What are the other Names for this Condition? (Also known as/Synonyms)

• Analgesic Rebound Headache
• Medication Misuse Headache
• Medication Overuse Headache (MOH)

What is Rebound Headache? (Definition/Background Information)

• Rebound Headache develops when there is a long-term abuse of medications that are primarily administered for headaches or migraines. This medication abuse is either in the form of overuse (mostly), non-compliance of the healthcare practitioner’s prescription, or drug usage instructions. It may be even due to the indiscriminate usage of ineffective over-the-counter drugs (self-medication)
• A chronically excessive intake of pain-relief medications, typically for headaches/migraines, can trigger Rebound Headaches through a withdrawal reaction that prompts the user to take more pain medication, resulting in a vicious cycle, leading to more severe headaches, which then start to occur on a daily/continuous basis, consequently bearing a high risk for chronic migraine development
• The common pain medications/analgesics causing Rebound Headache include aspirin, acetaminophen (paracetamol), ibuprofen, and pain-relievers containing caffeine. Since caffeine is also found in certain beverages and chocolate, consuming these along-with the painkillers increase the likelihood for Rebound Headaches
• It is important to note that individuals on pain medication for other chronic pain conditions, such as arthritis or back pain, are not generally vulnerable to Rebound Headaches, unless they have a pre-existing migraine/headache condition
• Longstanding or long-term abuse of pain medication can result in decreased effectiveness of the medicines used to control the primary headaches/migraines. Stopping or discontinuing the use of such medications decreases progression of Rebound Headache and can result in a cure. The prognosis is good in a majority of cases with adequate treatment

Who gets Rebound Headache? (Age and Sex Distribution)

• Individual of any age may be at risk for Rebound Headaches, but the condition is mostly observed in middle-aged adults
• Rebound Headaches are reportedly frequent among individuals taking medications (long-term) for certain types of headaches and migraines; the incident rate is about 1 in 50 to 1 in 100
• Both males and females are affected, although a greater number of cases are seen in women (3:1 female to male ratio)
• Individuals of all racial and ethnic background can be affected

What are the Risk Factors for Rebound Headache? (Predisposing Factors)

The key risk factor for Rebound Headache is the longstanding overuse/abuse of certain pain medications that are used for a headache or migraine condition. 

The analgesics and other drugs observed to induce this condition include:

• Acetaminophen/paracetamol
• Any combination of pain-relievers
• Aspirin
• Butalbital
• Certain opioids and other narcotics
• Codeine
• Drugs used for sinus relief
• Ergotamines (sublingual medication for migraines)
• Ibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs)
• Over-the-counter (OTC) pain and antimigraine medications containing caffeine
• Pain medicine containing barbiturate
• Sleep medicine
• Triptans (migraine medications)

Individuals at risk for Rebound Headaches include those with the following conditions:

• Tension-type headaches
• Cluster headaches
• Migraines
• Transformed migraines
• Any chronic pain condition, in some cases
• Individuals with anxiety and depression
• Consumption of other caffeine sources such as tea, coffee, chocolate, and soda/energy drinks

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Rebound Headache? (Etiology)

Rebound Headaches typically occur from the excessive use of acute pain medications that are usually administered for headaches or migraines, for prolonged periods. Hence, this secondary condition is also known as Medication Overuse Headache (MOH).

• The abuse of painkillers may also occur from a combination of factors including:
  • A random intake (self-dosage) of over-the-counter analgesic drugs
  • Not following drug label instructions appropriately
  • A disregard for prescription medication dosage instructions leading to excess consumption
• The onset generally occurs when individuals with headaches or migraines voluntarily use over-the-counter drugs that are not prescribed or, are less effective for their condition. This results in poor treatment and consequently frequent (self) overdosing
• When the effect of the drug wears off, there is a withdrawal reaction prompting the individual to alleviate the pain by taking more pain medicines, which then forces them to consume the medicine more frequently, until the headache pain intensity worsens (from mild to severe) and headache frequency instances increase, such that it becomes a chronic/daily condition
• Some pain medications, such as narcotics and caffeine-based drugs, are more powerful at inducing Rebound Headaches than other class of medications. The development of the condition is also dependent on the initial frequency of headache days/month and the frequency of drug intake

What are the Signs and Symptoms of Rebound Headache?

The signs and symptoms of Rebound Headache include:

• Increased severity of headaches following medication use; the pain reduces for a short while, and then returns
• Time intervals between headaches keep getting shortened, such that it (almost) becomes a daily condition
• Waking up in the morning with headaches; any part of the head may be involved
• Nausea
• Anxiety and restlessness
• Irritability and sleeplessness
• Feeling very tired or weak
• Memory and concentration problems; unable to perform at work

The severity of the signs and symptoms is related to the type and usage of the drug. The onset of signs and symptoms may vary from one individual to another.

