Treating rebound headaches with early preventative meds best choice, study finds

Your head is pounding yet again. You grab another round of pain meds, only to find they no longer work.

You may be suffering from a MOH -- a medication overuse headache -- brought on when the very medications you relied on for relief suddenly become the enemy.

Some 60 million people around the world suffer from headaches brought on by the overuse of medication. It typically happens to people who suffer from migraines, cluster headaches or tension-type headaches who are using medications that don't work.

When the pain doesn't ease, they take another pill, thus setting the scene for what is often known as a "rebound" headache.

Instead of a headache that might call for pain medications two or three times a week, people with MOH now have a headache nearly every day, typically upon awakening. For many, this is a new level of chronic pain -- and there's no miracle pill to fix it.

Is cold turkey best?

Withdrawal therapy is currently the only treatment for this disorder, sometimes combined with physical or behavioral therapy and preventative medicine treatments, sometimes called "bridge therapies."

Those preventative medicine treatments include anticonvulsants, antidepressants, beta blockers and calcium channel blockers that might help control withdrawal pain without risking medication overuse headaches. At times a patient may be given injections of Botox or antibodies designed to thwart migraines.

But not always. In Denmark, for example, guidelines suggest a complete withdrawal, totally discontinuing any pain medications for two months before other options are provided.

"Withdrawal has been recommended for years in European Guidelines, including the most recent published from May 2020," said Dr. Rigmor Jensen, a professor of headache and neurological pain who directs the Danish Headache Center at the University of Copenhagen, and is lead author on a new study to see if those recommendations were right.

In fact, doctors have long debated whether any preventative treatments were necessary to help patients wean off medications -- believing the vast majority of patients did just as well with a cold-turkey approach.

After all, most withdrawal headaches tend to improve in less than a week, although some patients did need to be hospitalized, especially if they were withdrawing from opioids.

"In placebo-controlled studies for preventive treatment, the effect has been modest," Jensen said. "So, we decided to compare these treatment strategies directly in this study to clarify the question."

Jensen and his coauthors hypothesized that withdrawal alone, or withdrawal with preventatives, would work better in reducing overall headache days per month than a preventative approach.

However,the results of their study, published Tuesday in the journal JAMA Neurology, surprised the authors.

While all three treatments were effective in reducing MOH, the largest reductions in headache and migraine days, days with short-term medication use and days with headache pain intensity were seen in the withdrawal plus preventive medicine group.

In addition, people who withdrew from meds with the help of preventatives had a significantly higher chance of being cured of their medication overuse headaches than patients who used preventatives or withdrawal alone.

"We were surprised of the study results and the excellent adherence to the treatment," Jensen said. "We now recommend withdrawal and early start of preventive treatment."

"Having good medical evidence to support the common practice of both stopping the offending agent or agents, and starting a patient on prevention medication right away, will clear up some of the controversy and confusion," said Dr. Rachel Colman, director of the Low-Pressure Headache Program at the Icahn School of Medicine at Mount Sinai in New York.

Doctors should use this study to "provide patients with guidance, support and hopefully relief from a disabling condition," said Coleman, who was not involved in the study and is a member of the National Headache Foundation Health Care Professionals Leadership Council.

Coleman also pointed out that due to timing of the trial, the study did not include the newest options for prevention, called CGRP monoclonal antibodies, that have become available in the last two years. These are a new class of medication created specifically for migraine headaches.

However, Jensen said that going "cold-turkey" may still have some benefits for patients, especially those with less severe rebound headaches. Prior studies have found that when patients feel their actions exert control over their headaches, it can help them from overusing medications in the future.

"Patients who withdraw completely experience that a headache can disappear by itself, and that experience is important when talking about preventing relapse into a new medication overuse," Jensen said.

What causes a MOH?

Just how much pain medication will cause a rebound headache depends on the medicine.

According to the American Migraine Foundation, over-the-counter pain relievers, such as aspirin, acetaminophen, ibuprofen, naproxen and indomethacin, can cause MOH when used 15 or more days per month.

It will only take about 10 days of use for medications that combine caffeine, aspirin and acetaminophen to contribute to a MOH. Ten days is also the max for tryptamine- and ergotamine-based drugs often prescribed for migraines, as well as any of the opiates: oxycodone, tramadol, butorphanol, morphine, codeine or hydrocodone.

Just 200 milligrams of coffee will also trigger a medication overdose headache. That's just one cup of coffee combined with a coke and a plain chocolate bar.

It's not just pain in the head either. Often MOH can cause memory issues, difficulty concentrating, depression, anxiety, irritability, restlessness and nausea.