Rebound Headache is Probably Over-diagnosed.

I was lucky enough to work for Dr. Joel Saper in the 1980s. He is still considered the top headache clinician in the world by most people who work in headache medicine.  He was the first in the world to identify what we use to call rebound headache. He and I published the first paper on this concept in the Journal of Pharmacology.

Since that time, the notion of rebound headache has not only been popularized but has become vogue. Now, when you pick up more than 9 sumatriptan the pharmacist starts to question if you are in rebound.  A very popular book written by a John Hopkins neurologist (but not a headache specialist) grossly overstated the problem and led to further misconceptions.

We now call this issue Medication Overuse Headache (MOH). It is of course real.  When you take certain medications such as over the counter pain medicine, prescription pain medicine and triptans too often, it could possibly make the headaches worse.  The only way to get better is to reduce the number of these medications.

However, I’m certain that this idea is now way over-diagnosed. There are many good patients out there who simply have horrible headaches. It is not their fault.  While it is important to address medication overuse early on, there is also a time that you must recognize for some people the frequent use of triptans or pain medications is what allows them to have some quality of life. Taking those medications has nothing to do with causing MOH or making their headaches worse.

I’ve seen many patients who have high frequency headaches and take a lot of triptans. They have done the hard thing of stopping all the potential rebounding medications and did not get better. Therefore I assume that that they are not in MOH and can use their triptans at a high frequency to give them some relief.  But then they talk to their pharmacist, their PCP, or a non-headache specialist neurologist (who has never, ever darken the doors of a headache meeting or read a headache journal) who tells them they are in rebound.  I think it is because I’m a PA that they decide not to trust me although I’ve worked in headaches for 33 years, gone to every headache research meeting and read every article on headaches during this time. But believe it or not there are still men out there who don’t trust what women say, or some people who don’t trust what people of color say . . . but I digress.

This month in the Headache Journal Dr. Lawrence Robbins, a neurologist and headache specialist who directs a major headache clinic in Chicago wrote a nice article supporting what I’ve been saying.  I have an article coming out in the next issue of the same journal supporting the same concept.  Here is a link to his article. This link has two articles on it and his is the second one that starts in the second column. If you can’t believe me because I’m a PA, please listen to him.  This is not a license to eat triptans like candy. But it is a license to feel less guilt if you have avoided the rebound medications and did not get better but now you need them more than two days a week.

J. Michael Jones, MPAS-C