Analgesic Rebound Headache Research Articles

089 Breaking the cycle of chronic daily headache with a low-dose subcutaneous lignocaine and ketamine infusion

IntroductionManagement of chronic migraine includes correcting analgesic rebound headache and implementing suitable medication for prevention and acute episodes. However, in many cases this management paradigm oversimplifies the complexity of chronic migraine, particularly the entrenched central pathways that perpetuate chronic migraine. Intravenous lignocaine can curtail chronic migraine and analgesic rebound headache (1). Further, ketamine provides short-term analgesia and enables reduction in central sensitisation of pain pathways, particularly in the setting of codeine/opiod overuse (2). This paper describes use of subcutaneous lignocaine and ketamine infusion in chronic migraine.MethodsA prospective observational cohort study was undertaken in patients with chronic migraine. Patients received a prolonged subcutaneous lignocaine and ketamine infusion (mean duration 11 days) and underwent evaluation at four-time points over six months. The effects on the excitability of motor axons in the median nerve were documented using standard procedures.ResultsFourteen patients were recruited. The infusion was well tolerated; no major side effects were seen. There were no significant long-term changes in the excitability of motor axons. At six months, 13/14 patients had sustained benefit. Three of 4 patients remained free of analgesic rebound headache. One patient remained headache-free. Conversion to episodic migraine occurred in 6/14. Improvement in chronic migraine was reported by 6/14. Three of six were able to return to work, with 1 returning to studies. Benefit was greater in those with depression and history of opiod/codeine use.ConclusionSubcutaneous lignocaine and ketamine can help break entrenchment in chronic migraine as part of a structured management plan.

Medication Overuse Headache: A Trap for the Headache Patients

Medication Overuse Headache (MOH) was previously termed analgesic rebound headache, drug-induced headache, and medication-misuse headache. It is not a primary headache but frequently coexists with primary chronic daily headache. All acute symptomatic medications used to treat headaches have the potential for causing MOH. Highest with opioids, butalbital-containing combination analgesics, and aspirin/ acetaminophen/caffeine combinations. The development is typically preceded by an episodic headache disorder, usually migraine or tension-type headache, that has been treated with frequent and excessive amounts of acute symptomatic medications. The diagnosis is based upon clinical impression. A history of analgesic use averaging more than two to three days per week in association with chronic daily headache is suggestive. The diagnosis is made when the pattern of frequent headaches fulfills the diagnostic criteria for MOH. The basic steps in the management: Patient education, withdrawal of the offending medication, bridge (transitional) therapy, establishment of a headache treatment regimen covering acute and preventive care, follow up and relapse prevention. Birdem Med J 2013; 3(2): 94-98 DOI: http://dx.doi.org/10.3329/birdem.v3i2.17213

Acute treatment of headache

Effective acute treatment of headache begins with making an accurate diagnosis and ruling out secondary causes of headache. Once a primary headache is diagnosed, it is important to choose the right combination of behavioural therapy and acute care (abortive and symptomatic) therapy for each patient. Some patients may need preventive medication on a daily basis. If patients overuse acute medications and develop medication overuse headache (previously called analgesic rebound headache), they often seek medical attention due to the chronicity and/or intensity of their pain and resultant disability. For acute care of migraine, physicians should choose a triptan they know and expect to work. They should prescribe the dose and route of administration that will provide the most rapid and complete response to all the associated symptoms of migraine, in addition to the pain. The effectiveness of the 7 available triptans in early, double-blind, controlled trials is more similar than different. How and when to give them will be discussed. Treatment of cluster headache will be presented briefly.

American Headache Society members' assessment of headache diagnostic criteria.

We assessed the views of physicians interested in headache as to the diagnosis of the most commonly occurring and currently controversial headaches. The International Headache Society (IHS) classification system has received wide professional endorsement and considerable empirical support, but in the United States, their adoption by clinicians may be proceeding more slowly. Questions remain, including what diagnostic criteria for migraine and tension-type headache clinicians may continue to favor over those outlined by the IHS, to what extent is the "transformed migraine" diagnosis used in clinical practice, and how is analgesic rebound headache diagnosed with regard to the various quantitative measures of analgesic use. Members of the American Headache Society rated the importance of IHS and non-IHS diagnostic criteria for migraine and tension-type headache and for analgesic rebound headache. Respondents also described their use of the proposed transformed migraine diagnosis. Two-thirds (67.3%) of the respondents reported use of the IHS criteria or the IHS criteria in conjunction with clinical judgment. For migraine and tension-type headache, IHS criteria were rated with high importance, but some respondents reported using additional non-IHS diagnostic criteria and de-emphasizing certain IHS criteria. For chronic headache, almost two-thirds (63%) of respondents reported using the transformed migraine diagnosis. For analgesic rebound headache, respondents preferred to make the diagnosis based on medication consumption that is lower than amounts stipulated in the IHS classification system. There remains a number of physicians interested in headache who do not use the IHS classification system, who modify the IHS criteria in practice, and who use the "transformed migraine" diagnosis for patients with chronic daily headache.

