Abstract
Rebound headaches usually present as daily or almost daily, prolonged, generalized tension-type headaches with superimposed migraine-like attacks. The latter are more frequent, more intense, and longer than any episodic migraine that the patient might have experienced prior to the development of the chronic daily headaches. Rebound presenting as migraine without tension-type pain has been mentioned in a few previous articles on chronic daily headache, but there have been no previous articles stressing that frequent migraine might relate to the analgesics that are being used. These case histories are presented to illustrate that frequent migraine and migraine status without tension-type headaches may be manifestations of rebound and improve when the offending analgesic agents are stopped. If the clinician fails to recognize this unusual presentation of rebound headache, the patient might be placed on unnecessary and often ineffective medications for prophylaxis instead of stopping the offending pain relief medications.
Introduction
Although chronic daily headache (CDH) is not included in the current classification (1) of headaches by the International Headache Society (IHS), there have been innumerable articles which point out that the patients with these daily headaches often note improvement after they stop the pain relief medications which they are using. This phenomenon has been given many names (2). Gallagher was apparently the first to describe these as rebound headaches (RH) (3).
Most patients with CDH are suffering from RH (4). These patients typically describe a daily or almost daily, prolonged or constant, dull, generalized tension-type headache (TTH) with superimposed migraine-like attacks (5, 6). They were using daily or almost daily medications for pain relief when they noted the onset of the chronic headaches. The migraine-like component is usually more frequent, more prolonged and more intense than any episodic migraine which might have been experienced in previous years.
An unusual presentation of RH is frequent or daily migraine without a TTH component. A few articles on rebound (7–10) have mentioned this occurrence, but apparently there have been no articles stressing that this is a presentation which might be seen occasionally in any headache referral practice. If this cause of frequent migraine is not recognized, unnecessary and often ineffective migraine abortive and prophylactic medications might be prescribed rather than correcting the problem by stopping the offending pain medications.
From the records of patients that were seen at Vanderbilt during the last 5 years, the following three case histories have been selected to give examples of RH presenting as: (i) frequent but not daily migraine, (ii) daily migraine, and (iii) frequent episodes of migraine status.
Case reports
1. Frequent but not daily migraine
This 40-year-old female noted the onset of migraine with auras of ipsilateral sensory loss at the age of 14 years. During the next 25 years these attacks occurred approximately three times each year with a maximum duration of 6 h. The pain was disabling, non-throbbing, always right-sided and accompanied by nausea, vomiting, photophobia and phonophobia. Movement accentuated the pain. In addition, in earlier years she experienced infrequent TTH which usually started in the late afternoon or evening hours and infrequent benign idiopathic stabbing headaches. In previous years she never used pain relief medication for more than 3 consecutive days.
Seven months prior to her initial visit she had an unusual, prolonged, flu-like illness for which she used acetaminophen 4 g daily for 1 week. Immediately thereafter the frequency of her migraines increased to three per week and the duration of each attack increased to 12–24 h. She no longer noted the sensory auras but might experience blurring of vision before the onset of pain. There was faster intensification of the pain and these recent headaches became more intense and more disabling than her previous infrequent migraines. Tightness in the neck muscles was noted with the headaches, a feature that she had not recalled in former years. Most episodes started after she had been awake for 3–6 h. Her previously infrequent, brief stabbing headaches increased to the point of occurring four to five times per week. She denied having any TTH component during this 7-month interval. On the 4 days of the week when she was not having migraine, her only pain might be the momentary jabs. She used acetaminophen or combinations of simple analgesics for these more frequent migraine attacks.
The history was otherwise non-contributory and the physical examination showed nothing other than obesity. Neuroimaging studies were not obtained.
She was given a description of the typical presentation and cause of RH and told that until proven otherwise, her recent frequent headaches were the result of the frequent but not daily medications which she was using for pain relief. She was instructed to abruptly stop all agents containing aspirin, acetaminophen, all non-steroidal anti-inflammatory drugs, narcotics, ergotamine, all triptans and caffeine. She was shown how to self-administer dihydroergotamine (DHE) 1 mg subcutaneously (maximum of two injections per 24 h, separated by at least 2 h) for any excruciating attacks. She was told to keep a headache calendar. No other pharmacological or non-pharmacological measures were used.
