Category: Living with migraine

Waking Up With a Headache

Table of Contents
  1. Why You May Wake Up with a Headache
  2. Treating Migraine and Comorbid Sleep Disorders
  3. Bottom Line
  4. FAQ Section
  5. Additional Resources

Nestled between sleep and wakefulness, a morning headache is a common occurrence among people with and without migraine. This painful and unwelcome experience uncovers sleep’s role in migraine, and simultaneously, migraine’s effects on sleep. Though this relationship may not be clear as day, creating an action plan to combat a morning headache is both accessible and effective. 

Why You May Wake Up with a Headache

1. Poor Sleep Habits

Poor sleep habits can impact both the quality and duration of sleep. Common traps that could induce an early morning headache include:

  • Not managing stress: Tension, either from tight muscles, anxiety, or an improper sleep position can trigger an early morning headache. Similarly, teeth grinding or clenching can also contribute to facial or head pain.1
  • Under- or oversleeping: Both scenarios can disrupt the body’s natural sleep-wake cycle, resulting in an early morning headache. 
  • Irregular sleep schedule: Whether erratic sleep is due to jet lag, shift work, or the weekend “catch-up”, inconsistent sleep can disrupt the circadian rhythms and impact the production and release of melatonin, a hormone responsible for inducing sleep.1,4
  • Electronic use: The blue light emitted from electronics interferes with the body’s natural release of melatonin, a sleep-inducing hormone.2
“Patients who don’t sleep well over time have trouble with pain control. So the less we sleep, the more likely we are to have pain.”1
Christine Lay, MD, FAHS

2. Sleep Disorders 

All sleep disorders constitute some level of decreased sleep quality or duration. 

  • Sleep apnea: Marked by gaps in breathing, sleep apnea can affect oxygen levels. If a morning headache lessens as oxygenation levels improve throughout the course of the day, sleep apnea may be the culprit.1
  • Insomnia: Lack of sleep or delayed sleep can trigger migraine or tension-type headache.4
  • Restless leg syndrome: Movement during sleep can impact sleep quality and contribute to a decreased pain threshold and morning headache.1
  • Sleep bruxism: Clenching the jaw or teeth grinding can increase muscle tension in the facial and head region, increasing the likelihood of a morning headache.1

3. Circadian Rhythm Disorders 

Circadian rhythm disorders refer to disturbances in the circadian rhythm, or internal biological clock. When this system is out of sync with the environment, sleep and other biological processes are impacted.5 Decreased alertness, daytime sleepiness, or a morning headache can all be caused by a circadian rhythm disorder. 

4. Headache Disorders

  • Migraine: Migraine attacks can be triggered by poor sleep quality and inconsistent sleep schedules. Additionally, people with migraine may experience poor sleep prior to a migraine attack. This may be due to spikes in serotonin levels during the night, causing fragmented sleep.2
  • Medication Overuse Headache: When over-the-counter pain relievers or prescription headache medications are used too frequently or for too long, a nighttime withdrawal could result in a morning headache.1
  • Hypnic Headache: Hypnic headache is a prime example of a dysregulated sleep-wake pattern. Characterized by attacks that awaken someone from sleep at the same time each night, this type of headache often begins in middle age and can last from 30 minutes to 6 hours.6
  • Cluster Headache: This type of headache is marked by severe pain in or around the eye or on one side of the head, congestion, excessive tearing or redness of the eye, and restlessness. Attacks can be cyclic and awaken someone from sleep.7 Excess sleep is a reported trigger for cluster headache.4
Did You Know?

While many with migraine may experience poor sleep as a trigger, it could actually be part of the prodrome, or the first phase of migraine. In other words, your migraine attack may be triggering poor sleep, not the other way around.1

5. Mental Disorders

  • Depression and Anxiety: Common among individuals with migraine, depression and anxiety are often accompanied by physical symptoms, such as appetite changes, sleep disturbances, or headache.9
    • Maladaptive Behavioral Patterns: If mornings become synonymous with head pain, consider evaluating any mental health factors that may be preventing a restorative and deep night’s sleep. For example, catastrophizing and hypervigilance, common behavioral patterns seen in people with migraine, may cause unease throughout the day and before bedtime.9,10 As a result, if you aren’t able to wind down your body and mind, sleep could be impacted.

