Rebound Headache

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.

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}

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

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

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

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?

• 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}

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