How is Rebound Headache Diagnosed?

A diagnosis of Rebound Headache essentially involves the following:

• Complete physical examination and evaluation of one’s presenting signs and symptoms
• Thorough analysis of personal and medical history, including one’s history of migraine (if any) and the usage of migraine medications and other drugs

Other exams and tests are usually not required, since Rebound Headaches/Medication-Overuse Headaches are diagnosed clinically based on the patient’s medical history and signs and symptoms. However, if necessary, the healthcare provider may conduct additional tests to exclude other underlying conditions (if any) such as:

• Laboratory tests
• Neurological examination by a qualified healthcare provider
• Imaging tests such as MRI and CT scans (of the head and neck region)
• Differential diagnosis to rule out other conditions that may manifest with similar signs and symptoms

The diagnostic criteria for Rebound Headaches outlined by the American Migraine Foundation are as follows:

• History of analgesic medication use, over 2-3 times per week, by an individual with chronic daily headache
• Individuals, taking analgesics should present headaches for over 15 days per month for a minimum period of 3 months
• Additional consideration: Increased medication use tends to increase headache frequency or get better with stoppage of medication overuse

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Rebound Headache?

The potential complications of Rebound Headache include the following:

• Development of chronic migraine
• Potential for addiction to analgesic medications
• Other side effects from excess consumption of such pain medications that may involve the digestive system or kidneys
• Withdrawal symptoms from immediate discontinuation of medication (especially strong painkillers)
• Mental stress and depression
• Poor performance at study or work

How is Rebound Headache Treated?

Discontinuing medications responsible for Rebound Headaches is the initial step towards treating the condition. However, the following factors must be taken into consideration:

• Medication withdrawal or detoxification must be planned by the healthcare provider by considering the class of drugs and their dosage being taken by the affected individual
• Tapering of medication (slow reduction in dosage and use frequency) may be necessary in case of opiates and other narcotics or with some caffeine-based medicines; it is not advisable to abruptly withdraw or discontinue certain medication types following a diagnosis
• In some cases, hospitalization of the patient may be necessary to watch for severe withdrawal symptoms, in order to quickly address the same, especially if the patient has been on strong doses of narcotics or sedative medications
• Steps must be taken to address the primary headache/migraine or chronic pain condition as well

Patients undergoing treatment must be informed that the headache severity will tend to increase (following drug discontinuation) before they subside and stop; also, information on possible drug withdrawal side effects must be provided.

Apart from the above, the following treatment and supportive measures may be needed to help the patient:

• Biofeedback and non-pharmacological therapy
• Targeted physical therapy
• Modified behavioral techniques
• Psychological counseling
• Support groups and summoning help of family members and friends
• Bringing about lifestyle changes

Follow-up care with regular screening and check-ups are important and encouraged.

How can Rebound Headache be Prevented?

The following steps may be considered towards preventing Rebound Headaches:

• Take pain medications only as prescribed and on a limited basis (generally not more than 2-3 times per week); duly comply with drug intake instructions, including the period for which it is prescribed
• Strictly follow drug label instructions on usage and dose
• Always avoid self-medication and self-adjustment of prescription medication dose
• Check with the healthcare provider about consumption of caffeine-based beverages, if the prescribed medication contains caffeine
• Check with the healthcare provider if present dosage levels are inadequate, or in case the headaches persist
• Check with the physician before taking any over-the-counter analgesics
• Ask the physician for alternative medications, if necessary
• Control factors that trigger the primary headache/migraine, where possible
• Keep the physician informed of any drug allergies
• Eat healthy, stay well-hydrated, and exercise regularly; address and control factors that tend to increase stress

Periodic monitoring or follow-up of the condition with the healthcare provider is recommended.

What is the Prognosis of Rebound Headache? (Outcomes/Resolutions)

• The prognosis of Rebound Headache is typically good upon discontinuation of the medication and on instituting adequate supportive measures
• In most cases, individuals observe an increase in their secondary headaches (in terms of severity and frequency), before it starts to recede and improve. However, usually within a few days to a week, the headache cycle stops, and the condition gets better
• Without due recognition of the condition, timely intervention, and appropriate treatment, Rebound Headaches tend to get worse, since it is progressive in nature. Also, the preventive medications prescribed for primary headaches, in the first place, will remain ineffective

Additional and Relevant Useful Information for Rebound Headache:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/health-topics/neurological-institute/