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The Vicious Cycle of Rebound

What is rebound? And how do you tell the difference between rebound or frequent/chronic migraine?  The more commonly used term in the medical community is medication-overuse headache (MOH).  We call it ‘rebound’ as MOH tends to imply patients are to blame for their pain. Rebound happens when prescribed and/or over-the-counter (OTC) meds used to relieve pain, begin to cause pain or “stop working.”

Initially, I didn’t know about rebound. And besides, I couldn’t possibly have rebound from medications prescribed by my doctor. Ha! My triptan (sumatriptan) had worked beautifully for many years…until it didn’t.  Maybe I just needed a bigger dose? Perhaps I could take it with ibuprofen or another NSAID (non steroidal anti-inflammatory drug). Or I could just rotate my triptan with ibuprofen, Aleve or Excedrin Migraine. Possibly a prescription for coated ibuprofen that would spare my stomach from the increasing amounts of medication I was taking every day.

While Migraine Strong writes about the latest in migraine treatments, this is not medical advice. We are patient educators and all information you read should be discussed with your doctor.

Could I really be In rebound?

Being told I was in rebound by my Jefferson Headache Center headache specialist was shocking. He recommended stopping all acute meds including sumatriptan and all NSAIDs. While I agreed to stop taking sumatriptan, I felt I needed the ibuprofen for my neck pain. I didn’t know that the neck pain was part of migraine! The specialist told me that too but I didn’t believe him.

He prescribed a preventive medication and two acute medications not associated with rebound. He firmly told me not to treat migraine attacks more than twice a week. A steroid taper to break my 24/7 intractable migraine pain was out of the question due to my continued NSAID use. However, the other prescriptions wouldn’t help while I was still using the NSAIDs and in continued rebound. He was correct. Eventually, the 24/7 pain made me miserable enough to trust his advice. I stopped the rebound meds. It was an important step on my road to relief.

This happened several years ago. I believe their approach has changed a bit as there are better medications to help people through rebound. Telling a person with daily pain to only treat twice per week is not a solution. We have options.

Assessing If You Are In Rebound

Rebound is real but so is the debilitating nature of frequent and chronic migraine.  How do you know if you are in rebound or not? What if your daily or frequent headaches and migraine attacks are independent of meds? Answering these 3 questions will help you assess yourself:

1. Are your medications putting you at risk for rebound?

This piece from the American Migraine Foundation has good info. These are the general guidelines that suggest your pain may be from rebound if you are taking:

  • triptans (i.e. sumatriptan, rizatriptan) or ergotamine more than 10 times per month on a regular basis for more than 3 months
  • opioids (i.e. oxycodone, codeine) more than 10 times per month on a regular basis for more than 3 months
  • COMBINATION analgesics (i.e Excedrin Migraine) more than 10 times per month on a regular basis for more than 3 months. Fioricet/butalbitol falls into this category. It can put some people into a rebound cycle in as little as 4 doses per month.
  • SIMPLE analgesics (i.e. NSAIDs, aspirin, acetaminophen) more than 15 times per month on a regular basis for more than 3 months
  • a combination of the migraine treatments more than 10 times per month on a regular basis for more than 3 months
  • caffeine intake of more than 200mg per day

Pay careful attention to the time frame specified – “more than X times per month on a regular basis for more than 3 months.”  Needing to take a medication for 5 days in a row, followed by weeks of taking 1 medication per week does not fit the risk criteria. 

2. If your frequency of treating migraine puts you at risk of rebound, ask yourself how you feel.

  • Do you always or frequently have some form of headache? Maybe with sporadic migraine on top of the headache?
  • Are the prescribed preventive meds and therapies failing?
  • Do you get relief from migraine? Does it come back when the acute meds wear-off?
  • Does everything feel like a trigger?
  • Do you get headaches and migraine attacks that start in the morning?

‘Yes’ answers to the above bullet points and you may be in rebound. And it is complicated by the high use of medications. Check out our Quick References for some lists that can help.

If you don’t meet the risk criteria stated in #1, and you have frequent migraine, you have likely avoided rebound.

The above is a SELF-assessment. Episodic migraine should be addressed by a doctor who specializes in migraine.

Rebound is a common problem

It’s important to understand that rebound is not your fault. When we have the pain and symptoms of migraine, we naturally want relief. Some structures help to keep us out of rebound. For example, limited number of prescribed pills from our doctors or limits imposed by insurance companies. But, there is no limit on access to OTC meds. And some of us need OTCs and prescribed pain-relievers to treat other medical conditions.

The director of the Jefferson Headache Center and professor of neurology at Thomas Jefferson University in Philadelphia, Stephen Silberstein, M.D., said “One of the greatest bugaboos we see every day in headache centers is patients with chronic daily or near-daily headache, who are overusing medication. It is our most common problem. These patients have often not responded to treatment and in an attempt to treat themselves, actually make the problem worse. This is not addiction or an attempt to get ‘high’; rather, it is motivated by the patient’s desire to relieve pain and dysfunction. Migraine preventive therapy is grossly underused.”

What you can do

Rebound, or medication-overuse headache is a sign of poorly controlled migraine. Again, it is NOT your fault. Heck, you might not even be in rebound. What is most important is that you get evaluated by a doctor with excellent assessment and treatment skills for MIGRAINE. So, give your doctor a call and be a squeaky wheel.

There are good treatments including prednisone for migraine to break the rebound cycle as well as medications to reduce your need for acute medications.

In some areas of the country, access to doctors with this type of expertise is very limited. There are very few certified migraine specialists in the US. There are many general neurologists, but sometimes migraine isn’t an areas of interest so they aren’t so great in treating it. Additionally, it may take weeks or months to get an appointment. You deserve excellent help right away. A resource that is affordable and available to many is Neura Health. This review of Neura’s teleheath service from headache specialists is very helpful. You could have a new, effective treatment plan in a few days.

Whether you use your current doctor, make an appointment with a local specialist or take advantage of Neura Health, please do not delay getting the care you need and deserve. Studies have shown that it is often harder to successfully treat long-standing chronic migraine than catching it when just episodic.

My follow-up article on escaping rebound has more specific, practical information that may help you.

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6 thoughts on “The Vicious Cycle of Rebound

  1. “He prescribed a preventive medication and two acute medications not associated with rebound” – why don’t you tell us in the article what these medications are?

    1. Hi, Irene. You are reminding me that I should write another article on rebound. In the article I wrote after The Vicious Cycle of Rebound,” I mentioned a few meds not associated with rebound. “6 Steps to Escape Rebound” has more specific information. Personally, I was prescribed were Reglan (a GI med) and Flexeril (an muscle relaxant) for acute relief and topimirate as a preventive medication. The new category of acute meds like Ubrelvy are also not associated with rebound. I will start working on a new piece! Thank you for your question.

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About the Author

Danielle Aberman RDN

My degree is in clinical nutrition and I’m a registered dietitian. I changed my career to focus only on helping people with migraine find relief and became a certified health and wellness coach to help me help my clients beyond just my expertise in food and nutrition. My fascination with diet, nutrition and migraine began when I made my condition worse by eating “clean and healthy.” This was mainly due to both rebound/medication-overuse headache and a diet high in beautiful, nutritious, wholesome food triggers. Implementing a comprehensive migraine elimination diet helped me dramatically. Continuing my research into diet, I transitioned to the Ketogenic diet which further improved my brain fog. My work with the Ketogenic diet for migraine relief has led me to working with one of the pioneers in reversing diabetes and obesity with Keto, Dr. Eric Westman. I love helping people take control of their wellness and get their lives back. For relaxation and enjoyment, I like to go on adventures with my family, spend time in the garden and cook for friends and family.

View all posts by Danielle Aberman RDN