Don’t Let Your Headache Medication Give You a Headache!
While most people will experience a headache at some point of their lives, there are some people for whom headaches become a regular part of life, causing extreme pain and even disability. This is not an American phenomenon; it is seen all over the world. Medications are commonly suggested for the treatment of headaches; however, these substances can create their own issues.
As early as the 1930s, some physicians were beginning to associate patient’s experience of prolonged migraine with the overuse of Ergotamine, an ergot alkaloid medicine used to treat certain types of headaches. In other words, they suspected the very medications being prescribed to relieve headaches could actually be making it worse. In 1951, researchers Peters and Horton published their findings on the “excessive use of ergotamine preparations and withdrawal effects in 19 patients who had used these preparations for prolonged period…Toxic symptoms were observed in 13 of the 19 patients… [the toxic symptoms] disappeared fairly promptly, when use of the drug was discontinued. However, when the ergotamine preparations were discontinued, seven of the 19 patients had withdrawal headache.”
It would be another 37 years before the first edition of the International Classification of Headache Disorders (ICHD) would be published in 1988 which introduced the term “drug-induced headache”. Definitions and diagnostic criteria have changed through the years.
When the 2nd edition of the ICHD was released in 2004, the term “medication overuse headache” (MOH) was coined. In that edition, diagnostic criteria included a mandatory time frame for return to previous pattern of headache. This was removed when the criteria was changed again in 2006, and then changed again with the 3rd edition of the ICHD.
While experts are still working on a consensus regarding the specifics, generally, MOH criteria includes a headache syndrome for which medication is overutilized resulting in the patient developing more frequent, even daily, headaches. Additionally, the headaches typically, though not always, improve after the medication is ceased, though there could be a withdrawal period of time.
A review of literature published in 2018 chronicled the history of medication-overuse headache (MOH), as well as the prevalence, potential causes, risk factors and treatment options and their success rates. Prevalence rates for MOH tend to fall in a range of 0.5% to 7.2% with the average falling between 1-2%. However, when looking at studies from headache specialist centers, the rate jumps to 30-50% of patients. While it would be expected to have more people taking medications at these clinics, that is a very high rate of overuse!
After conducting a systematic review, researchers found MOH to be most common among middle-aged adults from 30-50 years old. It was also found to be more common in females with a male to female ratio of around 1 to 3-4. The increased incidence among females extended to younger ages. Additionally, among patients with chronic headaches, as many as 21-52% of pediatric patients and around 35% of elderly patients over 64 years of age met the criteria for MOH.
As part of the research on headaches and MOH, numerous studies have been conducted in an attempt to identify risk factors so that preventative measures can be developed. They have determined that the type of drug used makes a difference in likelihood of developing chronic headaches and MOH.
Triptans and ergotamine have lower risk than combined analgesics. However, medications containing barbiturates or opiates have significantly higher risk of developing chronic headache. Some estimate as much as twice the risk. Additionally, those who exhibit a predisposition to migraine or tension-type headaches having a significantly higher risk.
Other factors found to be associated with MOH include the regular use of tranquilizers, a combination of chronic musculoskeletal complaints, gastrointestinal complaints and Hospital Anxiety and Depression Scale (HADS) score > = 11. Finally, having a personal or family history of MOH or another substance abuse may increase risk factors as much as 3 times.
While MOH patients do not have the common personality characteristics of drug addicts, MOH and dependence do share common neurobiological pathways. While it is not yet known exactly how, MOH are reported to be more likely to have multiple psychiatric comorbidities such as anxiety, OCD along with sleep complaints.
Once a patient has developed chronic MOH, the most common route is to stop taking the medication in question. Depending on the patient’s specific circumstances, length of time they have taken the medication and what medication they have been using, this may be a sudden cessation or it may require medical supervision for a gradual reduction over a period of time.
The majority of patients (50-70%) of MOH patients are able to stay off the medications up to a year, which is a good predictor for long-term success. In fact, one study showed a decrease in the frequency of headache of 73.7% compared to only 17.2% among those who were not able to detoxify and refrain from overuse for a year. Additionally, the duration of head pain was reduced by 61.2% (compared to 14.8%) and 70.7% were able to return to an episodic pattern of migraine, compared to only 15.3% of those who did not successfully detox.
Studies also reveal that MOH can usually be prevented. In numerous studies, MOH patients had little, if any, knowledge about how taking too much of their medication could in fact make their headache worse. Those who had received information often did not recall all of it or were unclear as to the meaning of what they were told. Having access to clear information early in treatment can help patients be more diligent about how often to use the medication and therefore prevent the development of chronic headaches and MOH.
Another way to prevent MOH is to utilize a non-pharmaceutical treatment such as chiropractic.
In 2017, the European Journal of Neurology reported on the results of a 17-month migraine study comparing chiropractic treatments with “usual pharmacological management” in patient care. Overall, there was a general reduction in the duration of migraine headaches for the participants; however, for the chiropractic group, this reduction was maintained through the study follow-up period of 12 months.
Additionally, the reduction in the duration of migraines was significantly more when compared to the control group that received medications only.
A 2019 meta-analysis of 5 randomized clinical trials showed a reduction in both duration as well as pain/intensity for patients who received chiropractic care. The researchers concluded that conservative care such as chiropractic treatments can often work as well or better.
These study results demonstrate the importance of ensuring migraine patients understand all of their options for relief. With proper care, it is possible for many patients to reduce the frequency and/or severity of their migraine symptoms while avoiding MOH and chronic headaches.
Chiropractic care should be considered as a treatment option to improve the quality of life for migraine patients. If you suspect that you or a loved one is having migraine headaches, or other musculoskeletal issues, schedule an evaluation with your health care provider. As you determine your treatment options, discuss how you can benefit from chiropractic care!
If you don’t have a chiropractor, you can find a TCA doctor near you at www.tnchiro.com/find-a-doctor/.
REFERENCES:
Horton BT, Peters GA, Clinical manifestations of excessive use of ergotamine preparations and management of withdrawal effect: report of 52 cases. Headache. 1963; 3: 214-226
What is ergotamine? https://www.drugs.com/mtm/ergotamine.html
Vandenbussche, N., Laterza, D., Lisicki, M. et al. Medication-overuse headache: a widely recognized entity amidst ongoing debate. J Headache Pain 19, 50 (2018). https://doi.org/10.1186/s10194-018-0875-x
Bigal ME, Rapoport AM, Sheftell FD, Tepper SJ, Lipton RB. Transformed migraine and medication overuse in a tertiary headache centre–clinical characteristics and treatment outcomes. Cephalalgia. 2004 Jun;24(6):483-90. doi: 10.1111/j.1468-2982.2004.00691.x. PMID: 15154858.
Rist PM, Hernandez A, Bernstein C, et al. The impact of spinal manipulation on migraine pain and disability: A systematic review and meta-analysis. Headache. 2019 Apr;59(4):532-542
Chaibi A, Benth JŠ, Tuchin PJ, Russell MB. Chiropractic spinal manipulative therapy for migraine: A three-armed, single-blinded, placebo, randomized controlled trial. European Journal of Neurology. 2017;24(1):143-153.
Rist PM, Hernandez A, Bernstein C, et al. The impact of spinal manipulation on migraine pain and disability: A systematic review and meta-analysis. Headache. 2019 Apr;59(4):532-542