Breaking a Rebound Headache: Management Plan
The most effective approach to breaking a rebound headache is immediate, complete withdrawal of all overused medications combined with initiation of prophylactic therapy, as continuing the offending agents will perpetuate the cycle and prevent any preventive treatment from working. 1, 2
Immediate Withdrawal Strategy
Stop all overused acute medications abruptly - this is the cornerstone of treatment, as preventive medications will not work while rebound is occurring. 1, 2, 3
Bridge Therapy During Withdrawal (First 6 Days)
To minimize withdrawal symptoms during the critical first week, use one of these options:
Prednisone taper: 60 mg/day for 2 days, then 40 mg/day for 2 days, then 20 mg/day for 2 days - this significantly reduces withdrawal symptoms and need for rescue medications compared to no bridge therapy. 4
Naratriptan: 2.5 mg twice daily for 6 days - also effective at reducing withdrawal symptoms, though slightly less adherence than prednisone in studies. 4
No bridge therapy: Patients can successfully withdraw without regular medications, but expect higher incidence of withdrawal symptoms (nausea, vomiting, worsening headache) and greater rescue medication consumption. 4
Strict Medication Limits Going Forward
Establish firm boundaries on acute medication use to prevent recurrence:
Limit simple analgesics (NSAIDs, acetaminophen) to fewer than 15 days per month. 1
Limit triptans to fewer than 10 days per month. 1
Avoid entirely: Medications containing barbiturates, caffeine, butalbital, or opioids - these carry the highest risk of causing rebound and should not be used. 5
Ideally, restrict any acute headache medication to no more than 2 days per week to minimize rebound risk. 6, 5
Initiate Prophylactic Therapy
Start preventive treatment immediately upon withdrawal, as most patients with rebound headache have underlying chronic migraine requiring prophylaxis:
Topiramate: Has double-blind, placebo-controlled trial evidence specifically in chronic migraine; watch for cognitive effects, paresthesias, and weight loss. 1
OnabotulinumtoxinA: Proven beneficial for chronic migraine when delivered using the Phase III protocol; reduces headache days, severity, and improves quality of life. 1
Amitriptyline: Drug of second choice for migraine prophylaxis; effective but causes dry mouth, sedation, and weight gain. 1
Valproate or gabapentin: Alternative options with evidence in chronic daily headache, though side effect profiles must be considered. 1
Critical Pitfalls to Avoid
Do not start prophylactic therapy without stopping the overused medication first - the rebound phenomenon will counteract any preventive treatment efficacy. 2, 3
Recognize atypical presentations - rebound can present as frequent migraine attacks without daily tension-type headache, not just the classic chronic daily headache pattern. 7
Expect high relapse rates - even after successful withdrawal, many patients return to overuse patterns; aggressive education and close follow-up are essential. 3
Avoid prescribing daily analgesics - this worsens the problem rather than helping. 6
Monitoring and Follow-Up
Maintain a headache diary to track headache days and medication use, facilitating early detection of overuse patterns. 1, 5
Expect 5 weeks minimum for initial improvement assessment after withdrawal. 4
Provide preemptive education on medication overuse headache risk at every visit to prevent recurrence. 1