Medication Overuse Headaches

Overview

What are medication overuse headaches?

Medication overuse headache is exactly as its name implies – a headache that results from taking analgesic (pain) medication too often to relieve your headache. The result of overusing headache medication is a daily or near daily headache for which the current medications you are taking become less and less effective.

Medication overuse headache is also called analgesic rebound headache, medication misuse headache or drug-induced headache.

How exactly does taking headache medication too often cause medication overuse headache?

When you get headaches, you most likely take your acute (immediate-relief) medication. However, if your headaches are not well controlled and you develop more headaches, you will take more and more as-needed medication to manage your headache. So this vicious cycle of taking more and more pain-relieving medications to lesson your headache actually leads to the development of daily or nearly daily headaches.

Technically, medication overuse headache is defined as having headaches on 15 or more days a month in someone who has a preexisting headache disorder who has been taking one or more acute medications to relieve symptoms for at least three months and who has no other known cause for their headache.

Who is most likely to get medication overuse headaches?

People most at risk include those with primary headache disorders like migraine, cluster or tension-type headache whose headaches are not managed well with medication, resulting in the need to take more and more medication.

Medication overuse headaches are more common in middle life and are three times more common in women than in men.

Symptoms and Causes

What are the symptoms of medication overuse headache?

Symptoms of medication overuse headache vary in number, severity and location. This is because the headaches themselves differ and because people who have headaches take different types and frequency of medication.

General symptoms of medication overuse headache include:

  • Daily or nearly daily headaches that usually start when you wake up.
  • Headache gets better when you first take analgesic medication but then headache returns when the medication wears off.
  • Headache may feel like a dull, tension-type headache or be more severe like a migraine-like headache.

Other associated symptoms include:

  • Nausea.
  • Irritability, restlessness.
  • Poor sleep.
  • Neck pain.
  • Depression, anxiety.
  • Runny nose, nasal stuffiness, teary eyes.
  • Weakness.
  • Difficulty concentrating, memory problems.

Which medications can cause medication overuse headaches?

Many commonly used immediate-relief medications, when taken too often, can cause medication overuse headaches.

Medications that were once considered as “safe” are the likeliest culprits. Among these medications are:

  • Aspirin.
  • Sinus relief medications.
  • Acetaminophen.
  • Nonsteroidal anti-inflammatory drugs (or NSAIDs, such as ibuprofen and naproxen).
  • Sedatives for sleep.
  • Codeine and prescription narcotics.
  • OTC combination headache remedies containing caffeine (such as aspirin with caffeine [Anacin®]; acetaminophen, aspirin and caffeine [Excedrin®], Bayer Select®, and others).

Other medications commonly associated with medication overuse headaches are:

Ergotamine-containing preparations:

  • Caffeine and ergotamine (Cafergot®, Migergot®, Ercaf®, Wigraine® .
  • Ergotamine (Ergomar®).
  • Belladonna, phenobarbital, ergotamine (Bel-Phen-Ergot S®, Phenerbel-S®.
  • Belladonna, caffeine, ergotamine (Cafatine PB®).

Butalbital combination analgesics:

  • Aspirin, caffeine, acetaminophen (Goody’s® Headache Powder, Excedrin®).
  • Excedrin®.
  • Aspirin, butalbital, caffeine (Fiorinal®); acetaminophen, butalbital, caffeine (Fioricet®).

Opiates

Triptans:

  • Sumatriptan (Imitrex®, Treximet®).
  • Zolmitriptan (Zomig®).
  • Rizatriptan (Maxalt®).
  • Eletriptan (Relpax®).
  • Almotriptan (Axert®).
  • Frovatriptan (Frova®).
  • Naratriptan (Amerge®).

How often is too often when talking about medications and the cause of medication overuse headache?

Headache specialists have found that medication overuse headache can be triggered in patients with migraine who take the following types of medications at the following frequency a month:

  • Butalbital combinations five or more days a month, or
  • Opioids for eight or more days a month, or
  • Triptans for 10 or more days per month, or
  • Nonsteroidal anti-inflammatory drugs for more than 10 days per month.

Diagnosis and Tests

How is medication overuse headache diagnosed?

Your healthcare provider will ask about the medications you take – both prescription and over-the-counter – to manage your headaches. He or she will ask you specifically how many days a week/month you have headaches, how long your headache last, what type of headache medication you take and how often you take headache/pain-relieving medications. You may be asked to track all of this information in a “headache diary.”

