Brain & Nervous System Headaches Causes & Risk Factors Rebound Headache: What to Know and How to Break the Cycle By Colleen Doherty, MD Published on November 24, 2023 Medically reviewed by Brigid Dwyer, MD Print Table of Contents View All Table of Contents Symptoms Who Is at Risk Drugs Causing Rebound Headache Treatment Prevention When to Seek Care Rebound headaches, also called medication-overuse headaches, are caused by the excessive use of acute (short-term) headache medication in people with a prior history of headaches, usually migraine or tension-type. This article explores how rebound headaches manifest and who is most at risk for having them. The treatment and prevention of this disabling yet often under-recognized headache disorder will also be reviewed. Ekaterina Goncharova / Getty Images What Does a Rebound Headache Feel Like? Rebound headaches are caused by the regular overuse of headache medication for over three months. Medication overuse is defined as taking headache medicine for 10 to 15 days or more per month, depending on the specific drug class. Rebound headaches occur 15 or more days per month and only develop in a person with a preexisting primary headache disorder. What Is a Primary Headache Disorder? Primary headache disorders exist on their own, with common ones being migraines, tension-type headaches, and cluster headaches. Rebound headaches vary considerably in severity, location, and quality (how they feel). However, they tend to be worse in the morning upon awakening and occur daily, nearly daily, or, in some cases, continuously. They are also associated with an increased sensitivity to pain in other areas of the body, namely the neck, shoulders, and back. Rebound headaches often cause psychological distress as they create an unrelenting cycle of worsening head pain followed by more medication intake. Who Gets Rebound Headaches? The most common primary headache disorder associated with rebound headaches is migraine. Migraine headaches cause throbbing pain on one or both sides of the head. The pain is often accompanied by nausea, vomiting, and sensitivity to light or sound. People with rebound headaches often report a history of migraine attacks that have slowly transformed over months to years from episodic to chronic form, thereby requiring more acute migraine medications. Factors associated with an increased risk of developing rebound headaches include: People assigned female at birth Smoking Physical inactivity Co-existing psychological conditions, like anxiety or depression Low socioeconomic status Family history of rebound headaches or substance abuse High daily caffeine intake Interestingly, genetic factors may also affect the likelihood of developing rebound headaches. Limited scientific evidence suggests that polymorphisms (slight changes in the DNA sequence of a gene) of the dopamine gene system may affect a person's vulnerability to rebound headaches. What Is Dopamine? Dopamine is a brain chemical associated with pleasure, motivation, decision-making, dependence, and addiction. Along the same lines, brain imaging studies have found structural changes within dopamine pathways—the reward system—in people with rebound headaches. Which Drugs Cause Rebound Headaches? Most acute headache medications can cause rebound headaches. While studies vary slightly, the consensus is that the highest risk for rebound headaches is associated with opioids and butalbital-containing combination analgesics. Opioids and butalbital-containing combination analgesics can cause rebound headaches with 10 or more days of usage per month. Examples of these drugs include: Opioids: OxyContin (oxycodone), Vicodin or Norco (hydrocodone/acetaminophen), and Percocet (oxycodone/acetaminophen) Butalbital-containing combination analgesics: Fiorinal (butalbital, aspirin, caffeine) and Fioricet (butalbital, acetaminophen, caffeine) Side Effects and Risks of Taking Oxycodone for Headaches With triptans, ergot alkaloids, and combination analgesics, such as Excedrin Migraine (a combination of acetaminophen, aspirin, and caffeine), medication overuse is defined as taking the drug on 10 or more days per month. What Are Triptans? Triptans, like Imitrex (sumatriptan), are abortive migraine medications, meaning they stop a migraine that has started. They are available in several formulations, including pills, dissolvable tablets, nasal sprays/powders, and shots. The lowest risk for rebound headaches appears to occur with aspirin, Tylenol (acetaminophen), and nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil or Motrin (ibuprofen) and Aleve (naproxen sodium). Progression to rebound headaches can develop in people taking these medications for 15 or more days per month. Lastly, there are newer headache (particularly migraine) drugs, where the risk for rebound headaches remains largely unknown. That said, early thoughts that they pose a lower risk for developing rebound headaches based on their mode of action are promising. These newer migraine