Is pain medication making your head pain worse?
You have probably heard of the term “rebound headache”, but did you know that even frequent use of over-the-counter medications like Aleve and Ibuprofen can take a problem like headaches and make them much worse? And that an estimated 50% of people suffering from chronic headaches are actually experiencing medication overuse headaches? This article will highlight the information from a recent study published in 2024 on medication overuse headaches.
Medication-overuse headaches occur when a person overuses certain prescription or over-the-counter medications. To be diagnosed, a person with a pre-existing headache disorder must experience headaches on 15 or more days each month for at least three months, as a result from the overuse of medication designed to relieve acute symptoms.
I work with many patients with daily headaches following one or more concussions. These headaches are often described as a constant dull pressure or ache, with additional moments of sharp stabbing pain, or throbbing pain. They are commonly accompanied by light and sound sensitivity, chronic neck tension, and poor sleep. There are often different underlying drivers for chronic headaches, which we will address in future blog posts, however, in this article I wanted to shed a light on the potential for certain medications and painkillers to actually make the problem worse.
Migraine Medications and Medication Overuse Headaches:
Episodic migraines can progress to chronic migraines if people take medications containing triptans, opioids, or barbiturates frequently. Most people are only prescribed a limited amount of triptans on a monthly basis for this reason, however, once people run out of their migraine abortive medications, many turn to over-the-counter painkillers like Aleve or Excedrin Migraine. Here is a summary of the thresholds for medications.
Once a person goes above these thresholds for three months, they risk an increase in headaches due to medication overuse headaches:
Combination analgesics, such as Excedrin Migraine: > 10 days per month.
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen: > 15 days per month
Acetaminophen: > 15 days per month
Triptans: > 10 days per month
Opioids: > 10 days per month
The use of multiple drug classes at the same time: > 10 days per month
How Do Medications Cause Rebound Headaches?
Chronic use of analgesics can lead to central sensitization, a process that makes the central nervous system more responsive to pain stimuli instead of less.
Frequent use of headache medications can alter the balance of neurotransmitters in the brain, particularly serotonin and dopamine, disrupting pain modulation pathways. Serotonin is an important neurotransmitter involved in pain processing.
Overuse of certain medications can cause adaptive changes in pain receptors and pathways, leading to decreased effectiveness and the need for higher doses.
Brain Changes in People Diagnosed with Medication Overuse Headaches:
A PET-scan study in 16 chronic migraine patients with medication overuse headaches showed hypometabolism in key brain areas before they underwent three weeks of medication withdrawal. The hypometabolism resolved in most parts of the brain, except for the orbital frontal cortex. Hypometabolism, especially in the frontal cortex is concerning, as that can interfere with normal cognitive functioning. Many people dealing with persistent post-concussion symptoms struggle with cognitive functions such as focus, attention concentration, and memory. A further decline in brain metabolism would contribute to a worsening of these types of symptoms.
Detoxification and Safer Migraine Medications
Treatment for medication overuse headaches often involves first, educating people on the dangers of overusing these medications described above, along with withdrawing from these medications under medical supervision. Simultaneously adopting other pain-management strategies can improve outcomes.
Ginger, it turns out, is a natural migraine abortive that works well for some people.
MQ-7 is an excellent migraine support formula that contains a combination of herbs (feverfew and butterbur), amino acids, vitamins and minerals.
Peripheral nerve stimulation devices that target the trigeminal nerve and occipital nerves can also help reduce headache frequency and intensity.
Acupuncture is an excellent therapy for reducing post-traumatic headaches and migraines.
High daily doses of Omega 3 essential fatty acids (~1800-2000mg/day) were shown to be effective in reducing the frequency of migraines.
For those suffering from migraines specifically, safer migraine medications include calcitonin gene-related peptide (CGRP) receptor antagonists (Ubrelvy), and CGRP Antibodies (Ajovy, Emgality). These classes of medication appear to reduce the frequency of migraine without the risk of causing medication overuse headaches.
I worked with one woman in her thirties who was recovering from a traumatic brain injury following a car accident. Many of her symptoms were improving, and she had returned back to work full time, however her daily tension headaches persisted. I would often ask her about her use of Ibuprofen, but for several months she downplayed it despite my concerns. Finally, I tried another tact, and I started to tell her about this recent scientific paper on medication overuse headaches, and that using ibuprofen for more than 15 days per month was one of the stated criteria. She then admitted to taking it practically every single day of the month, and agreed to discontinue it as an experiment to see if it was indeed making things worse. Turns out, it was. When I saw her a month later she told me she was no longer having headaches! For several months after that, she only had a couple of bad headaches, one that was clearly the result of a head cold and sinus congestion. For over a year she had suffered from daily headaches without realizing the very pain-killer she was taking was contributing to them.
If you are concerned your headaches may have turned chronic, in part due to over-the-counter or prescription medications, please talk to your doctor about other options that are available to you. Life After Impact has a free resource available to you to help communicate with your doctors. You can access our free Post-Traumatic Headache Journal and communication tool here.
References:
Gosalia, H., Moreno-Ajona, D., & Goadsby, P. J. (2024). Medication-overuse headache: a narrative review. J Headache Pain, 25(1), 89. doi:10.1186/s10194-024-01755-w
Tseng, P. T., Zeng, B. Y., Chen, J. J., Kuo, C. H., Zeng, B. S., Kuo, J. S., . . . Lin, P. Y. (2024). High Dosage Omega-3 Fatty Acids Outperform Existing Pharmacological Options for Migraine Prophylaxis: A Network Meta-Analysis. Adv Nutr, 15(2), 100163. doi:10.1016/j.advnut.2023.100163
Grazzi, L., Tassorelli, C., de Tommaso, M., Pierangeli, G., Martelletti, P., Rainero, I., . . . Group, P. S. (2018). Practical and clinical utility of non-invasive vagus nerve stimulation (nVNS) for the acute treatment of migraine: a post hoc analysis of the randomized, sham-controlled, double-blind PRESTO trial. J Headache Pain, 19(1), 98. doi:10.1186/s10194-018-0928-1
Chen, T., Zhang, W. W., Chu, Y. X., & Wang, Y. Q. (2020). Acupuncture for Pain Management: Molecular Mechanisms of Action. Am J Chin Med, 48(4), 793-811. doi:10.1142/S0192415X20500408
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