If you take as-needed medication for headaches more than two to three days per week and have daily or near daily headaches, you may be at high risk for medication overuse headache.

Other tests: Your healthcare provider may order imaging tests or blood tests to make sure there are no other possible causes for your headache.

Management and Treatment

What is the treatment for medication overuse headaches?

Simply stated, the goal of treatment for medication overuse headache is to:

  1. Wean you off the overused medication.
  2. Develop a plan for using preventive medication. Preventive medications include beta blockers, tricyclic antidepressants, anticonvulsants, calcium channel blockers and NSAIDs.
  3. Allow use of acute medication with limits.

Treatment of medication overuse headache begins with stopping the overused medication(s) to break the headache cycle. Based on your unique headache history and medication use, your doctor will decide if your medications should be stopped quickly or more gradually over weeks or months.

It’s important for you to know that your headaches are likely to get worse during the time your current medication(s) are being withdrawn. You may experience additional symptoms including nausea, vomiting, constipation, inability to sleep (insomnia) and restlessness. However, take comfort in knowing that once you get through this part of your treatment, your headaches will eventually get better.

Your headache specialist will start new preventive treatment either during or immediately after your current medications have been stopped. You will also learn which acute medication to take and how often to take it to manage new headaches that develop. You will likely not take medications for new headaches more than twice a week and for less than 10 days per month.

Some people may need to have their medications withdrawn under more carefully monitored medical conditions. If you take large doses of sedative hypnotics, sedative-containing combination headache pills, or narcotics such as codeine or oxycodone, you may need to be admitted to the hospital so your medications can be withdrawn under medical supervision. You may be treated with IV infused medications to break the headache cycle.

Your healthcare provider may recommend other therapy methods and lifestyle changes to help manage your headache. These methods may include:

The goal of treatment is to return your headache frequency back to occasional and not daily.

Prevention

How can medication overuse headaches be prevented?

You can help prevent medication overuse headaches by following this advice:

  • Always follow the labeling instructions of your preventive headache medications and the instructions of your doctor.
  • Use immediate relief (acute) pain-relieving medications on a limited basis, only when necessary. Do not use headache relief medications more than once or twice a week, unless instructed otherwise by your healthcare provider.
  • Before taking any OTC medication, including common analgesics and antihistamines, ask your healthcare provider if the medication has any potential for interacting with your current prescription medications.
  • Avoid caffeine-containing products while taking a pain-relieving medication, especially medication that already contains caffeine. This means avoiding coffees, teas, soft drinks and chocolate.

Outlook / Prognosis

What outcome can I expect if I have medication overuse headache?

With proper treatment, the prognosis for medication overuse headache is good. Medication overuse headache is a treatable condition. It can be prevented with careful monitoring of acute medication outcomes and number of headache days. Most people with medication overuse headache improve when weaned from current treatments and are treated with preventive medications and use of acute medications on a limited basis – usually no more than twice weekly. Following this regimen, your daily or near daily headaches will be reduced to more easily controlled occasional headaches.

A note from Cleveland Clinic

The adage “too much of a good thing,” is exactly true with regard to medication overuse headaches. It’s a vicious cycle of having headaches, taking medications to manage your headache pain, but then needing to take medication more often to continue to effectively manage your headache. Instead of reducing the number of headaches you have, you actually cause more headaches – as frequently as daily.

If this describes your headache history, seek help from a headache specialist. They are skilled in helping you “get off the nonstop cycle of headaches.” They will prescribe a preventive regimen to manage your headache and guide you in setting limits on your use of medications to relieve acute symptoms.

Last reviewed by a Cleveland Clinic medical professional on 12/18/2020.

References

  • National Headache Foundation. Analgesic Rebound (Medication Overuse Headache). Accessed 12/15/2020.
  • Llinas RH. Chapter 87. Headache. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS, eds. Principles and Practice of Hospital Medicine. New York: McGraw-Hill; 2012. Accessed 12/15/2020.
  • American Migraine Foundation. Medication Overuse Headache. Accessed 12/15/2020.
  • Tepper SJ, et al. Breaking the cycle of medication overuse headache. Cleveland Clinic Journal of Medicine. 2010;77:236. Accessed 12/15/2020.

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Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy