Too many medications used to treat migraine can can lead to rebound headaches
Medication,  Migraine,  Rebound

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! 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.

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!

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.

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 instead having daily or constant or frequent migraine 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 falls into this category. It can put some people into a rebound cycle in as little as 5 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 are likely in rebound. And it is complicated by the high use of medications. Check out our Quick References for some lists that can help.

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

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.”

Important:  The above information is based on reviews of medical literature, professional and personal experience.  It is for educational purposes and is not a substitute for medical advice.  Suggestions to “do your own research” should include your physicians as part of your research resources.

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 is 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.

6 Comments

  • Irene McIver

    “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?

    • Migraine Strong

      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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