'Rebound headache' linked to migraine medication misuse

An alarming number of Australians treating migraines with over-the-counter and prescription pain relievers are at risk of inducing 'rebound headaches' caused by medication overuse, according to research published today in the Medical Journal of Australia (MJA). Author of the study Associate Professor Richard Stark, neurologist from the Alfred Hospital in Melbourne spoke about the research in an interview with 2UE.

Click here to listen to the interview.

Associate Professor Richard Stark claims many Australian migraine sufferers are 'caught in a vicious cycle' where over-reliance on pain relievers and, in some cases, inappropriate use of medications can aggravate their condition.

"Doctors and their patients need to be alert for 'rebound headache' and limit frequent use of acute analgesic medications, notably opioids such as codeine and morphine derivatives, in the treatment of migraine," he said.

Affecting approximately 200,000 Australians, rebound (or medication overuse) headache occurs when the body becomes acclimatised to a frequently used pain reliever and then develops a 'withdrawal' effect when the medication is ceased. This often triggers a new headache, prompting the patient to re-introduce the pain reliever and exacerbate a cycle of debilitating symptoms.

Associate Professor Stark said the diagnosis of rebound headache and withdrawal of the offending medication is extremely important, not only because it can break the migraine cycle, but because patients are less likely to respond to preventative therapy while overusing painkillers.

The MJA study, which involved 191 general practitioners and 649 migraine sufferers, found that therapy that could prevent migraines was significantly under-utilised, especially in patients with frequent migraine.

"Our research found that only one in five patients who suffer three or more migraines per month take preventative therapy. These people could benefit enormously from the wide range of preventative medications now available in Australia," he said.

"Migraine prevention should be the primary goal for doctors and their patients. Preventative medication should be considered when headache frequency exceeds two events per month."

The study also found that 11 per cent of migraine patients were using acute pain relief medication as preventative therapy.

"These patients are at high risk of developing rebound headache," he said.

"The majority of patients who use preventative therapy can significantly reduce the frequency of migraine and improve their quality of life, as long as we choose the best agent for the individual. Sometimes this may require some trial and error, but it is well worth the effort."

Key Conclusions: MJA 'Management of Migraine in Australian General Practice'

What do Australian GPs do well in managing migraine?

It appears that the under-diagnosis of migraine may be less in Australian general practice than has been recorded elsewhere in the world.
Australian GPs appear, in general, to follow recommended guidelines in the use of acute medications. However, combined analgesics containing codeine are still overused.

How can we improve practice for patients with migraine?

Consider preventative agents when headache frequency is greater than two per month.
Consider using a broader range of preventative agents. If side effects or contra-indications limit the use of an agent or if the agent first chosen proves ineffective, consider the many other agents that may be suitable.
Be alert to the risk of medication overuse (rebound) headache and try to limit frequent use of ergotamines, triptans and particularly opiates.

What is a migraine?

Migraine is a neurological disorder that causes episodes of severe or moderate headache (which is often one-sided and pulsating) lasting between several hours to three days, accompanied by gastrointestinal upsets such as nausea and vomiting, and a heightened sensitivity to bright lights and noise. Up to 15 per cent of Australians suffer migraines, which are 2-3 times more common in women than men, as female hormones can trigger migraines.

What causes migraine?

The susceptibility to migraine is largely genetic and probably relates to the excitability of certain brain pathways. In someone prone to migraine trigger factors include lack of sleep, certain foods, stress and hormonal fluctuations. In many patients trigger factors are so numerous or variable that avoiding them is impractical.

The symptoms of migraine include:

A moderate to severe throbbing headache, lasting from several hours to a few days.
The headache may be preceded by an aura (ie, distorted vision or sensory disturbance).
The pain is typically centred over one eye or temple, or the back of the head.
Nausea and sensitivity to light and noise often accompany the headache.
Often migraines prevent normal activities, such as work or leisure, and the great majority of headaches that are bad enough to cause such disruption are regarded as migraines.