SEARCH

SEARCH BY CITATION

Keywords:

  • rebound headache;
  • recovery;
  • treatment;
  • outcome

Abstract

  1. Top of page
  2. Abstract
  3. CASE HISTORIES
  4. COMMENTS
  5. CONCLUSION
  6. REFERENCES

Objective.—To document that some patients with rebound headache require prolonged complete avoidance of the pain relief medications which might cause the daily or almost daily headaches in order to achieve a goal of 6 consecutive headache-free days.

Background.—Most articles on rebound headache imply that the patient improves after stopping the offending agents, but they fail to state the pattern of recovery, the time required for recovery, or the specific end point achieved.

Design.—Selected from the histories of approximately 1000 patients with suspected rebound headache who have been seen in a university headache referral clinic are the records of four patients who kept careful headache diaries, followed the treatment protocol (with minimal noncompliance by two patients), and required more than 6 months to achieve our goal of 6 consecutive headache-free days.

Conclusions.—Hopefully, other physicians treating patients with suspected rebound headache will benefit from this report and will be able to better manage their patients.

Abbreviation:
RH

rebound headache

In previous articles on rebound headache (RH), it is usually implied that the patients improved after stopping the pain relief medications. These articles usually fail to specify the pattern of improvement, the degree of improvement that is achieved, or the time required to reach a specific end point.1-3 One article described 2% of patients who were significantly improved during the fourth month after having “decreased and then stopping” analgesic intake.4 A previous case report from this clinic described a 65-year-old woman with 8 years of chronic daily headache who progressively improved and finally noted termination of the daily headache after having omitted the offending pain relief medications for more than 6 months.5

In the past 5 years, there have been seven additional patients at this clinic—approximately 0.5% of the total RH population—who have required more than 6 months to achieve our goal of 6 consecutive headache-free days. The longest times to reach this goal were 16 1/2 and 20 1/2 months (patients 3 and 4 in the Table 1). Below are illustrative case histories of four patients who kept detailed headache logs which allow documentation of the pattern and time of recovery from their frequent headaches.

Table 1.—.  Description of the Headaches and Time Required to Reach Stages of Recovery
FeaturePatient 1Patient 2Patient 3Patient 4
  1. TTH indicates tension-type headache; RH, rebound headache.

Age, y/sex52/F33/F33/F54/F
Previous headachesInfrequent TTHMigraine and TTHInfrequent TTHCannot recall
Precipitating eventSinus surgeryDental extractUnknownUnknown
Duration of RH, y414230+
Migrainelike attacks, No. per wk213-41-4
Days without headache previous yearNone1-2/moNoneNone
Benign stabbing headachesNoneOccasionalOccasionalFrequent
Results    
First day without headacheDay 36Day 34Day 240Day 155
2 consecutive daysDay 47Day 54Day 280Day 309
3 consecutive daysDay 155Day 91Day 441Day 426
4 consecutive daysDay 191Day 177Day 441Day 426
5 consecutive daysDay 297Day 415Day 476Day 590
6 consecutive daysDay 297Day 443Day 498Day 610
Time until> 50%    
headache-free days, mo5141519
Goal reached, mo9 1/214 1/216 1/220 1/2
ComplianceTotalNot 10th-13th moTotalNot 15th-16th mo

CASE HISTORIES

  1. Top of page
  2. Abstract
  3. CASE HISTORIES
  4. COMMENTS
  5. CONCLUSION
  6. REFERENCES

Patient 1.—Nine and a Half Months Until Termination of Rebound Headache

This 52-year-old woman had a 4-year history of almost daily headaches which followed sinus surgery. During the previous year, she had a constant tension-type headache with superimposed migrainelike attacks occurring twice each week, lasting 1 to 2 days. She denied having brief stabbing headaches. The past history revealed asthma and recent symptoms of depression. The review of systems and physical examination were otherwise unremarkable.

She was told that her headaches were most likely the result of the medications that she had used daily for pain relief. She was instructed to abruptly discontinue all the pain relief medications which might cause RH (aspirin, acetaminophen, any nonsteroidal anti-inflammatory drugs [NSAIDs], all narcotics, ergotamine, triptans, and caffeine). She was instructed how to administer dihydroergotamine (an agent that has never been reported to cause RH) subcutaneously for any excruciating headaches. During subsequent visits, she repeatedly stated that she was totally compliant with these instructions.

