Medication overuse headaches

Medication overuse headaches are the result of the long-term use of medicines needed to treat headaches such as migraines. It's OK to take pain relievers for headaches sometimes. But people who take them more than a couple of days a week may get medication overuse headaches, also called rebound headaches.

For people with a headache condition such as migraine, most medicines for pain relief can have this effect. This doesn't seem true for people who have never had a headache condition. But people with a history of headaches who take pain relievers regularly for another condition, such as arthritis, may get medicine overuse headaches.

Medication overuse headaches most often go away after stopping the pain medicine. This can make it challenging to manage pain in the short term. But your healthcare professional can help you find ways to prevent medication overuse headaches.

Symptoms of medication overuse headaches depend on the type of headache being treated and the medicine used. Medication overuse headaches tend to:

• Happen every day or nearly every day. These headaches often wake people from sleep.
• Improve with pain medicine but then return as the medicine wears off.

Other symptoms may include:

• Nausea.
• Restlessness.
• Trouble concentrating.
• Memory problems.
• Irritability.

When to see a doctor

It's common to have some headaches. But take headaches seriously. Some types of headaches can be life-threatening.

Seek immediate medical care if your headache:

• Is sudden and very bad.
• Happens with a fever, stiff neck, rash, confusion, seizure, double vision, weakness, numbness or trouble speaking.
• Follows a head injury.
• Gets worse even with rest and pain medicine.
• Is a new type of headache that's lasting, especially in people older than 50.
• Happens with shortness of breath.
• Happens when upright but goes away when lying flat.

Talk with your healthcare professional if:

• You 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 dose you're supposed to take of pain medicines you get without a prescription to relieve your headaches.
• Your headache pattern changes.

Experts don't know exactly why medication overuse headaches happen. The risk of getting these headaches varies depending on the medicine. But most headache medicines can lead to medication overuse headaches, including:

• Simple pain relievers. Common pain relievers such as acetaminophen (Tylenol, others), (Advil, Motrin IB, others) and naproxen sodium (Aleve) have a low risk of causing medication overuse headaches. Taking more than the daily dosages raises the risk.

• Combined pain relievers. Pain relievers you can buy at the store that combine caffeine, aspirin and acetaminophen (Excedrin) have a moderate risk of causing medication overuse headaches.

  This group also includes combined prescription medicines that have the sedative butalbital (Butapap, Lanorinal, others). Medicines with butalbital have a high risk of causing medication overuse headaches. It's best not to take them to treat headaches.

• Migraine medicines. Triptans (Imitrex, Zomig, others) used to treat migraine have a high risk of medication overuse headaches. The ergot dihydroergotamine (Migranal, Trudhesa) appears to have a lower risk of causing medication overuse headaches.

  A newer group of migraine medicines known as gepants don't seem to cause medication overuse headaches. Gepants include ubrogepant (Ubrelvy), rimegepant (Nurtec ODT) and zavegepant (Zavzpret).

• Opioids. Painkillers made from opium or from human-made opium compounds have a high risk of causing medication overuse headaches. They include oxycodone (Oxycontin, Roxicodone, others) hydrocodone, tramadol (Conzip, Qdolo, others), and combined codeine and acetaminophen. Taking them 10 or more days a month can lead to medication overuse headaches.

Risk factors for getting medication overuse headaches include:

• Long-term history of headaches. A long-term history of headaches, especially migraines, raises the risk. Medication overuse headache often occurs when a headache condition such as migraine is not well controlled and may make the underlying headache condition difficult to treat.
• Regular use of headache medicines. Your risk goes up if you use combined painkillers, opioids, ergotamine or triptans 10 or more days a month. Risk also rises if you use simple painkillers more than 15 days a month. This is especially true if you use these medicines for three months or longer.
• History of substance use disorders. A history of alcohol use disorder or another substance use disorder puts you at risk.

To help prevent medication overuse headaches:

• Take your headache medicine as prescribed.
• Contact your healthcare professional if you need headache medicine more than twice a week.
• Don't take medicines that have butalbital or opioids if possible.
• Use painkillers you can get without a prescription fewer than 14 days a month.
• Limit use of triptans or combined pain relievers to no more than nine days a month.

Taking care of yourself can help prevent most headaches.

• Stay away from headache triggers. If you're not sure what triggers your headaches, keep a headache diary. Write down details about every headache. 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 fluids that don't have caffeine.
• Exercise regularly. Physical activity causes the body to release chemicals that block pain signals to the brain. With your healthcare professional's OK, choose activities you enjoy. You might walk, swim or cycle.
• Lower stress. Make your schedule simpler. Plan your day. Try to stay positive.
• Lose weight. Obesity can add to headaches. If you need to lose weight, ask your healthcare professional to help you find a program that works for you.
• Quit smoking. If you smoke, talk to your healthcare professional about quitting. Smoking is linked to a higher risk of medication overuse headaches.
• Limit caffeine. Daily doses of caffeine also may add to medication overuse headaches. Caffeine may come from coffee, soda, pain relievers and other products. Read product labels to make sure you're not getting more caffeine than you know about.

