Caused by the overuse of acute pain-relief medicine
People who use acute pain-relief medicine more than two or three times a week or more than 10 days out of the month can set off a cycle called ‘medication-overuse headaches’ (MOH).
As each dose of medicine wears off, the pain comes back, leading them to take even more. This overuse causes your medicine to stop helping your pain and actually start causing headaches. MOH can occur with both over-the-counter and prescription pain-relief medicines. They can also occur whether you take them for headache or for another type of pain. Talk to your doctor if you think you have MOH.
Migraine or medication-overuse headache?
It is characteristic of migraine that people have episodic attacks of multiple symptoms (pain, nausea, vomiting, sensitivity to light and sound) but they go back to their usual state of health in between attacks. Medication-overuse headache, in contrast, is a dull constant headache which is often worse in the morning. It is present on most days or part of every day. It is possible to have medication headaches most days with episodic migraine pain superimposed on the ‘headache’.
Only people who are prone to headaches develop this syndrome, generally those with migraine or a family history of migraine. It is generally not seen in people taking painkillers for reasons other than headaches, such as arthritis or back pain.
It is a vicious cycle and even if the medication is stopped, withdrawal symptoms are commonly reported including chronic headache. The need to alleviate these withdrawal symptoms perpetuates further use of painkilling drugs and can result in a cycle of medication overuse.
Drugs involved in the development of medication-overuse headache
Drugs that are associated with the development of chronic daily headaches include: caffeine, ergots, paracetamol, codeine and the triptans.
The overuse of acute migraine drugs can also stop preventive migraine medications from working and long-term use of acute drugs may be damaging to the liver and kidneys.
The only way of treating this condition is to stop the medication. The withdrawal process is very individualised, based on the types of drugs you are taking. Some people will stop the drugs immediately, others may taper them and others may even need to be hospitalised for detoxification under medical supervision.
The following text was written by Dr Paul Shanahan and Dr Manjit Matharu, The Headache Group, The National Hospital for Neurology and Neurosurgery, London.
Migraine affects approximately one in eight people. While the majority of these thankfully have relatively infrequent (though disabling) headaches, a significant minority – perhaps 3% of the population as a whole, have chronic migraine, defined as 15 or more days of headache per month. While migraine at this frequency is best treated with preventive medication, studies indicate that as few as 13% of suitable patients are treated in this way. Our experience is that, when in this position, many sufferers with under-treated migraine will end up using frequent abortive medication (either over the counter or prescription analgesics or triptans).
It’s not hard to understand why this happens. Someone who finds that simple analgesia or triptans work very well for their occasional migraine will naturally be inclined to reach for the tried and tested solution if their headaches become more frequent. Some will avoid using pills if at all possible, but simply find that they can’t function when they have a headache unless they take something. Others will feel that the choice between “soldiering on” with a moderate headache or taking something and being pain free is a “no brainer”, and will opt for frequent painkillers rather than frequent pain. It has nothing to do with addiction, and everything to do with trying to cope.
In reality, however, this approach has several pitfalls. The most obvious of these is that frequent use of abortive medication does little to address the underlying issue of why the attacks are becoming more frequent. In many cases, unfortunately, it can contribute to the headache burden , either by leading to withdrawal or “rebound” headaches (which all too often end up being treated with more painkillers), or the emergence of a more pervasive “background” headache, or ultimately the occurrence of more frequent migraines, which escalates the pattern of abortive usage and becomes self-perpetuating. Some will also find that the abortive gradually lose effectiveness over time, though they need to keep taking it to avoid rebound headaches.
Many patients we see have found themselves in this situation, locked into a cycle of frequent pain and frequent painkillers, and in practice once this pattern has developed it is can be extremely difficult to make progress unless the usage of acute treatments can be limited. Doing so provides clarity in terms of establishing the underlying headache behaviour, and allows for optimal (and often, more effective) treatment.
There is no doubt, though, that withdrawing from analgesia or triptans after an extended period of over-usage can be an uncomfortable process. Withdrawal can be achieved in different ways; we will describe how we approach this problem in our practice at the National Hospital and what follows is a description of how we do things, rather than a suggestion that this is what others do or should do.