6. Other Medical Disorders

  • Intracranial Hypotension: If a morning headache occurs upon standing up, but is absent when lying down, intracranial hypotension could be playing a role. This type of headache is caused by low levels of cerebrospinal fluid, which cushion the brain and spinal cord. Without adequate cushioning, compensation occurs, causing vasodilation and increased pressure in pain-sensitive areas.11
  • Brain Tumor: Awakening from sleep with head pain in no way points to a brain tumor. However, if a severe headache in the morning is accompanied by other symptoms indicative of a brain tumor, speak to your doctor.12

7. Hormonal Factors

  • Female Sex Hormones: Fluctuating hormone levels are a common migraine trigger. In fact, hormones are believed to be a contributing factor in the three-fold higher prevalence of migraine among people with vaginas than those with penises. If you are experiencing morning head pain around menstruation, hormones may be a likely cause.13
  • Melatonin: Produced in the pineal gland, melatonin is a hormone that induces sleep. Studies show melatonin levels may be low in people with chronic migraine.8 Consequently, lower than normal levels of melatonin can negatively impact sleep quality and duration, causing an increased risk of an early morning headache.

8. Lifestyle Factors

Similar to sleep habits, these daytime habits can have a direct impact on sleep:

  • not staying well-hydrated
  • skipping meals or eating a large meal before bed
  • consuming caffeine past noon, or caffeine withdrawal
  • alcohol consumption 

9. Environmental Factors

  • Allergens: Dysfunction of the autonomic nervous system, which controls involuntary processes, links migraine and allergies. Allergen-induced inflammation triggers congestion, sneezing, fatigue, and headache.14 Additionally, the release of histamine causes dilated blood vessels and a rise in nitric oxide levels, which is associated with migraine attacks.15 
  • Mold: Mycotoxins, which are present in mold spores and released into the air, can cause headache, fatigue, or difficulty concentrating. While more research is needed in this area, bedrooms with mold may play a role in a morning headache.16
  • Chemicals: Sensory sensitivities are hallmarks of migraine disease. Synthetic fragrances or other chemicals found in some perfumes, air fresheners, or body products can trigger migraine. If you’re sleeping in a room with a triggering chemical or scent, it could be causing a morning headache.  

10. Medications

  • Sleeping pills: Studies show that certain sleep medications can actually worsen headache.1 Talk to your healthcare professional for medical advice if you think a sleep medication may be causing a morning headache. 
  • Overusing pain medication: Taking prescription or over-the-counter painkiller medication too frequently can cause medication overuse headache, which may be experienced upon awakening.1
Summary

Reasons Why You May Wake Up with a Headache

Common causes of morning headache may include issues related to:

  • sleep habits, including unmanaged stress, under or oversleeping, inconsistent sleep/wake times, or electronic use before bed
  • sleep disorders, circadian rhythm disorders, headache disorders, mental disorders, or other health conditions 
  • lifestyle, hormonal, and environmental factors 
  • medications

Treating Migraine and Comorbid Sleep Disorders

While a morning headache may respond to over-the-counter medications, such as acetaminophen or ibuprofen, embracing a holistic approach can promote wellness and prevent future morning attacks. 

Sleep Hygiene

“The most common [sleep disorder] really is just poor sleep hygiene. A third of us are guilty of that.”2
Alex Dimitriu, MD

Sleep hygiene refers to the healthy habits, behaviors, and environmental conditions that aid in achieving quality sleep. Incorporating sleep-friendly practices and avoiding sleep-disrupting activities is key for migraine and sleep disorder treatment.

