Analgesic Rebound and How to Reverse It (2002)

Alan M. Rapoport, MD (1, 2) and Marcelo E. Bigal, MD, PhD (1,3)

(1) The New England Center for Headache, Stamford, CT
(2) Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY
(3) Department of Neurology, Albert Einstein College of Medicine, Bronx, NY

In most clinical studies on Chronic Daily Headache, overuse of analgesics or other acute care medication figures prominently. A patient develops CDH after consuming a critical dose of a single medication or a combination of medications for an extended period of time, which can range, according to the medication, from 1 to 2 years (triptans) to 5 years (analgesics). Occasionally it occurs much faster. Acute withdrawal of the offending medication worsens headache for a finite time, usually from 3 days to three weeks. Both preventive and acute care treatment for the primary headache complaint usually fail if the offending medication or medications are not terminated.

Analgesic rebound headache (ARH) can, therefore be defined as the perpetuation and increased intensity of head pain in chronic headache sufferers, caused by the frequent and excessive use of immediate relief headache medications. A combination of pharmacological, non-pharmacological, behavioral and sometimes physical interventions is usually necessary for a favorable outcome in ARH sufferers. Support programs and behavioral medicine techniques are an important part in ensuring treatment plan success. The essential features of an effective treatment regimen include the following steps:

Educate the patient: Adequate instruction about the biology of ARH, and the self-sustaining and deleterious effects of certain medications used in excessive quantities and at too frequent intervals. The challenge lies in explaining to the patient that, despite the fact that effective therapies for treating these headaches do exist, it is essential to first reduce the levels of overused medications, or withdraw them completely, which may cause discomfort for as long as 3 or 8 weeks. Without a thorough understanding of whey they need to endure this short-term pain for long term gain, the patient is unlikely to be compliant.

Establish expectations and a follow-up plan: Patients who overuse acute care medication may not become fully responsive to acute and preventive treatment for 3-8 weeks and possibly as long as 12 weeks after overuse is eliminated.

Support the patient. Tell them you believe they are overusing medication just to be able to function and speak to their families, employer or school personnel if necessary.

Use non-pharmacological therapies: A number of non-pharmacological measures help to overcome the physiological component of analgesic rebound. In addition, they help to empower the patient in his or her own therapeutic course. Useful modalities include:

- Biofeedback and relaxation therapy

- Cognitive behavioral therapy

- Individual / family counseling as necessary

- Dietary instructions

- Chronobiologic therapy and sleep hygiene

- Daily exercise program

- Physical therapy and other physical techniques such as
acupuncture, acupressure, cranio-sacral therapy and
manipulation (where and when appropriate)

- Trial of large doses of magnesium and vitamin B2 orally

Discontinue all potentially offending medications and caffeine by gradual outpatient or inpatient detoxification procedures. This is probably the most important step. Patients must understand that the treatment will not be effective if they continue overusing acute medications.

Institute a program of acute care and preventive pharmacological therapy to avoid the setting in which analgesic rebound may recur.
The great majority of patients who present with CDH are overusing acute care medications. Implementing a successful treatment plan begins with educating the patient about their illness and possible contributing factors. An effective support system must be established so the patient does not fall back into the same patterns of overuse. Non-pharmacological therapies are often essential and multiple acute care and preventive medications are usually prescribed. When treated intensively and properly, there is an 85% chance of significant improvement.

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