Headache

Rebound Headache

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Rebound Headache, Rebound Migraine, Analgesic Overuse Headache, Medication Overuse Headache, Analgesic Rebound Headache

  • Pathophysiology
  1. Excessive use of Migraine Abortive Treatment medication
    1. Use more than 15-20 days per month confers risk
    2. Butalbital (Fiorinal) >5 days/month
    3. Opioids >8 days/month
    4. Triptans, NSAIDS, Excedrin (or other combinations) >10 days/month
  2. Drug dependent pattern of Headaches
  3. Increasing tolerance to Headache medication dosages
  4. Medications most prone to Rebound Headache
    1. Occurs with all Headache medications
    2. Butalbital (e.g. Fiorinal): 47%
    3. Acetaminophen: 45%
    4. Narcotic Analgesics: 31%
    5. Aspirin: 24%
    6. NSAIDs: 19%
    7. Excedrin: 18%
    8. Ergot alkaloids: 16%
    9. Triptans: 9%
    10. Medications containing Caffeine
    11. Bigal (2004) Cephalgia 24:483-90 [PubMed]
  • Symptoms
  1. Characteristics
    1. Variable type, severity, and location of Headache
  2. Timing
    1. Occur in the early morning (2am - 5am) daily
  3. Palliative
    1. Headaches resolve after pain medication discontinued
    2. Refractory to prophylactic medications
  4. Provocative factors
    1. Headache is easily precipitated
    2. Withdrawal symptoms on stopping pain medications
  5. Associated features
    1. Nausea and other gastrointestinal symptoms
    2. Asthenia
    3. Anxiety
    4. Depression
    5. Irritability
    6. Memory and concentration problems
  6. Common presentations
    1. Often presents to ER requesting Narcotics
  • Management
  1. General
    1. Most medications may be stopped abruptly
      1. Non-Opioid Analgesics
      2. Triptans
    2. Gradually taper over 5 weeks (risk of withdrawal)
      1. Narcotics
      2. Barbiturates
      3. Ergot alkaloids
      4. Benzodiazepines
      5. Caffeine
    3. Provide non-Narcotic rescue medications
      1. Migraine-specific medications (see below)
      2. Toradol
      3. Antiemetics
      4. Diphenhydramine or Hydroxyzine
  2. Withdrawal from Simple Analgesics
    1. Protocol
      1. Choose 1 medication from Group A and B
      2. Take bridge medication (Group B) on schedule
      3. Take rescue medication (Group A) as needed
        1. Only use for severe Headache
        2. Limit to twice weekly
    2. Group A: Rescue - Migraine specific medications
      1. Dihydroergotamine (DHE) or
      2. Long-acting Triptan (e.g. Amerge, Frova) or
      3. Midrin 1 PO tid for 1 week
    3. Group B: Bridge - Antiinflammatory medications
      1. NSAIDs for 3-6 weeks on schedule
        1. Naproxen 500 mg bid
        2. Nabumetone 750 mg/day
      2. Prednisone protocol
        1. Prednisone 60 mg qd for 2 days then
        2. Prednisone 40 mg qd for 2 days then
        3. Prednisone 20 mg qd for 2 days then
        4. Consider Ranitidine concurrently with Prednisone
          1. Dose: 150 mg PO bid for 6 days
      3. Triptan (not FDA approved)
        1. Use bid until 48 hours Headache-free (10 day max)
    4. Group C: Miscellaneous medications to consider
      1. Start Elavil at bedtime
      2. Cyproheptadine (Periactin) 4 mg PO tid
    5. References
      1. Maizels (2004) Am Fam Physician 70:2299-6 [PubMed]
  3. Withdrawal from Butalbital medication (e.g. Fiorinal)
    1. Consider Detoxification program
      1. Indicated for more than 8 Butalbital pills per day
    2. Midrin or Periactin at doses above
    3. Phenergan 25-50 mg tid prn for 1 to 2 weeks
    4. Clonazepam 0.5-1.0 mg PO for 1 week, then taper
    5. Phenobarbital 30 mg PO tid for 1 week
  4. Withdrawal from Ergotamine medications
    1. Consider inpatient withdrawal
      1. Indicated for more than 1.0 mg Ergotamine per day
    2. Naproxen (Anaprox) 500-1000 mg daily for 1-3 weeks
    3. Methylergonovine (Methergine) 0.2-0.4 mg tid
    4. Phenergan 25-50 mg tid for 1-2 weeks
  5. Withdrawal from Codeine containing Analgesics
    1. Clonidine 0.1-0.2 mg tid for 1-2 weeks, then taper
    2. Naproxen 500-1000mg qd for 1-3 weeks
    3. Promethazine 25-30 mg tid prn for 1-2 weeks
  • Prevention
  1. Limit acute Migraine abortive medications to 10 days per month or 2 days per week
  2. Long acting NSAIDs may be less likely than other simple Analgesics to cause Rebound Headaches
  3. Avoid butalbital (fiorinal) for Headaches
  4. Migraine Prophylaxis