Edward Lichten, M.D.,PC
555 S. Old Woodward Avenue Suite 700
Birmingham, MI 48009 

Email: drlichten



Lecturer #3:  Edward Lichten, M.D.
Director, Headache Institute for Women
Novi Headache Symposium 1994





    As often as the patient marks off "headache" on the initial history form, we find the box marked "taking more than 3 aspirin/other meds per week." This makes us suspicious of the medical condition referred to as A.R.H., Analgesic Rebound Headache. These patients have been seen by various doctors complaining of headache pain "all the time".

    These patients frequently start out with migraine, only to end up, years later with chronic daily headache. The presenting headache may be due to over use of medication. The patient may have an underlying psychological disorder. Whether there are demonstrable genetic, biochemical or pharmacological factors, these patients are the most difficult to diagnose and treat.

    As previous experts have explained, there is significant overlap between migraine and "tension-type" headaches. It is possible, as Raskin has proposed, that these two conditions are a clinical continuum" differing only in severity. They may represent " ... varied symptomatic expression of a central disturbance related to neurotransmitter abnormality"--that they are only different because the brain "sees" them as different.

    Mathews found an initial complaint of intermittent migraine in 76% of patients with A.R.H. His typical patient often awakened with headache, overused analgesics, had more severe attacks with menses, and reported symptoms of depression. Saper, Rapaport, MacGregor and other documented these salient features:

    1. daily or almost daily headache
    2. daily or almost daily use of symptomatic medication
    3. depression and sleep disturbances
    4. often a history of superimposed vascular or migraine-type headaches in addition to the baseline daily headache
    5. often a family history of headache, less often a history of alcoholism


    The first step in dealing with analgesic rebound headache is to stop the daily use of analgesics: butabarbital (Fiorinal™/ Esgic™/ Bellergal™), narcotics, tranquilizers/ muscle relaxers, caffeine, ergot preparations, and Tylenol. Outpatient attempts to "we an" patients off these medication often fail. Major universities and headache clinics have usually resorted to hospitalization.

    The physician must recognize and must explain to the patient that the chronic daily use of medication causes and contributes to chronic daily headaches. It has been shown repeatedly that migraine prophylactic medications are largely useless in these analgesic abusers; and that about two-thirds of these individuals, within several weeks of being withdrawn from their analgesics, improve in terms of having fewer headaches and once again responding to migraine prophylactic agents.

    The patient will resist. It was Osler's dictum (1891) that "a desire to take medication is, perhaps, the great feature which distinguishes man from the other animals." Psychological testing of ARH show these individuals to have elevated scores of hypochondriasis with lower scores of hysteria. Depression scales were higher in chronic tension-type headaches. These patients will require frequent physician contact for both medical treatment and psychological support.

    Previous treatment regimens have included hospitalization. The most frequently used medication is DHE™ (dihydroergotamine) 45 given as 1mg intravenously every 8 hours in the hospital preceded by Reglan™ 10mg (metoclopramide HCL) orally or intravenously. Less severe cases are treated with Periactin™ (cyproheptadine) 4mg three times daily plus vitamin B6 50-100mg daily. Oral steroids and intravenous steroids are used depending on hospitalization. Such drugs as Midrin™ (isometheptene mucate) or Methergine™, Phenergan™, and Xanax™ have been prescribed three times a day with varying success. These headache medications can be used, but, they may become an additional medication for the ARH patient to be withdrawn from in the future.

    Three month studies of hospitalized ARH patients report a 50% improvement at a cost of thousands of dollars. Seven months after discharge, Walker reported only 9 of 88 "headache free" with 61 noting "some improvement." Success in these patients is limited.

    Walker listed the various modalities used in an attempt to avoid repeat hospitalizations: DHE-45™ IM by patients, occipital nerve blocks, non-steroidal anti-inflammatory drugs, biofeedback, patient education and supportive counseling.

    We have incorporated this variety of techniques in an attempt to prevent hospitalization. In the last three years, only 4 patients have been hospitalized: 2 for 1 day, 1 for 2 days, and 1 for 8 days. The modality we have found most rewarding has been to co-ordinate treatment for cervicogenic headaches and hormonal migraine: occipital nerve blocks with physical therapy and prescribing Danazol™ 400mg daily.

    In our office practice, we find that the majority of the headache patients we see have a combination of chronic tension-type or cervicogenic headaches and intermittent hormonal migraine. Incorporating a treatment plan that addresses both has proved most successful in treating these patients.

    A second benefit of this approach has been the avoidance of expensive neurologic testing, referral to "headache centers," multiple medications, and repeated hospitalization. In an unpublished study of 150 consecutive "new" headache patients, the average cost from initial consultation to "significant improvement" was under $450. Add the cost of physical therapy to this, and the average expenditure was under $1000. A one-day hospitalization, a MRI and even some initial headache evaluations easily exceeds twice this amount.

    In conclusion, the analgesic rebound headache is a very common and complex problem that includes muscle tension-type, intermittent (hormonal) migraine, and psychological factors. Using a program of frequent office and physical therapy visits for support, occipital and trigger point injections for deep muscle therapy, and Danazol™ medication for its hormonal suppression and anti-inflammatory effects has been as successful as any in-hospital program at a fraction of the costs.

    Selected Reading

    1. Edmeads J. Analgesic-Induced Headaches: An Unrecognized Epidemic. Editorial. Headache 1990; 30:614-5.
    2. Walker J, S Parisi, D Olive: Analgesic Rebound Headache. Experience in a Community Hospital. Southern Med J1993; 86 (11):1202-5.
    3. Rapoprot AM, RE Weeks. Analgesic Rebound Headache. Headache: A Clinicians Guide to Diagnosis, Pathophysiology and Treatment Strategies. editors AM Rapoport Md, FD Sheftell, M.D. PMA Publishing Corp. Costa Mesa, California. 1993, p. 157-165.
    4. Raskin NH, Appenzeller O. Headache. New York, Churchill-Livingstone, 1980.
    5. Mathews NT, Stubits E, Nigam MP. Transformation of episodic migraine into daily headache; analysis of factors. Headache 1987; 27: 102-106.
    6. Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology 1986;36:995-997.
    7. Osler W. Science and Immortality. Science 17:170, 1891.
    8. Welch KMA. Drug Therapy of Migraine. New England Journal of Medicine. 1993; 329(20):1476-1483.

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    Revised: January 1, 2011