What is Rebound Headache (Medication Overuse Headache)?
Rebound headache is also known as medication overuse headache (MOH). It is one of the most common causes for chronic daily headache, specifically chronic migraine, that headache specialists encounter daily. MOH is caused when certain abortive (as needed) medicines are taken excessively at specific monthly frequencies. I’ll outline these frequencies for the various common medicines that cause rebound headache below.
Unfortunately, most doctors don’t understand this common reason that converts episodic migraine into a worsening frequency and severity, eventually leading to chronic migraine if not stopped. Even worse, they often cause this headache by prescribing too much medicine without even realizing it.
Chronic daily headache refers to 15-30 days of headache per month on average for 3 or more months. The most common cause of chronic daily headache is typically episodic migraine which has evolved into chronic migraine, in which at least 8 days out of those 15-30 days per month have migrainous characteristics (throbbiness, throbby, pounding, pulsating pain with nausea and/or sensitivity to light (photophobia) and sound (phonophobia)).
Patients that have a prior or current history of migraine tend to be highly susceptible to developing rebound headache when certain medications are being used too frequently.
The overused medications causing rebound headache are usually used for the headaches. At first they may help, but when they are used more and more, they start to “pour gas on the fire” and fuel the chronic daily headache cycle into worsening frequency and severity.
However, pain medicines are also commonly used for something entirely different such as chronic back pain, nerve pain or arthritis pain (such as daily over the counter pain meds or opiates). If the person has underlying migraine history, these medicines may inadvertently drive their episodic migraine into a higher frequency or even chronic migraine. So in a person with migraine, the reason these medications are being used doesn’t matter as much as the frequency of which they are being used in terms of rebound headache risk.
Once someone is stuck in the rut of chronic daily headache from chronic migraine and rebound headache, it can be very challenging and frustrating to pull them back out of this cycle, and the medication overuse must be eliminated with detoxification before improvement can begin to occur. Until detox happens from the overused pain medicines, the chronic migraine and chronic daily headaches will not have a chance to improve.
In a rebound headache cycle, preventative medications (daily medicines used to lessen the frequency and/or severity of headaches) and abortive (“as-needed” at headache onset) pain medications become less effective. So improvement of chronic migraine hinges on successfully detoxing from the overused medications.
How Much Medicine Causes Rebound Headache?
Research has shown that medication overuse can transform episodic migraine (0-14 days of headache per month) to chronic migraine (15-30 days of headache per month) if the following medications are used at the following frequencies (in general):
Greater than 10 days per month for 2 or more consecutive months of over the counter (OTC) pain medications (Tylenol, Excedrin, Acetaminophen, Aleve, Naproxen, Motrin, Advil, Ibuprofen, or other non-steroidal anti-inflammatories (NSAIDs)).
Greater than 10 days per month for 2 or more consecutive months of triptans (Sumatriptan, Rizatriptan, Zolmitriptan, Almotriptan, Frovatriptan, Naratriptan, Eletriptan).
Greater than 8 days per month for 2 or more months of any narcotic, opioid, or opiate medication (Vicodin, Norco, Hydrocodone, Oxycodone, Oxycontin, Percocet, Tramadol, Ultram, Ultracet, Morphine, Codeine, Dilaudid, etc.).
Greater than 5 days per month for 2 or more months of any butalbital containing medication (Fioricet, Fiorinal, Esgic); (also known as “the headache specialist’s worst enemy”).
It is important to point out that the gepants (Nurtec, Ubrelvy, Zavzpret) do not cause rebound headache! It is also felt that the Ditans (Reyvow) do not cause rebound headache. So if someone is overusing these, they do not run into this problem. In addition, if they are overusing triptans or other abortive medicines, the gepants can be used simultaneously and alternatively as another option to use while trying to detox since there are no interactions if used together. This allows the person to alternate what they are using different days and this can help in the weaning process.
@neuralgroover What is rebound headache (medication overuse headache), what medicines cause it, and how do you break free from that nasty rut of misery? I’ll tell you everything you need to know here! If you have a history of migraine, this is important for you to know! #migraine #headache #rebound #reboundheadache #chronicdailyheadaches #medicationoveruseheadache #chronicdailyheadache #neurology #neuro #NeuroTikTok #MedTikTok #HeadacheSpecialist #Neurologist #Medical #Health #Wellness #Pain #ChronicPain #headaches #migraines #migrainerelief #migrainetiktok #Detox #NSAIDs #Fioricet #Fiorinal #Butalbital #Opiates #Opioids ♬ original sound – Virtual Headache Specialist🤯
How Do I Get Out of Rebound Headache?
The chronic daily headaches will never improve until a weaning detoxification from the overused medications happens. It can take 4-6 weeks for improvement to start to occur beginning after there is a consistent detoxification and weaning off or down of the offending medication. This time-frame may vary depending on the medicine used, duration of use, frequency of use, and quantity of use.
It is also important to know that as the patient is weaning and detoxing from the overused medications, headaches will commonly get worse (rebound) before they get better. I always warn patients of this possibility. The hardest part of breaking out of this cycle can be getting through that rebound hump. Unfortunately, there is not typically a “quick fix” for this scenario. However, getting through this rebound phase will be well worth it on the other end once the headaches start to spread out and improve!
This process of weaning and detoxification is most successful when accompanied by the use of preventative daily headache medications. A general slow wean off of overused medications is seen below, and can be adjusted based on quantity and frequency of the overused medication:
Week 1: If using daily, decrease to half (or 2/3rd) of the amount of medication typically used daily (for example, if taking Tylenol 4 times per day, decrease to 2 times per day for the first week).
Week 2: Use no more than 6 days per week.
Week 3: Use no more than 5 days per week.
Week 4: Use no more than 4 days per week.
Week 5: Use no more than 3 days per week.
Week 6: Use no more than 2 days per week or less.
Some people prefer to get through this weaning process faster rather than a slow wean such as this. Some choose to stop their overused medications “cold turkey” to expedite the process. This should be discussed with your physician because it can be medically unsafe to abruptly stop some medications such as fioricet, fiorinal, butalbital, opioids and opiates which can result in seizures, irregular heart rhythms, blood pressure changes, or other life-threatening withdrawal syndromes.
A “bridging” medication to help “bridge” out of this cycle is often used, or provided as a rescue to save for use during a slow wean to take if the rebound headache becomes intolerable. These bridging rescue medications may include a course of steroids, NSAIDs, IV infusions, or many other options depending on what medicine is being weaned and other medical conditions present. There are other tricks such as weaning off excessive use of butalbital medications (fioricet, fiorinal) by changing to phenobarbital and weaning off from that. However, faster strategies must be performed with close instruction from your physician (as should weaning from any type of medicine).
The bottom line is that it can be a painful, frustrating, and challenging process to pull out of a rebound/MOH cycle. So hang in there and stick with it because once you successfully get out of this rut, you’ll be happy you did!
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