Rebound Headaches

What are rebound headaches?

Rebound headaches are a headache disorder that can happen when you treat headaches with medication too often. They’re formally known as “medication overuse headaches,” but “rebound headaches” is the more commonly used term. They’re always a secondary condition to other headache disorders like cluster headaches. They’re especially common with migraines.

Rebound headaches get that name from the way they happen. When you have rebound headaches, you get temporary relief from medications for your headache, but when the medications wear off, the pain “rebounds” and often feels worse.

Rebound headaches are possible with all medications that treat migraines. That includes prescription medications and over-the-counter painkillers. However, certain prescription medications — especially those that contain controlled medications like opioids and barbiturates — are most likely to cause rebound headaches.

How common are rebound headaches?

Rebound headaches are uncommon but widespread. Experts estimate they affect around 1% of people worldwide, but some estimates go as low as 0.5% and as high as 2.6% of people worldwide. They’re more common in females.

What are the symptoms of rebound headaches?

Rebound headaches are most likely to evolve from migraines or tension-type headaches. The symptoms of rebound headaches involve many features of the headaches you’re trying to treat, including:

• Pain.
• Nausea.
• Fatigue.
• Trouble concentrating.
• Memory problems.
• Depression, anxiety or panic.

These headaches also tend to happen in certain ways:

• You have them when you wake up or soon after waking up.
• They get better with medication but return after the medication wears off.
• The headaches can be more intense after the medication wears off.
• Medications of any kind are less effective when you have this condition.

What causes rebound headaches?

Rebound headaches happen when you treat headaches too frequently with medication. They’re possible with any headache medications but can develop more easily with some.

The medications that can cause rebound headaches are:

• Opioids and opioid-containing combination medications.
• Barbiturate-containing combination medications.
• Ergotamine and ergotamine-containing combination medications.
• Acetaminophen-aspirin-caffeine combination medications.
• Triptans.
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Acetaminophen (best known under the brand name Tylenol®).
• Calcitonin gene-related peptide (CGRP) antagonists.

To develop rebound headaches, you have to take these a minimum number of days per month. The number of days depends on the medication.

Pain centralization

Experts suspect that rebound headaches happen because of changes in how your body handles pain signals. Chronic pain changes how your body handles pain signals, making it easier for those signals to happen or changing how you feel pain (it becomes more severe, or you feel pain from sensations that didn’t hurt previously).

Likewise, frequent pain medication use also changes how your body handles and processes pain signals. It can mean you need higher doses of pain medications because you develop a tolerance to medications, or your nervous system might generate or relay pain signals differently. More research is necessary before experts can confirm if either of these possibilities plays a role in rebound headaches.

What are the risk factors for rebound headaches?

Rebound headaches are more common in females, especially those between the ages of 30 and 50. They're also more likely to occur in people who have:

• Metabolic syndrome.
• High caffeine intake (more than 200 milligrams per day).
• Mental health conditions, especially depression, anxiety, panic disorder and post-traumatic stress disorder.
• Tobacco use disorder.
• Family history of rebound headaches or substance use disorder, including alcohol use.

What are the complications of this condition?

There are a few possible complications of rebound headaches:

• Developing chronic migraines.
• Dependence on medications, including controlled substances.
• Toxicity or overdose from overuse of medications.
• NSAID-related complications like upper digestive tract bleeding (such as stomach ulcers).
• More frequent or worsening rebound headache symptoms.

How are rebound headaches diagnosed?

A healthcare provider can diagnose rebound headaches using the International Classification of Headache Disorders criteria. Those criteria are:

• Headaches that happen at least 15 days per month related to a previously existing headache disorder.
• Regular use of medications to treat the headaches for at least three months.
• Another condition or diagnosis doesn't better explain the headaches.

There aren’t any tests that can diagnose rebound headaches.

How are rebound headaches treated, and is there a cure?

Rebound headaches are very treatable. There isn’t a cure for them, but treatment can make them stop.

Treatment involves the following:

• Stopping the medication(s) contributing to the rebound headaches. This is the most important part of treating rebound headaches, and the stoppage has to be total for this to work. With some medications, especially opioids or barbiturates, your healthcare provider may slowly decrease your dose to prevent withdrawal. Your healthcare provider will guide you on safely stopping taking these medications.
• Alternate medications. Switching medications can help with the headache symptoms while you avoid taking the medication(s) that caused the rebound headaches. These are often called “bridge medications.” Bridge medications are medications that work differently from the one(s) that caused your rebound headaches. Onabotulinumtoxin A injections (commonly known as Botox®), long-acting NSAIDs (such as naproxen) or antiseizure medications like topiramate are some of the most likely alternate treatments.
• Nonmedication treatments. These help you adjust your body and mind to the changes in your treatment, especially if you have symptoms like anxiety or depression. These treatments can include psychotherapy, biofeedback, hypnotherapy and relaxation training. Mental health therapies, to reduce your stress levels in particular, can help you avoid the recurrence of rebound headaches in the near future.