Headache Disorders in the Elderly.

Headache prevalence declines in the elderly, but remains a common reason for patients to seek medical attention. Although primary headache types remain most frequent, secondary headaches become more likely in this age group. Accurate diagnosis is essential, and the clinician should maintain a lower threshold for ordering laboratory testing and neuroimaging. The elderly are more likely to have co-existent medical conditions, which present both therapeutic limitations and opportunities when selecting acute and preventative treatments for headache. Altered pharmacokinetics and pharmacodynamics in this age group may increase the likelihood of side effects and drug interactions. Downward dose adjustments and simplifying medication regimens are often appropriate, as is using nonpharmacologic therapies whenever possible. Due to frequent contraindications related to acute medications, preventative drug regimens and nonpharmacologic treatments assume greater prominence when treating the elderly suffering frequent/severe headaches. Medication-induced headache and analgesic rebound headache occur commonly in this age group and may initiate, aggravate, or perpetuate headache. Chronic daily headache is often due to these conditions, and recognition of these problems can allow effective intervention.

Low-dose tizanidine with nonsteroidal anti-inflammatory drugs for detoxification from analgesic rebound headache.

To describe an outpatient regimen for analgesic detoxification and resolution of analgesic rebound headache. Frequent analgesic use is believed to promote the transformation of episodic migraine into a chronic, pervasive headache syndrome. Management of pain precipitated by analgesic withdrawal is crucial to treatment success. Outpatient treatment protocols designed to achieve successful withdrawal will reduce costs and potentially lead to more widespread implementation of therapy. Patients with appropriate histories were managed on an outpatient basis for detoxification by discontinuation of the offending analgesic and initiation of treatment with tizanidine and a long-acting nonsteroidal anti-inflammatory drug. Patients kept diaries of pain and medication use. Results were evaluated at 6 and 12 weeks. Patients able to tolerate no or trivial analgesic use (ie, 4 or fewer doses in each 2-week period) were considered responders. At 6 weeks, 36 patients (65%) were responders. At 12 weeks, 38 patients (69%) were responders. The chronic daily headache pattern had resolved at 12 weeks in 34 patients (62%). This treatment protocol was well tolerated and yielded a high degree of efficacy, demonstrating that outpatient management can be effective for achieving analgesic withdrawal and resolution of analgesic rebound headache.

Medication-induced (analgesic rebound) headache: historical aspects and initial descriptions of the North American experience.

A review of the initial descriptions of medication-induced (misuse) headache in the North American literature indicates that this disorder was first identified in the mid-1950s. It was not until the early 1980s that this phenomenon became well established.

Intravenous lignocaine infusions for severe chronic daily headache.

To determine the safety and efficacy of intravenous lignocaine infusion in patients with severe chronic daily headache (CDH). Retrospective survey of consecutive patients. 19 patients, 18 with rebound headache and three with status migrainosus. Two patients had both conditions at different times. Neurology unit in a major metropolitan teaching hospital, 1994-1998. Adverse events; headache resolution; long term efficacy. The 19 patients (16 women) received 27 lignocaine infusions. Seven minor adverse events were noted during four infusions. Twenty-two infusions were given for analgesic rebound headache in 18 patients, with headache resolution in 82% of infusions (17 of the 18 patients responded at least once). Four patients obtained lasting relief, six returned to their regular manageable pattern of migraine (in two of these patients CDH recurred after six months), four were lost to follow-up, and in four there was no long term benefit. Five infusions were given for status migrainosus in three patients, with four of these infusions successfully relieving the headache. Intravenous lignocaine appears to be useful in the management of severe intractable CDH and status migrainosus.

Medical management of posttraumatic headaches: pharmacological and physical treatment.

Posttraumatic headache can be a very difficult syndrome to manage, especially if chronic. As with most other types of headache, medications are the primary treatment modality, although there is very limited evidence-based data to support any given approach. A number of physical interventions also are available to be used in conjunction with medication, particularly for headaches with a musculoskeletal component. This article will review the general principles of pharmacological treatment for headache and the physical approach to treatment of headaches and head and facial pain. The major categories of medications commonly used for treatment of many varieties of headache will be discussed. In addition, the problems encountered in diagnosing and treating chronic daily headache and analgesic rebound headache are addressed. The approach to treatment of such syndromes as myofascial pain, cervico-zygapophyseal joint pain, neuritic pain, and craniocervical somatic pain are outlined.

