Drug Induced Headache

Creator: Jayashree Thakwani
Keywords: headache, medication overuse headache, moh, medication induced headache, migraine attacks

Author - Jayashree Thakwani, M.Pharm.Sci

Medically Reviewed by The Medindia Medical Review Team on Sep 06, 2018

Drug Induced Headache - Overview

Drug-induced headache is also known as medication misuse headache, withdrawal headache or analgesic rebound headache. It is nowadays commonly termed as Medication-overuse headache (MOH).

Medication-overuse headache is a chronic daily headache caused by some medications, when used excessively by patients already prone to headaches. MOH is often observed in people suffering with headache disorders like migraine, cluster or tension-type headaches and is usually caused by the over-use of acute pain-relief medicines. It occurs more often in women than men.

The drug-induced headaches were earlier classified according to

Headaches that have warning signs (e.g. chronic migraine, evolved migraine)
Mechanism of headache (e.g. analgesia rebound headache)
Pattern of headache (chronic daily headache)
Cause of headache (drug-induced headache, painkiller headache, stress headache)

Medication overuse now defined by the amount of medication taken by a patient per month. It varies with the type of medication. There are two types of medication-induced headaches (MIH) that are caused by medication overuse -

When medications like Triptans, ergot alkaloids, combination analgesics, and opioids are consumed for ten or more than ten days per month
When medications like simple analgesics, and non-steroidal anti-inflammatory drugs (NSAIDs) are consumed for 15 or more days

What are the Common Drugs that Cause Headaches?

The common medications which cause drug-induced headache are:

Non-opioid analgesics - e.g. Acetaminophen or Paracetamol, Non-steroidal anti-inflammatory drugs like Acetyl salicylic acid or Aspirin, Diclofenac sodium, Naproxen, Ibuprofen
Opioid analgesics - Codeine, Narcotics, Oxycodone, Propoxyphene

Barbiturate-analgesic combinations - e.g. Butalbital plus acetylsalicylic acid and Caffeine, with or without Codeine
Triptans - e.g. Sumatriptan succinate
Other analgesics - e.g. Pentazocine, Buprenorphine
OTC drug combinations - e.g. Acetaminophen plus Codeine
Caffeine-containing medications
Ergotamine

What are the Symptoms and Signs of Drug-Induced Headaches?

Patients suffering from MIH have the following characteristic symptoms:

A chronic headache that occurs daily or almost daily, for more than 6 months
A headache that leads to non-performance of the patients, in terms of home, work and social activities
The headache improves with pain relief medications but recurs again when the effect of the medication wears off
The patient suffers from symptoms of both tension-type headache and migraine headache
The patient suffers from a headache on waking up from sleep

The other general symptoms include:

Anxiety
Restlessness
Nausea
Irritability
Poor concentration
Memory problems

How do you Diagnose Drug-Induced Headaches?

There are no specific diagnostic tests for MIH. Diagnosis is based on the clinical symptoms of the patient and the patient's history.

The characteristics of MIH vary with the type, location and severity of the headache.

Those with a history of chronic tension-type headache have a dull, generalized headache
Triptan-induced headaches have characteristics similar to migraines for which triptan treatment was initiated
Ergot-induced medication overuse causes a throbbing type of headache

How do you Treat Headaches Caused by Drugs?

MIH can be treated by withdrawing or discontinuing the medication that has caused the headache with excessive use. The treatment can be followed with a combination of pharmacological, behavioral and physical therapy.
Opioids cannot be withdrawn suddenly. The dose has to be decreased gradually and eventually discontinued. The doctor must be consulted when decreasing the dose.
Recurrent migraine headaches can be cured by prescribing migraine-specific agents such as Sumatriptan succinate. It relieves the patient of the migraine and associated symptoms like nausea, vomiting, and sensitivity to light and sound.
For drug-induced headaches due to ergot compounds or analgesics, the withdrawal symptoms include nausea, vomiting, tachycardia and hypotension. These symptoms can be cured with additional treatment using antiemetics and vasoactive drugs like Clonidine or Propranolol.
The patient must be educated on the side effects of the medicaments being consumed for non-headache conditions and the alternate medication for the disease should be recommended by the healthcare provider.
Some patients may need to be hospitalized for detoxification, under medical supervision.
In some cases, behavioral therapy like stress management, meditation, and aerobic exercises can help treat headaches

How do you Prevent Drug-Induced Headaches?

MIH is preventable. It can be avoided by following the guidelines given below:

All efforts must be taken to avoid the occurrence of a headache or a rebound headache
Triggers for headaches must be avoided, by identifying the cause and pattern
Appropriate drug therapy must be prescribed to relieve the person of the primary headache which would avoid the need for additional medications causing headaches
Appropriate headache medications must be used, under a doctor's advise
Avoid Opioids and Butalbital types of medications
The relapse rate of MIH is very high. It is best to avoid overuse of acute medications

References:

Medication overuse headache - (https://americanmigrainefoundation.org/understanding-migraine/medication-overuse-headache-2/)
Medication-induced headache: overview and systematic review of therapeutic approaches - (https://www.ncbi.nlm.nih.gov/books/NBK67634/)
Drug-induced headache - (https://www.ncbi.nlm.nih.gov/pubmed/2259318)
Strategies for diagnosing and managing medication-induced Headache - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2255116/pdf/canfamphys00065-0067.pdf)
From drug-induced headache to medication overuse headache. A short epidemiological review, with a focus on Latin American countries - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3451648/)
Medication-overuse Headache - The Migraine Trust - (https://www.migrainetrust.org/about-migraine/types-of-migraine/other-headache-disorders/medication-overuse-headache/)
About Medication-overuse Headache - (https://www.nps.org.au/australian-prescriber/articles/medication-overuse-headache)
Headache Types - Medication-Overuse Headache - (http://headacheaustralia.org.au/news/medication-overuse-headache/)
Rebound Headaches - (https://www.mayoclinic.org/diseases-conditions/rebound-headaches/symptoms-causes/syc-20377083)
Headaches: Rebound Headaches - (https://my.clevelandclinic.org/health/diseases/6170-headaches-rebound-headaches)

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