Analgesic Rebound Headache

Abstract

Analgesic rebound headache, which is also known as analgesic overuse headache, occurs in headache sufferers who overuse abortive medications to treat their symptoms. The overuse of these medications results in increasingly frequent headaches that become unresponsive to both abortive and prophylactic medications. Clinically, analgesic rebound headache manifests as a transformed migraine or tension-type headache and may assume the characteristics of both these common headache types, thus blurring their distinctive features and making diagnosis difficult. Common to all analgesic rebound headaches is the excessive use of any of the following medications: simple analgesics, such as acetaminophen; sinus medications, including simple analgesics; combinations of aspirin, caffeine, and butalbital (Fiorinal); nonsteroidal antiinflammatory drugs; opioid analgesics; ergotamines; and triptans, such as sumatriptan. Treatment of analgesic rebound headache consists of discontinuation of the overused or abused drugs and then complete abstention of the overused or abused drug or drugs for at least 3 months.

Keywords

analgesic rebound headache, transformed migraine, tension-type headache, butalbital, nonsteroidal antiinflammatory drugs, ergotamine, sumatriptan

ICD-10 CODE G44.10

The Clinical Syndrome

Analgesic rebound headache, which is also known as analgesic overuse headache, is a recently identified headache syndrome that occurs in headache sufferers who overuse abortive medications to treat their symptoms. The overuse of these medications results in increasingly frequent headaches that become unresponsive to both abortive and prophylactic medications. Over a period of weeks, the patient’s episodic migraine or tension-type headache becomes more frequent and transforms into a chronic daily headache. This daily headache becomes increasingly unresponsive to analgesics and other medications, and the patient notes an exacerbation of headache symptoms if abortive or prophylactic analgesic medications are missed or delayed ( Fig. 6.1 ). Although the exact underlying pathophysiology responsible for the evolution of analgesic rebound headache has not been fully elucidated, it has been postulated that dysfunction of the trigeminal modulating system and central sensitization may play a role. Analgesic rebound headache is probably underdiagnosed by health care professionals, and its frequency is on the rise owing to the heavy advertising of over-the-counter headache medications containing caffeine.

Signs and Symptoms

Clinically, analgesic rebound headache manifests as a transformed migraine or tension-type headache and may assume the characteristics of both these common headache types, thus blurring their distinctive features and making diagnosis difficult. Common to all analgesic rebound headaches is the excessive use of any of the following medications: simple analgesics, such as acetaminophen; sinus medications, including simple analgesics; combinations of aspirin, caffeine, and butalbital (Fiorinal); nonsteroidal antiinflammatory drugs; opioid analgesics; ergotamines; and triptans, such as sumatriptan ( Box 6.1 ). As with migraine and tension-type headache, the physical examination is usually within normal limits, although psychiatric comorbidities may be more prevalent in this group of headache sufferers.

Box 6.1

Drugs Implicated in Analgesic Rebound Headache