Start a Sleep Routine
  • Sleep schedule: Strive for regular and consistent sleep patterns, i.e., wake up and fall asleep at around the same time each day. 
  • Sleep duration: Adults should aim for eight hours of sleep each night, while children and teens need eight and a half to ten hours of sleep.
  • Wind down time: Set aside time to wind down before bed, and include relaxing activities, such as meditation. Dimming the lights can also help cue the body for sleep.
  • Electronics: Avoid using electronic devices before bed, as the blue light emitted from electronics inhibits the release of melatonin. If complete elimination is not realistic, you can use the “night mode” function to reduce blue light and prepare the brain for sleep.
Did You Know?

Studies show that people who meditate before bed have enhanced melatonin levels, slow-wave (deep) sleep, and rapid eye movement (R.E.M.) sleep.17,18

Optimize Bedroom Conditions
  • Cool temperatures: Keep the bedroom between 65 and 68 degrees Fahrenheit, and avoid dressing too warmly.
  • Quiet environment: Use a sound machine if noise is an issue.
  • Dark bedroom: Use shades or blackout curtains to prevent light from peeking through windows.
Key Point
How fast should I fall asleep?

Ideally, sleep onset should occur after 20 minutes of being in bed. Rapid sleep onset may be a sign of sleep deprivation or exhaustion, while delayed sleep onset could indicate various issues pertaining to sleep hygiene or a sleep disorder.1

Lifestyle Changes

As you optimize sleep hygiene, consider exploring how daytime habits may be impacting sleep.

  • Sunlight: Get your daily dose of sunshine to help keep the circadian rhythm functioning as nature intended.
  • Stress management: Reduce stress through meditation, deep breathing, talk therapy, or social support. If temporomandibular joint (TMJ) disorder or teeth grinding is present, talk to your doctor about using a mouth guard. 
  • Diet: Eat regularly to keep steady blood sugar levels, and avoid a large meal before bed.
  • Hydration: Stay well-hydrated throughout the day, and avoid drinking too much water right before bed.
  • Caffeine and alcohol: Avoid caffeinated beverages past noon, and limit alcohol consumption.
  • Smoking: Don’t smoke—nicotine disrupts sleep, and smoking is a risk factor for snoring and sleep apnea.19
  • Exercise: Strive for daily sweat-inducing movement, but avoid exercising within two hours of bedtime.
  • Bedroom activities: Only use the bedroom for sleep or sex.
  • Napping: While a nap can help fight a migraine attack, it can also disrupt the circadian rhythm and cause more sleep problems. If you need to nap, limit them to no more than 30 minutes, or consider going to bed earlier.

Cognitive Behavioral Therapy for Insomnia

Cognitive behavioral therapy for insomnia (CBTI) is a first-line treatment option for people with insomnia. Drawing from cognitive behavioral therapy, CBTI explores the underlying behavioral issues that may be perpetuating sleep deprivation. It focuses on two facets: stimulus control and sleep restriction.1

  • Stimulus control addresses any environmental stimuli that could be preventing sleep onset and continuity.
  • Sleep restriction aims to eliminate nighttime awakenings by restricting the time spent in bed. For example, if someone is in bed for ten hours but only sleeps for five and a half hours, then their time in bed would be restricted to six hours. This process will repeat, until over time, their time spent in bed parallels their time spent sleeping.
Key Point
Treat Sleep Apnea

Sleep apnea causes snoring, pauses in breathing, and daytime sleepiness. It also causes drops in oxygen levels throughout the night, making treatment especially important. If you think you may have sleep apnea, seek a sleep specialist to obtain a sleep study. Treatment often includes a CPAP (continuous positive airway pressure) machine to help keep the airways open for better oxygenation and better sleep.

Supplements

Widely available and generally cost-effective, supplements can be a relatively simple addition to your migraine toolbox.  

  • Melatonin: Naturally produced in the brain, melatonin prompts sleepiness, aids in relaxation, and reduces alertness. Studies show that people with chronic migraine have lower than normal levels of melatonin.8 Taking 3 mg of melatonin may help raise levels and decrease migraine attacks.20 
  • Magnesium: Magnesium is a critical mineral that aids in relaxation, stress reduction, and sleep. Magnesium deficiencies, which 50% of people with migraine have, can cause irritability, insomnia, tension headache, or migraine attacks.21,22 While this supplement can be taken in various forms, 400 mg in pill form is a great place to start.21
  • Iron: Ferritin is a protein that stores iron and releases it as needed. Low ferritin levels could indicate an iron deficiency and is a common cause of restless leg syndrome.1 If you experience this sleep disorder, speak to a healthcare professional about the possible benefits of an iron supplement. 

Medications

Sometimes poor sleep and increased migraine attacks may require pharmacological intervention. In these cases, adding a sleep medication can help break that cycle and offer an emotionally corrective experience.

Zolpidem (Ambien) and eszopiclone (Lunesta) are commonly used for insomnia. These medications have less habituation and less tolerance than benzodiazepines. In addition, usually, the same dose can be taken for longer periods of time.2

Summary
Treating Migraine and Comorbid Sleep Disorders

Treatment options for migraine and comorbid sleep disorders include behavioral intervention, supplements, and medications. 

For better sleep, start a sleep routine that incorporates sleep-friendly habits:

  • Keep the bedroom dark, cool, and quiet, and avoid working where you sleep.
  • Aim for 8 hours of sleep every night.
  • Wind down before bed by meditating and limiting electronic devices. 

Be mindful of how daytime habits may affect sleep:

  • Get sunshine.
  • Manage stress.
  • Eat regularly and stay hydrated.
  • Limit caffeine and alcohol, and don’t smoke.
  • Exercise no later than 2 hours before bed.
  • Keep the bedroom for sleep or sex.

For those with insomnia, cognitive behavioral therapy for insomnia is a first-line treatment.

Additionally, supplements, such as melatonin, magnesium, or iron can aid in sleep. In some cases, medication may be necessary to break a poor sleep and migraine cycle. 

Bottom Line

Due to sleep’s highly impactful nature, there are numerous reasons why someone may wake up in the morning with a headache. Issues related to sleep, medical conditions, or lifestyle factors could be possible causes of a morning headache. 

Improving sleep quality and consistency is key to the successful treatment of migraine and comorbid sleep disorders. Through behavioral intervention, supplements, and medications, a morning headache can be addressed, treated, and prevented.

FAQ Section

Additional Resources

Rebound Headache

Table of Content
  1. Introduction
  2. What is Rebound Headache?
  3. What causes Rebound Headache?
  4. Who gets Rebound Headache?
  5. What happens when you have Rebound Headache?
  6. How do you know if you have Rebound Headache?
  7. Treatment Options
  8. How soon does Rebound Headache respond to acute treatment?
  9. Why is it important to recognize and treat Rebound Headache?
  10. When to see a healthcare provider?
  11. Bottom line/Conclusion
  12. FAQ Section

Introduction

Rebound headache can be caused by the medication that we’ve been advised to take for migraine disease. It’s a debilitating disorder, with at least 15 headache days per month, and in severe cases, daily migraine attacks. Approximately 1-2% of the world’s population experience rebound headache, yet the majority don’t know they have it and are not informed on how to prevent it.

As an individual’s migraine or cluster or tension headache disease worsens, they may take medication more frequently. This temporarily lessens the pain, but when it wears off, and they again experience headache pain, they may take another dose, which again wears off, and they may take more. The rebound phenomenon develops when this cycle happens over a period of at least three months. The rebound headache is often worse than their original headache disorder because of the increased frequency triggered by the frequent use of pain relievers and other acute medications.11

What is Rebound Headache?

Rebound headache is referred to as medication overuse headache (MOH) by the International Headache Society’s (IHS) International Classification of Headache Disorders. Rebound headache is a term used by many and is perhaps more well-known than MOH. 

