Medication overuse: headaches

Jon Konzen, DO
Neurology
Chippewa Valley Neurosciences
Eau Claire

The problem of headache transcends time. By the time a person reaches adulthood, most have experienced a headache. These have been described in many ways as “migraine, muscle, stress or sinus” depending on a person’s symptoms. Headache is common enough that a recent survey in the United States indicates that
2.4 million of 90 million emergency room visits were headache related. It turns out that headache is the fourth most common cause for emergency room visits in the United States. In order to treat this problem, many medications – both prescription and over-the-counter are used. This unfortunately has led to the less commonly known, but growing problem of chronic headache caused by medication overuse.

“...headache is the fourth most common cause for emergency room visits in the United States.”

The various over-the-counter or prescribed medications utilized to try to rid a headache may actually lead to the development of this specific type of headache. It can occur as a separate headache problem for the primary headache patient (i.e. someone who already has a diagnosis of migraine, muscle tension type or cluster headache.) The problem was probably first medically recognized around 1988 with the introduction of the pain medication phenacitin in Switzerland. Free samples were given to workers of the pharmaceutical manu-facturer of the medication. However, many other medications are now known to produce this problem, some of which have been around since the early 1900s. In the past, the problem has been described as “drug-induced headache, analgesic overuse headache and narcotic overuse headache”. In 2004, all of these terms were combined into the currently used entity, “Medication Overuse Headache” (MOH).

Common every day medications that can precipitate this problem include medications such as aspirin, Tylenol/acetaminophen, Motrin/ibuprofen and caffeine. Further, newer agents specifically designed to stop headache such as Imitrex and the other tryptans can produce this problem. In fact, all drugs used to try and stop an acute headache may cause MOH. The chance that a medication used to try and stop headache may induce MOH increases in the person with a known history of primary headache.

The cause of MOH is unknown. However, several theories likely play an important role in its development. The first is a genetic predisposition. It is known that patients with frequent and previously diagnosed primary headaches are more likely to develop MOH than non-primary headache patients. A second potential factor may be brain receptors and brain enzyme pathways. Brain receptors that headache medications attach to, to work, may decrease in number (down regulate) as quickly as 24 to 96 hours after repeated exposure to the same headache medication. Therefore, there are less receptors available to become active to stop a headache. Certain enzymes that are required in conjunction with headache medications for them to work may be inhibited. There may also be psychological and behavioral mechanism that contribute to MOH. Drug consumption can be reinforced. The patient takes a medication, the headache goes away, the patient gets the headache back and continues to take the same headache medication, often increasing the amount taken. Sometimes the patient may take a medication intended to stop a headache before the headache is present. This may be done anticipating the development of the headache.

Treatment of MOH can be extremely challenging for both physician and the patient. This requires stopping the offending medication. As a result, this often can invoke anxiety in patients with headaches over fear of returning headache. Outside of habit forming drugs, like narcotics, that may need to be tapered off, it is not clear whether or not tapering or abrupt withdrawal is the best method. Unfortunately, many patients may experience withdrawal headaches regardless of the method used. The typical withdrawal is usually 2 to 10 days with an average of 3.5 days. Sometimes preventative headache medications are tried during the withdrawal. Other times, if severe headaches develop, hospitalization might be necessary with the use of IV medications.

If a correct diagnosis of MOH is identified and the offending agent is removed, over 70% of the time the headache condition can be stopped in one to six months. Unfortunately, patients who experience this type of problem are susceptible to relapses. This usually is related to whether or not the patient had a significant prior history of primary headaches and the type of medication that produced medication overuse headache. Interestingly, patients with muscle tension type headaches are more likely to relapse than those with migraine.

If you are a primary headache patient and feel that you are having increasing numbers of headaches requiring increasing amounts of headache medication, you may be developing medication overuse headache. Talk to your doctor about this possibility.

Dr. Konzen – Chippewa Valley Neurosciences
For information or to schedule an appointment:
715-831-0811 | www.oakleafmedical.com
Dr. Konzen sees patients in Eau Claire.