A Publication of the East Bay Headache Support Group
A Member of the American Council for Headache Education
(ACHE) Support Group Network

VOLUME 7, ISSUE 5
September  2002

September 10th Meeting - Talk it Over Night

We will meet in the Ball Auditorium, downstairs at John Muir Medical Center, from 7:30 to 9:00 p.m. on Tuesday, September 10. For more information, call 925-228-1084.

Celebrating Women:  Mind, Body & Spirit

Visit the Women’s Health Fair presented by the Women’s Health Center, part of the John Muir/Mt. Diablo Health System. This FREE event will be held Saturday, September 28, from

10:00 a.m. to 3:00 p.m. at the Women’s Health Center and

adjoining Grower’s Square Pavilion in downtown Walnut Creek at 1656 North California Boulevard.

Stop in to say hello at the East Bay Headache Support Group booth, and then check out the other resources and businesses which offer services and products specific to women and their families.

Leslie Griffith, KTVU Channel 2 News Anchor, will be the opening speaker at the Women’s Health Fair - 10:00 a.m.

In addition, the Women’s Health Center is presenting a series

of FREE evening lectures by area experts on women’s health issues. All lectures are held at the Women’s Health Center from 7:00-8:30 p.m. Please call for reservations—space is limited.  925-941-7900, option 3.

Sept 18: So Many Choices About Menopause—What Do You Do?

Sondra Altman, MD, Gynecologist

Oct 9: Sexuality Through Menopause—What Changes?

Robert Cole, MD, Ob/Gyn

Lynne Forette, RN, Nurse Practitioner

Oct 16: Are You at Risk? Finding Out Your Real Risk for Breast Cancer

Angela Musial, MS, CGC, Geneticist

And a FREE introductory workshop essential for women:

Oct 1: Get Your Message Heard...Before You Say a Word

Huda Baak, StandOut Communication

The Women’s Health Center also offers workshops and classes on

Next Meeting:

November 12, 2002: To be determined

Do you have a suggestion for a topic or speaker?

Contact Leslie Davis at 925-228-1084, or

ladavis98@aol.com.

Editor’s Note: Headache Cybertext is a Web site for the diagnosis and treatment of headaches and migraines, found at http://www.upstate.  edu/neurology/haas. David C. Haas, MD, headache specialist and neurologist at SUNY Upstate Medical University in Syracuse, New York, authored two articles on medication-abuse headaches which I have combined and condensed somewhat to fit into our newsletter.  Please visit Dr. Haas’ Web site for the complete articles.  Medication-Abuse Headaches (Rebound) By David C. Haas, MD

Rebound headaches—Why they occur and what they are

Folks who take analgesics, ergotamine, triptans, or any other type of drug frequently for several consecutive weeks to alleviate migraines or episodic tension-type headaches risk inducing a chronic daily headache. In general, the more potent the drug, the less often it need be taken to induce such a headache state. Opioids (narcotics), such as tablets with codeine or hydrocodone, may be used only three times a week for several weeks before the headache becomes daily, whereas tablets of acetaminophen may need to be taken almost daily to induce such a state. When the headache becomes daily, folks need more frequent dosing to keep it suppressed enough to function. We see

patients who take, for example, 100 Excedrin tablets a week to maintain some degree of headache suppression. Such large doses are more typical for patients whose original headaches were migraines.

Headache is more likely to develop or flare up when the medication level in the body is waning (hence the term “rebound headache”), but it can also occur despite heavy medication levels. When doses are missed or delayed, the headache generally flares up, since the headache mechanism is no longer suppressed by medication. Hence, patients become convinced that their alleviatives are necessary for head-ache control, not realizing that the

alleviatives have induced the daily headache state. In some as yet unknown way, too-frequently suppressing head-aches by drugs makes the brain more likely to generate headache.

Daily headaches induced by excessively frequent use of alleviative medicines are called rebound headaches or medication-abuse headaches whether they develop from migraines or episodic tension-type headaches. When they develop from migraines, they are commonly also referred

to as transformed migraines, meaning that naturally occurring episodic migraine attacks have been transformed into a chronic daily headache with migrainous features.

Many patients with chronic tension-type headache also take analgesics daily. Such use may worsen the headache and make it less responsive to preventive medicines.

Verifying diagnosis of analgesic-abuse headache

Although frequent use of alleviative medications strongly suggests that a chronic daily headache is from drug abuse, the diagnosis must be verified by seeing the headache lessen notably after a period (generally one to several months) of complete abstinence from the abused drug(s) without substituting other drugs taken as alleviatives. After such a period, patients with transformed migraines generally return to having intermittent migraines, and those whose daily headaches developed from episodic tension-type headaches generally experience the latter type once again. Those whose original headaches were the chronic tension-type continue to have a chronic daily headache, but it generally lessens in severity and shows a responsiveness to standard preventives not present during heavy analgesic use.

Diagnostic Criteria

Migraine can be transformed into chronic daily headache with any of the following abuses for at least one month:

Simple analgesic use: over 1000 mg of aspirin or acetaminophen, or an equivalent of another drug, more than 5 days per week.

Compound analgesic use: over 3 tablets per day more than 3 days per week.

Opioid use: over 1 tablet per day more than 2 days per week.

Ergotamine use: 1 mg more than 2 days per week.

Excessively frequent analgesic use can also change episodic tension-type head-ache into chronic daily headache, and can make it less responsive to the beneficial effects of preventive drugs.

And headache specialists have recognized that too-frequent use of the triptans, such as sumatriptan (Imitrex), can also induce chronic daily headache of the transformed-migraine type.

