Analgesic Rebound Headache

THE CLINICAL SYNDROME

• Overuse of abortive drugs causes analgesic rebound headache, also known as analgesic overuse headache.
• Limiting headache analgesics can prevent this condition.
• Misuse of these drugs increases headache frequency and resistance to headache treatments.
• Over weeks, acute migraines or tension-type headaches become chronic everyday headaches. When preventative or abortive analgesics are omitted or delayed, this daily headache gets worse.
• Despite the lack of a clear pathogenesis, malfunction of the trigeminal regulating system and central sensitization may contribute to analgesic rebound headache.
• Due to the widespread advertising of caffeine-containing over-the-counter headache remedies, analgesic rebound headache may be underdiagnosed.

SIGNS AND SYMPTOMS

• In a clinical setting, analgesic rebound headache manifests as a converted migraine or tension-type headache.
• It may also assume the characteristics of both of these frequent headache types, so blurring their individual aspects and making diagnosis difficult.
• The overuse of any one of the following medications is the primary cause of analgesic rebound headaches: simple analgesics, such as acetaminophen; sinus medications, including simple analgesics; combinations of aspirin, caffeine, and butalbital (Fiorinal); nonsteroidal antiinflammatory drugs; opioid analgesics; ergotamines; and triptans, such as sumat- riptan.
• The physical examination is often within normal limits, but psychiatric comorbidities may be more prominent in this group of headache sufferers.
• This is similar to migraine and tension-type headaches, both of which have similar symptoms.

TESTING

• There is currently no diagnostic procedure available for analgesic rebound headache.
  • The primary goal of the testing is to discover a hidden pathologic process or other diseases that may present symptoms similar to tension-type headaches or migraines.
• Magnetic resonance imaging (MRI) of the brain and, if significant occipital or nuchal symptoms are present, magnetic resonance imaging (MRI) of the cervical spine should be performed on all patients who have recently experienced the onset of chronic daily headaches that are thought to be analgesic rebound headaches.
• In patients who had previously stable tension-type or migraine headaches but who have recently seen a change in the severity of their headache symptoms, an MRI should also be conducted.
• If the diagnosis of analgesic rebound headache is uncertain, screening laboratory tests, which include a complete blood count, erythrocyte sedimentation rate, and automated blood chemistry, should be conducted.

DIFFERENTIAL DIAGNOSIS

• On the basis of clinical evidence, the diagnosis of analgesic rebound headache is typically made by collecting a specific headache history.
• Because analgesic rebound headache assumes many of the characteristics of the underlying primary headache, diagnosis can be confusing if a careful medication history is not taken, including specific questions regarding over-the-counter headache medications and analgesics.
• This is because analgesic rebound headache assumes many of the characteristics of the underlying primary headache.
• Any modification to a headache pattern that was previously stable needs to be regarded carefully, and it should not be instantly attributed to an excessive amount of analgesic use without first doing a rigorous reevaluation of the patient.

TREATMENT

• The treatment for analgesic rebound headache comprises of discontinuing the drugs that have been misused or abused and then abstaining completely from the drug or substances that have been overused or abused for a period of at least three months.
• Individuals who are experiencing analgesic rebound headache may benefit from the inclusion of an appropriate preventative headache treatment (such as propranolol for the migraineur), which may further reduce the frequency of headaches experienced by these patients.
• Care should be taken to avoid sudden withdrawal of drugs such as the barbiturates and/or opioids because significant side effects, including seizures and acute abstinence syndrome,may develop. In this particular scenario, gradual reduction of the problematic medicine is required, and doing so may call for hospitalization.
• Many patients cannot tolerate outpatient withdrawal of these medications and ultimately require hospitalization in a specialized headache unit.

COMPLICATIONS AND PITFALLS

• Patients who overuse or abuse medications, including opioids, ergotamines, and butalbital, develop a physical dependence on these drugs, and the abrupt cessation of their use results in a drug abstinence syndrome that can be life threatening if it is not properly treated.
• Patients who overuse or abuse medications, including opioids, ergotamines, and butalbital, develop a physical dependence on these drugs.
• As a result, the majority of these individuals require inpatient tapering in an environment where they can be closely monitored.