Excess headache pills rebound the pounding

WASHINGTON – One after another, teenagers trickle into Dr. David Rothner’s office with the same complaint: almost daily headaches, despite popping over-the-counter painkillers four, then six, then eight times a week.

Many get a diagnosis of rebound headache, a vicious cycle where the more painkillers some people use, the more likely new headaches are to crop up between doses.

Headache specialists say it’s not uncommon for adults to fall into that trap, and Rothner’s check of records at the Cleveland Clinic suggests a surprising number of teens and preteens may, too.

Of 680 patients referred to the hospital’s pediatric headache center, 22 percent were overusing nonprescription headache medicine – meaning at least three doses a week for more than six weeks.

“We have a lot of kids that are overusing OTC medicine,” warned Rothner, a Cleveland Clinic pediatric neurologist who presented the data to the American Headache Society last week.

Overuse increases the risk of such side effects as stomach bleeding or kidney or liver damage, problems many people don’t realize can occur even with over-the-counter drugs.

“Three days a week is probably excessive. That’s not good for their health, let alone their headaches,” said Dr. David Dodick, a neurologist at the Mayo Clinic in Scottsdale, Ariz. Parents should “do everything they can to get these kids off of the analgesics. That means they need better headache management.”

Less appreciated, Rothner said, is that overmedicating actually can worsen some headaches, a syndrome called rebound headache that eventually can spur almost daily headaches.

Specialists have known for more than a decade that certain adults get rebound headache, although it’s little-discussed outside of headache clinics.

Up to 32 percent of adults are thought to overuse painkillers for headaches, and true rebound headache is thought to hit 1.5 percent, Dodick said.

And while it strikes just a fraction of headache sufferers, it’s unnecessary pain.

Doctors can’t predict who’s at risk, although people with migraines in the family seem most prone to rebound headache, said Dr. Jesus Eric Pina-Garza, a Vanderbilt University pediatric headache specialist.

Also, some specialists think months of painkiller use by migraine sufferers can transform their pain, until the rebound-prone experience a chronic tension-type headache.

Pina-Garza and Rothner say people should use nonprescription painkillers for headaches no more than twice a week.

For daily headaches, specialists first make sure there’s no underlying disease cause. If analgesic overuse is the suspect, they order patients to quit cold-turkey and customize treatment to break the rebound cycle. Pina-Garza uses small doses of prescription drugs that work differently, such as Phenergan or Migranol nasal spray, to temper the resulting temporary pain spike. Rothner prefers low doses of amitriptyline, an old antidepressant used to prevent migraines.

Once the chronic rebound headache is gone, patients can get appropriate treatment for migraines or other periodic headaches.

For most people, it’s “common sense that anybody that has pain will usually reach for an (over-the-counter) medicine first,” said Pina-Garza. “That’s an acceptable practice if you get good relief” and don’t do it too often.

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