She rapidly improved and after having omitted the forbidden pain relief medications for 10 days, she had the onset of 7 consecutive pain-free days. She did not use the DHE. After reaching the goal of once-a-week headaches, she was advised to limit the previously forbidden pain relief medication to 2 days per week, there being a risk of return of the frequent migraines if she exceeded this limit. During the following 7 months she had a migraine once each month which was rapidly stopped by sumatriptan 50 mg plus three tension-type headaches which ceased after 4 h without therapy. She had no brief jabs of pain during that interval.
2. Daily migraine
This 43-year-old male developed migraine without aura as a teenager, the attacks occurring six to 12 times per year and lasting as long as 24 h. The pain began in the right neck and spread to the postorbital region on either side. At maximum the pain was pulsitile and accompanied by photophobia, phonophobia and occasional nausea. He denied previous TTH or benign idiopathic stabbing headaches. Throughout the years the migraines were treated with over-the-counter analgesics.
Eighteen months earlier there had been an unexplained gradual increase in frequency of the migraine attacks to the point of occurring daily for the past year. The character of the pain did not change. The pain might start at three in the morning, be first noted as he would awaken or start after he had been awake for 4 or 5 h. He took rizatriptan or zomatriptan daily for these headaches. Starting 2 or 3 h after using the triptan he would note absence of headache for the next 8–16 h. When not having the migraine he never had a TTH. Twice each month he awoke without a headache and used one of the triptans to prevent that day's headache from occurring. He would usually remain headache free the remainder of the day. In addition, in recent months he used occasional naproxen, rofecoxib or over-the-counter analgesic.
The past history was non-contributory. The physical examination showed only his long-standing obesity. A recent magnetic resonance imaging (MRI) of the head was reported to be normal.
He was given the same explanation of the cause of pain that is given to all patients suspected of having RH. He was given the same instructions to omit all pain relief medications, to use DHE and to keep a headache calendar.
He gradually improved. After having omitted the forbidden pain medications for 50 days (using the DHE 11 times during this interval), he had the onset of eight consecutive headache-free days. During the following 5 months he reported a total of six headaches which responded rapidly to a triptan.
3. Frequent episodes of status migrainosus
This 22-year-old female had a history of unilateral migraine or migraine status without aura since aged 3 years. Following puberty there was a maximum frequency of one per month and usual duration of 4 days. At times the attacks might last for 7 days. Each was pulsitile, right-sided and accompanied by nausea, photophobia, phonophobia and osmophobia. She denied having TTH at any time in her life.
Ten months earlier there was an unexplained sudden increase in headache frequency and duration. For 10–20 days she would have cycles of intense migraine for 3 or 4 days, followed by less intense migraine for 1 or 2 days, followed in turn by the intense migraine for another 3 or 4 days. Following these cycles she might have a maximum of 5 or 6 days during which her only headaches were frequent momentary jabs of pain. Propranolol 60 mg daily failed to reduce the frequency of the attacks. On the 10–20 days with status migrainosus she obtained partial relief by using butorphanol or large amounts of over-the-counter analgesics. Injections of sumatriptan never improved the pain.
The history was otherwise unremarkable and the examination was normal. A previous MRI was reported to be normal.
She was told that the almost daily headaches were probably the result of the pain medications and advised abruptly to stop the same list of drugs (see case 1 above). She was instructed to use DHE and keep a headache calendar. There was rapid improvement. When she returned to the clinic 39 days later, she reported that the previous headaches ceased by the end of the fourth day and she remained headache free for the next 3 weeks. Then she had an 8-day constant, non-throbbing, right periorbital, minimal headache without nausea, photophobia, phonophobia, or osmophobia. She reported total freedom from headache for the following 2 months.
Discussion
Currently there is no laboratory test for RH. It is a condition which can be suspected from the history but proven only by observing delayed improvement after the offending pain medications have been stopped. Each of these three patients noted a marked increase in the frequency of their pre-existing episodic migraines and each increased the number of days per week that they used an analgesic or triptan for the pain. When seen in the clinic no pharmacological agents were added other than the DHE, which was prescribed as a prn rescue medication for unbearable pain. Termination of the frequent migraines occurred after abruptly stopping the offending agents, and each achieved the goal of 6 or more consecutive days without any headache. They had only episodic headaches in subsequent months. Thus, the diagnosis of RH was established in each incidence.
