Medication overuse headache (MOH), or "rebound headache", is a common and disabling headache disorder that can DEVELOP AND PERSIST BY THE FREQUENT AND EXCESSIVE USE OF SYMPTOMATIC PAIN MEDICATIONS. Often these headaches begin early in the morning, and the location and severity of headache may change from day to day. People who have MOH may also have nausea, irritability, depression, or problems sleeping.
In susceptible individuals with a pre-existing episodic headache condition (most frequently migraine or tension-type headache), the frequent, near-daily use of simple analgesics (aspirin or paracetamol), combination analgesics (containing caffeine, codeine, or barbiturates), opioids, ergotamine, or triptans "transforms" the headache into one that occurs daily.
Characteristic features of MOH include the following:
1. the frequency of the headaches increases over time, without the patient being aware;
2. patient often wakes up in the early morning with a headache, even though this was not a feature of the original headache type;
3. some of the headache attacks may become nondescript – lacking features specific to migraine or tension-type headache;
4. the patient gets a headache more easily with stress or exertion;
5. greater doses of the medications are needed to alleviate the headache;
6. headaches occur within a predictable period after the last dose of medication, usually with reduced efficacy.
How much medication is too much?
The new 2004 International Headache Society (IHS) criteria guidelines2 state that MOH can be associated with the use of:
simple analgesics for 15 days or more, for more than 3 months
combination medications for 10 days or more, for more than 3 months
opioids for 10 days or more, for more than 3 months
ergotamine and triptans for more than 10 days per month, for more than 3 months
Frequent and regular use (ie. two or three times per week) is much more likely to cause MOH than taking medication in clusters of several treatment days separated by prolonged treatment-free intervals.
Caffeine is an ingredient in some headache medications. It may improve headaches initially, but daily intake of caffeine-containing medications, or caffeine-containing beverages, can result in greater headache frequency and severity. Stopping caffeine may actually make headaches worse, and some patients require professional help to overcome caffeine dependency.
As well, the new IHS criteria defines headache secondary to medication overuse as headache which has worsened in the face of 10 or more days of triptan use or 15 or more days of analgesic use. Headache must be present 15 or more days per month.
Treating MOH
Patients with CDH who overuse acute pain medications are advised to discontinue or taper the overused medication. There is the possibility of developing tolerance to the drug, and/or dependence. There is also the risk of developing liver, kidney and gastrointestinal disorders.
Most patients with MOH can be treated in the outpatient setting. Hospitalization is usually for patients overusing opioids, barbituates, or benzodiazepines, those with severe psychiatric comorbidities, or those who have failed previous withdrawal attempts as an outpatient.
Simple analgesics, ergotamines, triptans and most combination analgesics can be abruptly discontinued whereas opioids and barbituate-containing analgesics should be gradually tapered. Patients should be given a pain medication in a class they are not overusing, in limited doses, to help alleviate withdrawal symptoms, such as headache, nausea, vomiting, sleep disturbances, etc.). These symptoms typically last from 2 to 10 days.
The first step to treating MOH is to educate the patient about the role of medication overuse in the patient’s chronic daily headache. If there is comorbid depression and/or anxiety, it needs to be addressed at the same time. Biofeedback can be used to help the patient learn relaxation techniques, and lifestyle habits have to be modified. This can include decreasing caffeine consumption, increasing exercise, using stress management strategies, and improving sleep habits.
The goal of withdrawal is to get rid of daily or near-daily medication use and its associated symptoms, to restore an episodic pattern of headache, and to establish an effective treatment strategy including both preventive and acute medications. In patients with a long history of near-daily or daily headaches it may be more realistic to aim to reduce the intensity of daily pain, restore the patient’s ability to function, and to provide an effective strategy for acute management of severe headaches.
References:
1. Dowson AJ, Dodick DW, Limmroth V. Medication overuse headache in patients with primary headache disorders: epidemiology, management and pathogenesis. CNS Drugs 2003 (in press).
2. Headache Classification Subcommittee of the International Headache Society. The International classification of headache disorders, 2nd ed. Cephalalgia 2004;24(suppl 1):1-160.
Sources:
Gladstone J, Eross E, Dodick DW. Chronic daily headache: a rational approach to a challenging problem. Semin Neurol 2003;265-276.
American Family Physican - Rebound Headache.
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