Patients taking medication(s) for their primary headache disorder may develop rebound headache, a secondary headache disorder, because of that medication. This generally happens after taking more than the recommended number of doses of acute medications for at least three months.2 

Secondary headache disorders are headaches due to an underlying illness or condition  condition such as sinus infection, meningitis, brain tumor, brain hemorrhage or head trauma, and in this case, medication:3

There are three main categories of primary headache disorders: 

  • migraine 
  • tension-type headache 
  • trigeminal autonomic cephalalgias, such as cluster headache

Rebound headache can happen with any of these primary headache disorders.4

Migraine occurring 15 or more days a month is known as chronic headache or chronic migraine, regardless of whether it’s the medication-induced rebound phenomenon or has developed without frequent acute medications. So by definition, rebound headache is chronic headache, but not all chronic headache is rebound headache.1

Note that the same medications that initially relieve the headache pain can trigger chronic, and sometimes daily headache attacks if used more than the 10 or 15 days per month. See specific guidelines below (Medications and Frequency Thresholds).

Terminology Stigma

Some clinicians and patient advocacy organizations have taken issue with the fact that rebound headache is classified as medication overuse headache or “MOH” by the IHS International Classification of Headache Disorders. They believe the MOH term places a stigma on the individual with migraine disease.

Key Point

A person with migraine disease should not be blamed for using the medication prescribed or recommended by their physician, especially when they have not been informed by their healthcare provider about rebound headache. Often a healthcare provider will say “take this medication as needed.” It’s important to give the right parameters for each individual medication.15

Whereas rebound headache is not a perfect term because it does not indicate the role that medication does indeed play, it’s generally accepted by the medical community, and it does not place undue blame on people with migraine disease.

“Medication Response Headache” and “Medication Adaptation Headache” are alternative non-stigmatizing terms suggested by the Coalition for Headache and Migraine Patients (CHAMP). These terms are not yet widely used, but they more accurately reflect the causal nature of medications in this type of headache.5

History

The phenomenon of rebound headache was first described in the 1930s by physicians with migraine patients who used ergotamine, an early migraine treatment extracted from the ergot fungus. Physicians noted exacerbation of migraine in patients was associated with ergotamine overuse, and improvement occurred after the drug was stopped. 

In the 1970s physicians began noting increased headache frequency in association with barbiturates and opiates, specifically, codeine. 

In 1988 the first edition of the International Classification of Headache Disorders (ICHD) introduced “drug-induced headache” to describe “headache induced by chronic substance use or exposure.” 

Later, when triptans were used for migraine treatment, they were added to the list of drugs that could “transform” episodic migraine to chronic, if used more than 15 days per month. 

In 2004 the ‘“medication overuse headache” and “MOH” terms were first introduced to describe the disorder, along with acute medication and frequency thresholds that existed.6 7 

What causes Rebound Headache?

Medications and Frequency Thresholds

15 Days Per Month 

Taking only over-the-counter (OTC) medications, for 15 days per month, to relieve migraine pain will trigger this chronic/rebound headache condition. 

The OTC non-steroidal anti-inflammatory drugs (NSAIDS) and analgesics are pain relievers that fall into the 15-day-per-month threshold. Ibuprofen, naproxen (Aleve), aspirin, and acetaminophen (Tylenol) are just a few in this drug class. 

Since these OTC medications are readily available without the need for a prescription, and are relatively inexpensive, it is easy to unknowingly trigger a rebound headache. Although they may temporarily lessen or relieve the pain, more medication is often required to treat increasingly frequent attacks as the primary headache disorder worsens. This can lead to a vicious cycle of rebound headache. All anti-inflammatories and analgesics can potentially trigger rebound headache when used 15 days per month.1 2 

10 Days Per Month

Triptans are another common class of drugs used to treat migraine. These include brand names such as Imitrex, Relpax, and Zomig, and can transform migraine to chronic/rebound with 10 or more doses per month. Since these are prescription drugs, physicians and insurance companies generally won’t approve a number high enough to cause rebound headache. However, patients may have extra tablets from months when they experienced fewer migraine attacks. Without being informed about the phenomenon of rebound headache, taking 10 or more doses in several consecutive bad months could unwittingly trigger this condition. 

Ergotamine was the first migraine medication associated with rebound headache when taken 10 or more days a month, and is still in use today. 

