Medication Overuse Headache
Britt Talley Daniel, M. D.
Dallas, Texas, 75230
Medication Overuse Headache
The International Classification of Headache III describes Medication Overuse Headache (MOH), old name Rebound Headache, as a syndrome related to overtreating. Chronic Daily Headache is a term that implies having headache over 15 days a month, 8 of which are like migraine. 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 to 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 to a chronic 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. 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 features to this syndrome:
1. Daily or very frequent headaches which may come with sensitivity to light and sound, nausea, and irritability
2. This syndrome causes serotonin, a calming brain neurochemical, levels to drop so the patient may also develop anxiety, depression, poor concentration, panic attacks, and insomnia, which also are core symptoms of the disorder.
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, Triptans—Imitrex, Maxalt, Zomig, Axert, Frova, Relpax, or Amerge; NSAIDS—(Nonsteroidal Anti-inflammatory Drugs) such as Motrin (ibuprofen, Advil), Naprosyn/Anaprox (Alleve), Miloxicam, and Tylenol; Narcotics—Vicodin (hydrocodone, Narco), Tramadol, Demerol, Nucynta, OxyContin, Tylenol with codeine; Drugs with barbiturates-- Fiorinal, Fioricet, Phrenilin, Esgic, generic butalbital.
The International Headache Society criteria for medication overuse headache are:
Triptans or Ergotamine intake >10 days/month (like sumatriptan)
Non-opioid simple analgesics >15days/month (like Tylenol, caffeine, or Advil)
Opioids or Analgesics combined with barbiturates >10days/month
The best 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 is treated with cortisone, also called “Bridge Medication” a terrific headache would come after stopping their pain killers. The patient should stay off all pain killers on the list above during this time. Cortisone treatment may be: one or two weeks dose of oral cortisone, as prednisone 20 mg 3X/day for 7 days or Medrol Dosepak, for the chemical brain inflammation. For spikes of headache DHE given IM or as Migranol nasal spray every 3 hours, or Timidol eye drops, or Alleve may be used 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 previous medication abuse. Clearing may be noted by 5 headache free days after which regular acute migraine Rx may resume. After this the patient should limit painkillers to no more than 2 days/ week for the rest of their life. Preventive medications such as topiramate, amitriptyline, valproic acid, or beta-blockers should be started to reduce the number of monthly migraines. 50% of patients with MOH have depression, 40% have generalized anxiety disorder (GAD) or panic disorder which may need treatment and 50% of patients with MOH get it again.
Stop the following drugs:
Do: the migraine lifestyle—www.doctormigraine.com
Take: For prevention 10 mg amitriptyline every night for the next few months, a drug which can decrease migraine by 50 % and promote sleep, or propranolol, topiramate, or Depakote (not for fertile women.)
For acute treatment either Migranol Nasal Spray every 3 hours as needed, or DHE 1cc Intramuscularly every 6 hours as needed, or Timidol eye drops 0.25% sol, 1 in each eye as needed for headache, may repeat in 1 hour, or if too expensive—take Alleve (naproxen) 200 mg every 12 hours once or twice a week.
For reduction of brain inflammation- either 20 mg or prednisone 3X a day for 7 days or a Medrol dose pack.
For nausea use either Zofran 4 mg every 4-6 hours or Phenergan 25 mg orally every 4-6 hours.
Be patient with this problem, it takes a while to improve and the time depends upon how long you have taken the offending drug and which drug you have used. For example, 3 weeks of overtreatment with caffeine or Advil may take 2-3 weeks to clear, while 12 months of butalbital 2-3/day may take 2-3 months.
Try to regularize your life during the detox time—rest your eyes and your body, but don’t sleep during the day (maintain a normal sleep/wake schedule.) Stay hydrated with fluids.
Other treatments that may help headache are ice packs, lying down with your eyes closed for a short rest, prayer, and mild exercise. Don’t develop the practice of treating every headache with medication, try to bear through some of them without treatment.
Migraine in the brain has 4 stages: 1 Trigeminal activation, the sensory pain fibers in the fifth cranial nerve send pain to the face or back of the head, usually on one side, 2 within 20-40 minutes the ganglia in the brain of the trigeminal nerve and the arteries start to release 3 toxic neurochemicals which last 3 days and inflame the brain and dilate the arteries, 3 at 2 hours arterial vasodilatation occurs with the pulsing blood from the heart stretching the chemically inflamed arteries, 4 the thalamus, which is the pain center of the brain, is inflamed by the chemicals and migraine process usually about 3-4 hours into the headache causing severe, level 10 pain headache and allodynia (the head is sensitive to touch.)