The extent to which frequent usage of analgesics or triptans causes problems seems to vary from one drug to another, and in all likelihood varies considerably from one patient to another. Our experience is that over-usage of ergotamine, triptans and opiate based medications (from codeine-based products up to morphine) tend to cause problems most frequently, with paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen or naproxen less likely to do so. The International Headache Society criteria for medication overuse reflect this, with opiate or triptan over-usage defined as ten days or more per month, whereas over-usage of paracetamol or NSAID is deemed to be present when these drugs are used 15 or more days per month.
Cessation of abortive medication can result in a range of withdrawal symptoms: for many, the most obvious withdrawal symptom is worsening of headache, though this may be temporary and in many cases, after an initial period of worsening, the headache will improve simply as a consequence of withdrawal. Other withdrawal symptoms include nausea, poor sleep, restlessness, and tummy upset or diarrhoea (particularly if withdrawing from constipating drugs such as codeine). These symptoms are transient, though they may last up to a few weeks. Getting through this period of withdrawal requires willpower and commitment, and is probably helped by understanding the transient nature of the symptoms and an awareness that further treatment for the headaches will follow the withdrawal period. It is important to realise that for many patients it is not sufficient to stop analgesia and expect that this will be all that’s required to sort the problem out – obviously the underlying headache will still need to be addressed. The importance of analgesia withdrawal is to facilitate subsequent treatment when this is necessary; analgesia withdrawal is the first step in treatment, not the last.
Many patients can achieve withdrawal from medication as an out-patient, and for most this is the straightforward way to do it. Some may find this easier to do when there are fewer demands on them: the run up to a stressful period or major event (a family holiday, or Christmas for example) may not be the most auspicious time to try. Sometimes a period of transition to a less provocative medication (switching codeine to ibuprofen, say) before stopping may make withdrawal easier to deal with. We sometimes offer a greater occipital nerve block to make the process more comfortable – this works for 50-60% of patients and may result in a week or two or reduced pain, which can make withdrawal less daunting.
From time to time, however, we encounter circumstances where a patient may need to be admitted to hospital to withdraw effectively from analgesia. This may be necessary if, for example, someone is on regular high doses of opiates such as morphine, where withdrawal may need to be slower and more side-effects can be anticipated. Alternatively, someone may have tried(often repeatedly) to withdraw as an out-patient but been unable to do so. Medication withdrawal as an-inpatient is still not a pleasant or pain-free process, but does afford us the opportunity to provide some additional support for withdrawal symptoms – controlling nausea, preventing dehydration, helping with restlessness and sleep for example. We arrange for a one-week in-patient stay to come off the painkillers, and then in appropriate patients, we may follow-up the withdrawal with an in-patient course of intravenous dihydroergotamine (IV DHE).
DHE is best thought of as a “transitional” treatment. A four-day course of IV DHE, given via a drip three times a day for ten doses (to a total dose of 9.25mg), can result in a variable period of pain reduction lasting days, weeks or even months This can serve to bridge the gap between withdrawing from analgesia and starting preventive medication. The degree of improvement seen with IV DHE varies widely; we have patients who get no benefit at all, and others who are pain free for 4-6 months afterwards. When helpful, it can be useful for controlling pain while starting and building up a preventive medication, particularly as preventives may take a few months to be fully effective.
IV DHE is not without its side-effects: it can be very nauseating, so we routinely administer anti-nausea medications prior to each dose. It may also cause abdominal cramps, loose bowel motions and leg cramps, and should not be given during pregnancy. Most importantly, it constricts blood vessels temporarily and therefore (as with triptans) we are careful not to give it to people with a past history of cardiovascular disease or stroke. We routinely perform an ECG and blood pressure measurement prior to treatment, to ensure there is no evidence of cardiovascular problems, and if there is any uncertainty on this point we will arrange a thorough cardiac check-up before proceeding.
We are fortunate to have a variety of effective preventive medication for migraine which can work well in those who need them. For those who get a couple of headaches per month, using painkillers when needed is a sensible strategy. For frequent pain, however, painkillers all too often become part of the problem, and in these circumstances withdrawal (outpatient or inpatient) helps to clear the way to more effective treatment.