An approach to intractable headache

An interesting article from Medscape. Note that while she was experiencing rebound headaches, the migraine meds did nothing for her.

Scott 8)

Hi. I am Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York.

I’d like to describe a person in my practice and share a pearl to use when you approach similar patients in your own practice. Individuals are often referred to me because they are thought to have intractable pain, intractable headache, and so on. This patient was a 41-year-old woman who was referred to me because of her intractable headache. She had previously been seen by her primary care physician who had taken multiple preventive measures, but I’ll describe that in more detail later.

During her mid 30s, she began to experience regular migraine headaches. Her primary care doctor advised her to use various over-the-counter medications because her headaches were only occurring once or twice a month, and not necessarily associated with any specific trigger.

During her late 30s, her headaches became more frequent. She then had such a severe headache that she was seen at a local emergency department. Her primary care doctor advised the emergency department by phone to obtain an imaging test and blood work, all of which were negative with respect to any specific intracranial abnormality or any structural explanation for her headache. The emergency physician sent her home with a prescription for Fioricet®, which is a combination of butalbital, acetaminophen, and caffeine.

Once this was done, the patient began to take this medication several times a month and then several times a week because her headaches became more frequent, and eventually she was having these headaches every day. Her primary care physician finally said, “Okay, you’re experiencing more headaches than you used to; let’s begin a preventive strategy.”

She was prescribed topiramate, which is a US Food and Drug Administration (FDA)-approved treatment for migraine prevention. It didn’t help her very much, even at dosages up to 100 mg/day and 200 mg/day, which is the maximum dose approved for treatment of migraine, although you can go higher for other indications.

Next she was given a trial of valproic acid, which did not help her either. During this time, she continued taking a generic form of butalbital/acetaminophen/caffeine up to 6 times daily. She was then referred to me with treatment failure.

When I examined this woman, who is still under my care, I found no clear neurologic abnormalities. I learned that she was still taking the butalbital/acetaminophen/caffeine combination every day. She said, “Without taking it, I’m going to have a headache.” That was the phrase that really crystallized what was going on for me. She had now begun to experience analgesic rebound headaches, sometimes called medication overuse headache.

I bring it up today because it is not as uncommon as you may think. Very often in the insidious, subtle, “Oh, it’s not going to happen to this patient,” manner, many physicians think that because this is a generic medication, easy to prescribe, and because patients often respond to it [it is a benign medication]. But over time – over years, sometimes less – patients will become physically dependent on the butalbital/acetaminophen/caffeine preparation and have rebound headaches when they don’t take it.

As in this example, when rebound headaches or medication overuse headaches occur, it is unlikely that patients will respond to preventive treatment; you would not expect her to respond to topiramate or valproic acid because most individuals do not respond in the usual manner when they are also experiencing analgesic rebound.

For this patient, treatment involved tapering her off of the offending agent, in this case the butalbital/acetaminophen/caffeine combination. After doing so, her headache frequency decreased and after 3-4 weeks of being off the butalbital/acetaminophen/caffeine combination, she went days and then weeks without having headaches.

It is very important to prevent the development of medication overuse headaches. Prophylactic measures won’t work when patients are experiencing medication overuse headache. Many tapering or detox regimens are available that will help individuals get through this process. Most often, less is more. Tapering a person from what may be causing the medication overuse headache is extremely important.

Good reminder here Scott. There are probably many here that don’t know this stuff. Great update. Caffeine every day itself was probably contributing to my problems. I don’t have caffeine anymore. Just a little bit here and there. Maybe twice a month. Dumping caffeine seemed to help me out a lot. Didn’t help with the dizziness, but definatley helped some migrainous activity, whether it was a little headache or just some brain fog/feeling out of it. I still drink soda, but caffeine free and I don’t miss the caffeine anymore.


Scott, I was told I had rebound headaches so I struggled and came off all painkillers for 3 months. I did this twice. Then I took a preventative, the first was propanalol and then amitryptiline. I noticed the headaches (head pain) was greatly reduced but I was more dizzy. This always seems to happen to me. Its the same if I come of the small amount of painkillers I take now to function. If I stop them completely the dizzies come back, my small amount of painkiller keeps my dizziness level down.