Medication Overuse
Created 05-14-2009
Painkillers—How much is too much?
Headaches that bounce back again and again, until they become almost daily are an aggravating problem. Your headache is bad, so you take a pill. It comes back, so you take another one. But if you do this often enough, you may actually be bringing on your next headache. If you are medicating for headache three or more days a week, there is a good likelihood that this may be happening to you.
Some people think that in order for their headaches to be termed a “rebound headache” the pattern must be one of taking a pill one day, and then experiencing a headache the next day. While this is a common pattern seen in analgesic-induced headaches, it is not the only pattern seen. This is one of the reasons the preferred name has been changed in the medical literature to “medication overuse headache”. Some affected people simply have chronic head pain and do not necessarily take analgesics every single day. If you are particularly susceptible to developing medication overuse headache, as little as two days a week may be all it takes to maintain chronic headache.
There is a transition that occurs as you take more and more medication, and sometimes you don’t even notice that your headaches are changing because it occurs so gradually. The pain becomes less throbbing and more dull. It involves more of your head, and is less localized, harder to pinpoint. You may not experience as much nausea or acute sensitivity to light or noise as you did with your migraine attacks. You may not be completely unable to think or concentrate like during a migraine. You just feel somewhat bad all the time. Some people in this transition phase still get migraine attacks on top of having daily or near-daily headaches. Eventually, those may go away and only daily head pain is the result, often awakening you in the morning or in the pre-dawn hours.
If you see yourself slipping into this pattern of frequent medication usage, this may indicate the need for a headache preventative medication. Only about 10% of those who would benefit from preventative medications are on an effective regimen. If you are already on a medication for prevention, you should work with your doctor to make certain it is as effective as it could be, and to decrease your pain medications to make certain you are not in danger of developing medication overuse headache.
Between three and four per cent of the population have chronic daily headache. Not everyone with daily headache has medication overuse, however, and in many cases the daily headaches came first, and the medication overuse occurs as a consequence. It is therefore difficult to interpret studies that say 50% to 86% of chronic daily headaches are due to medication overuse. At US headache clinics, 30% to 86% of new patients seen have medication overuse headache as a component of their problems. It is the third most common type of headache encountered by primary care physicians.
A recent large population-based study (Bigal et al, 2008) found that barbiturate-containing medications, such as butalbital, and opioids were the most likely to cause a transformation from episodic migraine to chronic headache. The prevalence of transformed migraine is 2.5%, and that due to medication was found to be 1.5%.
There are long-term risks to taking daily pain medications, even over-the-counter ones. These include stomach irritation, ulcers, gastrointestinal bleeding, and acid reflux disease from aspirin-containing headache remedies and anti-inflammatory medications. Long-term use of NSAIDs and acetaminophen can cause kidney damage, and excessive use of acetaminophen can result in liver damage.
The treatment for medication overuse headache is simple, but not easy: stop taking daily pain medication. Depending on how long you have been taking pain medications and on how much you have been taking, the recovery period can vary from three weeks to three months. No one can wave a magic wand to make you instantly better, but headache specialists can support you through the process. Preventative medications can help, but take time to work, and may not be fully effective until you have weaned off the analgesic medications. Behavioral treatment strategies such as cognitive behavioral therapy, relaxation training, biofeedback, and hypnotherapy can also be helpful.
The best strategy? Avoid medication overuse in the first place. If you have frequent headaches, and you are using medication more than nine days a month or more than two days each week, you may be suffering from medication overuse headache. Think twice before grabbing that medication bottle. Seek help instead.
1. Bigal, ME, Serrano, S, Buse, D, Scher, A, Stewart, WF, Lipton, RB, Acute Migraine Medications and Evolution From Episodic to Chronic Migraine: A Longitudinal Population-Based Study, Headache, 2008; 48(8):1157-1168
By Christina Peterson, MD