Complications/side effects of treatment

One of the possible side effects of treatment is headache symptoms that worsen temporarily. You may be able to limit this side effect by carefully tapering off of your current medications. Using bridge medications or alternative medications to manage your headaches may also help.

If the medications you took were potentially habit-forming, like opioids or barbiturates, withdrawal is also a possibility. Your healthcare provider will likely reduce your medication doses gradually to help you avoid this.

How soon after treatment will I feel better?

The recovery time can vary depending on the medications you took, the dosages you were taking and other factors. Your healthcare provider is the best person to tell you about your likely recovery timeline and what you can do to help yourself along the way.

Can rebound headaches be prevented?

Yes, rebound headaches are very preventable. The key to preventing them is limiting how often you use medications of any kind to treat your headaches.

For some people, headaches — especially migraines (which account for 80% of rebound headache cases) — are unavoidable. As anyone who’s had a migraine can tell you, these are not just bad headaches. They range from extremely unpleasant to totally incapacitating. Without treatment to stop a migraine, some people will only get vague symptom relief by finding a dark, quiet room to hide in until the migraine passes.

Rebound headaches aren’t preferable, but neither are frequent migraines that disrupt your life. Fortunately, newer treatments (especially preventive treatments) open the door to preventing migraines or limiting how often they happen. These treatments can reduce the number of migraines you experience. You can also work with your provider to determine if you have migraine triggers and then avoid them.

That may make it possible for you to use “rescue” meds that stop migraines less frequently, which might be enough to prevent developing rebound headaches.

If you have questions about how you can prevent migraines or headaches, talk to your healthcare provider. They can offer a range of treatment options, including medications and other methods, which might help reduce migraine and headache frequency and severity.

IMPORTANT: You should always follow your healthcare provider’s guidance on medication dosage and how often to take them. This is an essential part of helping you avoid rebound headaches. Don’t take medications — even over-the-counter ones — more frequently than your provider recommends.

What can I expect if I have rebound headaches?

If you have rebound headaches, you can expect a continuing cycle of headaches that worsens as long as you keep taking the medication(s) contributing to the “rebound” effect. Stopping the medication(s) causing the rebound headaches is essential to reversing this condition.

How long do rebound headaches last?

Rebound headaches will continue to happen as long as you take the medications that cause or contribute to them. The headaches themselves can vary in length, and many factors can affect their duration. Your healthcare provider is the best person to tell you what you should expect from the headaches themselves.

How long will it take for rebound headaches to go away?

Most people will see their rebound headaches fade and stop within two months. For more severe cases, it may take up to six months. During that time, your healthcare provider will help you manage your symptoms to reduce how they affect you. They’ll also monitor your symptoms as needed to make sure your treatments are working as they should.

What’s the outlook for rebound headaches?

The outlook for rebound headaches is generally positive, especially if you recognize them and get treatment sooner rather than later.

Treatment is generally successful in helping people with this condition. But relapses and the return of the headaches are possible. If you notice them returning, it’s important to talk to your healthcare provider as soon as possible. Treating rebound headaches early can make treatment faster and easier.

Without treatment, or with delayed treatment, the outlook isn’t as favorable. Rebound headaches can have very negative effects on your quality of life. Recovery also gets more difficult the longer you continue using the medication that causes your rebound headaches. These factors are part of why early diagnosis and treatment are so important.

How do I take care of myself?

If you have rebound headaches, following your healthcare provider’s guidance on treating them is important. One key to that treatment is avoiding taking the medication(s) that contributed to the rebound headaches in the first place. Doing so will speed up how quickly the headaches go away.

When should I see my healthcare provider?

You should see your healthcare provider as recommended during your treatment for rebound headaches. You should also see your provider if you notice any changes in headache frequency or symptoms, or if the symptoms change in a way that affects your daily routine.

Rebound headaches aren’t dangerous on their own. Some of the medications that people take to treat them can be, though.

What does a rebound headache feel like?

Rebound headaches feel much like the headaches you have previously experienced. But they often feel worse in terms of symptom severity. You may experience additional symptoms like anxiety or depression, to name a couple.

Does caffeine make rebound headaches worse?

Yes, if you consume more than 200 milligrams of caffeine a day. Limiting caffeine intake can help improve your chances of success and limit the severity of rebound headaches.