Treatment of medication overuse daily headache
Chronic daily headache is a term that is often used to describe frequent headache disorders that occur on a daily, or near daily, basis and which last for at least 4 hours. Although some forms of daily headache are thought to be due to a transformation of episodic migraine, or are chronic forms of tension-type headaches, one important cause for the development of chronic daily headache is medication overuse.
The problem
For many people, painkillers are a safe and effective way of treating headache or other pain. However for a small percentage of people with headache, taking these drugs too frequently can aggravate the problem, apparently increasing the frequency of attacks. Medications containing ergotamine, codeine and caffeine have particularly been implicated but frequent use of any of the acute treatments for migraine (including aspirin and other Non-Steroidal Anti-Inflammatory Drugs [NSAIDs]; paracetamol; triptans) have the potential to promote daily headache.
In most patients with regular migraine, attacks typically occur once or twice a month. These are usually adequately controlled with simple analgesics or specific acute migraine medications, if necessary. Sometimes an additional headache may develop, or the migraine attacks become more frequent. In such cases the patient may start to take these acute medications more often than usual. Gradually, the headaches increase in frequency and it is possible that these drugs contribute to a transformation from episodic headaches to daily headaches. Many patients continue to have attacks of migraine. The exact mechanism of this change is unknown. The headache may be quite different from a typical migraine and patients often state that a migraine may develop unless they take treatment.
The symptoms
Typically a mild headache is noticed on waking. The pain is dull and constant but may come and go throughout the day. Although painkillers and other acute medications may have been effective initially, they usually lose effect with time. As patients use these short acting drugs over long periods of time, for many patients their bodies become used to these drugs and they become less effective, necessitating increases in doses and sometimes shorten the periods between treatments. This may be due to systems in the body adapting or changing in response to the repeated use of drugs. The drugs may then not work as effectively and a higher dose is needed to produce an effect. Avoiding taking the drugs may result in a withdrawal syndrome which causes aggravation of the headache and may trigger migraine. The need to alleviate these withdrawal symptoms perpetuates drug use and can result in a vicious cycle of medication overuse.
There are other important problems which can occur because of acute medication overuse. The overuse of acute migraine drugs can also stop prophylactic or preventative migraine medications from working and long-term use of the acute drugs may be damaging to the liver and kidneys.
The treatment
Unfortunately the only way of treating this condition is to stop the acute medication - either immediately or by gradually reducing the amount (either by reducing the number, or strength, of the tablets) over 2-3 weeks. The best method of withdrawal is really very individualised. Some patients will stop the tablets immediately when everything is explained to them and they will do quite well. Many will taper them and do quite well. Some will need to be an in-patient. (Some will reduce their tablets and it will have no effect whatsoever). A long-acting NSAID (e.g. naproxen), combined with an anti-emetic (e.g. domperidone), may sometimes be given to help deal with some of the symptoms that may occur during the withdrawal period. It is important that this be done in concert with medical advice as there are the potential issues, particularly in epileptics, of sudden changes in medication. Clinical studies show that the overall success rate for patients who reduce their medications is up to 60%.
Withdrawal from acute medication is a really important issue and problem for patients, so medical advice should be sought before considering this course of action. For patients who want to try to reduce their medications, it is wise for them to have some medical supervision to exclude any other underlying causes of headache and if they need to start taking a headache preventative medication as soon as they have withdrawn from their acute medication.
It must be stressed that only people who are prone to headaches develop this syndrome; it is generally not seen in patients taking daily analgesics for reasons other than headaches such as arthritis or back pain. The problem may effect up to 5% of the headache population, but for the rest, painkillers and other acute migraine medications remain the mainstay of effective migraine therapy.
In summary
* For many people, painkillers are a safe and effective way of treating headache or other pain conditions
* In a small number of migraine sufferers, taking painkillers and other acute migraine drugs too frequently can aggravate the problem and may result in daily headaches
* Increased use of acute medications may start because these treatments were not adequately controlling a migraine attack or because the attacks became more frequent
* For patients who have become dependent on their acute drugs, avoiding taking the drugs may result in a withdrawal syndrome, for which more drugs are taken - resulting in a vicious cycle which can be difficult to break
* The only way of treating this condition is to stop the acute medication, either immediately or by gradually reducing the amount -a long-acting NSAID, combined with an anti-emetic, may be useful
* It is important for migraine sufferers to seek medical advice if they want to try to reduce their medications and only withdraw their acute medications under medical supervision
An excellent article for health professionals which discusses the problem of overuse of drugs taken to treat migraine, and how to treat medication-overuse headache was published in the Prescriber "Chronic overuse of acute antimigraine preparations" by Dr A Bahra and Prof P J Goadsby - September 1999; Volume 10, Issue 17 Pages 109-115.
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This page was last updated: December 23, 2005
