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Analgesic Rebound Headache
Medication Overuse Headache – Rebound Headaches due to Triptans, Butalbital, Acetaminophen, Narcotics – Treatment
Analgesic Rebound Headache
Rebound headache is a unique pain syndrome. Rebound headache is caused by a dependence on pain medications. Those medications responsible for the rebound headache don’t have to be addictive otherwise.
The headache comes either daily or close to daily. Heavy sensation in the head and poorly localized head pain are the most common complaints. Taking pain killers calms the headache for some time but it comes back once the medication effect wears off. The next dose has to be taken in a few hours or the following day.
This cycle repeats itself over and over for months and years. Even if the headache does not go away with the pain killers – they are taken anyway.
Only certain drugs may produce rebound headaches. NSAIDs such as Ibuprofen, Naproxen, or Diclofenac, for example, don’t cause any rebound headaches.
Rebound headaches are produces by frequently taken substantial doses of pain killers. The word “substantial” meaning would vary depending on the medication it is applied to. For Sumatriptan it would be 1 every other day. For Tylenol it might mean 8 pills per day 4 times a weak. For Fioricet even 2 pills per week is enough.
Who Gets Affected by Rebound Headaches
The most typical victims of rebound headaches are patients with other headache syndromes, such as migraine. Not unusual, though, to see a patient with no other headache varieties. The chain of events can be triggered by a head injury, viral disease, depression, or an episodic tension headache leading to the years of self-treatment.
From my own observations, rebound headache is frequently either under-diagnosed or over-diagnosed. Not all the people, who are popping pills, have rebound headaches. Chronic migraine, for example, can be easily confused with rebound headaches.
A true rebound headache is not as common as it is suspected. On the other hand, it is not unusual to see patients who are prescribed Fioricet for years.
Cause and Mechanism of Rebound Headache
Regularly taken pain medications alter the brain pain processing mechanism leading to a bizarre type of dependence. The most common drugs responsible for rebound headache are Tylenol (Acetaminophen), Aspirin, Caffeine and their combinations, Paracetamol (not available in the US), Narcotics, Triptans and Butalbital.
Ability to cause chronic pain syndrome varies widely among these medications. Tylenol (Acetaminophen) causes rebound headaches if taken at least every other day. Narcotics and Triptans require 8 to 10 days per month in order to cause a rebound headache.
Butalbital is the worst offender – 5 days of use per month may produce a chronic pain syndrome. Butalbital is a component of Fioricet and Fiorinal prescription drugs. Most countries, but the US, have abandoned this drug.
Association of rebound headache with depression and sleep disturbance often complicates the mater. Chronic daily headache is extremely common in depression. Depressed people sometimes take large amounts of pain killers due to variable pain syndromes. It is hard to say whether the headache is related to depression or to medication overuse.
Treatment of Rebound Headache
Treatment of rebound headaches is a frustrating experience for both – patients and doctors. Some patients are in denial and are unwilling to accept the fact that pain their medications are responsible for the chronic suffering.
Other patients are aware about the cause of the problem but clearly state that abstinence from the pain medications is not an option for them.
Very few are truly surprised by this new discovery and are willing to participate in the most logical treatment.
The best approach is quitting the offending medication in a “cold turkey” style. From my experience, gradual dose decrease does not do better than quitting smoking by decreasing the number of cigarettes per day.
Patients who do stop the medications report no horrible experience. The headache may get slightly worse for a day or two but it gradually subsides later on.
Cold turkey approach is contraindicated in Butalbital dependence due to potential life threatening barbiturates withdrawal symptoms (seizures).
Chronic migraine with overuse of pain killers requires more complex individual approach. Pain medications withdrawal has to be accompanied by an induction of a migraine preventive treatment.
Those occasional patients who do allow to be weaned off the pain killers often go back on the same medication months or years later.
My perception is that patients with rebound headaches are conditioned to take pain killers in response to any type of stress or discomfort. There is a strong association of rebound headache with anxiety, depression, multiple chronic medical conditions, and other chronic pain syndromes. Rationalization and explanation do not help much. These patients often agree with all the doctor’s arguments while in the office but they go back to the same routine as soon as they are left alone.
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