Medication overuse headaches

Date Updated: 12/08/2020

Overview

Medication overuse headaches or rebound headaches are caused by regular, long-term use of medication to treat headaches, such as migraines. Pain relievers offer relief for occasional headaches. But if you take them more than a couple of days a week, they may trigger medication overuse headaches.

If you have a headache disorder, any medication you take for pain relief can cause rebound headaches. Pain relievers taken regularly for another condition, such as arthritis, haven't been shown to cause medication overuse headaches in people who never had a headache disorder.

Medication overuse headaches usually stop when you stop taking pain medication. It's tough in the short term, but your doctor can help you beat medication overuse headaches for long-term relief.

Symptoms

Signs and symptoms of medication overuse headaches may differ according to the type of original headache being treated and the medication used. Medication overuse headaches tend to:

Occur every day or nearly every day, often waking you in the early morning
Improve with pain relief medication but then return as your medication wears off

Other signs and symptoms may include:

Nausea
Restlessness
Difficulty concentrating
Memory problems
Irritability

When to see a doctor

Occasional headaches are common. But it's important to take your headaches seriously. Some types of headaches can be life-threatening.

Seek immediate medical care if your headache:

Is sudden and severe
Accompanies a fever, stiff neck, rash, confusion, seizure, double vision, weakness, numbness or difficulty speaking
Follows a head injury
Gets worse despite rest and pain medication
Is a new type that's persistent, especially in someone older than 50
Occurs with shortness of breath
Happens when you're upright but goes away if you're lying flat

Consult your doctor if:

You usually have two or more headaches a week
You take a pain reliever for your headaches more than twice a week
You need more than the recommended dose of over-the-counter pain remedies to relieve your headaches
Your headache pattern changes

Causes

Doctors don't yet know exactly why medication overuse leads to rebound headaches. The risk of developing medication overuse headaches varies depending on the medication, but any acute headache medication has the potential to lead to medication overuse headaches, including:

Simple pain relievers. Common pain relievers such as aspirin and acetaminophen (Tylenol, others) may contribute to medication overuse headaches — especially if you exceed the recommended daily dosages. Pain relievers such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) have a low risk of contributing to medication overuse headaches.
Combination pain relievers. Over-the-counter (OTC) pain relievers that combine caffeine, aspirin and acetaminophen (Excedrin, others) are common culprits.

This group also includes prescription medications such as Fiorinal, which contains the sedative butalbital. Butalbital-containing compounds have an especially high risk of causing medication overuse headaches, so it's best not to take them to treat headaches.
Migraine medications. Various migraine medications have been linked with medication overuse headaches, including triptans (Imitrex, Zomig, others) and certain ergots — such as ergotamine (Ergomar, others). These medications have a moderate risk of causing medication overuse headaches. The ergot dihydroergotamine (D.H.E. 45) appears to have a lower potential for leading to this problem.
Opiates. Painkillers derived from opium or from synthetic opium compounds include combinations of codeine and acetaminophen (Tylenol with Codeine No. 3 and No. 4, others). These medications have a high risk of causing medication overuse headaches.

Daily doses of caffeine — from coffee, soda, and pain relievers and other products containing this mild stimulant — may fuel medication overuse headaches, as well. Read product labels to make sure you're not wiring your system with more caffeine than you realize.

Risk factors

Risk factors for developing medication overuse headaches include:

History of chronic headaches. A history of chronic headaches, especially migraines, puts you at risk.
Frequent use of headache medications. Your risk increases if you use combination analgesics, ergotamine or triptans 10 or more days a month or simple analgesics more than 15 days a month — especially if this regular use continues for three or more months.

Prevention

To help prevent medication overuse headaches:

Take your headache medication as prescribed.
If you need headache medication more than twice a week, contact your doctor.
Avoid medications that contain butalbital or opioids.
Use OTC painkillers less than 15 days a month.
Limit use of triptans or combination analgesics to no more than nine days a month.

Taking care of yourself can help prevent most headaches.

Avoid headache triggers. If you're not sure what triggers your headaches, keep a headache diary with details about every headache. Eventually, you may see a pattern.
Get enough sleep. Go to bed and wake up at the same time every day — even on weekends.
Don't skip meals. Start your day with a healthy breakfast. Eat lunch and dinner at about the same time every day.
Stay hydrated. Be sure to drink plenty of water or other uncaffeinated fluids.
Exercise regularly. Physical activity causes your body to release chemicals that block pain signals to your brain. With your doctor's OK, choose activities you enjoy — such as walking, swimming or cycling.
Reduce stress. Get organized. Simplify your schedule, and plan ahead. Try to stay positive.
Lose weight. Obesity can contribute to headache development, so if you need to lose weight, find a program that works for you.
Quit smoking. If you smoke, talk to your doctor about quitting. Smoking is linked to a higher risk of medication overuse headaches.

Diagnosis

Your doctor can usually diagnose medication overuse headaches based on a history of chronic headaches and frequent use of medication. Testing usually isn't necessary.

Treatment

To break the cycle of medication overuse headaches, you'll need to restrict your pain medication. Depending on the drug you're taking, your doctor may recommend stopping the medication right away or gradually reducing the dose.