The headaches were more intense for the initial 5 days. After 2 weeks, she reported that she often was headache-free for the first 4 or 5 hours each day. Her first completely headache-free day occurred after omitting the medications for 36 days. On day 47, she, for the first time, had 2 consecutive pain-free days. Three consecutive headache-free days began on day 155. Starting the 25th week, she had 17 of 28 days without a headache and could no longer be classified as having “chronic tension-type headache.”6 On day 191, she had 4 consecutive days of freedom. Finally, after having omitted all the forbidden medications for 297 days (42 1/2 weeks), she had 6 consecutive headache-free days. Thereafter, she had a total of seven headaches in the next 45 days, most being of short duration and minimal intensity.

Patient 2.—Fourteen and a Half Months Until Termination of Rebound Headache

A 33-year-old woman presented with almost daily headaches for 14 years. The precipitating event was using analgesics following removal of wisdom teeth. About once each month, she might note 1 or at times 2 consecutive days without any headache. Migrainelike attacks occurred once a week on average, lasting 1 to 2 days. Her almost constant tension-type pain was confined to the neck and lower occipital region. She had occasional brief stabbing pain when having the tension-type headache or even on a day when she was otherwise headache-free. During the 14 years, she had used almost daily medications for pain relief, including narcotic injections and various triptans. Symptoms of depression had been noted for the past 10 years.

In previous years, she had experienced occasional tension-type headache but no migraine. The history was otherwise noncontributory, and the examination was normal.

She was told the likely cause of her almost daily headaches and given a list of the pain relief agents to discontinue. During the three follow-up visits, she repeatedly stated total compliance with these instructions with two exceptions. On 3 days during the 10th month she used a nonsteroidal for pleuritic pain/pneumonia following a physician's orders. During the 13th month, she received butorphanol following laparoscopy.

Her headaches were more intense for the initial 10 days but then started to improve. During the second month, she had 5 headache-free days and had 8 headache-free days during the third month. On day 91, she, for the first time, recorded 3 consecutive headache-free days. The previously prolonged tension-type headaches shortened to 2 to 6 hours on most days. There were a total of 12 days of headache freedom during the sixth month, and she noted 4 consecutive headache-free days starting day 177. Migrainelike attacks continued at their original frequency but were shortened by subcutaneous and later nasal dihydroergotamine. During the 14th month, she finally had 17 headache-free days including 5 consecutive days (starting day 415). The goal of 6 consecutive days without headache was achieved beginning on day 443 (14 1/2 months after the initial visit).

During the following 2 months, she had 1 migraine (which stopped 1 1/2 hours after using zolmitriptan) and a total of 16 tension-type headaches. The latter started between noon and 7 pm and lasted 2 to 4 hours. Six of the tension-type headaches responded to sodium naproxen and 10 ceased without analgesics.

Patient 3.—Sixteen and a Half Months to Achieve the Goal of Six Headache-Free Days

This 33-year-old woman in previous years had infrequent tension-type headache but no migraine. Without any definite precipitating illness or event, 2 years earlier, she noted the onset of constant tension-type headache with superimposed migraine occurring as often as three to four times per week, lasting 1 to 7 days. During the 2 years, she had occasional brief stabbing jabs. Subsequent to the onset of daily headache, she developed symptoms of depression and gained 50 pounds, the latter possibly related to the various medications which had been prescribed by other physicians. The history was otherwise noncontributory, and the examination showed no abnormality. She was given the same instructions to abruptly stop all pain relief medications and use dihydroergotamine on an as needed basis.

After having noted intensification of the headaches during the first month, she began to improve— the tension-type headaches becoming less intense and somewhat shorter in duration. She felt better in general. By the end of the sixth month, she would often note freedom from tension-type headache from awakening until noon each day. She continued to have two to three migrainelike attacks each week for which dihydroergotamine provided partial improvement. Her first headache-free day was recorded 240 days after stopping the forbidden medications. Repeated episodes of 2 consecutive headache-free days started on day 280. By the end of 1 year, she was still having headaches of some type 20 days each month. She was no longer missing days from work and no longer experiencing the symptoms of depression. On day 441, she recorded the onset of 4 consecutive days without any headache. During the 15th month, she finally was headache-free on 16 of 31 days and noted 5 consecutive days without headache starting day 476. Finally, after having completely omitted all the forbidden pain relief medications for 16 1/2 months, she had the onset of 6 consecutive pain-free days (day 498). During the following 4 months, she recorded migraine one to two times per month, usually starting during the afternoon hours and persisting 4 to 6 hours until she got to sleep.

Patient 4.—Twenty and a Half Months Until Termination of Rebound Headache

A 54-year-old woman presented with a history of chronic daily headaches which had been present for more than 30 years. She could not recall a precipitating event and could not recall if she had headaches as a teenager. Intense bilateral migraine attacks with aura occurred 1 to 4 times each week, lasting 1 to 4 days. At other times, she had a constant tension-type headache. Brief stabbing headaches were noted 15 to 20 times daily. She was uncertain of the frequency of pain medications that had been used in earlier years but had used these only 1 to 4 days each week in recent years. Symptoms of depression started after the headaches. The review of systems revealed no other significant problems, and the examination was normal. She was given the same explanation of the cause of her headaches and told to stop the medications which might cause RH.