Some might argue that these cases were examples of natural fluctuations in migraine frequency. In case 1 the frequency suddenly changed from three per year to three per week after the patient used an analgesic for another problem. At the same time there was a marked increase in the occurrence of the jabs of pain. Many of the patients with RH give a similar story of a precipitating event and frequent benign jabs (7). Case 2 had the gradual transformation from episodic migraine to daily migraine as he used increasingly frequent doses of triptan. Case 3 changed from monthly migraine or migraine status to almost daily status migrainosus. These changing patterns are more extreme than those seen in natural fluctuations in the frequency of episodic migraine.
The unusual feature in the histories of these patients was their denial of any TTH when having the CDH. One of the three (case 1) recalled episodic TTH in earlier years. The other two denied these.
This presentation of RH as migraine without tension-type pain has been mentioned infrequently in other articles and does not appear in the recent headache textbooks. It was noted in a previous study from this centre to occur in two out of 50 consecutive patients who were suspected of having RH (7). In the recent article by Katsarava et al. (8) 69 patients with ‘medication-overuse headaches’ were classified as having only migraine. The total patient population from which these 69 individuals were selected was not specified and thus no incidence for the condition can be calculated. The authors went on to state that the patients with only almost daily or daily migraine were more likely to be using a triptan as a single agent rather than monotherapy with simple or combination analgesics. These patients achieved a 50% reduction of headache days (8). Case 2 in this report was using daily triptans in the last year of his daily headaches, but in addition was using occasional non-steroidal or other analgesics. Case 1 never used a triptan and case 3 obtained no relief from using sumatriptan infrequently.
Limmroth et al. (9), in an article describing headaches after frequent triptan use, stated that three of their 11 patients had daily migraine-like attacks. The case history by Evans and Robbins (10) describes a patient who developed a daily migraine responding to daily sumatriptan therapy with no mention of any tension-type pain during the portions of the day when not having migraine. Both Drs Evans and Robbins suspected that this patient was probably having RH. That particular patient did not stop the triptan and therefore the diagnosis of RH cannot be proven.
There are other reports of daily migraine which are not RH. For instance, a recent article by Merims and Kuritzky (11) described five patients with migraine with aura occurring one to six times per day. The article does not clearly state the absence of tension-type pain during those portions of the day when not having the migraines with aura. There was inadequate description of the abortive therapy that these patients were using, but there was ‘no such overuse’ of drugs when they changed from having episodic migraine to the daily headache pattern. Each was age 48 years or older when the change occurred and there was some improvement using various anti-epileptic prophylactic therapy. From the information provided these cannot be considered as having RH.
The article by Linton-Dhalöf et al. (12) mentions that some of their patients were overusing ergotamine and sumatriptan and these patients more commonly described a daily migraine headache. This article again does not specifically state that there was absence of TTH during the portions of the day without any migraine pain.
The revisions being considered for the 1988 IHS classification of headaches include the addition of ‘chronic migraine with or without drug overuse’. It is not certain that there will be a requirement for pre-existing episodic migraine or a description of these patients as always having TTH during the hours or days when not experiencing the migraine. Case 1 in this report was using analgesics only 3 days per week on average. Overuse of analgesics does not always occur in the patient having RH.
This report of three patients having RH without a tension-type component to their headaches suffers from there being no biological marker to distinguish a minimal migraine from a TTH. Raskin and Appenzeller (13) stated that ‘this lack of distinguishing features between migraine and tension headaches suggests the possibility that these disorders are at two ends of a continuum’. Spierings (14), Lipton et al. (15) and Cady et al. (16) discussed this in a recent series of letters. Until there is a specific test to distinguish migraine from TTH, these will be separated by their clinical features. The latter approach has been the basis for this paper showing that RH might present as migraine in the absence of TTH pain.
Conclusion
Rebound headaches can present as frequent but not daily migraine, daily migraine and frequent episodes of status migrainosus without the patient having any tension-type headache during those days or portions of the day when not having the migraine-like pain. If the clinician fails to recognize this unusual presentation of RH, the patient might be placed on unnecessary and often ineffective medications for prophylaxis, instead of having the offending pain relief medications stopped.