Multiple drug classes, including over-the-counter Excedrin, or use of triptans, along with NSAIDs or analgesics, can trigger rebound headache at 10 days of usage per month.1 2

Key Point

Few individuals with frequent migraine are taking just a single acute medication. When taking some days of triptans and some days with combination analgesics and some days with nonsteroidals, it’s probably best to assume that if one is taking 10 or more days of acute treatment per month — putting barbiturates and opioids aside — that one is likely to get medication overuse headache and transformation into chronic migraine.1

1 or 2 Days Per Week 

Opioids and barbiturates are most likely to cause rebound headache when taken for relief of migraine pain. They are also highly addictive. Fioricet and Fiorinal are brand names for medications containing barbiturates as well as other pain medications. Just one day per week of barbiturate use, or two days of opioid, regardless of the type of opioid, are associated with high-frequency rebound headache. These subtypes of rebound headache are extremely debilitating and difficult to treat.1 2 11 

No Threshold

Almost all acute medications used to treat migraine disease can cause rebound headache.1 

One exception is dihydroergotamine or DHE. This particular derivative of ergotamine is used by injection or nasal spray to terminate migraine. Most headache specialists believe it does not cause rebound headache.1 

Another exception is the newer group of medications, the gepants.  Gepants include ubrogepant (Ubrelvy), and rimegepant (Nurtec), which do not appear to cause rebound headache. In fact, in a one-year rimegepant trial, more frequent doses of rimegepant resulted in fewer migraine days. The study showed that gepants work acutely for attacks, but also can be used preventively for migraine.1 10 

Other Drugs 

Other substances and drugs can contribute to rebound headache for those individuals with an existing primary headache disorder. These include:1

  • caffeine at 100 or 200 milligrams per day
  • over-the-counter decongestants
  • over-the-counter antihistamines (not including newer ones like cetirizine (Zyrtec)
  • benzodiazepines (anti-anxiety agent such as Prozac) – are thought by some clinicians to trigger rebound headache
  • amphetamines
  • sleeping pills – most can trigger rebound headache
  • lasmiditan (REYVOW) – a new drug, is a selective serotonin agonist. Preclinical studies suggest that it may trigger the rebound phenomenon similar to the triptans.8
  •  

Who gets Rebound Headache?

Prevalence

Did You Know?

The estimates vary, but approximately 1%-2% of the general population have rebound headache. That makes it about as common as epilepsy. It’s an extraordinarily common phenomenon.2 Worldwide, only 10% of people that experience rebound headache are professionally diagnosed.16 

Risk Factors

The following are risk factors for developing rebound headache:1 9

  • High frequency episodic migraine – eight to 14 migraine days per month.
  • Migraine that doesn’t respond to various acute medications.
  • Comorbidities – a person with other pain disorders, such as arthritis, fibromyalgia or pain due to injury, in addition to their primary migraine disease.

In these situations, a person with migraine disease is more likely to take frequent medications to relieve headache and/or other pain over a period of months, resulting in triggering rebound headache.

In addition:

  • The use of opioids or barbiturates (Fioricet, Fiorinal) for pain relief poses a strong risk for developing rebound headache. Taking these drugs for just one or two days a week often triggers rebound headache. Additionally, these drugs are addictive which makes them easy to overuse.

What happens when you have Rebound Headache?

Physiological changes

Neurology experts do not yet understand all the pathophysiology associated with rebound headache. It’s believed that over time, when taking acute medication for headache, the brain starts to think this is part of the normal chemistry, and it upregulates receptors for those drugs. When that drug isn’t present, perhaps after a long night’s sleep, the brain thinks that something is missing. The brain communicates that with pain. Taking more medication relieves the pain temporarily but doesn’t treat the underlying disorder.3

How do you know if you have Rebound Headache?

