, vomiting, anxiety and problems sleeping. These can last an agonizing one-to-two weeks.
But before you decide to stop or taper off your medication, it’s important to get your healthcare provider’s guidance. Some people can handle the medication detoxification at home, but others need in-patient treatment. In some cases your doctor will want to reduce your medication use gradually, in others it may be okay to stop abruptly. “In the meantime, we can do bridge therapy to help patients come off the overused drugs while providing symptomatic relief,” says Dr. Cabret-Aymat. For example, someone taking triptans may be prescribed a newer drug type called gepants (Ubrevly is one), which can be used to prevent or abort a migraine and are less likely than triptans to cause a medication overuse headache. Gepants can be intravenous or oral medications.
Some common bridge therapy options include:
- Physical therapy: This type of therapy can help to manage pain and improve mobility—especially for certain types of migraine.
- Biofeedback: This technique teaches people how to control bodily processes like breathing and muscle tension. Biofeedback can reduce headache frequency by 45% to 60% in people with migraine and tension-type headaches.
- Transcutaneous electrical nerve stimulation (TENS): TENS delivers low-voltage electrical currents to stimulate nerves and help bring pain relief. Research shows it can significantly reduce the number of days per month users have headaches.
- Use of non-analgesic medications to control symptoms: Prescription drugs such as alpha and beta blockers, blood pressure medications, and antidepressants may be used to ease the symptoms of medication withdrawal in some cases.
It’s common sense: The fewer headaches you get, the lower your chance of medication overuse headaches. And that makes preventive treatment key. To reduce headache frequency:
- Steer clear of known headache triggers—for example, if you know chocolate, alcohol, or stress tend to bring on an acute migraine, try to avoid those things.
- Take your headache medication as prescribed. Don’t add on doses or take more than recommended unless you first follow up with your healthcare provider.
- Talk to your provider if you have a headache more than four days a month. You may need to take a prophylactic, or preventive medication, such as Botox (onabotulinumtoxinA). In one study looking at the use of Botox in people with chronic migraines and medication overuse headaches, Botox reduced the number of headache days and the number of days subjects took medication compared to baseline.
- Avoid butalbital-containing medications or opioids. These have a high likelihood of producing medication overuse headaches.
As vexing and disabling as chronic headaches can be, there is hope for breaking the medication overuse cycle. Treatment of medication overuse headaches may involve trying newer drugs less likely to cause rebound headaches and nondrug therapies that can bring pain relief. There are also preventive medications that can stop a headache before it even starts.
“Acute and preventive headache treatment should be individualized to each patient, considering comorbidities, risk factors, and side effects,” Dr. Grosberg says. Ultimately, you need to talk to your healthcare provider about your options.
“There’s not one universal medication for acute headache management that works for everyone,” adds Dr. Cabret-Aymat. “This has to be tailored to the patient’s needs.”