Diseases & Conditions

Rebound headaches

You feel a headache coming on, so you reach for a pain reliever. Or maybe you take pain medication in advance — even every day — to stave off frequent headaches. After all, that's what pain relievers are for, right?

Think again.

Pain relievers may offer quick relief for occasional headaches. But there's a limit. If you find yourself taking pain medication more than two or three days a week, you may actually be contributing to your headaches rather than easing them. It's a cycle known as rebound headaches.

The cycle starts when you take too much headache medication — more than the label instructs or your doctor prescribes. Soon, your body adapts to the medication. You may not even realize that you've been dosing yourself too often until you miss a day and your head starts to hurt again — sometimes more intensely than before.

The only way to stop rebound headaches is to reduce or stop taking the pain medication that's causing them. It's tough, but your doctor can help.

Nearly any pain reliever can contribute to rebound headaches. But some medications are more likely to lead to rebound headaches than are others.

• Simple pain relievers. Common medications such as aspirin, acetaminophen (Tylenol, others) and ibuprofen (Advil, Motrin, others) may contribute to rebound headaches — especially if you exceed the recommended daily dosages.
• Combination pain relievers. Over-the-counter pain relievers that contain a combination of caffeine, aspirin and acetaminophen (Excedrin, others) are common culprits. This group also includes prescription medications such as Fioricet, Fiorinal and Esgic, which also contain the sedative butalbital.
• Migraine medications. Various migraine medications have been linked with rebound headaches, including ergotamine (Ergomar, others) and triptans (Imitrex, Zomig, others). Interestingly, the ergot dihydroergotamine appears to have a lower potential for leading to this problem.
• Opiates. Painkillers derived from opium or from synthetic opium compounds include combinations of codeine and acetaminophen (Tylenol with Codeine No. 3 and No. 4, others). These can lead to rebound headaches as well.

Daily doses of caffeine — from your morning coffee, your afternoon soda, or any pain reliever or other product containing this mild stimulant — may fuel rebound headaches as well. Read product labels to make sure you're not wiring your system with more caffeine than you realize.

The doctor will ask a series of questions about your headaches, such as when they started and what they feel like. Be sure to list all the medications you're taking, including the doses. Remember, your doctor is there to help you. The more the doctor knows about your headaches and medication use, the better care he or she will be able to provide.

Your doctor will probably do a physical exam to check for signs of illness, infection or neurological problems. If the cause of your headaches remains uncertain, you may need blood or urine tests to identify any underlying medical conditions. Sometimes imaging studies — such as an X-ray, computerized tomography or magnetic resonance imaging — are recommended.

Drug dependency may be a risk of any drug that results in rebound headaches. Excessive use of some types of pain medication also may cause stomach ulcers, liver damage and kidney problems.

To break the cycle of rebound headaches, you'll need to restrict how much pain medication you use. Depending on what drug you've been taking, your doctor may recommend stopping the medication right away or gradually reducing the dose until you're taking the drug no more than twice a week.

Withdrawal symptoms
Stopping pain medication isn't easy. Expect your headaches to get worse before they get better. You also may experience withdrawal symptoms such as nervousness, restlessness, nausea, vomiting, insomnia, abdominal pain, and diarrhea or constipation. But it doesn't last forever. Within a week to 10 days, your headaches may become less intense and less frequent. With perseverance, most people break the rebound headache cycle within two months.

Your doctor may prescribe various treatments to help alleviate headache pain and the side effects associated with drug withdrawal. Dihydroergotamine (D.H.E.), an injectable ergot, helps relieve rebound headache pain during the withdrawal process. When taken during the withdrawal period, D.H.E. also seems to reduce the incidence of future relapses.

Hospitalization
Sometimes it's best to be in a controlled environment when you stop taking pain medication. A short hospital stay may be recommended if you:

• Haven't been able to stop using pain medication on your own
• Have other conditions, such as diabetes, depression or anxiety
• Are taking high doses of drugs that contain opiates or the sedative butalbital
• Are abusing substances such as tranquilizers or decongestants
• Are experiencing prolonged, unrelenting headaches with other signs and symptoms, such as nausea and vomiting

Preventive medications
After you've broken the rebound headache cycle, you and your doctor can find a safer way to manage your headaches.Before, during or after withdrawal, your doctor may prescribe a daily preventive medication, such as:

• A tricyclic antidepressant such as amitriptyline or nortriptyline (Aventyl, Pamelor, others)
• An anticonvulsant such as divalproex sodium (Depakote, others), topiramate (Topamax) or gabapentin (Neurontin)
• A beta blocker such as propranolol (Inderal, InnoPran, others)

These medications can help control your pain without risking another cycle of rebound headaches. If you're careful, you may be able to take a medication specifically meant for pain during future headache attacks. Be sure to take any medication exactly as prescribed.