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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.
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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.