Medication-Induced Headache: Overview and Systematic Review of Therapeutic Approaches

To review medication-induced headache (MIH) through a systematic evaluation of the literature regarding the pharmacologic management of this condition. To identify and evaluate all pharmacologic interventions for MIH, we conducted a qualitative systematic review of the English-language literature from 1966 to June 1998 using MEDLINE. The following search terms were used: chronic daily headache, transformed migraine, analgesic withdrawal headache, analgesic rebound headache, drug-associated headache, medication-induced headache, detoxification, and dihydroergotamine. In addition, a review of the references from relevant literature was also conducted to collect reports not identified in the MEDLINE search. Numerous therapies for acute management of MIH have been evaluated, although no rigorously conducted clinical trials were identified. Therapies evaluated include abrupt withdrawal of analgesics, initiation of dihydroergotamine, nonsteroidal antiinflammatory agents, methylergonovine, dihydroergotamine, sumatriptan, amitriptyline, dexamethasone, piracetam, prothipendyl, and valproate. Epidemiology, diagnosis, clinical features, pathophysiology, and long-term prognosis of therapy are discussed and therapeutic guidelines are offered. MIH is an underrecognized and difficult condition affecting headache-prone patients. The published literature concerning treatment of patients with MIH is scant and of poor quality, making it difficult for clinicians to decide on appropriate therapy. Recognition and treatment of MIH may lead to a long-term improvement in headache relief for many patients. It appears that complete withdrawal of the medications being overused is required for favorable long-term results.

Analgesic rebound headache in children and adolescents.

For more than a decade, the frequent use of analgesics has been recognized to lead to daily headaches in adults. To date, no studies on the occurrence of analgesic rebound headache have been done on the pediatric population. We retrospectively reviewed all charts of patients with the diagnosis of headache seen in our pediatric headache clinic between January 1996 and May 1997. Among the 98 patients seen, 46 (47%) suffered from daily or near daily headaches; 30 of them were consuming daily analgesics. Twenty-four patients (mean age 12.1 years, and mean follow-up 6.2 months) successfully discontinued their analgesics. Twenty-two patients were also placed on amitriptyline. A significant reduction in the frequency (80%), severity (47%), and number of school days missed (74%) were seen. In conclusion, this data is comparable to previous observations reported in adults, and suggests that the daily use of analgesics might result in daily or near daily headaches in the pediatric population. Discontinuing daily analgesics, with the concomitant use of amitriptyline, is an effective treatment for analgesic rebound headache in this population.

Practical evaluation and diagnosis of headache.

Establishing an open and honest physician-patient relationship is essential for the proper evaluation and management of headache disorders. Obtaining a complete headache and medical history is the most important part of the initial diagnostic evaluation. This history should include information about headache onset, pain intensity, character of the pain, presence of aura, associated autonomic symptoms, and trigger factors. Special attention must be paid to the frequency of analgesic use, both prescription and over-the-counter, to identify analgesic rebound headache. A thorough neurologic examination must also be performed; if it is normal, there is usually no need for special tests. Headaches are classified as either primary or secondary. Primary headaches have no structural or metabolic cause, while secondary headaches are caused by an underlying pathologic or metabolic process. Migraine, tension-type, cluster, and analgesic-rebound headaches are all primary headache disorders. Secondary headaches are caused by conditions such as increased intracranial pressure, pseudotumor cerebri, subdural and intracerebral hematomas, hypertension, meningitis, temporal arteritis, Lyme disease, and brain tumors. Accurate diagnosis of headache is essential to determine the appropriateness of further testing and to guide proper treatment of the patient's condition.

Analgesic rebound headache in clinical practice: data from a physician survey.

Frequent, excessive use of over-the-counter or prescription analgesics may lead to analgesic rebound headache. Little is known about the magnitude of the health problem posed by analgesic rebound headache, its epidemiology, the characteristics of analgesic rebound headache sufferers, or about physicians' approaches to treatment. Four hundred seventy-three practitioners, who had previously expressed an interest in the treatment of headache, were mailed a questionnaire designed to capture information about the frequency and management of analgesic rebound headache and about the characteristics of analgesic rebound headache sufferers. Completed questionnaires were returned by 174 practitioners (37%) from 40 states, the District of Columbia, and Puerto Rico. More than 40% of respondents indicated that analgesic rebound headache was present in at least 20% of their patients. On average, the physicians reported that 73% of patients with analgesic rebound headache were women. Analgesic rebound headache was most likely to occur in patients aged 31 to 40 years. No one analgesic was consistently identified as causative, although acetaminophen, butalbital + aspirin + caffeine, and aspirin were commonly used by patients. Eighty percent of respondents indicated that depression was commonly observed in analgesic rebound headache sufferers; 77% indicated that physical conditions (especially gastrointestinal symptoms) were commonly observed. A variety of therapeutic strategies, including pharmacotherapy, were used in the management of analgesic rebound headache. Analgesic rebound headache was recognized as a distinct entity and a substantive component in more than 40% of the practices of 174 surveyed practitioners. General practitioners, who see a wide variety of patient types with a spectrum of complaints, need to be able to diagnose analgesic rebound headache by taking a good history.