Symptoms

Generally, you experience a pattern of starting with relatively frequent migraine symptoms (eight to 14 days per month), taking an acute medication to get headache relief, obtaining the relief, and then over time the pattern becomes one of increasing headache frequency and increasing medication usage, with headache reoccurring when the dose wears off.  It’s common to wake with head pain in the early morning hours. In this scenario, once you have exceeded 15 migraine days per month for three months, you have likely developed rebound headache.2

Rebound headache symptoms vary. It doesn’t matter if the head pain location is front, back, right, or left side. It can be mild, moderate, or severe. It’s not the type of headache symptoms, it’s the number of headache days. It must be 15 or more headache days per month according to the International Classification of Headache Disorders’ criteria. And there must be the frequent use of acute medications for at least three months.1 

Threshold for Triggering Rebound Headache
FrequencyDrug ClassesExamples
15 days/month NSAIDS and AnalgesicsOTC pain relievers including naproxen (Aleve), Ibuprofen, aspirin, acetaminophen (Tylenol, Paracetamol)
10 days/monthMultiple drug classes or any combination of multiple classes without exceeding the threshold for any one particular drugExcedrin (acetaminophen, aspirin, caffeine)
Combination of triptans and NSAIDS or analgesics
10 days/monthTriptanssumatriptan (Imitrex), Relpax, zolmitriptan (Zomig)
10 days/monthErgotamineErgomar
2 days/weekOpioidsHydrocodone, Oxycodone, Codeine
1 day/weekBarbituratesButalbital, Fioricet, Fiorinal
Table depicts medication thresholds when used for at least 3 months, regardless of dose.

It’s important to maintain a headache diary or calendar to track the number of days you are experiencing migraine symptoms, along with the acute medications that you are taking each day. It can be as simple as noting this information on a calendar, or downloading a free app on your smartphone. This will prepare you for partnering with your doctor to accurately diagnose and treat the disorder.1

Diagnosis

Your doctor can diagnose rebound headache based on your history of a primary headache disorder, recent headache frequency, and medication use. Tests are usually not necessary. Your headache calendar records will be extremely helpful.1 

Treatment Options

Prevention

The typical recommendation is to limit acute medications for migraine to no more than two, or at most, three days per week and avoid opioids and barbiturates. This plan of action will generally prevent rebound headache.

Headache specialists often tell their patients, “This medication will work best if you take it early in your attack. Try to take it while your pain is mild, but don’t take too much.” In reality, that can be difficult to adhere to. Patients trying to avoid rebound headache often delay treatment that may make their disease harder to manage long term.2 

Taking steps to reduce headache frequency by combining different types of preventive methods are key. Partner with your physician to determine which may work best for you. These include:1 2 11 12 15

  • Education regarding migraine management.
  • Lifestyle changes – adequate sleep, regular meals, staying hydrated, exercise, and reducing stress.
  • Behavioral methods including Cognitive Behavioral Therapy (CBT) to help identify and avoid headache triggers.
  • Physical therapy, massage, chiropractic treatment, especially for those with comorbidities such as back pain, fibromyalgia, and arthritis.
  • Neuromodulation device therapy.
  • Preventive medications.
    • Preventive medications include several varieties that are taken on a daily basis. 
    • Botox or the CGRP monoclonal antibodies can be used to reduce headache frequency.
    • The gepants are offering much hope for use as both preventive and acute treatments without triggering rebound headache.10

Acute Treatment

”The most important treatment is education of the patient. If you came in to see me and you had this problem and you were using Excedrin 6 [days] a week for a year, and I explained to you what you’re doing wrong and I said to you, I need you to come off. You can stop it tomorrow. You can stop it over a 2-week period. It doesn’t really matter. You’re going to feel worse for a little bit of time. At the end, you’ll feel at least the same and most probably better, and then I’ll have other medication for you to try as well. If you buy into that and you do it, I think that you’re going to get better.”11 
Alan Rapoport, MD

Breaking the cycle of rebound headache requires restricting your pain medication. The process to do that depends on the types of medications you’re taking. Your doctor may recommend stopping the medication right away or gradually reducing the dosages. They may recommend adding or changing preventive treatments.

