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Headache Associated With Substance Use Or Withdrawal
A medication-induced headache occurs in people whose chronic tension-type headaches or migraines have worsened, in response to which they have ingested increasing amounts of medication (more than three times/week) for 3 months or more. All patients with chronic headaches are prone to this form of chemical dependency, one of the commonest headache types seen in referral practice. The drugs prescribed (or bought over the counter) for management of such headaches and able to induce this syndrome include muscle relaxants, benzodiazepines, ergot preparations, simple analgesics (often with codeine), NSAIDs, and caffeine. The intermittent use of these agents is appropriate but their frequent use leads to down-regulation of nociceptor pathways in the brain, creating the vicious cycle of medication-induced headache. Narcotics should not be prescribed again for these patients.
Typically the headaches are present daily or nearly every day, are present on waking, and are reduced but not removed by ingestion of the usual medication taken. Nausea, malaise, anergia, depression, and sleep disturbances are almost invariable accompaniments, with the production of a syndrome of daily or near-daily "rebound" headaches that are worse on waking in the morning, briefly reduced by the next dose of the usual medication(s), and inhibiting the useful effects of oral prophylactic agents. Many patients utilize several sources of supply for their medications.
The best treatment strategy is to discontinue all of the analgesics the patient has taken, supplying instead DHE, 0.5
The second stage of the treatment plan is just as important. After the subject is off the daily analgesics, it is likely that prophylactic medications will be effective again and they should be restarted, even if they had failed before in competition with the analgesics. Behavioral modification with biofeedback, hypnosis, counseling, and, occasionally, formal psychologic or psychiatric therapy may be needed to help remodel lifestyles that are detrimental. When true migraine attacks do occur in the future, specific therapies (the triptans) or DHE should be prescribed rather than the analgesics that got the patient into trouble in the first place.
Drugs that may cause headaches when ingested are listed in
Withdrawal from prolonged steroid therapy may be accompanied by the first appearance of headaches, probably caused by idiopathic intracranial hypertension. Reinstatement of the previous dose, with subsequent slower reduction of the dose, is the best solution.
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Textbook of Primary Care Medicine, 3rd ed.
By: William Pryse-Phillips, T. Jock Murray © 2005 ELSEVIER Inc. All Rights Reserved |
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