Subcutaneous sumatriptan in a clinical setting: the first 100 consecutive patients with acute migraine in a tertiary care center.

The first 100 consecutive patients at our center receiving subcutaneous sumatriptan (6 mg) were evaluated over a total of 455 migraine attacks. Parameters included overall efficacy, average time to relief, recurrence rate, average time to recurrence, adverse events, comparison to previous abortive agents, and subjective global ratings. Overall efficacy (defined as headache severity reduction from severe or moderate to mild or none) was 84%. Average time to relief was 40 minutes. Nine percent failed to respond at all. Recurrence rate was 46.5% with 36% of patients having no recurrence. Fourteen percent of patients reported 100% recurrence (minimum 3 attacks; average 5.4 attacks). Time to recurrence varied widely, but averaged 9.1 hours. Eighty-one percent rated the drug better or much better than previous abortive medications in terms of sumatriptan's ability to abort the attack. Seventy-seven percent reported some adverse event (generally mild and transient) with 23% reporting no adverse events. Sixty-nine percent reported a global rating of Good to Excellent and 31% rated Poor or Fair. The rate of recurrence and average time to recurrence were the most significant factors affecting the global ratings. These parameters were further evaluated with respect to a variety of subgroups: 1) migraine alone 2) migraine with co-existent tension-type headache 3) drug-induced headache (analgesic rebound headache) 4) posttraumatic headache 5) preventive versus no preventive medication 6) presence or absence of adverse events 7) presence or absence of recurrence and 8) average duration of migraine with no medication.

Analgesic rebound headache: experience in a community hospital.

In the past, chronic daily headaches have been attributed to many possible causes, including "tension," excessive contraction of pericranial muscles, and depression. A careful history reveals that many patients start out with fairly typical intermittent migraine attacks that evolve over the years into a pattern of daily or almost daily head pain. Overuse of analgesics is usually a part of this clinical picture, which has been termed "analgesic rebound headache." Fifty-three of the first 100 patients admitted to a community hospital's inpatient headache treatment program had chronic daily headaches and were overusing analgesics or other headache relief medications. We report our retrospective review of these patients and describe treatment of this difficult and sometimes unrecognized syndrome, primarily with intravenous dihydroergotamine (DHE). Results at hospital discharge and at follow-up several months later showed significant reduction of pain.

The refractory headache patient—II. High medication consumption (analgesic rebound) headache

‘Analgesic rebound headache’ is identified by habituation of an individual to pain reducing medication, the exacerbation of headache pain a few hours after medication consumption and a marked increase in headache frequency and intensity for several weeks after medication is discontinued. We describe three studies undertaken to clarify the existence and characteristics of this proposed headache syndrome. In Study 1 we compared a group of headache sufferers who consume large amounts of analgesic medications to headache sufferers who did not consume excessive analgesics. It was found that the two groups did not differ on age, duration of headache problem or gender. However, the groups did differ on subjective headache pain (with the high medicators experiencing more headache pain than low medicators) and diagnosis (with high medicators being more likely to have a muscle contraction component to their headaches). In an analysis of drug use within the high medication group, it was found that 91% were taking some kind of analgesic and that a majority (84%) were taking more than one type of medication. In Study 2 we found that the group of high medicators were not as successful in reducing headache activity as a result of a self-regulatory behavioral treatment as the matched controls. Furthermore, there was a direct relationship between reduction and treatment success in the high medication consuming population. Lastly, in Study 3 we examined the current psychological functioning of the two groups; no differences were found between the two groups indicating the lack of ‘addictive’ personality characteristics as an explanation for the high medicating population. These findings all support the existence of a sub-population of headache sufferers who consume excessive amounts of analgesic medication and who are relatively refractory to behavioral treatment.

Analgesic rebound headache refuted.

Analgesic Rebound Headache Refuted C. Miller Fisher M.D., C. Miller Fisher M.D. Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.Search for more papers by this author C. Miller Fisher M.D., C. Miller Fisher M.D. Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.Search for more papers by this author First published: November 1988 https://doi.org/10.1111/j.1526-4610.1988.hed2810666.xCitations: 7AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume28, Issue10November 1988Pages 666-666 RelatedInformation