Britt Talley Daniel M.D.
7777 Forest Lane Suite B-220
Dallas, Texas 75230
Medication Overuse Headache
The International Classification of Headache II describes medication overuse headache (MOH), formerly known as rebound headache, as a syndrome related to overtreating with painkillers, triptans, or over the counters. Chronic Daily Headache is a term that implies having headache over 15 days a month, 8 of which have migraine features. A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly. MOH may come from overtreating with simple pain killers like caffeine, Tylenol or Advil, opioid narcotics, pain killers with barbiturates, or triptans. Patients typically rotate different drugs and take many drugs at the same time that may cause MOH. After awhile the preexisting headache problem, which is usually migraine, but may also be tension type headache, becomes transformed from an intermittent, like once a week or a month, to a chronic every day or multiple times a week headache problem. It is like what happens to the patient who drinks a lot of coffee every day and then gets a headache when they don’t drink coffee. When the brain becomes sensitized to these drugs, repeat dosing causes neuro-inflammatory chemicals to be released in the brain which keeps the headache going.
There are two main clinical features of medication overuse headache:
1. The patient develops a constant, daily or near daily headache problem usually in the neck or one side of the head often times with sensitivity to light or sound, nausea, and irritability.
2. Because serotonin levels in the brain drop, the patient may also develop anxiety, depression, panic attacks, poor concentration, and insomnia, which also are core symptoms.
Drugs that can cause this syndrome are:
Caffeine, such as Excedrin, BC Powder, Vanquish; pseudoephedrine (Sudafed) the decongestant in over the counter sinus meds, such as Tylenol sinus or Advil sinus, or the D in Allegra-D; Ergotamine drugs—Cafergot, Wigraine; Triptans—Imitrex (sumatriptan), Treximet, Maxalt (rizatriptan), Zomig (zomatriptan), Axert (almotriptan), Frova (frovatriptan), Relpax (eletriptan), or Amerge (naratriptan). NSAIDS—(Nonsteroidal Anti-inflammatory Drugs) such as Motrin (ibuprofen, Advil), Naprosyn/Anaprox (Alleve), and Tylenol (acetaminophen), Narcotics—Vicodin (hydrocodone, Narco), Demerol, MS OxyContin, Tylenol with codeine, Drugs with barbiturates– Fiorinal, Fioricet, Phrenilin, Esgic.
The International Headache Society criteria for medication overuse headache are:
Triptans or Ergotamine intake 1 pill >10 days/month
Non-opioid simple analgesics 1 pill>15days/month
Opioids or Analgesics combined with barbiturates 1 pill >10days/month
Medication overuse headache may develop with the use of any of the drugs listed above more than 2 days per week. The limit here is two days a week for: hydrocodone, butalbital, triptans, advil and other over the counter medications, or caffeine. Many patients are drinking 1-2 cups of home coffee a day which is 130-260 mg of caffeine. Then if a migraine attack comes and the patient takes medication for more than 2 days the brain is sensitized to release the inflammatory neurochemicals–CGRP, substance P, and neurokinans. The patient is then set up for a revolving repeat performance of irritability, migraine headache, and repeat neurochemical release that won’t stop until the offending drugs are stopped. I’ve seen a patient taking Advil 6-8 every day for headache develop medication overuse headache from age 6 to age 60 when I met her. She improved just by stopping Advil after several weeks.
The only effective treatment for medication overuse headache is stopping the offending drugs, usually on 1 day, or sometimes by tapering over several weeks if the patient has been on a high dose of an opioid or barbiturate for a long time. Unless the patient was treated with “Bridge Medication” a terrific headache would come after stopping medication and then the headache would clear. The patient has to stay off any drug on the list above during this time. Bridge medication is: one or two weeks dose of oral prednisone or Medrol Dosepak, for the chemical brain inflammation and DHE as Migranol nasal spray or intramuscularly every 3 hours as needed for acute treatment of headache. The time for clearing of MOH varies from several weeks to 1-2 months, depending on the type, amount, and duration of medication abuse. Clearing may be noted by 5 headache free days after which regular acute migraine Rx may resume. The patient should limit painkillers to no more than 2 days/ week for the rest of their life. The patient with medication over use headache should be given a preventive medication such as topiramate, amitriptyline, depakote, or a beta-blockers to reduce the number of monthly migraines. 40% of patients with MOH have generalized anxiety disorder (GAD) or panic disorder and 50% have depression which may need treatment. 50% of patients with MOH will get it again, usually at a time when they just don’t limit headache medication to only 2 days a week.