drugs include: Reyvow (lasmiditan) Calcitonin gene-related peptide (CGRP) blockers like Nurtec ODT (rimegepant), Ubrelvy (ubrogepant), and Zavzpret (zavegepant) Migraine Treatments: Everything You Need to Know How a Rebound Headache Is Treated There are three key steps to treating rebound headache. Medication Discontinuation/Reduction The first and crucial step is stopping or significantly decreasing the dose of the overused headache medication. Depending on the drug, this process of discontinuation or reduction varies. For example, if the offending medication is an NSAID or triptan, it can usually be stopped or weaned down immediately at home under the guidance of a healthcare provider. Excedrin Migraine or other OTC headache analgesics that contain caffeine require a slow taper at home, as they can cause unpleasant caffeine withdrawal symptoms (e.g., anxiety, fast heart rate, and nausea). Those who are taking frequent and/or high doses of opioids or butalbital combination drugs require hospitalization when tapering down because the withdrawal symptoms from taking these drugs can be severe, if not potentially life-threatening. Whether discontinuing at home or in a hospital setting, note that a person's headaches will temporarily worsen. During the headache medication withdrawal period—which lasts around 10 days and sometimes up to three weeks—a healthcare provider may recommend what are considered rescue medications, such as prednisone (a steroid), to help relieve headaches. Prevention The second step for treating rebound headaches is to start a preventive medication around the same time or after discontinuing/reducing the overused medication. The type of preventive therapy chosen depends on the underlying primary headache disorder. Examples of preventive migraine drugs include: An anti-seizure drug called Topamax (topiramate) A high blood pressure drug called Inderal (propranolol) A calcitonin gene-related peptide (CGRP) inhibitor such as Aimovig (erenumab), Vyepti (eptinezumab), or Emgality (galcanezumab-gnlm) Likewise, preventive medications for tension-type headaches include: The tricyclic antidepressant Elavil (amitriptyline)The serotonin-norepinephrine reuptake inhibitor (SNRI) Effexor (venlafaxine) Incorporating Complementary Therapies Besides taking a preventive headache medication, a provider may recommend a non-drug therapy, like biofeedback, to further minimize rebound headaches and medication use. Close Follow-Up During and after discontinuing or significantly reducing the offending headache medication, close follow-up with a healthcare provider is vital to ensure adherence to the new treatment plan. Starting a calendar or journal to record the number of headache days and medication dosage is a valuable tool to help keep a person on track and prevent relapse. Can a Rebound Headache Be Prevented? Preventing rebound headaches and the debilitating cycle of pain and medication overuse they create is essential, especially considering how grueling and time-consuming the discontinuation process can be. If you experience headaches, talk with a healthcare provider about strategies to prevent medication overuse, such as taking a highly effective medication at an optimal dose as soon as possible at the start of a headache. More specifically, limit your use of triptans, ergot alkaloids, and combination analgesics to less than 10 days per month. Aspirin, Tylenol, and NSAIDs should be limited to less than 15 days per month. Avoid opioids and butalbital, if possible, and start a preventive headache medication if you are experiencing eight or more headaches days per month. When to Contact a Healthcare Provider If you notice an escalation in your headache medication use, promptly schedule an appointment with a healthcare provider or headache specialist (neurologist). Also, see a provider if your headaches are changing in pattern, becoming more severe, or if the following scenarios pertain to you: You are older than 50.You are pregnant or postpartum.You are immunocompromised. When Should You Worry About a Headache? Summary Rebound headaches, known formally as medication-overuse headaches, occur as a consequence of excessive use of acute headache medication over a three-month timeframe. Factors like a history of smoking, anxiety, substance abuse, and high caffeine intake can increase a person's risk of developing this disabling headache disorder. Rebound headaches occur 15 or more days per month and only develop in a person with a pre-existing primary headache disorder, usually migraine or tension-type headaches. 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Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144. doi:10.1212/WNL.0000000000006697 By Colleen Doherty, MD Colleen Doherty, MD, is a board-certified internist living with multiple sclerosis. See Our Editorial Process Meet Our Medical Expert Board Share Feedback Was this page helpful? Thanks for your feedback! What is your feedback? Other Helpful Report an Error Submit