After abruptly stopping the offending pain relief medications, her pain intensified for 2 days then progressively improved. Migraines reduced in frequency and responded to dihydroergotamine. The previously constant tension-type headaches shortened to 4 to 5 hours on most days. Her symptoms of depression cleared. On day 155, she had her first headache-free day, and during the following 5 months, she had 10 additional headache-free days. On day 309, she had the onset of 2 consecutive headache-free days, and starting on day 426, she had repeated episodes of 3 or 4 consecutive days without a headache. During the 13th and 14th months, she still had headaches of some type on 40 of the 62 days. Starting the 19th month, she was headache-free for over half the days, and for the first time, she had 5 consecutive headache-free days (beginning day 590). The goal of 6 consecutive headache-free days was reached on day 610 (20 1/2 months).

She repeatedly stated that she completely avoided all the pain relief medications with the exception of 2 days during the 15th month when she used acetaminophen for an influenzalike illness and an additional 2 days during the 16th month when she used NSAIDs for arthritic pain.

From the 21st to the 26th month, she continued to omit the previously forbidden medications. Migraine occurred one to three times per month, responding to dihydroergotamine. Short tension-type headaches were noted about twice each month. Brief stabbing pains in the right temple were experienced at a maximum frequency of four to six times per week. Her main complaint during that 5-month interval was continued low back pain which was not treated with medications.

COMMENTS

  1. Top of page
  2. Abstract
  3. CASE HISTORIES
  4. COMMENTS
  5. CONCLUSION
  6. REFERENCES

Previous studies report that chronic daily headache occurs in up to 5% of the population. These patients account for 20% to 30% of the insurance claims for headache. The frequent migrainelike attacks often cause absenteeism from work or school and are a burden to the patient's family. Clinical experience at this center has shown that almost all of these patients are experiencing RH. They can most often be successfully treated by a careful explanation of the cause of their constant headache followed by instructions to abruptly terminate the pain relief medications that might cause RH. They are shown how to use subcutaneous injections of dihydroergotamine for excruciating headaches and asked to keep a careful daily headache calendar. Outcome studies at this clinic7 have shown that 77% of the patients who follow these instructions can achieve our goal of 6 consecutive pain-free days and thereafter have infrequent migraine and/or tension-type headache. The mean time to achieve this goal was about 85 days.

From having successfully treated innumerable patients suspected of having RH, it is apparent that the time required to achieve the 6-day headache-free goal follows a bell-shaped curve. A few patients note the onset of 6 consecutive headache-free days after having stopped the offending medicine for only 4 to 7 days. The majority of the patients note termination after omitting the medications for 30 to 120 days. There are some that require an even longer interval of total or almost total abstinence of the pain relief agents. The four patients whose histories were documented in this article fall on the extreme right slope of the bell-shape curve.

These four patients were suspected of having RH at their initial visit, a diagnosis that was established by observing delayed termination of the daily headache after the pain relief agents were discontinued. Only one of the patients could recall migraine dating back to puberty, and two of the patients denied preexisting migraine. Two of the patients related the onset of headache to surgical procedures for which they used analgesics. The other two could not recall a definite precipitating illness, injury, or operative procedure. The duration of headache (2, 4, 14, and 30+ years) was somewhat longer than that noted by the usual patients with RH seen in this clinic. Our prospective study of patients with RH has shown that there is no linear correlation between duration of headache and time to achieve the 6 headache-free day goal.7 Each of the four patients was experiencing migraine attacks at least weekly. Three of the patients denied having any headache-free days during the previous year. Three of the patients had brief stabbing pains.8,9 When asked specifically, most of the other patients with RH seen in this clinic also note these momentary pains while in the rebound state and relate reduced frequency or termination of these pains after RH ceases. Each patient noted depression starting after the onset of the headache.

Each of the patients was given a careful explanation of the chronic daily headache problem caused by the daily or almost daily use of pain relief medications. Following that, each patient was given a written list of pain relief medications (aspirin, acetaminophen, NSAIDs, opiates, ergotamine, triptans, caffeine, or any combination of these agents) that might cause RH. A nurse instructed the patients how to use subcutaneous injections of dihydroergotamine for excruciating headaches that they might experience while awaiting the termination of the prolonged tension-type headache. They were told to limit the dihydroergotamine injections to twice per 24 hours, separated by at least 2 hours. They were instructed to refrain from using analgesics for any headache which was not excruciating. No other pharmacological or nonpharmacological agents were prescribed. They were asked to keep a careful headache calendar.