The basic therapy for rebound headaches is discontinuation of all alleviative drugs (those taken when the headache “calls” for them) and abstention from them for roughly 8 to 12 weeks. Most patients can discontinue medications as outpatients, given a proper plan; some with transformed migraine need hospitalization to be withdrawn from them.

Among the outpatients, some can discontinue medications abruptly, whereas others do better with a slow stepwise cessation during a period of a few weeks. During this stepwise withdrawal, the drugs should be taken during set times (by the clock), not when patients feel the need to take them to suppress headache. The reason for this is that taking medications as preventives by the clock does not perpetuate (or induce) rebound headache, whereas taking them to suppress worsening headache does perpetuate the rebound state and is what induced this state.

Discontinuation is difficult for patients, not because they have become addicted to their drugs (aside from rare exceptions), but because their headaches worsen when they do not take them. After withdrawal of the abused drugs, almost all patients’ headaches become intermittent within a few weeks to a few months and then return to their natural frequency, whatever that may be.

Out-patient Withdrawal

During and for some time after discontinuation of alleviative drug use, patients with transformed migraine need a strong preventive medicine for short-term use to decrease the occurrence of headache flare ups. Short term preventives are less important for patients whose rebound head-aches arose from episodic tension-type headaches, because flare ups of tension-type headache are less severe than those of migraines.

In general, the most reliable short-term preventive drug to use during withdrawal of alleviatives for patients with rebound migraine is dihydroergotamine (DHE), although some patients can get by with naratriptan. DHE must be injected by the patient, but all my patients learn to do this in one 10-minute session in my office.  Because it can constrict coronary arteries, DHE should not be given to anyone with known or probable coronary artery disease.  Frequency of preventive DHE injections is slowly decreased as headaches improve, and finally can be discontinued. Thereafter, either DHE or one of the triptans can be used to suppress severe migraine attacks, but such use should be limited to 3 days per week, lest overly frequent use perpetuate the rebound headache. Thus, patients may need to endure less than severe headaches without taking any alleviative medication for some weeks at least.

Unfortunately, the standard migraine preventives for long-term use, such as propranolol and amitriptyline, are not potent or reliable enough to be used as the sole preventive during withdrawal from alleviative medications for patients with transformed migraines.

Naratriptan in a dose of one 2.5 mg tablet twice a day is a fair substitute for DHE for some good responders to triptans. This triptan is preferable to the others because its longer duration of action gives better sustained preventive effects (its mean half life is 6 hours).  Although the standard migraine preventive pills for long-term use cannot substitute for DHE injections or naratriptan tablets during withdrawal from alleviative drugs, most patients should be started on one of them in the early phase of withdrawal to combat their strong migraine tendency. The best choice is usually amitriptyline, given as a single nightly dose. It has the added benefit of promoting sleep, often hard to come by during the withdrawal phase. In fact, many patients do better with an added sleeping pill.

Short-term preventives useful during analgesic withdrawal in patients with rebound headaches that developed from episodic tension-type headache are naproxen sodium or cyclobenzaprine.

Once the chronic daily rebound headache is replaced by a natural, intermittent headache pattern, the use of short-term preventives can be gradually eliminated. Then, alleviative drug use can be resumed, but with strict limits on the frequency of such use, lest patients slip back into a rebound headache state. If the patient’s post-rebound headache frequency warrants the taking of a long-term preventive, then one should be found for the patient. These and other preventive measures for migraine are presented in my Web page on migraine therapy and the preventive measures for episodic tension-type headache are presented in my page on tension-type therapy.

Patients who have been taking compounds containing butalbital, such as Fiorinal and Esgic Plus, may need to take a substitute barbiturate to control restlessness if they are withdrawn quickly from their medication. I generally prescribe declining doses of phenobarbital for a few weeks after discontinuation of the butalbital compound.

Patients who were abusing weak opioids, such as propoxyphene or codeine, can generally be weaned from them as outpatients, and even those on more potent opioids, such as oxycodone and meperidine, can generally be so weaned. I ask patients to abstain from taking opioids on an as-needed basis and prescribe doses at set intervals unrelated to the state of the headache. I often prescribe one of the long-acting opioid tablets to be taken two to three times per day at set times. I’ve often used long-acting oxycodone (OxyContin) and morphine (MS Contin). Every week or so, the dose is gradually decreased until it is low enough to be discontinued without withdrawal symptoms developing. For some patients, taking oral prednisone for a week or two might make withdrawal from opioids easier.

Withdrawal in Hospital

Hospitalization is not needed for patients whose rebound headaches developed from excessively frequent use of analgesics to suppress episodic tension-type headaches. Hospitalization may be needed for certain patients with rebound migraine who have been heavily using strong opioids, butalbital compounds, or ergotamine. In the hospital, those on opioids or butalbital can be monitored for withdrawal symptoms during gradual discontinuation of the offending substances, while their migraines can be suppressed by infusions of DHE. Those on ergotamine can be withdrawn abruptly from their tablets or suppositories under DHE infusions. Patients who tried but failed outpatient withdrawal from any offending substance should also be hospitalized. During and after hospitalization, the use of long-term preventives to suppress the migraine tendency is the same as it is for outpatient withdrawal.

Patients who respond well to DHE in the hospital are taught to inject themselves. Armed this way, patients have good control over migrainous flare ups of headache after discharge.

Prognosis

Over 90% of patients who discontinue their use of analgesics, opioids (narcotics), ergotamine, or triptans and who continue to abstain from the offending drug(s) have their headache return to a natural episodic pattern, whatever this may be, within several months. These patients are very grateful for and often amazed at their recovery from daily headaches. Even patients with many years (even decades) of rebound headache can be relieved from their chronic daily headache.