Could your headache medication actually be causing headache?

There has been much attention in the press recently regarding the increasing use of opiate based medication and the potential for addiction or even fatality with long term use of this class of painkillers.  A lesser known consequence of misusing opioids, as well as other pain relieving medication, in headache sufferers is the development of chronic headache, or ‘medication-overuse headache’.

Medication-overuse headache is described by the International Classification of Headache Disorders as worsening headache in patients with a primary headache diagnosis that occurs on 15 or more days per month, has been present for at least 3 months and is associated with overuse of medication used for acute headache treatment.  Commonly used painkillers and non-steroidal anti-inflammatory drugs such as paracetamol, co-codamol and ibuprofen, as well as ‘abortive’ drugs such as ‘triptans’ are the most frequently used drugs used to treat the acute pain of migraine headache. In other words, the medicine that is intended to have a therapeutic effect ends up making things worse.  

One issue is that many headache sufferers, especially migraineurs, are poorly managed in the first place and often resort to self treatment rather than getting expert advice.  Migraine is under-diagnosed and so patients may not even realise that there are much better medical options available to them that could help. In addition, many patients who do seek help are only offered medical treatments rather than also getting help with other coexisting conditions that can significantly help head pain in many cases.  Medication overuse headache is most likely to develop in patients with more frequent headaches and in particular chronic migraine. It is more common in women and in patients with depression, anxiety, sleep disorders and other chronic pain conditions suggesting that a multidisciplinary approach managing patients within a biopsychosocial framework is likely to provide better outcomes than medical management on its own. That said, medical help must be the main treatment approach for medication overuse headache and we would advocate that patients seek advice from either a specialist GP or neurologist.  It is worth asking if there is a GP at your practice who has a specialist interest in headache conditions.  

“Successful treatment is difficult and requires the engagement of the patient who really needs to trust his or her doctor.” explains local physiotherapist Nick Critchley.  Guidance, education and reassurance is vital on an on-going basis as the process of detoxification takes time. Relapses are common, especially in those with other chronic pain conditions and with those taking opioid medication but there is a 50-70% success rate overall. 

The optimal therapeutic approach is not clear and research is still needed in this area in order to really understand the long term benefits of preventative medication versus their potential side effects and the benefits of these drugs over controlled acute medicine for immediate symptom relief.

One thing is clear though; patients need to feel that they can trust their doctors when discussing headache conditions. Education is vital and requires collaboration between the patient and different clinicians working together as a team.  Each patient will have a unique presentation of underlying biological and genetic influences but also psychological and social factors that are often very influential in driving pain and illness. This approach encourages patients to continue to engage with treatment options rather than quickly becoming disillusioned or not trusting the process in the first place.