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Rebound Headache
Aka: Rebound Headache, Rebound Migraine, Analgesic Overuse Headache, Medication Overuse Headache, Analgesic Rebound Headache
- See Also
- Medication Causes of Headache
- Migraine Headache
- Migraine Headache Management
- Acute Recurrent Headache
- Headache
- Chronic Non-Progressive Headache
- Definitions
- Medication Overuse Headache
- Headache on 15 or more days of the month with known preexisting Primary Headache AND
- Regular overuse of abortive Headache medication over 3 months
- Opioids, Ergotamine and Triptans >10 days/month
- Nonopiate Analgesics (e.g. NSAIDS, Excedrin) >15 days per month
- Epidemiology
- Accounts for 30-50% of chronic Headache patients
- See Chronic Non-Progressive Headache
- Pathophysiology
- Excessive use of Migraine Abortive Treatment medication
- Use more than 15-20 days per month confers risk
- Butalbital (Fiorinal) >5 days/month
- Opioids >8 days/month
- Triptans >10 days/month
- Nonopiate Analgesics (e.g. NSAIDS, Excedrin) >15 days per month
- Drug dependent pattern of Headaches
- Increasing tolerance to Headache medication dosages
- Medications most prone to Rebound Headache
- Occurs with all Headache medications
- Butalbital (e.g. Fiorinal): 47%
- Acetaminophen: 45%
- Opioid Analgesics: 31%
- Aspirin: 24%
- NSAIDs: 19%
- Excedrin: 18%
- Ergot alkaloids: 16%
- Triptans: 9%
- Medications containing Caffeine
- Bigal (2004) Cephalgia 24:483-90 [PubMed]
- Symptoms
- Characteristics
- Variable type, severity, and location of Headache
- Timing
- Occur in the early morning (2am - 5am) daily
- Palliative
- Headaches resolve after Pain Medication discontinued
- Refractory to prophylactic medications
- Provocative factors
- Headache is easily precipitated
- Withdrawal symptoms on stopping Pain Medications
- Associated features
- Nausea and other gastrointestinal symptoms
- Asthenia
- Anxiety
- Depression
- Irritability
- Memory and concentration problems
- Neck Pain
- Vasomotor symptoms (Rhinorrhea, nasal congestion)
- Common presentations
- Often presents to ER requesting Opioids
- Diagnosis: Medication Overuse Headache
- Questions
- "Do you take a treatment for Headache attacks on more than 10 days per month?"
- "Do you do this on a regular basis?"
- Interpretation: Identifies Medication Overuse Headache in patient with frequent Migraine
- Test Sensitivity: 95.2%
- Test Specificity: 80%
- References
- Dousset (2013) J Headache Pain 14:81 [PubMed]
- Diagnosis: Drug Use Disorder
- Drug use disorder is commonly comorbid
- Questions
- "How many times in a year have used an illegal drug or used a prescription medication for non-medical use?"
- Interpretation: Drug Use Disorder
- Test Sensitivity: 100%
- Test Specificity: 74%
- References
- Smith (2010) Arch Intern Med 170(13):1155-60 [PubMed]
- Management
- Analgesic Withdrawal
- Most medications may be stopped abruptly
- Non-Opioid Analgesics (e.g. nsaids)
- Triptans
- Gradually taper over 5 weeks (risk of withdrawal)
- Opioids
- Barbiturates
- Ergot alkaloids
- Benzodiazepines
- Caffeine
- Provide non-Opioid rescue medications during withdrawal
- Antiemetics (metoclopramide, Promethazine)
- Antihistamines (Diphenhydramine or Hydroxyzine)
- Most effective adjunctive withdrawal agents
- Prednisone 60 mg daily for 5 days (caution, due to adverse effects)
- Migraine Prophylaxis agents
- Topiramate (Topomax) 100-200 mg daily
- Amitriptyline 50 mg daily
- References
- Evers (2011) Eur J Neurol 18(9): 1115-21 [PubMed]
- Initiate Headache prophylaxis simultaneously with withdrawal
- Decreases Headache frequency and sustains resolution of Medication Overuse Headaches
- Beta blocker Migraine Prophylaxis was used in this study
- Carlsen (2020) JAMA Neurol 77(9): 1069-78 [PubMed]
- Other measures with limited evidence
- Consider switching from Triptan to Rimegepant or Ubrogepant
- Botulinum Toxin Injection
- Valproate
- Munksgaard (2019) Acta Neurol Scand 139(5): 405-14 [PubMed]
- Management: Older Withdrawal Regimens (use with caution)
- Displayed for historical purposes and for additional strategies
- Many of the medications listed here have been replaced (e.g. fiorinal, Ergotamine)
- Withdrawal from Simple Analgesics
- Protocol
- Choose 1 medication from Group A and B
- Take bridge medication (Group B) on schedule
- Take rescue medication (Group A) as needed
- Only use for severe Headache
- Limit to twice weekly
- Group A: Rescue - Migraine specific medications
- Dihydroergotamine (DHE) or
- Long-acting Triptan (e.g. Amerge, Frova) or
- Midrin 1 PO tid for 1 week
- Group B: Bridge - Antiinflammatory medications
- NSAIDs for 3-6 weeks on schedule
- Naproxen 500 mg bid
- Nabumetone 750 mg/day
- Prednisone protocol
- Prednisone 60 mg qd for 2 days then
- Prednisone 40 mg qd for 2 days then
- Prednisone 20 mg qd for 2 days then
- Consider Ranitidine concurrently with Prednisone
- Dose: 150 mg PO bid for 6 days
- Triptan (not FDA approved)
- Use bid until 48 hours Headache-free (10 day max)
- Group C: Miscellaneous medications to consider
- Start Elavil at bedtime
- Cyproheptadine (Periactin) 4 mg PO tid
- References
- Maizels (2004) Am Fam Physician 70:2299-6 [PubMed]
- Withdrawal from Butalbital medication (e.g. Fiorinal)
- Consider Detoxification program
- Indicated for more than 8 Butalbital pills per day
- Midrin or Periactin at doses above
- Phenergan 25-50 mg tid prn for 1 to 2 weeks
- Clonazepam 0.5-1.0 mg PO for 1 week, then taper
- Phenobarbital 30 mg PO tid for 1 week
- Withdrawal from Ergotamine medications
- Consider inpatient withdrawal
- Indicated for more than 1.0 mg Ergotamine per day
- Naproxen (Anaprox) 500-1000 mg daily for 1-3 weeks
- Methylergonovine (Methergine) 0.2-0.4 mg tid
- Phenergan 25-50 mg tid for 1-2 weeks
- Withdrawal from Codeine containing Analgesics
- Clonidine 0.1-0.2 mg tid for 1-2 weeks, then taper
- Naproxen 500-1000mg qd for 1-3 weeks
- Promethazine 25-30 mg tid prn for 1-2 weeks
- Prevention
- Maximize Migraine Prophylaxis
- Limit acute Migraine abortive medications to 10 days per month or 2 days per week
- Long acting NSAIDs may be less likely than other simple Analgesics to cause Rebound Headaches
- Avoid butalbital (fiorinal) for Headaches
- Get control of Migraine Headaches soon after episode onset (e.g. start Triptan at higher, effective dose early)
- Reference
- (2022) Presc Lett 29(4): 19-20
- Mathew (1997) Neurol Clin 15(1):167-86 [PubMed]
- Millea (2002) Am Fam Physician 66:797-805 [PubMed]
- Walling (2020) Am Fam Physician 101(7):419-28 [PubMed]