Abusive headache

Overuse headache, or so-called "rebound" headache, drug headache is one of the secondary forms of cephalgia, closely related to migraine. In recent years, it has become increasingly important in our country. This is due to the widespread use and availability of various painkillers.

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Epidemiology of medication overuse headache

Abuse, or abuse, depends on how many days a month the patient takes the drug. Important factors are the frequency and regularity of taking the drug/drugs. So, if the diagnostic criteria mention taking the drug for at least 10 days a month, this means 2-3 days of treatment per week.

Overuse headache is the third most common headache after migraine, its prevalence among patients in specialized cephalgia centers reaches 10%, and in the population - 1%.

Abusive headache is manifested by bilateral cephalgia of a pressing or squeezing nature, of minor or moderate intensity. Painful sensations when the patient abuses painkillers (at least 15 days a month for 3 months or more) bother from 15 days or more, up to daily.

What causes medication overuse headaches?

Overuse headache is most often caused by such drugs as: analgesics and NSAIDs, combination analgesics, ergotamine derivatives, serotonin agonists, triptans, opioids. When studying the anamnesis of patients with overuse headache, it is found that some time ago the patients had typical forms of primary cephalgia: 70% - episodic attacks of migraine.

The cause of abusive headache is drug abuse, the main risk factor is regular use of painkillers. Alternating periods of frequent drug use with relatively long periods without treatment leads much less often to the formation of abusive headache. Drug abuse is the main factor in the transformation of episodic cephalgia into chronic. The mechanism of such a paradoxical action of painkillers has not yet been studied. The basis of abusive headache is the presence of migraine. Interestingly, chronic abuse of analgesics for reasons not related to pain in the head (for example, due to arthritis) does not cause abusive headache.

Along with drug abuse, affective disorders - depression and anxiety, which contribute to the development of psychological dependence on drugs, are considered pathogenetic factors of such a condition as medication overuse headache. It has been shown that depressive disorders cause patients to abuse drugs: it is noted in 48% of people with depression (versus 38.6% in patients without depression). Many patients with medication overuse headache have a hereditary predisposition to alcoholism, depression, and medication overuse.

Symptoms of medication overuse headaches

As already mentioned, medication overuse headaches occur in patients who have suffered from primary forms of cephalgia for a long time. Therefore, in the early stages, medication overuse headaches manifest themselves as a more or less typical picture of episodic migraine, which over time, as the medication overuse factor increases (increased frequency of medication intake and/or their dose), transforms into a chronic one. In the advanced stage, medication overuse headaches occur daily, usually persist throughout the day, varying in intensity. It is present already at the moment of awakening, patients describe it as weak, moderate, dull, bilateral, frontal-occipital or diffuse. A significant increase in pain may occur with the slightest physical or intellectual stress, as well as in cases where medication intake is interrupted. Painkillers cause transient and usually incomplete relief of cephalgia, which forces patients to take medications again and again. In addition, cephalgia, combined with abuse, can change its characteristics quite sharply, sometimes within one day.

It has been shown that abuse is the most common cause of increased migraine frequency up to 15 days per month or more, as well as the development of mixed cephalgia, characterized by both migraine features and clinical signs of cephalgia, also occurring with a frequency of more than 15 days per month.

Overuse headache: classification

Cephalgia due to drug overuse is one of the subsections of ICHD-2. In addition to medication overuse headache, this section includes the following subsections: "8.1. Cephalgia due to acute or prolonged exposure to substances"; "8.3. Cephalgia as a side effect of long-term use of drugs"; "8.4. Cephalgia associated with drug withdrawal".

• 8.2. Medication overuse headache.
  • 8.2.1. in case of excessive use of ergotamine.
  • 8.2.2. in case of excessive use of triptans.
  • 8.2.3. in case of excessive use of analgesics.
  • 8.2.4. in case of excessive use of opiates.
  • 8.2.5. in case of excessive use of combination drugs.
  • 8.2.6. caused by excessive use of other drugs.
  • 8.2.7. possibly caused by excessive use of medications.

Among all types of medication overuse headaches, the most clinically significant in the world is cephalgia associated with the abuse of analgesics or combination drugs (i.e. combinations of analgesics with other medications: codeine, caffeine, etc.). It is assumed that any component of combination drugs can cause medication overuse headaches, but the largest "share of responsibility" (up to 75%) lies with analgesics. At the same time, this type of medication overuse headache is characterized by significant therapeutic resistance.

How is medication overuse headache recognized?

One of the main questions that a physician faces when he or she suspects drug overuse in a patient with cephalalgia is the degree of probability of the diagnosis (a definite or only possible connection exists between cephalalgia and the effect of the substance). In many cases, the diagnosis of "overuse headache" becomes obvious only after the pain syndrome decreases after the effect of the substance is stopped. If the cephalalgia does not stop or is not noticeably relieved within 2 months after the "guilty" drug is stopped, the diagnosis of "overuse headache" can be considered doubtful. In such a case, it is necessary to look for other causes of chronic cephalalgia (primarily emotional disorders).

8.2.3. Cephalgia due to excessive use of analgesics

• A. Cephalgia present for more than 15 days per month, fulfilling criteria C and D and having at least one of the following characteristics:
  • double-sided;
  • pressing/squeezing (non-pulsating) character;
  • slight or moderate intensity.
• B. Taking simple analgesics at least 15 days a month for 3 months or more.
• C. Cephalgia developed or significantly worsened during excessive use of analgesics.
• D. Cephalgia resolves or returns to the previous pattern within 2 months after stopping analgesics.

It should be emphasized that patients with primary cephalalgias who develop a new type of cephalalgia or whose migraine becomes significantly worse due to drug overuse should be given not only the diagnosis of the underlying primary cephalalgia but also the diagnosis of "overuse headache." An example of a diagnosis is "Cephalgia with tension of the pericranial muscles. Overuse headache." Many patients who meet the criteria for possible overuse headache also meet the criteria for possible chronic migraine. Until the actual cause is determined after the drug overuse is discontinued, such patients should be given both diagnoses.

No additional tests are needed to diagnose medication overuse headaches. The most informative method for confirming the presence of medication overuse is a headache diary kept by the patient, in which he notes the time of headache attacks and the number of painkillers taken.

Treatment of medication overuse headaches

Treatment of medication overuse headaches includes explaining to the patient the mechanism of pain formation, gradual complete withdrawal of the "culprit" drug, relief of withdrawal symptoms and specific therapy of residual cephalgia. To prevent medication overuse, the doctor should explain to patients (especially with frequent attacks of cephalgia) the danger of analgesic abuse. Medication overuse significantly complicates the treatment of patients with chronic forms of migraine. Therefore, the most important condition ensuring the effectiveness of preventive therapy for migraine is the withdrawal of the drug that caused the overuse. If medication overuse is detected, it is necessary to convince the patient to reduce the dose of painkillers, up to complete withdrawal of analgesics. Complete withdrawal of drugs (provided that it is a non-narcotic analgesic) is the only effective treatment. In severe cases, patients undergo detoxification in a hospital setting. It has been shown that the number of days with overuse headache per month decreases by 50% 14 days after discontinuing the "culprit" drug. In case of successful treatment, cephalgia is transformed into its original form.

In parallel with the withdrawal of the “culprit” drug, the patient should be prescribed traditional migraine therapy.

One of the most effective approaches to the treatment of medication overuse headaches is the prescription of antidepressant therapy. Despite the known side effects, one of the most effective drugs remains the tricyclic antidepressant amitriptyline. A positive effect when prescribing amitriptyline is noted in 72% of patients, in contrast to 43% when stopping taking analgesics without concomitant antidepressant therapy. In some patients, antidepressants from the group of selective serotonin reuptake inhibitors (paroxetine, sertraline, fluoxetine) and selective serotonin and norepinephrine reuptake inhibitors (duloxetine, venlafaxine, milnacipran) have a good effect. If medication overuse headaches are combined with chronic migraine, anticonvulsants (for example, topiramate) are the drugs of choice.

Due to the significant recurrence rate (more than 30%) after medication overuse is stopped, it is important to warn the patient about the possibility that medication overuse headache may return and to explain to him the need to strictly control the amount of painkillers.

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