Breaking the cycle

When you stop your medication, expect your headaches to get worse before they get better. Drug dependency may be a risk factor for drugs that result in medication overuse headaches, and you may have withdrawal symptoms such as:

Nervousness
Restlessness
Nausea
Vomiting
Insomnia
Constipation

These symptoms generally last from two to 10 days, but they can persist for several weeks.

Your doctor may prescribe various treatments to help alleviate headache pain and the side effects associated with drug withdrawal. This is known as bridge or transitional therapy. Treatments may include nonsteroidal anti-inflammatory drugs, corticosteroids or dihydroergotamine, an ergot that may be given through a vein (intravenously).

There's debate over how much benefit bridge therapy may offer, and whether or not one drug is more effective than others. Withdrawal headaches tend to improve in less than a week.

Hospitalization

Sometimes it's best to be in a controlled environment when you stop taking pain medication. A short hospital stay may be recommended if you:

Have other conditions, such as depression or anxiety
Are taking high doses of drugs that contain opiates or the sedative butalbital
Are abusing substances such as tranquilizers, opioids or barbiturates

Preventive medications

Preventive medications may help you break the cycle of medication overuse headaches. Work with your doctor to avoid relapsing and to find a safer way to manage your headaches. During or after withdrawal, your doctor may prescribe any of the following daily preventive medications:

An anticonvulsant such as topiramate (Topamax, Qudexy XR, Trokendi XR)
A tricyclic antidepressant such as amitriptyline or nortriptyline (Pamelor)
A beta blocker such as propranolol (Inderal, Innopran XL)
A calcium channel blocker, such as verapamil (Calan, Verelan, others)

These medications can help control your pain without risking medication overuse headaches. If you're careful, you may be able to take a medication specifically meant for pain during future headache attacks. Be sure to take medications exactly as prescribed.

Injections

Injections of onabotulinumtoxinA (Botox) may help reduce the number of headaches experienced per month as well as headache severity.

Cognitive behavioral therapy (CBT)

During this talk therapy, you learn ways to cope with your headaches. In CBT, you also work on healthy lifestyle habits and keeping a headache diary.

Alternative medicine

For many people, complementary or alternative therapies offer relief from headache pain. However, not all complementary or alternative therapies have been studied as headache treatments, and others need further research. Discuss the risks and benefits of complementary therapy with your doctor.

Possible therapies include:

Acupuncture. This ancient technique uses fine needles to promote the release of natural painkillers and other chemicals in the central nervous system. This therapy may ease headaches.
Biofeedback. Biofeedback teaches you to control certain body responses that help reduce pain. During a session, you're connected to devices that monitor and give you feedback on body functions, such as muscle tension, heart rate and blood pressure. You then learn how to reduce muscle tension and slow your heart rate and breathing to help you relax, which may help you cope with pain.
Herbs, vitamins and minerals. Some dietary supplements — including magnesium, riboflavin (vitamin B2), feverfew and coenzyme Q10 — seem to help prevent or treat some types of headaches, but there's little scientific support for these claims. If you're considering using supplements, check with your doctor. Some supplements may interfere with other drugs you take or have other harmful effects.

Coping and support

You may find it helpful to talk to other people who've been through the same experience you're having. Ask your doctor if there are support groups in your area, or contact the National Headache Foundation at www.headaches.org or 888-643-5552.

Preparing for an appointment

You're likely to start by seeing your family doctor or a general practitioner. You may then be referred to a doctor who specializes in nervous system disorders (neurologist).

Here's some information to help you get ready for your appointment.

What you can do

Keep a headache diary. Write down your symptoms, even those that seem unrelated to headaches. Note what you were doing, eating or drinking before the headache began, how long the headache lasted, and the medications and amounts you took to treat the headache.
Write down key personal information, including major stresses or recent life changes.
List questions to ask your doctor.

For medication overuse headaches, some questions to ask your doctor include:

How could I cause a headache with medicine I took to treat a headache?
Could there be other reasons for my headaches?
How can I stop these headaches?
Are there alternatives to the approach you're suggesting?
If my original headaches return, how can I treat them?
Are there brochures or other printed material I can have? What websites do you recommend?

Don't hesitate to ask any other questions.

What to expect from your doctor

The doctor will ask questions about your headaches, such as when they started and what they feel like. The more the doctor knows about your headaches and medication use, the better care he or she will be able to provide. Your doctor may ask:

What type of headache do you usually have?
Have your headaches changed in the past six months?
How severe are your symptoms?
What headache medications do you use, and how often?
Have you increased the amount or frequency of taking them?
What side effects have you had from medications?
Does anything help improve your symptoms?
What, if anything, appears to worsen your symptoms?

What you can do in the meantime

Until your appointment, take your medication only as directed by your doctor, and take care of yourself. Healthy lifestyle habits — such as getting adequate sleep, eating plenty of fruits and vegetables, and getting regular exercise — can help prevent headaches. Avoid any known headache triggers.

A headache diary can be very helpful for your doctor. Keep track of when your headaches occur, their severity and duration, what you were doing when the headache began, and what your response to the headache was.