analgesic rebound headache (transformed headache)

Etiology

• daily use of analgesics
  • consider in any patient taking
    • opioid, ergotamine, triptan or combination analgesic for > 10 days/month
    • simple analgesic for > 15 days/month
• drug tolerance

History

• severity of dependence scale may be useful screening tool

Clinical manifestations

• often occur in the morning or upon awakening
• generally diffuse
• prophylactic medications ineffective

Management

• patient education
• avoid butalbital & opioids as these agents are associated with increased risk of analgesic rebound headaache
• prophylactic therapy:
  • amitriptyline (Elavil) 10-75 mg PO QHS
  • desipramine (Norpramin) 1-50 mg PO QHS
  • valproic acid
    • start 125 mg PO QD
    • titrate over 4-5 weeks to therapeutic dose of 250 mg PO TID
• allow analgesic use to continue for 3-4 weeks while patient is stabilizing on prophylactic therapy
• taper analgesics over 1 week

More general terms

• drug-induced headache; medication overuse headache