Expert Answer: Migraine, narcotics, & rebound headaches

Question: Is it possible for a patient that has been on narcotics for 10 plus years to suddenly have rebound headaches? Or would it have been a symptom after taking then let’s say for a year? (or less)

Before answering your question some background information will be helpful in understanding my answer. Narcotic or opioid drugs are medications such as codeine, Vicodin (hydrocodone), Percocet and Oxycontin (oxycodone), morphine, Dilaudid (hydromorphone) Demerol (meperidine), and other. They are very effective pain medications and can restore many patients from severe disability due to pain to normal functioning. Unfortunately, these drugs can be addictive and can have other side effects. Originally, narcotics were used only for cancer patients because at the end of life there is no concern about addiction. In the past 20 years the use of opioid drugs has spread to the treatment of non-cancer pains such as back pain, severe arthritis, shingles, headaches, and other. In addition to the risk of addiction, these drugs carry the risk of side effects such as severe constipation, nausea, itching, and other. Many patients also develop tolerance or habituation, which means that the medication becomes less effective over time and the dose needs to be increased. This can become a problem when this habituation occurs quickly and the dose of the narcotic becomes very high and starts causing side effects. Almost all patients who take these drugs for a long time develop physical dependence, which means that the drug cannot be stopped suddenly because severe withdrawal symptoms may occur.


Many headache specialists believe that headaches actually can get worse from the frequent use of opioid drugs. A study by Dr. Richard Lipton suggested that taking narcotics as infrequently as 5 times a month can cause worsening of headaches and lead to “rebound” or “medication overuse headaches”. My personal experience treating patients with chronic migraines and a report by Dr. Joel Saper suggests that a small number of patients with severe chronic headaches can be maintained on narcotic medications for a long time without a problem. However, a large number of patients with headaches who attempt taking these drugs daily don’t do well in the long run. Some become addicted, some develop unacceptable side effects, and some stop responding to the medicine but have a hard times stopping it because of withdrawal symptoms. Patients can do well when they do not need to increase the dose of a narcotic over a long period of time, don’t have serious psychological problems, and see the doctor on a regular basis (every 1 – 3 months).

If someone, like you, has been on a daily narcotic for 10 years or even a year and the dose hasn’t changed it is very unlikely that they would develop rebound headaches. However, if you find that the dose has significantly escalated over time, then the answer is yes – these could be rebound or medication overuse headaches. The most common scenario is when someone starts with one migraine a week, takes a narcotic medication with good relief, but over a period of months finds that the headaches become more frequent, more severe, or longer in duration and the amount of medication needed to relieve them keeps going up. I limit my patients to four doses of a narcotic a month. If the headaches are more frequent, I first offer prophylactic treatments, such as Botox injections, beta-blockers, antidepressants, blood pressure medications, and other. Before starting these drugs we make sure that the patients does not have medication overuse headache from caffeine, dietary intake, or in Excedrin or Fioricet. We also always recommend regular meals, sleep hygiene, aerobic exercise, magnesium supplements, etc.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

Comments

View Comments (13)
  • ujijin
    2 years ago

    As both scientist and migraineur, please allow me to post this observation: Time can be used as a controlling variable.

    I’ve had migraines since I was in high school. I am now at 54 and the migraines have gotten progressively worse and more frequent. Only recently I’ve had to take morphine [XR, varying doses, but have worked myself down to almost nothing].

    SO: Bad migraines before opioid use, bad migraines after. A time series perspective like that can “control” for opioid medication as a variable.

  • kateymac
    4 years ago

    Four doses of narcotic medication per month? I’m sorry, but that’s hilarious.

  • Teresa Powell
    7 years ago

    I think it depends on each individual. Those who have a history of over using narcotics or pain relievers probably shouldn’t be prescribed them. Of course the Dr. would know that by how many pills they are going through a month. You can also become addicted to OTC drugs as well, which can result in rebound migraines. I’ve been taking Acetaminophen/Butalbital for years. My neurologist told me how important it was not to take more than 2 in a week because they can be addictive. I try to ride out the pain the best I can and only take my medicine as a last resort. I probably average 4/5 pills a month. Excedrin for most people with very severe migraines is like eating candy. I also have toradol, oxygen and phenegran. I have a pretty high tolerance to pain so I can go without using these unless I get the skull smashing, horrendous throbbing, puking migraines.. Then… I’m basically out of commission as far as work or anything else goes. I can’t imagine suffering through that kind of pain without having something to help take the edge off and offer me some kind of relief.

  • Henry Troyer
    7 years ago

    Teri Robert In my experience, there is no difference between overuse headaches and migraines. Or maybe I have never had overuse headaches. Could you please explain the difference between the two?

  • Teri Robert
    7 years ago

    Teresa,
    You said, “You can also become addicted to OTC drugs as well, which can result in rebound migraines.” A couple of points here. Medication overuse headache isn’t an addiction issue. You can get MOH from taking a medication too many days a week but that is NOT addiction. Second. medication overuse headaches are headaches, not Migraines. There’s a big difference.

  • Ellen Schnakenberg
    7 years ago

    A physician and I just recently had a conversation re: opioid treatment for Migraine in an ER setting. I take a middle of the road stance I suppose. I believe that the first and most important goal is to abort the attack. Patients who are successful in aborting their attack are much more successful and happy in the end. That said, by the time a patient arrives and is seen at an emergency department, they are desperate, some to the point of considering suicide. I believe there is a time and a place for narcotics (emergency rescue) and the general welfare of the patient in that particular situation should be considered and explained to them. I truly wish more ER doctors would try to abort the attack, but let the patient know that – should their medication choice not work – they will be sure that the patient receives relief from their pain until they can get to their regular physician. In my experience, most patients will agree to try a non-narcotic first when it is presented to them that way. In the end, all we really want is for the attack to cease and the pain to vanish. For me, you could tell me to dress in grandma’s nightie and climb the hill at midnight waving a naked chicken at the moon, and if you said that would take my pain away, I would probably be willing to try it. Being honestly, truly desperate does strange things to a person…

  • Karen Walker Hilton
    7 years ago

    I honestly don’t know wbat I would do without the narcotic that my neuro prescribed. When the Maxalt doesn’t work, a lot of times the narcotic does. I have not.
    abused them and can pretty much guarantee that, when taken, I don’t experience a rebound or MO headache. I’m beyond grateful that I have such a caring doctor.

  • Karen Walker Hilton
    7 years ago

    Karen – I take Vicodin.

  • Karen Spann Lee
    7 years ago

    What drug do you take?

  • Susan Stradling
    7 years ago

    Thank GOD that you are getting them under control…<3

  • Karen Spann Lee
    7 years ago

    I have occasional migraines USUALLY alleviated by Imitrex. Occasionally though, Imitrex does nothing. I’d sure like to have a back-up drug for those times. I have fiorinal with codeine, but it makes me so dizzy I can only take it before bed. Any suggestions?

  • Pamela Curtis
    7 years ago

    Oh come now… the WORSE medication for rebound headaches is actually the Tylenol included in these medication to keep addicts from being about to crush the pills and inject them, because Tylenol burns.

    Also, the FDA and the DEA BOTH say that when narcotics are used as directed there is LITTLE TO NO RISK OF ADDICTION. http://makethislookawesome.blogspot.com/2011/11/end-war-on-patients.html

    Rebound headaches from opioid narcotics is actually not very common at all, are much less painful, and much easier to manage than rebound headaches from Tylenol.

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