Your healthcare professional most often can diagnose medication overuse headaches based on your history of headaches and your use of medicine. Most people don't need testing. People who are diagnosed with medication overuse disorder have a headache condition, have headaches on 15 or more days a month for more than three months, and take too much headache medicine.

A vital part of treatment is learning about medication overuse headaches and other ways to relieve pain. To break the cycle of medication overuse headaches, you'll need to stop or cut down on pain medicine. Your healthcare professional may advise stopping the medicine right away or lowering the dose little by little.

Breaking the cycle

When you stop your medicine, expect headaches to get worse before they get better. You may depend on some medicines that result in medication overuse headaches. Withdrawal symptoms may include:

• Nervousness.
• Restlessness.
• Nausea.
• Vomiting.
• Insomnia.
• Constipation.

These symptoms most often last 2 to 10 days. But they may go on for weeks.

Your healthcare professional may prescribe treatments to help with headache pain and the side effects of medicine withdrawal. This is called bridge or transitional therapy. Treatments may include nonsteroidal anti-inflammatory drugs, corticosteroids, nerve blocks and anti-nausea medicines. Your healthcare professional also might suggest that you take the ergot dihydroergotamine through a vein.

Hospitalization

Sometimes it's best to be in a hospital when you stop taking pain medicine. You may have a short hospital stay if you:

• Have other conditions, such as depression or anxiety.
• Are taking high doses of medicines that have opiates or the sedative butalbital.
• Are using substances such as tranquilizers, opioids or barbiturates.

Preventive medicines

Preventive medicines may help you break the cycle of medication overuse headaches and ease the underlying headache condition, such as migraine. Work with your healthcare professional to keep from relapsing and to find a safer way to manage your headaches. During or after withdrawal, your healthcare professional may prescribe a daily medicine to prevent headaches such as:

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

If you have a history of migraine, your healthcare professional might suggest a CGRP monoclonal antibody such as erenumab (Aimovig), galcanezumab (Emgality), fremanezumab (Ajovy) or eptinezumab (Vyepti). People take erenumab, galcanezumab and fremanezumab as shots every month. People take eptinezumab through a vein every three months.

Injections

Shots of onabotulinumtoxinA (Botox) may help lower the number of headaches you have each month. They also may make headaches less severe.

Cognitive behavioral therapy, also called CBT

This talk therapy teaches ways to cope with headaches. In CBT, you also work on healthy lifestyle habits and keep a headache diary.

For many people, complementary or alternative therapies offer relief from headache pain. But not all these therapies are backed by studies. Some therapies need more research. Discuss the pros and cons of complementary therapy with your healthcare professional.

Possible therapies include:

• Acupuncture. Acupuncture uses fine needles to put into the skin to release natural painkillers in the body. For some people, this therapy eases headaches.
• Biofeedback. Biofeedback teaches control of certain body responses that help ease pain. During biofeedback, you're connected to devices that keep track of those body responses. They give you feedback on your body, including muscle tension, heart rate and blood pressure. You then learn how to ease muscle tension and slow your heart rate and breathing. This helps you relax, which may help you cope with pain.
• Mindfulness. This is a type of meditation in which you focus on what you're sensing and feeling in the moment. Mindfulness involves the use of breathing methods and other ways to relax and lower stress. For some people, this practice may help ease headaches.

• Herbs, vitamins and minerals. Some dietary supplements seem to help prevent or treat certain types of headaches. They include magnesium, feverfew, coenzyme Q10 and riboflavin, also known as vitamin B-2. But there's little scientific support for these claims.

  If you want to try supplements, check with your healthcare professional. Some supplements may get in the way of other medicines you take. Or they may have other harmful effects.

It might help to talk to other people who've had medication overuse headaches. Ask your healthcare professional if there are support groups in your area. Or contact the National Headache Foundation at www.headaches.org or 888-643-5552.

You're likely to start by seeing your main healthcare professional. Your healthcare professional may send you to a doctor who specializes in nervous system disorders, called a 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 did, ate or drank before the headache began. Also note how long the headache lasted. Include the medicines 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 healthcare professional.

For medication overuse headaches, some questions to ask include:

• How does medicine I take to treat headaches cause headaches?
• Could there be other reasons for my headaches?
• How can I stop these headaches?
• If I keep getting headaches, how can I treat them?
• Are there brochures or other printed material I can have? What websites do you suggest?

Be sure to ask all the questions you have.

What to expect from your doctor

Your healthcare professional will ask questions about your headaches, such as when they started and what they feel like. Questions might include:

• What type of headache do you most often have?
• Have your headaches changed in the past six months?
• How bad are your symptoms?
• What headache medicines do you use, and how often?
• Have you increased the amount of headache medicines you take or how often you take them?
• What side effects have you had from medicines?
• Does anything make your symptoms better?
• What, if anything, makes your symptoms worse?

What you can do in the meantime

Until your appointment, take only as much of your medicine as often as your healthcare professional tells you to. And take care of yourself. Healthy lifestyle habits can help prevent headaches. Get enough sleep, eat plenty of fruits and vegetables, and get regular exercise. Stay away from known headache triggers.

A headache diary can help your healthcare professional. Keep track of when your headaches happen, how bad they are and how long they last. Also write down what you were doing when the headache began and what your response to the headache was.