Thread by @beth_morton

This week’s #MigraineChatAMA invited Qs abt rebound headache: a topic I wish was more rigorously studied for lots of reasons. The research in this thread is not w/o limitations or issues.

Nothing shared is medical advice. Talk to an HCP before making changes. #MigraineChat /1

Medication overuse headache is the ICHD-3 term. Unofficially, it is often referred to as “rebound” headache. Some organizations are trying to get the name updated to medication adaptation headache (to avoid the stigma of blame). For space, I’ll use rebound. /2 #MigraineChatAMA

How common is rebound headache (HA)? A “true prevalence that is unknown, partly resulting from various changes in diagnostic criteria, but estimates are in the range of 0.5 to 2.6%.” /3 #MigraineChatAMA
ncbi.nlm.nih.gov/books/NBK53815…

What causes rebound HA? It’s not clear. Central sensitization likely plays a key role. Possibly also genetic factors that ⬆️ susceptibility and dependence behavior (see more on this later). Those in rebound might also be “locked” in a hyper responsive state. /4 #MigraineChatAMA

In sum, a combo of “changes in the central nervous system, specifically in pain processing and dependence networks, sensitization, and receptor density, all… help to explain the clinical features of [MOH].” /5 #MigraineChatAMA
ncbi.nlm.nih.gov/books/NBK53815…

Q: Is this 1. an issue for people w/o HA but w/migraine and 2. does low dose daily aspirin count?

Dr. @CSWhiteMD answers part two of this question here ⬇️. Low dose aspirin should be okay. /6 #MigraineChatAMA

https://twitter.com/cswhitemd/status/1582081322130231296?s=61&t=DxyVMNZS5pApTZ_tDsb-Dg

For part one, let’s define rebound HA. It is:

(1) HA occurring on 15+ days/month,
(2) in ppl w/pre-existing primary HA (like migraine),
(3) w/regular use of one or more acute medication(s),
(4) on 10-15+ days/month for > 3 mos.

/7 #MigraineChatAMA

Related Q: Is this an issue for everyone in the population or just people with migraine?

Any pre-existing primary HA disorder, but not people w/out a HA disorder.

/8 #MigraineChatAMA

.@Neuralgroover shared ⬇️ that rebound is more common in migraine vs. other headache disorders. This is backed by this article: ncbi.nlm.nih.gov/books/NBK53815…

/9 #MigraineChatAMA

https://twitter.com/neuralgroover/status/1582115924408029185?s=61&t=DxyVMNZS5pApTZ_tDsb-Dg

I didn’t find much research on rebound in migraine types w/o HA, just anecdotal accounts of rebound in vestibular migraine. @thedizzydoc shared this a while back (if he sees this and wants to weigh in, I’d be grateful). /10 #MigraineChatAMA

https://twitter.com/thedizzydoc/status/1227232801432522752?s=61&t=A_Nvzaa80LbYhRx5TkB3_g

Q: Are there risks of taking acute meds frequently/daily short term (i.e., illness or injury, menstrual migraine).
Rebound generally takes time to develop (see tweet 7). A short course of an acute med is typically okay even w/a history of migraine. /11 #MigraineChatAMA

That said, for ppl w/migraine, acute med use for non-migraine reasons still counts toward your acute med days/month. So check with your HCP. It may depend on the med and your past susceptibility to rebound. /12 #MigraineChatAMA

Q: What medications can lead to rebound? What is known about acetaminophen? Related, how much of each med is too much?
The short answer is that many of our acute migraine treatments have the potential to cause rebound, but some are worse offenders. /13 #MigraineChatAMA

The long answer, it does vary:

Higher risk:
- Opioids
- Combination treatments like Fioricet (butalbital) or Excedrin migraine (caffeine)
These should be used very sparingly: just 1-2x/week can ⬆️ rebound risk.

/14 #MigraineChatAMA

Medium risk:
- Triptans
- Ergotamines
Use <10 days/month

/15 #MigraineChatAMA

Lower risk:
- OTC meds like acetaminophen, ibuprofen, aspirin.
Use <15 days/month, incl days used for non-migraine symptoms.

/16 #MigraineChatAMA

Considered safe:
- Gepants
- Devices (Cefaly, gammaCore, Nerivio, etc)
The research indicates these do not contribute to rebound and some can be used preventively.

/17 #MigraineChatAMA

Note: count days of med use, not doses. If a med allows re-dosing on the same day, that counts as one day. As above, based on current research, the gepants are not thought to contribute to rebound, so those days wouldn’t count.
/18 #MigraineChatAMA

Q: Is med “overuse” habit forming? Can it create physiologic dependence? Some research puts rebound in the spectrum of substance use disorders (SUD) bc it seems to share neurobiological pathways or ppl w/rebound were more likely to have family hx of SUD.
/19 #MigraineChatAMA

This is beyond my knowledge and I’ll admit, I think some studies don’t satisfactorily account for other explanations. W/o better evidence, I worry these findings are stigmatizing. Here are a few sources though:
…adachejournal.onlinelibrary.wiley.com/doi/10.1111/j.…
…alofheadacheandpain.biomedcentral.com/articles/10.11…
/20 #MigraineChatAMA

Some acute txs seem to be associated w/higher risk of this “dependency behavior.” E.g., opioids and triptans (more risky) vs. aspirin or ibuprofen (less risky).