Most of the previous articles on RH have stated that the patients might improve following termination of the offending medications, but they fail to specify the pattern of improvement, the degree of improvement that is achieved, or the time required to reach a specific end point. Most patients having only isolated migraine attacks or infrequent tension-type headache experience 6 or more consecutive days between headaches. Based on that observation, this clinic has, for several years, set the goal of 6 consecutive pain-free days in treating patients with RH and has advised the patients to completely omit the pain relief medications until after they reach that goal.

In order to further justify the goal of 6 consecutive pain-free days, the following case history is cited.

This 42-year-old woman presented with a 5-year history of daily headaches which followed a concussion and neck injury that occurred in an automobile accident (others might erroneously consider the diagnosis of chronic posttraumatic headache). Immediately thereafter, she developed a constant tension-type headache with superimposed migraine attacks, the latter occurring on average twice each week and lasting 1 to 4 days. In addition, she had frequent benign brief stabbing pains. She used daily medications for pain relief and had received multiple medications from other neurologists which failed to prevent her migraines.

In the previous 20 years, she had isolated migraines that had slowly increased to the point of occurring once each week and lasting 1 or 2 days. There had been no previous tension-type headaches or stabbing pains. Subsequent to the development of daily headaches, she noted symptoms of depression and had occasional elevations of her blood pressure. The history was otherwise noncontributory, and her examination was unremarkable.

After completely stopping the forbidden pain relief medications, she improved. The tension-type headaches were often noted only 4 or 5 hours during the day, and migraines were shortened by using dihydroergotamine. When she returned 3 months later, she reported a maximum of 4 consecutive headache-free days and a total of 12 days freedom from headache.

During the next 14 months, she returned for five additional visits. Her headache calendar indicated that her condition was at a plateau. Headaches occurred 15 or more days each month, and half of these were migraines. On other days, she had dull neck pain or tightness in the neck.

When she returned 17 months after the initial visit—after previously having denied using any of the forbidden pain relief medications—she finally confessed to having used aspirin and/or acetaminophen on average 8 days per month during the last 14 months. She again was told to completely stop the pain relief medications that were listed in her previous written instructions.

During the following 3 months, there was rapid recovery to the point of having freedom from headache for as many as 8 or 9 days. Thereafter, she was headache-free for 25 days each month.

In summary, she initially improved in the first 3 months without pain medication, and reached a plateau during the following 14 months when she was using the forbidden medications 8 days per month. She finally achieved termination of the chronic headaches when she completely avoided the medications for an additional 2 1/2 months. This history illustrates that partial improvement is not a satisfactory goal and that RHs might occur at a reduced frequency when pain relief medications are used twice each week.

It is felt that if the patient with RH does not avoid the forbidden pain relief medications until after the 6-day goal is achieved, the patient will continue to have unnecessarily frequent headaches. After the patient reaches this goal, they are allowed to use one or more of the previously forbidden medications as often as 2 days a week. If they exceed this limit, they are likely to note a recurrence of the RH state.

The time required for recovery from RH is unpredictable. Patient 3 did not have a completely headache-free day until after avoiding the forbidden medications for 239 days. Clinical experience has shown that the time required to achieve the 6-day headache-free state does not correlate with the age or sex of the patient, the initial illness for which the pain relief medications were taken, the duration of daily headache, the type of pain relief medications which were used, or even the number of pain tablets that were consumed in a given day. There have been other patients—similar to patient 4—who started RH with daily medications and had perpetuation of the daily headaches when using pain relief medications only 1 or 2 days each week.

A few patients seen in this clinic have noted termination of the daily headaches after having omitted the offending medications for only 3 or 4 days, and our outcome study of RH showed that the mean time to achieve the 6-day goal was approximately 85 days. Some patients in that outcome study (which included patient 1) as well as the other patients cited in the Table 1 required more than 6 months to achieve termination of RH. The reason for this extreme variation in time of recovery is not apparent.

CONCLUSION

  1. Top of page
  2. Abstract
  3. CASE HISTORIES
  4. COMMENTS
  5. CONCLUSION
  6. REFERENCES

The time for recovery from RH might be prolonged—even as long as 20 1/2 months. If other physicians who are treating patients with suspected RH withhold the medications for only a few weeks or months, they are not going to achieve optimum results. During follow-up visits, the physician has to carefully review the headache diaries with the patient and point out to them that recovery is occurring and the patient has to be “patient” and continue to follow the instruction of completely avoiding the pain relief medications which might cause RH.

REFERENCES

  1. Top of page
  2. Abstract
  3. CASE HISTORIES
  4. COMMENTS
  5. CONCLUSION
  6. REFERENCES