A Hidden Cause of Headache Pain
By
PETER JARET
Sometimes, the cure is
worse than the disease. Sometimes, the cure is the disease.
Four percent of Americans
suffer headaches daily, and scientists have suspected culprits as diverse as
undiagnosed jaw disorders, genetic susceptibility and stress. But according to
recent research, a sizeable and growing number of headaches are being caused by
the very medications taken to alleviate them — and the problem is far more
common than scientists had realized. Half of chronic migraines, and as many as
25 percent of all headaches, are actually “rebound” episodes triggered by the
overuse of common pain medications. Both prescription and over-the-counter
drugs may be to blame.
Patients begin by popping
too many pills to deal with a migraine or a simple tension-type headache. When
the medications stop, another headache follows, similar to a hangover.
Sufferers race again to the medicine cabinet, and before long they are locked
in a cycle of headaches and overmedication.
At any given time, more
than three million Americans are suffering from headaches they are inflicting
on themselves, according to Dr. Stephen D. Silberstein, a professor of
neurology and director of the Jefferson Headache Center at Thomas Jefferson
University in Philadelphia. “If a patient’s headaches have grown markedly worse
or more frequent, the problem is almost always medication overuse,” Dr.
Silberstein said.
The International
Headache Society last year published revised criteria to help doctors recognize
and treat headaches from medication overuse. Signs of trouble include headaches
that occur 15 or more days a month, according to the society, along with the
heavy use of pain medications for three months or more. Overuse is defined as
taking pain medication for 15 or more days a month.
“Overuse has less to do
with how many pills you take to relieve a single headache than with how often
you take them,” said Dr. Robert Kunkel, a headache specialist at the Cleveland
Clinic Headache Center. “If you get more than two headaches a week and take
pain pills for them, you’re at risk.”
The only way to know
whether medication is contributing to your headaches is to stop taking them.
Unfortunately, it can take as long as two months for medication-dependent
patients to see an improvement.
Migraine sufferers seem
to be especially susceptible to rebound episodes. Many doctors begin weaning
these patients off painkillers by
prescribing drugs to help prevent attacks, then gradually reducing doses of the
painkillers used to treat acute episodes.
Several drugs have been
approved to prevent migraines. The most recent is topiramate (Topamax), which
studies suggest may lessen the frequency of attacks for up to 14 months. In
addition, early trials suggest that Botox injected into the scalp can prevent
or reduce the frequency of both migraines and tension headaches.
(Although not yet
approved by the Food and
Drug Administration for headaches, botulinum toxin is being offered by a
growing number of headache clinics. When it works — which is by no means
certain — it can provide relief for up to three months.)
Tension headaches can
frequently be prevented with stress reduction techniques and avoidance of
certain triggers. With close attention to prevention, sufferers should not need
to resort to painkillers often enough to risk rebounding.
Yet almost any kind of
pain pill can cause rebound problems if used to excess. Among over-the-counter
drugs, those with caffeine, like Excedrin, are the likeliest villains, studies
show. Among prescription drugs, triptans are most commonly associated with
rebounding, Dr. Silberstein said.
But in terms of both
rebound and dependence, the most problematic drugs are those containing
butalbital, a barbiturate. Two such medications, Fioricet and Fiorinal, have
been banned in Germany because they so often led to medication-related
headaches. Both are still prescribed in the United States.
Now that research has
begun to spotlight the extent of the problem of medication-overuse headaches,
more and more doctors on are on the lookout for signs of trouble. “Believe me,
a lot of patients don’t want to hear that they have to stop taking their pain
pills in order to get relief,” Dr. Kunkel said. “But for these kinds of
headaches, that’s really the only solution.”
Once weaned from
medicine, most patients show significant improvement after three months. They
also learn their lesson and steer clear of overusing pain pills, research
shows. In one study, 87 percent continued to report significant improvement two
years after stopping overusing painkillers. Many headache sufferers have been praying
for a miracle cure. Now it’s here, though it may not be what they expected.