Most people with rebound headache are able to eliminate their acute medications with some increased pain, but fairly easily, once they understand the goal and why it’s necessary.11 15

For some people, rebound headache becomes such a trap that medication withdrawal has to be done in the hospital or in an outpatient center under close supervision of a headache specialist. Protocols are in place for keeping the patient comfortable using intravenous therapies until any withdrawal symptoms have disappeared and the process is complete.  That can be necessary if, as medication is withdrawn, severe pain results, or the patient is unable to stop their acute medications.2 

Inpatient treatment provides particular value to the 30% of patients experiencing depression as a result of rebound headache. The frequent headaches make people feel hopeless and helpless, unable to escape the downward cycle. If discharged and headache-free for the first time in years, that often relieves those hopeless feelings.2

The recent availability of the gepants offers promise, and already significant success, for prevention and acute treatment of rebound headache, eliminating what could otherwise be a difficult withdrawal period. 1 10

How soon does Rebound Headache respond to acute treatment?

Overall prognosis for recovery

The majority of patients with rebound headache are able to stop using their acute medications which typically breaks the cycle within a few weeks.  

Patients that struggle most with medication withdrawal and require intravenous therapies usually see a quick improvement. However, the relapse rate is typically 25% within the first year. It’s important to be vigilant with effective preventive treatments to keep from falling back into the rebound cycle. It’s also important to partner with a headache specialist to ensure you are on the preventive treatments that work for you. If something doesn’t work for you, be willing to keep trying until you find effective therapies.2

Why is it important to recognize and treat Rebound Headache?

Key Points

The problems with frequent use of the acute medications are not just the headaches and the worsening of the headaches. These medications can cause a lot of associated medical problems. 

  • The anti-inflammatories and the combination analgesics are not so benign when taken frequently. They can cause:
  • ulcers
  • exacerbation of blood pressure problems
  • kidney dysfunction
  • Though frequent triptan use can cause rebound headache, it’s not generally a problem in terms of overall health.1
  • Opioids are narcotics that alter the pain regulatory system. Use of opioids in migraine patients worsens overall health including frequency of headaches, cardiovascular health, depression, and anxiety. 
  • Butalbital, a potentially dangerous barbiturate, causes sedation. Withdrawal from butalbital can cause seizures. People may be at risk when they’re not aware they’re at risk. It can cause cognitive problems, as well as exacerbating depression. It’s been withdrawn from most markets worldwide including Europe, South America, Asia, and most of Canada, however it’s still available in the U.S.1

When to see a healthcare provider?

If you suspect you have rebound headache, and are experiencing more than two headaches a week, you will need to partner with your primary physician or headache specialist to officially diagnose and put together a treatment plan. The treatment to reduce your need for acute medications by reducing the frequency of your headache days will vary based on the medications you have been taking and your health history.1 11

”If you’re taking more than two days [per week] of acute pain medication for anything, maybe you’re not taking it just for your headache, you’re taking it for something else, I would seek medical attention and try to find out are there different strategies that work for you that you can do that gives you the relief that you need to carry on and have a high quality of life.”15
Larry Charleston IV, MD
Tweet

Bring your headache diary/calendar to your appointment. Come prepared to talk about your headache symptoms, frequency, and any other pain history.1 11

Bottom line/Conclusion

  1. Inform yourself about migraine disease. Keep up-to-date with new treatments being offered. Partner with your physician and take control of your disease.
  2. Seek out a headache specialist, especially if you feel trapped in a cycle of frequent migraine days. Partnering with a headache specialist will ensure you are getting the best treatments, including the newer migraine-specific drugs if appropriate. Note that not all neurologists are headache specialists so be sure to check credentials. 
    1. Find a Migraine & Headache Specialist | AMF (americanmigrainefoundation.org)
    2. Healthcare Provider Finder | National Headache Foundation (headaches.org)
  3. Do not give up. There are many preventive treatments. Keep trying until you find what works for you. The last few years have finally brought forth migraine-specific CGRP and gepants medications. Consider lifestyle and other non-medication preventive options.
  4. Know that you aren’t alone. There are one billion people with migraine disease world-wide.14 You can find support through your local or national migraine patient advocacy organization. 

FAQ Section