NSAIDs might actually be protective in people w/EM (< 10 HA days/mo):
…adachejournal.onlinelibrary.wiley.com/doi/10.1111/he…
/21 #MigraineChatAMA

Q: Who’s studying it? The MOTS trial is one of the biggest studies of med overuse. They recently compared two groups of people with rebound: those started on a preventive who 1) did not stop the “overused” acute med and 2) did stop the “overused” acute med.
/22 #MigraineChatAMA

Both groups had similar reductions in reduction of moderate-to-severe HA days. In other words, adding the preventive was helpful with or without stopping the offending acute treatment.
n.neurology.org/content/98/14/… [abstract]

See also ⬇️

https://twitter.com/schwedtt/status/1511426561202864132?s=61&t=fg6XRvzevWMCN-mHBh82LQ

/23 #MigraineChatAMA

Historically, treatment for rebound included stopping the overused med before switching to a new preventive or acute medication. This can be both a tough approach to ride out and impractical.
/24 #MigraineChatAMA

Newer txs like the CGRPs mAbs have shown effectiveness in rebound. Given the MOTS trial results, it is effective to start a new preventive treatment like the CGRPs (or another) to treat rebound w/o stopping the “overused” acute med.

https://twitter.com/beth_morton/status/1578873246623027200?s=61&t=0PdVFS2hrbu1IoVbFA9LDQ

/25 #MigraineChatAMA

During the transition, a bridge therapy might be needed if new acute or preventive ones added & the overused med is stopped. These might incl: NSAIDs (not the overused tx), steroid tapers, DHE (inpatient or home options), antiemetics, nerve blocks and more.
/26 #MigraineChatAMA

One of the problems with research on rebound is this chicken vs egg issue: “It is unknown if the high headache frequency leads to more drug consumption and thus MOH or if patients with higher frequency attacks are more prone to MOH.”
ncbi.nlm.nih.gov/books/NBK53815…
/27 #MigraineChatAMA

Likewise, with “risk factors:” e.g., ppl with rebound frequently report depression or anxiety, but it is unknown if this is a risk factor or consequence of rebound/disability.
/28 #MigraineChatAMA

Notes: I often put terms like “overuse” and “dependency” in quotes because of the stigmatizing connotation they have. The former feels blame-y and I shared my concerns with the research on the latter.
/29 #MigraineChatAMA

The thread jumps around bc of the overlap/interrelatedness of questions. I hope you followed.

I also welcome others - including researchers - to clarify or share their thoughts on this topic.

Errors are mine. Lmk if you need clarification on abbreviations.
/30 #MigraineChatAMA

Please do not use thread readers to unroll these #MigraineChatAMA threads or directly repost this without attribution. Collecting this info takes a lot of research. I don't want others to post/profit off my work.
/31 #MigraineChatAMA

Find these threads helpful? The tip option in my profile is live or support #MigraineChat these other ways ⬇️
#MigraineChatAMA /32

https://twitter.com/beth_morton/status/1550208122194731008?s=61&t=2K5MVqBMpdq44e67GE_uvw

One clarification: for almost any tweet in the thread that doesn’t have an embedded source, I use this article. It is a very thorough summary. I link it in a few tweets, but wanted to be more transparent.

/33 #MigraineChatAMA

ncbi.nlm.nih.gov/books/NBK53815…

Another Q I meant to answer:

Is rebound an ongoing thing? If you “overused” OTC or other meds before chronification but don’t anymore, could you still be in rebound? /34 #MigraineChatAMA

A: I'm not sure. Maybe not according to the ICHD-3.

Related, I read that about half of ppl w/chronic migraine (CM) improve when they stop the "overused" med (source ⬇️).

/ 35 #MigraineChatAMA

If you don't improve, does that mean it was never rebound or that rebound made the CM harder to reverse? These are Qs I still have.

Predictors of better outcomes: 1) fewer HA days/month and 2) less time w/CM before rebound started.

/36 #MigraineChatAMA

Some additional sources:
1. medscape.com/viewarticle/97…
2. merckmanuals.com/professional/n…

/37 #MigraineChatAMA

As for my personal concerns about the rigor of evidence on rebound HA: I like this article by Drs. Loder, Rizzoli, and Scher for the questions they raise.
n.neurology.org/content/89/12/…
[abstract]
/38 #MigraineChatAMA

@threadreaderapp unroll