COMMENTARY by Alan M. Rapoport, MD—An Uncommon Problem Receives Needed Attention

I was recently in London for a meeting of the International Headache Society’s Board of Trustees, and I was interested to see that the lead article in the local newspapers and on TV was that aspirin causes headache. The news media had picked up on the newly released guidelines for general practitioners on the diagnosis and care of headache in the UK. Clearly, the most newsworthy part of the guidelines was the idea that pain medicines could be part of the problem for those with chronic headache.

We have been talking about medication overuse headache since 1979, shortly after Dr. Lee Kudrow, an internist and headache specialist from Los Angeles, and Dr. Hansruedi Isler, a neurologist and headache specialist from Zurich, published an article on what used to be termed “rebound headaches.” For more than 30 years, headache specialists have been studying, lecturing about, and writing about this unusual condition that afflicts 1% to 2% of the population (more women than men). We have done a pretty good job educating doctors and patients about this syndrome.

The average person sent to me for a second opinion knows exactly what I am going to say—that he or she is overusing one or two acute care medications. Patients even tell me that they have rebound or medication overuse headaches, but they have no idea what to do about them. They say that they have tried to stop the overused medicine and had to restart because their headaches became unbearable. No one told them that on the other side of the withdrawal they would be much better.

These guidelines will provide valuable information to doctors, and maybe even to patients, about how to avoid overusing analgesics. But patients will continue to overuse analgesics until they see the right headache specialist who explains why what they are doing is wrong and how they can get through the withdrawal with the least difficulty. Simply telling a patient to stop taking an apparently effective medication is not helpful.

Doctors have to learn how to prescribe good withdrawal protocols and bridge therapies to reduce the worsening of the pain. They need to refer patients to excellent behavioral therapists and discuss changes in lifestyle, vitamins, minerals, herbs, preventive medications, exercise programs, and whatever patients need to change their lives easily and improve their headaches. These new guidelines should help by informing doctors about this problem and about diagnosing and treating it. It is up to the doctor and the patient to come up with the most effective treatment regimen.

To read the accompanying article, please click here.